Cardio

A 42-year-old man complains of 2 days of worsening chest pain and dyspnea. Six weeks ago, he was diagnosed with stage II non-Hodgkin's lymphoma with Lymphadenopathy of the mediastinum and supraclavicular areas, and has been treated with radiation therapy. His most recent treatment was 1 week ago. He has no other medical or surgical history and takes no medication. His chest pain is constant and unrelated to activity. He becomes short of breath with minimal exertion. He is afebrile, his heart rate is 115 bpm with a thready pulse, his respiratory rate is 22 beats per minute, and his BP is 108/86 mm Hg. The systolic BP is noted to drop to 93 mm Hg on inspiration. He appears uncomfortable and is diaphoretic. His jugular veins are distended to the angle of the jaw, and his chest is clear to auscultation. He is tachycardic, his heart sounds are faint, and no extra sounds are appreciated. The chest is seen here. EKG shows significant variablity in the height of each QRS complex. What is the most likely diagnosis in this patient?

"

4. Umbilical Artery"

1, 2

What is the recommended target LDL to reduce the risk of coronary artery disease in a diabetic patient?

100mg/dL

George "W" has been evaluated by you multiple times in the past. His blood pressure has been both significantly elevated and normal at various times within the past 9 months. He complains of occasional headaches and "spells" of palpitations, sweating and anxiety. What test will most likely provide you with the diagnosis?

24 hour urine for free catecholamines and vanillylmandelic acid

A 19 year old male athlete present to your office for a physical. He has no complaints and present a form from his college requesting medical clearance to participate in track and field. The clearance requires a urinalysis, a ECG, and a CBC. The urinalysis and CBC are pending. ECG is noted here. Which of the following is the most likely diagnosis on ECG (growing PR interval with a dropped QRS)?

2nd degree AVB, type 1

Annual blood pressure determinations should be obtained beginning at the age of

3 years old

Who is most likely to require subacute bacterial endocarditis (SBE) prophylaxis prior to dental procedure?

36 year-old male with a bio-prosthetic mitral valve

Angiography is performed on the below patients. Which one should not receive PCI with stenting, but should be referred for CABG instead?

80% left main artery stenosis

A 55-year-old male presents complaining of episodic substernal chest pain that occurs especially during strenuous exercise. Suspecting coronary artery disease (CAD), an exercise stress test is ordered. The test is considered to be abnormal if which of the following occurs?

A 2 mm ST-segment depression is seen on the ECG at peak exercise.

Which of the following patients with congenital heart disease would be expected to exhibit cyanosis?

A 2 y/o girl with tetralogy of Fallot and concomitant aplastic anemia with a hemoglobin concentration of 5g/dL

The patients described below present to a rural emergency room with 2 hours of substernal chest pain, acute ST-segment elevations in leads V2-V4 on ECG, and elevated serum troponin. Cardiac catheterization is not available. All the following patients should receive intravenous thrombolytics except

A 62-year-old male who had a hemorrhagic cerebrovascular accident (CVA) 6 weeks ago. He did not receive thrombolytics at that time.

Per the latest ACC/AHA guidelines, which of the following patients with heart failure (HF) should receive an implantable cardiac defibrillator (ICD) for sudden cardiac death (SCD) primary prevention?

A 72 year-old male with HF with an EF of 25% who is on optimal medical management

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 grade IV/VI systolic murmur heard best at the apex with radiation to the left axilla.

A 75-year-old patient presents to the ER after a sudden syncopal episode. He is again alert and in retrospect describes occasional substernal chest pressure and shortness of breath on exertion. His lungs have a few bibasilar rales, and his blood pressure is 110/80. On cardiac auscultation, the classic finding you expect to hear is

A harsh systolic crescendo-decrescendo murmur heard best at the upper right sternal border

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?

ACE-I

Which type of anti-hypertensive agent is NEVER recommended in pregnancy?

ACE-I

A 21-year-old male is brought to the ED by his fraternity brothers because he is complaining about his heart "trying to jump out of my chest". He had consumed a large amount of alcohol over the course of the day. He is obviously intoxicated & quite anxious. His EKG is seen below

AF with a rapid VR

A 37-year-old female with a new onset of atrial fibrillation is sent to the emergency department by her primary care provider. She complains of a recent onset of fatigue and dyspnea on exertion which has now progressed to dyspnea at rest. The patient also admits to associated orthopnea and peripheral edema. On cardiac exam, prominent right ventricular and pulmonary arterial pulsations are visible and palpable. The second heart sound is widely split on auscultation and does not vary with breathing (fixed split) and a loud systolic ejection murmur is heard in the second and third interspaces parasternally. The patient states she was told that she had a murmur when she was a child, but she does not recall what it was or if she had any other testing. What congenital heart defect is most likely the cause of this patient's symptoms?

ASD

Which of the following conditions is most closely associated with an increased intensity of the P2 heart sound?

ASD

A patient presents for a follow-up visit for chronic hypertension. Which of the following findings may be noted on the funduscopic examination of this patient?

AV nicking

Which of the following conditions is most suggestive of an asymptomatic abdominal aortic aneurysm?

Abdominal mass

A 56 year-old male presents to the office with a history of abdominal aortic aneurysm. He was told that he will need ongoing evaluation to assess whether the aneurysm is expanding. What is the recommended study to utilize in this situation?

Abdominal ultrasound

Which factor accounts for the prolonged QRS complex depicted in this figure (V6 lead)?

Accessory conducting fibers parallel to the AV junction

A newborn presents with blue discoloration of the peripheral extremities which worsens with exposure to cold and improves with warming. Which of the following is the most likely cause?

Acrocyanosis

Which of the following is the mechanism of action of a thrombolytic agent?

Activates plasminogen in conversion to plasmin

A 45 year-old female presents to the ED c/o palpitations, anxiety, and diaphoresis. Her HR is 220 bpm, BP 140/86, RR 18, Temp 98.7 F. The following rhythm strip is displayed on the monitor. Which of the following is the next best step? (SVT)

Adenosine 6 mg

A 22 year-old white male comes to the ER due to a sensation of fast heart rate, slight dizziness, and vague chest fullness. Blood pressure is 110/70. The following EKG was obtained. The patient has had prior episodes similar to this one, which resolved on their own. The initial pharmacologic therapy of choice in above stable patient is (SVT)

Adenosine 6 mg rapid IV bolus

You are the code team leader and arrive to find a patient with above rhythm (PEA) and CPR in progress. Team members report that the patient was well but reported chest pain and then collapsed. She has no pulse or respirations. Bag-mask ventilations are producing visible chest rise, high-quality CPR is in progress, and an IV has been established. What would be your next order?

Administer epinephrine 1 mg

A 42-year old man is brought to the emergency room by ambulance after a sudden onset of severe retrosternal chest pain that begun an hour ago while he was at home moving the lawn. He describes the pain as sharp, constant, and unrelated to movement. It was not relieved by three doses of sublingual nitroglycerin administered by the paramedics while en route to the hospital. He has never had symptoms like this before. His only medical; history is hypertension, for which he takes enalapril. There is no cardiac disease in his family. He does not smoke, drink alcohol, or use illicit drugs. He is a basketball coach at a local high school, and is usually very physically active. On physical examination, he is a tall man with long arms and legs who appears uncomfortable and diaphoretic. He is lying on the stretcher with his eyes closed. He is afebrile, with a heart rate of 118 bpm, and blood pressure of 156/100 mm Hg in the right arm and 188/94 in the left arm. His head and neck exam is unremarkable. His chest is clear to auscultation bilaterally and incidental note is made of pectus excavatum. His heart rate is tachycardic and regular, with a soft early diastolic murmur at the right sternal border. His abdominal exam is benign, and neurologic exam is nonfocal. His CXR shows a widened mediastinum. Initial management of the above patient includes:

Administration of an intravenous beta-blocker and obtaining a transesophageal echocardiogram, or CT angiography of the chest

A 30-year-old male has experienced a syncopal episode lasting approximately 45 seconds. He states he is athletic and that this is the first episode of "passing out". The nurse hands you his EKG(shown) and after your review you would?

Admit the patient to a monitor bed with a consult to a cardiologist for placement of a AICD - stat

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?

Admit to the hospital for work up of left ventricular dysfunction

The patient is diagnosed with Prinzmetal's angina. Which of the following is the prophylactic treatment of choice?

Amlodipine

A 58 year-old male presents for evaluation after an episode of chest pain noted last night after an argument with his wife. The pain lasted about 20 minutes and was described as a tightness and burning sensation in his chest behind the sternum and radiated to the left shoulder and upper arm. He states the pain improved after he rested. The patient states this is the third such episode during stressful situations this month. Which of the following is the most likely diagnosis for this patient?

Angina pectoris

Which of the following drugs is beneficial in the treatment of the patient's condition by virtue of both afterload and preload reduction?"

Angiotensin-converting enzyme inhibitor- enalapril

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 vital 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?

Antibiotic prophylaxis

A 67-year-old man presents to your office for an insurance physical. During blood pressure measurement, the nurse notes that korotkoff sounds are heard with the cuff completely deflated. The blood pressure is 180/60 mm Hg. Physical examination reveals bounding pulses and a high-pitched, blowing diastolic murmur, heard best along the left sternal border. Which of the following is the most likely diagnosis?

Aortic Regurgitation

A 28 year old English professor complains of chest pain with exertion. The symptoms began approximately 4 months ago and have been accompanied by dyspnea. On several occasions she became lightheaded and felt faint while exercising. On several occasions she became lightheaded and faint while exercising. PE, her BP is 154/92, pulse is 82/min and RR are 16. A head and neck examination is normal. There is no JVD. Her lungs are clear. Her carotid upstrokes are delayed and diminished in amplitude. On cardiac examination there is a forceful apical impulse and a soft S2. There is a harsh late peaking, crescendo-decrescendo systolic murmur that is heard best at the right second intercostals space and radiates to the carotids. An ECG reveals a NSR and LVH by voltage criteria Which of the following is the most likely diagnosis?

Aortic Stenosis

A grade IV/VI harsh cresendo-decresendo systolic murmur heard best in the 2nd right intercostals space which radiates into the neck and is also heard in the second left interspace is indicative of:

Aortic Stenosis

On cardiac auscultation, you hear a mid-diastolic low-pitched mitral murmur heard best at the cardiac apex. The presence of this sound is most characteristic of which valvular abnormality?

Aortic regurgitation

A tall, thin 16 year-old male comes into your office for the first time. PE findings are as follows: Height greater than 95% for age, weight 50 % for age, pectus carinatum, scoliosis, hyperflexibility oh his joints, arm-span-to-height ratio greater than 1.05 and arachnodactyly. Which of the following should be your main cardiac concern for this patient?

Aortic root dilatation

A 75-year old man is noted to have chest pain with exertion and has been passing out recently. On exam he is noted to have a harsh systolic murmur. Which of the following is the best therapy for this condition?

Aortic valve replacement

A 55-year-old construction worker presents for evaluation of swelling in his feet. He has smoked two packs of cigarettes daily since the age of 15. He has noticed pain in both legs when walking, which is relieved with resting for 10 minutes. On physical examination, his dorsalis pedis pulses are decreased bilaterally in comparison with his femoral pulses. His feet are cool to the touch when compared with his upper legs. He has no pedal edema. What is your most likely diagnosis?

Arterial insufficiency

"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 to be cool to the touch and the toes to be cyanotic. The popliteal pulse is absent by palpation and Doppler. The femoral pulse is absent by palpation but weak with Doppler. The right leg and upper extremities have 2+/4+ pulses throughout. Given these findings what is the most likely diagnosis? What is the most likely diagnosis?"

Arterial thrombosis

A 59-year-old male smoker complains of severe substernal squeezing chest pain of 30-minute duration. The paramedics have given him SL NTG and oxygen by nasal cannula. His BP is 110/70 mm Hg and HR is 90 bpm on arrival to the ER. The EKG is normal. Which of the following is the best next step?

Aspirin

A patient presents with moderate mitral stenosis. Which of the following complications is associated with an increased risk of systemic embolization in this patient?

Atrial Fribrillation

A patient presents to the office following a syncopal episode. The patient claims that the syncope occurs when he changes position such as rolling over in bed or when he bends over to tie his shoes. Which of the following is the most likely explanation for this presentation?

Atrial Myxoma

When evaluating jugular venous pulsations a prominent a wave represents which of the following?

Atrial contraction against a closed tricuspid valve

Which of the following is the most common cause of arterial embolization?

Atrial fibrillation

Which of the following electrocardiographic findings represents a manifestation of digitalis toxicity?

Atrial tachycardia with variable block

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

Atrioventricular dissociation

A 24 year-old male comes to the clinic with a one week history of pain and swelling that involves the entire right upper extremity. He exercises frequently and has noticed the pain worsening while lifting weights.Examination shows enlarged cutaneous veins over the right anterior chest wall with a palpable cord. His right hand appears dusky. Which of the following is the most likely diagnosis?

Axillary-subclavian venous thrombosis

Which of the following treatment modalities has been proven to lower mortality and should be instituted for all patients having a MI (unless contraindications exist)?

BB

A 55-year-old presents with orthopnea and paroxysmal nocturnal dyspnea. On physical exam JVD and pulmonary rales are noted. Which of the following laboratory tests would most likely be elevated in this patient?

BNP

High ventricular filling pressures are indicated by a rise in which of the following?

BNP

Which of the following is considered to be a key finding on a patient's physical examination when the patient has coarctation of the aorta?

BP greater in upper extremities than lower extremities

Which of the following lifestyle recommendations would most benefit the heart failure patient's quality of life?

Begin a regular exercise program

A 15 year old man has a harsh non-radiating 3/6 systolic murmur that decreases with squatting and LVH criteria on EKG. Which of the folowing is the best treatment option

Beta-blocker

In addition to verapamil (Calan), which of the following medications is considered the treatment of choice for patients with hypertrophic cardiomyopathy?

Beta-blockers

Which of the following population groups represent the greatest risk for developing primary hypertension?

Black non-Hispanic

Patients who undergo percutaneous angioplasty or who have coronary artery revascularization often are treated with glycoprotein IIb/IIIa inhibitors. What is the major side effect associated with these agents?

Bleeding

A 62 year-old man has the sudden onset of a cold, painful right arm. BP 112/64 mm Hg; pulse 130/min/irregularly irregular. The right forearm and hand are pallid and cold. No pulses are felt in the right arm or wrist. Which of the following is the most likely diagnosis?

Brachial artery embolus

A 60 y/o male has unstable angina, but is otherwise healthy. A 90% lesion is found in the left main coronary artery. Which of the following interventions is most appropriate?

CABG

A 42-year-old male patient with viral myocarditis has developed fatigue, progressively worsening shortness of breath, and lower extremity over the past three days. Chest x-ray shows no significant increase in heart size that reveals prominence of a superior pulmonary vessels. Which of the following is the most likely diagnosis?

CHF

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

Calf pain with walking

A 82-year-old woman has progressive weakness for 1 month. BP 150/50 both arms sitting; pulse is 102/min/regular. Apical impulse is in the 6th ICS in anterior axillary line. A 2/6 LSB diastolic murmur is heard. In addition to furosemide and metoprolol, which of the following is the preferred medicine to be administered?

Captopril

A 75-year-old male presents with a two-day history of shortness of breath at rest. He states he has not been able to complete his normal daily activities. On physical examination, his blood pressure is noted to be 90/40 mm Hg, pulse 95/minute. Diffuse pulmonary rales bilaterally, and 3+ pitting edema to the mid-tibia bilaterally are noted. EKG, serum electrolytes and cardiac enzymes are normal. Which of the following is the best initial therapy for this patient?

Captopril and hydrochlorothiazide

A patient has developed greater than normal (10mm Hg) inspiratory decreases in systolic blood pressure. The arterial pulse (taken with the patient's wrist overlying his lap) almost seems to disappear when palpated during inspiration. These findings are most consistent with:

Cardiac tamponade

Which of the following is the most common initial chest x-ray manifestation of chronic left-sided heart failure?

Cardiomegaly

The following statement about diastolic dysfunction is TRUE:

Causes include HTN, DM, and hypertrophic cardiomyopathy(HOCC)

An 8-year-old boy has an undiagnosed large ventricular septal defect. Presence of which of the following signs on examination is most suggestive of the development of Eisenmenger syndrome?

Central cyanosis

Which of the following is the only cardiovascular abnormality that is increasing in incidence in the United States?

Chronic HF

A 56 year-old DM smoker describes progressive "tiredness" and "cramping" in his left calf for 6-8 months. Two years ago he jogged 1-2 miles every day. Now walking 5-6 blocks or climbing stairs produces leg discomfort that is relieved with 2-3 minutes of rest. These symptoms are MOST consistent with:

Chronic arterial insufficiency

Which of following physiologic changes can occur in MR, but typically does not occur in MS?

Chronic volume overload in the LV

Which of the following is a proven risk factor for the development of abdominal aortic aneurysm?

Cigarette smoking

Which of the following coronary arteries is typically involvved in a lateral wall MI?

Circumflex artery

A 12 year-old girl is found to have elevated BP readings on 3 separate occasions. Her BP is normal in her legs but femoral pulsations are weak. EKG demonstrates LVH. What is the most likely diagnosis?

Coarctation of aorta

Cardiovascular syphilis is most likely to be manifested by all of the following findings EXCEPT

Complications of syphilitic aortitis occur weeks following initial infection

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?

Compression stockings

A patient 10 years status-post deep vein thrombosis presents with chronic lower extremity edema. Which of the following prevention strategies is most appropriate for this patient?

Compression stockings

A 45 year-old male presents to the Emergency Department complaining of sudden onset of tearing chest pain radiating to his back. On examination the patient is hypertensive and his peripheral pulses are diminished. Electrocardiogram shows no acute ST-T wave changes. Which of the following is the diagnostic study of choice in this patient?

Computed tomography (CT) scan

Yesterday you admitted a 55-year-old white male to the hospital due to chest pain and ruled out MI. The patient tends to be anxious about his health. On admission, his lungs were clear, and his heart revealed a grade II/VI systolic crescendo-decrescendo murmur at the upper right sternal border; cardiac enzymes were normal, and resting ECG showed right bundle branch block with less than 1 mm ST segment depression. The idea of performing a routine Bruce protocol treadmill exercise test (stress test) to further assess coronary artery disease was considered, but rejected primarily due to which of the following?

Concern about the presence of aortic stenosis, a contraindication to stress testing

A 49 year old male suffers an acute myocardial infarction from severe coronary atherosclerosis with thrombosis of the left anterior descending coronary artery. During his recovery, the LEAST likely complication is:

Constrictive pericarditis

A pericardial knock is heard in which of the following disorders?

Constrictive pericarditis

Which of the following conditions would cause a positive Kussmaul's sign on physical examination?

Constrictive pericarditis

A 80 y/o man was at church and briefly blacked out. He has recently had several episodes of dizziness, and near syncope. You suspect he may be having Stokes- Adams attacks. A monitor in the ED reveals the below rhythm (Tachy-brady). Of the following what would be the most appropriate treatment?

Consult for a pacemaker

A patient undergoes biopsy for suspected myocarditis. Which of the following is the most likely etiologic agent?

Coxsackie B virus

A 12 month-old child with tetralogy of Fallot is most likely to have which of the following clinical features?

Cyanosis

Hypertensive emergency is said to be present in a patient if:

Diastol Hypertension >140 mmHg and evidence of end-organ damage (acute renal failure)

Perfusion of the coronary arteries occurs primarily during which of the following?

Diastole

A 68-year-old woman with a history of HTN and DM presents with SOB of breath. She denies CP and palpitations. PE reveals a BP 130/60 , HR 72. The patient's lungs are normal, & heart auscultation reveals an S4 gallop. She has no JVD and no peripheral edema. CXR shows a normal-size heart and ECG shows LVH. Echocardiogram concentric left LVH with a hyperdynamic LV. Which of the following is the most likely diagnosis?

Diastolic dysfunction

Which of the following statements regarding cardiomyopathy is FALSE ?

Diastolic dysfunction is a hallmark of Dilated Cardiomyopathy

Which of the following medications should be AVOIDED in this patient who has bouts of tachycardia? (EKG of WPW)

Digoxin

A 28 year-old female, 3 months post-partum, complains of gradually increasing dyspnea on exertion. She also complains of near syncope last week. She denies chronic medical conditions and hospitalizations other than for the delivery of her child. She denies tobacco, alcohol or illicit drug abuse. Cardiovascular examination is noteworthy for a laterally displaced apical impulse, an S3 and a systolic murmur best heard in the left axilla. Which of the following is the most likely diagnosis?

Dilated cardiomyopathy

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

Dilated cardiomyopathy

A 82-year-old woman with chronic hypertension has the sudden onset of severe, tearing posterior chest pain. BP 160/96 mm right arm; BP 126/90 left arm. A new 2/6 LSB diastolic blowing murmur is heard. Which of the following is the most likely diagnosis?

Dissection of aorta

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

Distended neck veins

Which of the following diagnostic tests should be ordered initially to evaluate for suspected deep venous thrombosis of the leg?

Duplex ultrasound

Which of the following is the earliest symptom for patients with left ventricular failure?

Dysnea on exertion

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

ECHO

An 81 year-old male is hospitalized for acute onset of shortness of breath and lower extremity edema. He lives by himself and cannot even make it to the bathroom without experiencing fatigue. He has not seen a health care provider in several years, but was told in the past that he had high blood pressure. On physical exam, his Jugular Venous Pulsation is measured 9cm above the sternal notch, inspiratory crackles are heard at his lung bases, and there is 3+ b/l lower extremity edema. Which of the following will confirm the most likely diagnosis?

ECHO

Which of the following is the ideal method for the prevention of venous thromboembolism in a 38 year-old male undergoing an inguinal hernia repair?

Early ambulation

A 3 month-old female presents with her mom for physical examination. The patient's mom denies any complaints. On examination you note a well-developed, well-nourished infant in no apparent distress. There is no cyanosis noted. Heart examinations reveals a normal S1 with a physiologically split S2. There is a grade 3 high-pitched, harsh pansystolic murmur heard best at the 3rd or 4th left intercostal space with radiation across the precordium. Which of the following is the inital diagnostic study of choice in this patient?

Echo for VSD

You are seeing in your office a patient with the chief complaint of relatively sudden onset of shortness of breath and weakness but no chest pain. ECG shows nonspecific ST-T changes. You would be particularly attuned to the possibility of painless, or silent, myocardial infarction in the

Elderly diabetic

An elderly patient is admitted for probable heart failure. Which of the following signs indicates right heart failure?

Elevated JVP

What is the single most important risk factor for CAD?

Elevated LDL level

Which of the following agents has been shown to reduce mortality in patients with congestive heart failure?

Enalapril

A 76 year old female with known chronic aortic regurgitation has a 3-week history of arthralgia, weakness, and low-grade fever. BP is 135/65, pulse is 90, and resp. is 22. Axillary temp is 100.2 degrees. Exam showed an alert, oriented patient with conjunctival petachiae and a 2/6 left sternal border diastolic murmur. Hemeglobin is low at 9.4 g/dL and WBC count is high at 18.2 K/UL. Which of the following is the most likely diagnosis?

Endocarditis

Standing increases which of the following murmurs?

HOCM

Cardiac output is defined as

HR x SV

A patient is having a routine physical examination. Funduscopic examination reveals AV narrowing and venous nicking. The nasal border of the optic disc appears blurred. Which of the following is the most likely underlying cause?

HTN

Which of the following is NOT a cause of high-output HF?

HTN

A 56-year-old man is admitted to the hospital for chest pain of 2-hour duration. His heart rate is 42 bpm, with sinus bradycardia on ECG, as well as ST-segment elevation in leads II, III, aVF. Which of the following is the most likely diagnosis?

He likely has suffered an IWMI

A 53 year-old male with a history of Class C NYHA II HF with a depressed EF of 40% is taking Lisinopril 20mg daily (ACE inhibitor) and Lasix 40mg twice a day (loop diuretic). Spironolactone (aldosterone inhibitor) is added to this patient's medications. Serum electrolytes were drawn in 1 week to make sure the patient did not develop _________ after the addition of spironolactone.

Hyperkalemia

A 59-year-old man is brought to the emergency department because of a 4-day history of nausea, vomiting, and diarrhea. He also has been confused and agitated during this period. He has a history of mild hypertension. His current medication is a diuretic. His temperature is 37°C (98.6°F), pulse is 108/min, respirations are 26/min, and blood pressure is 70/47 mm Hg. Physical examination shows delayed capillary refill of the lips and nail beds and cool extremities. His oxyhemoglobin saturation in a central vein is 60% (N=70-75). These findings are most consistent with which of the following types of shock?

Hypovolemic

A 62-year-old male survives an episode of ventricular fibrillation. There is no evidence of a myocardial infarction. What is the recommended treatment for this patient

ICD

After ruling out the patient for an MI, which of the following medications should be administered now to this patient with acute decompensated heart failure?"

IV Lasix

A patient is seen in the ED with a BP of 234/130 mm Hg. There are signs of HTN encephalopathy. Which of the following is the most appropriate therapy?

IV Sodium nitroprusside

A 2-week-old newborn is brought to the physician because his lips have turned blue on three occasions during feeding; he also sweats during feeding. He was born at 38 weeks' gestation and weighed 2466 g (5 lb 7 oz); he currently weighs 2778 g (6 lb 2 oz). His temperature is 37.8°C (100°F), pulse is 170/min, respirations are 44/min, and blood pressure is 75/45 mm Hg. A grade 3/6 harsh systolic ejection murmur is heard at the left upper sternal border. An x-ray of the chest shows a small boot-shaped heart and decreased pulmonary vascular markings. Which of the following should NOT be part of this patient's treatment plan?

Ibuprofen

A 44-year-old female is brought to the emergency department by her husband with 6 h of chest pain and shortness of breath. The chest pain began about 2 h after she finished dinner, while she was cleaning up. The pain is sharp and constricting, predominantly around the left sternum and radiating to the back. She has a history of hypertension treated with a diuretic and smokes a pack of cigarettes a day. Physical examination is notable for a blood pressure of 160/100 and a heart rate of 105/min. The lungs are clear to auscultation. A chest radiogram is normal. The electrocardiogram is shown below (diffuse ST elevation). What is the most appropriate next intervention?

Ibuprofen 600 mg PO qd

Which of the following is the primary pathophysiologic abnormality in systolic heart failure caused by chronic aortic regurgitation?

Increased preload

orth

Increases with the Valsalva maneuver

A 29-year-old multipara presents to a rural clinic. She successfully delivers a baby boy; a continuous, rough, machinery-like murmur is heard on cardiac auscultation of this newborn?What is the drug of choice to administer to this newborn?

Indomethacin

"A 66-year-old female who is overweight and has HTN drinks a small glass of wine with most of her evening meals. She has failed dietary intervention and remains 40 lbs overweight. Her cholesterol measurements are as follows: HDL 42, LDL 165, Triglycerides 380 What is the most appropriate intervention for this patient at this time?"

Initiate drug therapy for LDL and triglyceride levels.

A patient presents with pericarditis and exhibits Kussmaul's sign. Which of the following best describes this finding?

Inspiratory rise in jugular venous pressure

A 52-year-old male comes to your office for his "yearly work up." He is a typical type A personality: hard driving ; married to my job and proud of it." He has had previous problems with "high cholesterol" & wishes to have his cholesterol checked today. His family history is significant for HTN in both parents. His uncle sustained a MI at age 58 years and his older brother had "heart problems" at age 55 years. On examination, his BP is 170/100 mm Hg. His pulse is 84 bpm and regular. His body mass index (BMI) is 31. His abdomen is obese. His spot cholesterol level in your office (nonfasting) is 328 mg/dL The patient is asked to return in 1 week for a fasting sample. The results are as follows:Total cholesterol (TC) 288 mg/dL Triglycerides: 262 mg/dL HDL:37 mg/dl LDL: 199 mg/dl mg/dL. Regarding this patient's lipid profile, which of the following statements is true?

Intense dietary therapy with weight loss and exercise should be considered immediately. If unsucessful start medication

A 55-year-old white male with no past medical history presents to a rural hospital emergency department 4 h after the onset of severe substernal crushing chest pain with radiation to the left arm and neck. The patient has no clear-cut medical contraindications to anticoagulation. EKG is seen below. Assuming there are no cardiac catherization facilities available which of the following would be the optimal management strategy at this time

Intravenous tissue plasminogen activator, heparin, and aspirin

Which of the following is true regarding the fourth heart sound (S4)?

It is absent in patients with atrial firbrillation

The carotid artery is considered the most suitable artery for evaluation of cardiac function because

It is the most accessible artery close to the heart

Which of the following conditions would NOT cause a positive Kussmaul's sign on PE ?

LV failure

When palpating the precordium, a heave is identified, with lateral displacement of the apical pulse. Such a finding may indicate:

LVH

A 62 year-old male with a hx of CAD & HTN presents with AMS x2 hours. BP is 220/110 mmHg & papilledema is noted on fundoscopic exam. Which of the following should be started immediately?

Labetalol

A 34-year-old woman contemplating pregnancy is diagnosed with stage 1 hypertension, and after an evaluation is noted to have no complications. Which of the following antihypertensive classes may be appropriate for this individual?

Labetolol

A patient's EKG reveals widened P waves in lead II and large negative deflection of the P wave in lead V1. Which of the following is the most likely underlying cause for this?

Left atrial enlargement

Patients with known CAD should strive for which of the following LDL goals?

Less than 100mg/dl

A 67 year-old male with history of mitral valve stenosis undergoes a mechanical valve replacement. Which of the following is the appropriate duration of anticoagulation therapy if the patient has no other risk factors for thromboembolic events or significant bleeding risks?

Lifelong

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?

Lisinopril (Zestril)

A patient with a history of chronic venous insufficiency presents for routine follow-up. Which of the following findings is most likely on physical examination?

Lower extremity edema

A loud S1 (increased intensity) is heard in which of the following conditions?

MS

A mid or late systolic murmur that may be preceded by a systolic click describes which of the following valvular abnormalities

MVP

A 74-year old man has new-onset exertional angina pectoris. EKG shows (low voltage, one PVC). Which of the following is the preferred therapy for the patient?

Metoprolol

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

Metoprolol (Lopressor)

A 25-year-old female undergoes echocardiography for evaluation of atypical chest pains and palpitations. Results reveal a floppy valve with mitral valve prolapsed. What physical finding was most likely present on PE?

Mid-systolic click

A 13 year-old patient is hospitalized with a fever of 102.5 F and a rash. After 36 hours the rash has rapidly progressed to enlarging macules that appear ring or crescent shaped with central clearing. He also complains of multiple arthralgias involving his ankles, knees, and now his elbows. The electrocardiogram shows evidence of a first degree AV block. Labs were significant for an elevated erythrocyte sedimentation rate and leukocytosis. Which of the following physical examination findings would be most likely in this patient?

Mitral regurgitation

A blowing holosystolic murmur that radiates to the axilla and does not increase with inspiration most likely represents which of the following

Mitral regurgitation

A 26-year-old woman presents to the emergency room complaining of a sudden onset of palpitations and severe shortness of breath and coughing. She reports that she has had several episodes of palpitations in the past, often lasting a day or two, but never with dyspnea like this. She has a history of rheumatic fever at age 14 years. She is now 20 weeks pregnant with her first child and takes prenatal vitamins. She denies use of any other medications, tobacco, alcohol, or illicit drugs. On examination, her heart rate is between 110 and 130 bpm and is irregularly irregular, with a blood pressure of 92/65 mm HG, and a respiratory rate of 24 breaths per minute with an oxygen saturation of 92% on room air. She appears uncomfortable with labored respirations. She is coughing, producing scant amounts of frothy sputum with a pinkish tint. She has ruddy cheeks and a normal jugular venous pressure. She has bilateral inspiratory crackles in the lower lung fields. On cardiac examination, her heart rate is irregularly irregular with a loud S1 and a low-pitched diastolic murmur at the apex. Her apical impulse is nondisplaced. Her uterine fundus is palpable in the umbilicus and she has no peripheral edema.An EKG rhythm is obtained and seen below (A-fib). The most likely diagnosis in this patient is:

Mitral stenosis

Causes of a systolic murmur include all of the following EXCEPT:

Mitral stenosis

Endocarditis prophylaxis may be excluded in a patient who has which of the following?

Mitral valve prolapse

Which of the following would be the definitive clinical intervention?"

Mitral valve replacement

The electrocardiographic rhythm strip below demonstrates a cardiac arrhythmia. Select the best diagnosis from the choices below:

Mobitz Type I 2nd degree AV Block

A 60 y/o man is admitted to a hospital because of respiratory failure & tachycardia.T 101 F, RR 32 & BP 100/60. What does this rhythm strip seen below reveal?

Multifocal atrial tachycardia

Cardiac monitoring shows horizontal ST segment depression in an 84 year old male who has just undergone major abdominal surgery. The patient has no cardiorespiratory symptoms. The EKG finding are most suggestive of which of the following?

Myocardial ischemia

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?

Myocarditis

A 42 year-old female presents to your office for complaints of episodic palpitations. On physical exam you hear a mid systolic click with a late systolic murmur. Which of the following is the most likely etiology?

Myxomatous degeneration of the mitral valve

A 30 year-old man has chest pain for the past 8 hours that is somewhat better when he is sitting up. 4 days ago he had upper respiratory symptoms. On physical exam, a three-component pericardial friction rub is heard over the precordium. ECG reveal diffuse ST segment elevation. Which of the following is most appropriate in this patient?

NSAID

A 78 year old male with chronic stable angina has been taking sildenafil for therapy of erectile dysfunction. He now has severe chest pain and is diagnosed with an acute MI. BP is 126/84, pulse is 96 and regular. Cardiac and pulmonary exams are normal except for the presence of an apical S4 gallop. Which of the following is contraindicated in therapy?

Nitroglycerin

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

Nuclear stress test

A 49-year-old patient with Type 2 DM returns for follow-up of a nonfasting cholesterol of 235 mg/dL obtained during a community health fair. Which of the following is the most appropriate response?

Obtain fasting lipid profile

A 2 day old full term male infant is noted to have a systolic and diastolic continuous murmur at the right upper sternal border. His vital signs are normal and he is overall doing well and is being observed. Which of the following is the most likely diagnosis?

PDA

A mother brings her 11-year old son to your office because he easily becomes short of breath while running. She states that he does not seem to be able to play as long a period of time as his friends. The patient's blood pressure is 140/60 mm Hg and he has bounding peripheral pulses. On auscultation of the heart you detect a harsh loud continuous murmur heard best below the left clavicle. Which of the following is the most likely diagnosis?

PDA

A premature infant noted to have a 'machinery' murmur, bounding pulses, and widened pulse pressures with respiratory distress has:

PDA

A 36-year-old woman has severe burning chest pain that radiates to her neck. The pain occurs particularly after meals, especially when she lies down, and is not precipitated by exertion. She is admitted for observation. Serial EKG and troponin levels are normal. Which of the following is the best next step?

PPI

Which of the following would be expected on physical examination of a newborn diagnosed with Tetrology of Fallot?

Palpable right ventricular lift

Which of the following physical exam findings suggests worsening or severe aortic stenosis?

Palpable thrill over the right second intercostal space

A male patient presents with severely elevated triglyceride level with a normal LDL. Therapy is aimed at reducing the risk for which of the following complications?

Pancreatitis

The acute onset of congestive heart failure associated with a loud systolic murmur along the left sternal border in a patient with myocardial infarction suggests which of the following?

Papillary muscle rupture

Which of the following is considered to be the first EKG evidence of acute myocardial infarction?

Peaking of T waves

A patient presents with a fever and a new onset heart murmur. She has chronic mitral valve prolapse. Blood cultures are positive for group B streptococci. Vegetations are seen on the atrial cusp of the mitral valve. What is the most appropriate antibiotic therapy?

Penicillin and gentamycin

A patient complains of fatigue and shortness of breath. Objective findings note and elevated jugular venous pressure and Kussmaul sign. There is low voltage on the ECG with nonspecific depolarization changes. An echocardiogram shows impaired diastolic filling with preserve contractile function. You suspect which of the following diagnoses?

Pericardial effusion

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

Pericardiocentesis

A patient presents with dyspnea, hypotension, and echocardiographic evidence of cardiac tamponade. The patient is hemodynamically unstable and receiving oxygen and isoproterenol. A fluid bolus did not yield adequate response. What is the most appropriate intervention?

Pericardiocentesis

"A 65 year-old female who recently had an anterior MI returns to clinic for follow-up six weeks after. She has no chest pain, but reports decreased exercise tolerance. Electrocardiogram (ECG) shows persistent ST elevation in leads V2-V4.Which of the following is the most likely diagnosis?"

Pericarditis

A 66 y/o female with a history of CAD presents with a new onset of dizziness and fatigue for two weeks. She recalls nearly passing out on one occasion.PE is unremarkable except for bradycardia. EKG reveals a HR of 50 with a normal PR interval followed by a normal QRS. There are several non-conducting P waves and no lengthening of the PR interval. Which of the following interventions is the therapy of choice?

Permanent pacemaker

Which of the following is a systemic manifestation of infective endocarditis?

Petechiae

Which of the following is not a physical exam findings associated with atrial fibrillation

Presence of the "a" wave on examination on ECG

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. Physical examination is normal. A complete laboratory evaluation was performed with unexplained hypokalemia as the only abnormality found. Which of the following is the most likely diagnosis for this patient?

Primary aldosteronism

Which of the following is considered to be the most common pathology leading to angina pectoris?

Progressive narrowing of the coronary vessels by atherosclerotic plaque

Examination in an asymptomatic 14 year old boy shows a left parasternal lift, 2/6 pulmonic area ejection murmur and fixed splitting of S2. Which is the expected abnormality on chest radiography?

Prominent pulmonary artery with increased pulmonary vascularity

A 44 year-old female presents to clinic for evaluation of a syncopal episode that occurred while walking her dog two days ago. She denies amnesia or head trauma. She has had increasing dyspnea on exertion and pedal edema. Physical examination reveals clubbing of her fingers and central cyanosis. Auscultation of the heart reveals tricuspid insufficiency, widely split second heart sound with a palpable P2. Echocardiogram reveals a large ostium secundum atrial septal defect with bidirectional flow. Which of the following is a secondary complication in this patient?

Pulmonary HTN

Which of the following valvular diseases would produce a diastolic murmur?

Pulmonic Regurgitation

A 25-year-old male presents to the clinic c/o mild dyspnea on exertion. Examination reveals a prominent jugular pulsation and a palpable parasternal lift. There is a harsh systolic murmur best hear at the second and third left intercostal space; it radiates to the left shoulder. An early systolic sound precedes the murmur during expiration. ECG demonstrates right-axis deviation. What is the most likely diagnosis?

Pulmonic Stenosis

The level at which the JVP is visible gives an indication of

RA pressure

A 18-year-old girl is brought to the emergency room because she fainted at a rock concert. She apparently recovered spontaneously, did not exhibit any seizure activity, and has no medical history. She has a heart rate of 90 bpm and a blood pressure of 110/70 mm Hg. The neurological examination is normal. The pregnancy test is negative. Which of the following is the most appropriate management?

Reassurance and discharge home

A routine EKG on a healthy asymptomatic 65-year-old reveals from 3 to 5 unifocal nonconsecutive PVC's per minute. These decrease in frequency with exercise. Which of the following is the most appropriate intervention?

Reassure patient that treatment is unnecessary

Sympathetic stimulation of the heart results in all of the following EXCEPT

Reduced BP

An otherwise healthy 56-year-old man presents to the clinic with chest pain. Myocardial infarction is not evident on ECG or enzymes. He is found to have left main coronary artery stenosis of 85%. Which of the following is the best long-term treatment for this patient?

Refer for coronary artery revascularization

A 36 year-old male presents for follow-up of his hypertension. The patient is currently on three anti-hypertensive medications without improvement of his blood pressure. On examination his BP is 170/86 mmHg and his HR is 60 bpm and regular. His heart examination reveals a regular rate and rhythm without S3, S4 or murmur and his lungs are clear to auscultation bilaterally. Abdominal examination reveals a bruit over his left upper abdomen. Which of the following is the most likely underlying etiology for this patient's hypertension?

Renal artery stenosis

A 37 year-old man with amyloidosis presents to her physician assistant complaining of increased fatigue and shortness of breath over the past 3 months. She also reports that her socks and shoes do not fit like the use to. She states that she is more comfortable sitting than lying down when she sleeps. She has Jugular venous distension. An echocardiogram shows increased thickness of the left and right ventricular walls, abnormal myocardial texture (granular sparkling), & an ejection fraction of 55%. Which of the following is the most likely diagnosis?

Restrictive cardiomyopathy

A 21 year-old man complains of nosebleeds, headaches, cold feet, and cramping & muscle weakness in his legs. He admits to shortness of breath which is increased with exercise. You note an elevated blood pressure recording on his vital signs and hear a 2-3 systolic ejection murmur at the left upper sternal border with radiation to the scapular region. Which abnormality is anticipated to be on his chest x-ray?

Rib notching

A 44-year-old patient presents to the office with dyspnea on exertion. Physical examination reveals a prominent heave, a II/VI systolic ejection murmur over the second and third interspaces left of the sternum, and a widely split S2 that does not vary with respiration. Based on these findings, what would be expected on electrocardiography

Right atrial and right ventricular hypertrophy

A colleague asks your opinion of the heart sounds of one of his patients. On auscultation, you hear a regular rate and rhythm. S1 sounds normal. S2 is split and the split increases with inspiration and decreases but does not disappear with expiration. No murmurs are heard. Which of the following ECG findings are consistent with this patient's heart sounds

Right bundle branch block

A split S1 is most commonly caused by which of the following?

Right bundle branch block

Which of the following is the first complication seen with mitral stenosis?

Right ventricular failure

A patient with a hx, of HOCM presents with fever, dyspnea, & joint & back pains. Exam reveals a III/VI systolic murmur, conjunctival petechiae, & exudative lesions in the retina. What is the name of these retinal lesions?

Roth's spots

The carotid pulse coincides with which heart sound

S1

You are listening to a patient's heart sounds in the aortic and pulmonic areas. You notice a sound that results from the closure of the semilunar valves, indicating the end of systole. What is that sound?

S2

Which of the following electrocardiographic findings is the hallmark of pericarditis?

ST elevation

A patient admitted with substernal chest pain undergoes cardiac catheterization. Angiography reveals 98% occlusion of the right coronary artery. All other vessels are 100% patent. Which of the following is the most expected electrocardiogram finding in this patient?

ST elevation in leads II, III, and avF

A 72 year-old male presents to the ER with crushing chest pain, dyspnea, and palpitations for 2 hours in duration. Enzymes are pending and he has been given apririn and sublingual nitroglycerin. He is rushed to the cath lab where they find a totally occulded distal right coronary artery. Which of the following ECG findings supports the diagnosis?

ST segment elevation in leads II, III, aVF

A 24 year-old white male comes to the ER due to a sensation of fast heart rate, slight dizziness, and vague chest fullness. Blood pressure is 110/70. The following EKG was obtained. The most likely rhythm is:

SVT

A 65-year-old presents to your office with a complaint of intermittent palpitations. She cannot remember the exact onset of her symptoms. She is otherwise healthy Her PE demonstrates an irregular heart rhythm at 75 bpm & BP of 110/70. She appears in no acute distress with any diaphoresis, pallor or cyanosis. Respirations are unlabored. Lung fields are clear to A/P bilaterally. There are no murmurs, rubs or gallops, and no JVD. Pulses are 2 +and equal throughout with no edema, clubbing, or cyanosis. The remainder of her PE is within normal limits. Her EKG is seen below. Of the below which of the following is the most appropriate treatment option?

Schedule the patient for a TEE to exclude the presence of an atrial thrombus prior to cardioversion

A 34 year-old male presents with an acute onset of fatigue and dyspnea. He has experienced repeated episodes ofnear-syncope and an unresolved chest discomfort described as a "fluttering" sensation over the past 3 hours. His electrocardiogram reveals no definable p waves and his R-R interval is irregular. His blood pressure is 88/60 mmHg. Which of the following is most appropriate for this patient?

Sedate for synchronized cardioversion

A 75 year-old female with a history of long-standing hypertension presents with shortness of breath. On examination you note a diastolic murmur at the left upper sternal border. Which of the following maneuvers would accentuate this murmur?

Sitting up and leaning forward

A 38-year-old male gives a history of cold and painful extremities and intermittent claudication that has been getting worse over the past few years. Examination finds atrophic changes and several painless small red tender cords on the lower legs. This patient should be counseled to avoid

Smoking

A patient presents with a heart murmur that occurs when regurgitant blood in the left ventricle strikes the anterior leaflet of the mitral valve. Which of the following would best describe this murmur

Soft, low-pitched rumbling mid-diastolic murmur

A 24-year-old male comes to the clinic for chest pain at rest that is not always related to exercise. He reports two episodes of fainting during exercise, but has otherwise been healthy. There is a similar family history, and he relates that his father collapsed and died suddenly at age 50 while playing tennis. Physical examination reveals a systolic ejection murmur that is loudest along the left sternal border. Echocardiogram shows asymmetric septal hypertrophy flow obstruction. Which of the following interventions would be most likely to DECREASE the patient's systolic murmur?

Squatting

Murmur of Hypertrophic cardiomyopathy becomes softer with:

Squatting

A 70-year-old male patient comes to the ER after having an episode of left-sided chest pain radiating to his left arm for 10 minutes. He had been mowing his lawn when the chest pain occurred. It resolved about five minutes after he sat down to rest. He states that he often gets similar symptoms during physical activity. The symptoms resolved with rest. He currently has no medical complaints. His past medical history includes hyperlipidemia and obesity. His physical examination is normal. His vital signs are as follows: BP is 155/91, Pulse is 88 bpm, pulse ox is 98% on room air, and respirations are 16. Based on the past medical history and physical examination, what is the most likely diagnosis?

Stable angina

You are completing a physical on a patient and his blood pressure is 160/100. According to The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. What category would this blood pressure qualify as?

Stage 2 HTN

A 61-year-old man with coronary artery disease complains of progressive orthopnea and pedal edema. He is hospitalized with a blood pressure of 190/105mm Hg. The cardiac enzymes and EKG are normal. Intravenous furosemide has been administered. What is the best next step?

Start an ACE-I

A patient with renal artery stenosis is unresponsive to medical therapy. Which of the following is the next most appropriate intervention?

Stenting of the renal artery

Which of the following conditions is most likely to cause the changes seen in this ECG (II, III, avL)?

Subendocardial Ischemia

A 78 year-old male with history of coronary artery disease s/p coronary artery bypass grafting, hypertension, and dyslipidemia presents for routine physical examination. He feels well except for occasional brief episodes of substernal chest pain with exertion that are relieved with rest. He denies associated dyspnea, nausea ordiaphoresis. Physical examination reveals a BP of 110/70 mmHg, HR 56 bpm, regular, RR 14, unlabored. Lungs are clear to auscultation, heart is bradycardic, but regular with no S3, S4 or murmur. Electrocardiogram done in the office shows no acute ST-T wave changes. Which therapy is indicated for the acute management of this patient's symptoms?

Sublingual nitroglycerin

A healthy 75-year-old man undergoing an ultrasound examination for suspected gallbladder disease is found incidentally to have a 6.0-cm abdominal aneurysm of the aorta. Which of the following is the best management for this patient?

Surgical repair of the aneurysm

A 72-year-old man is brought to the ED after fainting while in church. He had stood up to sing a hymn and then fell to the floor. His wife, who witnessed the episode, reports that he was unconscious for approximately 5 minutes. When he awakened, he was groggy for another minute or two then seemed himself. No abnormal movements were noted. This has never happened to him before, but she does report that for the last several months he has had to curtail activities such as mowing the lawn, because he becomes weak and feels light-headed. His only medical history is osteoarthritis of his knees, for which he takes acetaminophen. On examination, he is alert, talkative and smiling. He is afebrile, his heart is regular with a rate of 35 bpm, and his blood pressure is 118/72 mm Hg, which remains unchanged on standing. He has a contusion on his face, left arm, and chest wall, but no lacerations. His chest is clear to auscultation, and his heart is regular but bradycardic with a nondisplaced apical impulse. He has no focal deficits. Laboratory exam shows normal blood counts, normal renal function and serum electrolytes, and negative cardiac enzymes. His EKG is shown here. What is the most likely diagnosis?

Syncope as a consequence of third-degree AV block

The 4 cardinal symptoms of aortic stenosis are:

Syncope, dyspnea, angina, sudden death

In a patient with a history of positive untreated streptococcal pharyngitis, which of the following would be considered 2 major Jones criteria for the diagnosis of Acute Rheumatic Fever?

Syndenham's Chorea and Erythema Marginatum

What is the hallmark finding that is essential to the diagnosis of primary dilated cardiomyopathy?

Systolic dysfunction

The most common congenital cyanotic lesion associated with hypoxic episodes, a systolic ejection murmur at the left sternal border, and a classic finding of a 'boot-shaped' heart is

TOF

Which of the following statements is true concerning the measurement of blood pressure?

The bladder should encircle approximately 80% of the circumference of the limb

Characteristics of a systolic murmur which would lead you to diagnose the murmur as "innocent" included all of the following EXCEPT:

The murmur intensity is Grade 3

A 60 year old with uncontrolled HTN presents for a follow up appointment with a blood pressure of 200/ 110. On your physical exam, you see bilateral papilledema with hemorrhages. You immediately send her to the hospital to be treated. To treat her papilledma, you tell the intake nurse:

The papilledema should resolve with proper BP control

Her ECG reveals significant ST segment elevation in the anterior leads.Within 1 hour, the ST segment has returned to normal.CK-MB fraction levels done over the next 3 days are normal. Which of the following statements regarding this patient is (are) true?"

This patient probably has Prinzmetal's angina

A 30 year-old male with a history of infective endocarditis requiring a prosthetic heart valve is scheduled to undergo dental cleaning. What should this patient receive for antibiotic prophylaxis prior and after the dental cleaning?

This patient should receive Amoxicillin 3.0 gms. p.o. 1 hour before the procedure

A 44 year-old male with a known history of rheumatic fever at age 7 and a 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 and after the dental cleaning?

This patient should receive Amoxicillin 3.0 gms. p.o. 1 hour before the procedure

Which of the following is associated with an abnormal jugular venous pulse?

Tricuspid valve regurgitation

One week earlier, a 59 year old man had severe "indigestion" with sweating that lasted about 1 hour. Which of the following is the preferred serum diagnostic test to confirm myocardial infarction?

Troponins

A 56 year-old male with a 30 pack-year smoking history presents with substernal chest pain. The pain is described as a pressure that radiates to his jaw. The pain has lasted consistently for 30 minutes with variable relief. His current medications include atorvastatin (Lipitor) and glyburide (Micronase). Which of the following aggravating or relieving factors about the pain would support the diagnosis of a AMI?

Unrelieved by nitroglycerin

A 2 month-old infant appeared well until three weeks ago when he became dyspneic and had difficulty feeding. A 4/6 holosystolic murmur is heard at the left lower sternal border in the 3rd ICS. An electrocardiogram (ECG) shows left and right ventricular hypertrophy. Which of the following is the most likely diagnosis?

VSD

A 4 year-old girl presents for a routine checkup. She is new to the practice. PE reveals a harsh, holosystolic grade 3 mumur at the LSB with wide radiation & fixed split S2. There is no change with position or respiration. What is the most likely diagnosis?

VSD

A hyperactive precordium, a systolic thrill noted at the lower left sternal border, a loud S2 with a possible complication of Pulmonary Hypertension, and a 30-60% occurrence with Down's Syndrome is:

VSD

A neonate is found to have RVH, right ventricular outflow obstruction, and an over-riding aorta via cardiac imaging. What additional findings would you expect to see in this child?

VSD

A 19-year-old college student, upon hearing that she is failing a required course in her major, suddenly becomes nauseated, sweaty, & pale, and then passes out in the classroom. Exam on site reveals tachycardia & a normal BP. Later evaluation at student health, including lying, sitting & standing BP, cardiac auscultation, & a EKG is unremarkable, Nothng like this has happened to her before. What is the most likely cause of this episode?

Vasomotor syncope

During physical examination an elderly patient is noted to have a painless, brown-colored ulceration in the area of the medial malleolus. Which of the following is the most likely diagnosis?

Venous ulcer

S3 and S4 gallops are both signs of which type of cardiac abnormality?

Ventricular dysfunction

A 72-year-old man collapses while playing golf. He has a 5-year history of angina and type 2 diabetes mellitus. Paramedics arrive in 10 minutes. Examination shows no respirations or blood pressure. Cardiopulmonary resuscitation is attempted for 10 minutes without success. Which of the following is the most likely cause of death in this patient?

Ventricular fibrillation

A 64 year-old white male comes to the ER due to a sensation of fast heart rate, slight dizziness, and vague chest fullness. Blood pressure is 90/70. The following EKG was obtained. The most likely rhythm is:

Ventricular tachycardia

A patient who has long QT syndrome is most likely to have syncope caused by which of the following ?

Ventricular tachycardia

A patient is scheduled for an elective cardioversion. Which of the following agents should be used prophylactically?

Warfarin

Which of the following physical examination findings is consistent with chronic aortic regurgitation?

Wide pulse pressure

A 79-year-old male with a history of HTN, controlled with hydrochlorothiazide, & mild COPD presents with dyspnea. He states it began 2 days ago on exertion & has progressed over the last 12 hours to dyspnea at rest. Physical exam reveals JVD & 2 + pitting edema to the ankles. Which of the following is most likely to be found on cardiac exam?

a third heart sound(S3)

A patient presents with chest pain that initially occurred three days ago. The EKG shows loss of R wave progression across the anterior chest leads. Which of the following is the best explanation for this finding?

acute myocardial infarction

An 82-year-old patient with a history of paroxysmal supraventricular tachycardia presents with a rapid heart rate that did not respond to repeated Valsalva's maneuvers. Which of the following measures should be used next for conversion?

adenosine

A 63-year-old black woman with a long history of hypertension and diabetes is brought to the emergency department by relatives because she has become incoherent over the past 24 h. Physical examination reveals a disoriented woman whose blood pressure is 230/160, respiratory rate is 25, and pulse is 110. The patient is afebrile. The chest reveals bibasilar rales. Cardiac examination is remarkable only for the presence of an S4. There is no organomegaly or focal neurologic findings. The patient is oriented to person only. The family revealed that the patient has not been taking her antihypertensive medicines in the past several weeks. The patient is placed on a cardiac monitor, and both intravenous and intra-arterial lines are placed. An emergent CT scan reveals no evidence of hemorrhage or mass lesion. The most appropriate next step in management would be to

administer sodium nitroprusside

A patient's carotid pulse has a quick upstroke associated with wide pulse pressure. These findings are suggestive of

aortic regurgitation

Ashman's phenomenon

atrial fibrillation the next beat following a long interval is conducted abherrantly.

The mother of a 14 year-old firl came to the OB/GYN clinic complaining that her daughter has not had her first menstural period yet. On taking furthur hx, she confirmed having no other health problems. Her mother said that she is a little bit slow and goes to special eduation classes. On examination: the girl is 4'5" tall, her neck skin shows fold on the side as webs, her breasts are not fully developed, and her nipples are widely separated. On listening to the heart, no mumurs were detected. On feeling the pulse, the lower limb pulses were felt to be weaker than the upper extremities. What is the most probable cause of the feeble pulse in the lower limbs?

coarctation of aorta

A patient with hypovolemic shock would most likely exhibit which of the following signs?

decreased CVP; decreased BP; increased pulse rate

A 75 year-old female presents to your office for the evaluation of syncope. States she was walking to the store when she passed out. There were no witnesses, however, she estimates she was out for less than a minute. Upon physical exam, you hear a 4/6 systolic crescendo-decrescendo murmur at the right second intercostal space that radiates toward the neck. What other physical exam finding could you appreciate in this patient?

delayed and diminished carotid upstroke

Which drug would you prefer to initiate anti-hypertensive therapy in this patient?"

enalapril

On examination, the patient is confused. His blood pressure is 69/49 mm Hg and he has a heart rate of 48 bpm. After initiating oxygen and atropine, which of the following is the best treatment for this patient's presentation?"

glucagon

Which of the following is not a secondary cause of hyperlipidemia?

hyperthyroidism

The major hazard associated with antihypertensive therapy in the elderly is:

hypotension

All right heart sounds....

increase with inspiration

Which of the following is true regarding the third heart sound(S3)?

it is a low pitched sound best heard at the apex of the heart with the bell

Following an episode of syncope, a 32-year-old male is diagnosed with long QT syndrome. Should he become ill with a bacterial infection, he should be advised to avoid antibiotic drugs from which of the following classes?

macrolides

Which of the following antihypertensive medications can be safely used in a pregnant woman?

methyldopa

A patient with dilated cardiomyopathy may also have which of the following secondary valvular abnormalities?

mitral and tricuspid regurgitation

An elderly patient presents with attacks of dizziness. Objective findings show a slow pulse. ECG is noted here. What is the most appropriate treatment? (3rd AVB)

pacemaker

A 16-year-old boy with Marfan syndrome has the sudden onset of severe, tearing chest pain. Thirty minutes later, blood pressure 60/40 mm Hg, pulse 140/min/regular. Jugular venous pressure is elevated. Which of the following is the most likely cause of his hypotension and elevated JVP.

pericardial tamponade

A trauma patient who has increased venous distension, loss of arterial pulses peripherally, muffled heart sounds and low voltage on his EKG is most likely to be diagnosed with

pericardial tamponade

According to the Joint National Commission VII Guidelines, blood pressure targets are lower in patients with diabetes mellitus and what other condition?

renal disease

Single vessel coronary artery disease has the highest mortality when it involves

the left anterior descending coronary artery.

Which of the following criteria distinguishes internal jugular pulsations from carotid artery pulsations?

the level of pulsation change with position

A 26-year-old asymptomatic female presents for pre-employment PE. A mid-systolic click is noted during cardiac auscultation. Echo reveals no abnormalities. Which of the following recommendations should be provided to this patient?

the patient has no physical limitations & should receive routine health advice

Which of the following is the most common cause for acute myocardial infarction?

thrombus development at a site of vascular injury

A 55 year-old morbidly obese male is seen in the office for routine examination. He has a history of pulmonary hypertension and cor pulmonale. Examination reveals a visible jugular venous pulse and a systolic flow murmur on the right side of the sternum. Which of the following is the most likely diagnosis?

tricuspid insufficiency

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

Referral for coronary artery revascularization.

Which of the following situations in the periinfarction period would suggest the presence of ventricular septal perforation

Systolic murmur, large v waves in pulmonary capillary wedge tracing; Po2 in right atrium is less than that in right ventricle

Which of the following physical examination maneuvers should you have the patient perform to best identify a pericardial friction rub.

Take a deep breath while leaning forward

A 68 y/o female with a medical history 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?

2 (age and Hx of smoking)

A 55-year-old woman presents with palpitations described as "skipped heartbeats" that cause a momentary lump in her throat. The palpations occur several times per day. An ECG and rhythm strip show a sinus bradycardia with a rate of 54 beats/minute and rare PVC's. Your next step is to:

Take a thorough cardiac history

You are helping with school sports physicals and see a 13-year-old boy who has had some trouble keeping up with his peers. He has a cardiac murmur, which you correctly diagnose as a ventricular septal defect based on which of the following auscultatory findings?

A holosystolic murmur at the mid-left sternal border

On physical exam he has a blood pressure of 84/52, and his pulse is 54. He has jugular venous distention to the angle of the mandible and clear lung fields. His rhythm strip reveals a Wenkebach pattern. Given his hypotension, a Swan-Ganz catheter is placed. Right atrial pressure is estimated at 16 mm Hg (normal 0-5), pulmonary artery pressure at 20/10 mm Hg (normal 12-28/3-13), and the pulmonary capillary wedge pressure is 8 mm Hg (normal range 3-10). Which of the following is most consistent with this clinical picture?"

A right ventricular infarction

Which of the following is a non-invasive quick method of evaluating a patient with suspected lower extremity arterial insufficiency?

ABI

A 50 year-old male has an Austin Flint murmur (mid-diastolic, low- pitched rumbling murmur) and a wide pulse pressure on exam. His Ejection Fraction is 65%. Which of the following is the treatment of choice for this patient?

ACE-Inhibitor

A 61-year-old presents to your office with a complaint of intermittent palpitations. She cannot remember the exact onset of her symptoms. She is otherwise healthy Her. PE demonstrates an irregular heart rhythm at 75 bpm & BP of 110/70. She appears in no acute distress with any diaphoresis, pallor or cyanosis. Respirations are unlabored. Lung fields are clear to A/P bilaterally. There are no murmurs, rubs or gallops, and no JVD. Pulses are 2 +and equal throughout with no edema, clubbing, or cyanosis. The remainder of her PE is within normal limits. What is the patients most likely heart rhythm?

AF with LBBB

A 59 year-old male with longstanding uncontrolled hypertension presents with nausea and a 5 pound weight gain in the last 2 days. He states "my belly is getting bigger and I can't fasten my pants." Which of the following physical examination findings would be most likely in this patient?

Ankle edema and elevated jugular venous pressure

A 67 year-old presents as a new patient complaining of progressive dyspnea. Examination reveals 3+ pitting edema of the lower extremities bilaterally and wheezing audible in lower lung fields bilaterally. Which of the following tests is the most appropriate initial study in the patient?

BNP

Mitral regurgitation "

Aortic valve stenosis

A 10 year-old female experiences fever and polyarthralgia. On examination you note a new early diastolic murmur. Laboratory results are positive for antistreptolysin O. The patient has no known drug allergies. Which of the following is the recommended prophylaxis for this condition?

Benzathine penicillin G

A 74-year-old woman is admitted to the hospital for shortness of breath, an inability to walk around the house, orthopnea, and shortness of breath at rest. The patient has progressively deteriorated over the course of 6 months. On auscultation, there is S3 gallop rhythm and accented sounds over the pulmonary artery. Her BP is 110/85 mmHg and HR is 84 bpm. Among other measures, you decide to initiate the treatment with a beta-blocker. What beta-blocker is approved for the treatment of such patients?

Carvedilol

65-year-old woman, with a history of hypertension, presents with a 3 week history of an ulcer on her left ankle. Patient is a non-smoker. On physical examination the ulcer is located over the left medial malleolus. The edges are rough and the surrounding skin is darkly pigmented, edematous, and atrophic. Pedal pulses are 2+ and the feet are warm. Sensory exam is normal. Which of the following is the most likely diagnosis?

Chronic venous insufficiency

A 68-year-old woman with a history of hypertension and diabetes mellitus type 2 comes to the emergency department with her son, who noticed that while decorating for Christmas she seemed more dyspneic than normal, and had to sit down frequently. In addition, he noticed that she was pale and diaphoretic, and insisted on driving her to the emergency department. On questioning, she denies chest pain, but admits to being more fatigued than usual, with frequent jaw discomfort during activity. Activities such as vacuuming her house cause dyspnea, and she now has to stop several times while carrying laundry up from the basement. On physical examination, the patient's blood pressure is 90/50, pulse 99 bpm, respirations 22, and she is afebrile. Auscultation of the chest demonstrates a new systolic murmur. An EKG demonstrates normal sinus rhythm with nonspecific ST and T wave changes. Serial troponin elevations above the 99th percentile of normal are noted. Which of the following would be the most appropriate next step in the management of this patient?

Clopidogrel, heparin, and aspirin, followed by cardiac catheterization

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?

Daily weights

A previously healthy 58-year-old man is admitted to the hospital because of an acute inferior myocardial infarction. Within several hours, he becomes oliguric and hypotensive (BP is 90/60 mmHg). Insertion of a pulmonary artery (Swan-Ganz) catheter reveals the following pressures: pulmonary capillary wedge, 4 mm Hg; pulmonary artery, 22/4 mm Hg; and mean right atrial, 11 mmHg. This man would best be treated with

Fluids

A 29-year-old woman presents with a history of a mitral valve replacement. Based on the recommendations by the American Heart Association, endocarditis prophylaxis would be recommended before which of the following procedures?

Dental cleaning

You are evaluating a patient who complains of worsening orthopnea and dyspnea on exertion for the past year. He admits to drinking a 12-pack of beer on a nightly basis for approximately 20 years. Physical examination shows a laterally displaced PMI, audible rales, and an audible S3 on cardiac auscultation. Echocardiogram shows a dilated left ventricular and an ejection fraction of 35%. Which of the following is the most appropriate counseling to slow the progression of this patient's condition?

Discontinue alcohol use

A two-week-old female is being evaluated in the clinic, and on examination she is noted to have bounding pulses with a widened pulse pressure. There is a rough, machinery sounding murmur present at the second left intercostal space. Cyanosis is not present. Which of the following diagnostic tests would be the most useful in confirming the suspected diagnosis in this patient?

Echocardiogram

A 15 year-old male is brought to the emergency department 1 hour after an episode of syncope while running in a 400-meter race. He had a similar episode 2 years ago. His mother and maternal first cousin died suddenly at the ages of 32 and 17 years, respectively. Examination shows abrasions of the face, hands, and knees. Neurologic examination shows no abnormalities. Which of the following is the most appropriate initial test?

Electrocardiogram

A 59 y/o male arrives at your office after a week-long camping trip. During the first 3 days of his trip, he experienced substernal chest pressure while at rest but worsened with exertion. Presenting on day #7, he states that his pain is gone but he still has fatigue and thinks that he might have had a heart attack. You draw cardiac enzymes. Assuming the patient had an MI, what is likely to be seen on his cardiac profile?

Elevated Troponin T & I, normal CK-MB and Myoglobin

A 64 year-old man presents to the emergency department after "passing out" while climbing the stairs. He reports dyspnea on exertion for the past year. His blood pressure is 126/92 mm Hg, heart rate is 88/min, respiratory rate is 14/min, and temperature is 97.7F. Physical exam reveals a systolic crescendo-decrescendo murmur best heard in the second right intercostal space with a soft S2. ECG shows left ventricular hypertrophy. Which of the following interventions would be contraindicated?

Exercise Stress Test

A 18 year-old male high school basketball player comes to clinic for a routine physical exam. His height is 193 cm(76 in.); arm span is 201 cm (79 in.). He has long fingers and toes. Blood pressure is 146/62 mmHg and pulse is 64/min. Which of the following exam findings is most consistent with the diagnosis?

Grade 2/6 high-frequency diastolic murmur at the third right intercostal space

A 22 year-old man collapses on the baseball field after he is hit in the chest by a fastball. He is unresponsive and does not have a pulse. CPR is initiated, EMS arrives quickly, & a rhythm strip shows (VF)

Immediate unsyncronized cardioversion 200J (biphasic)/defibrillation

Which of the following is the primary pathophysiologic abnormality in aortic valve stenosis?

Increased afterload

Which of the following is the primary pathophysiologic abnormality in Eisenmenger syndrome?

Increased pulmonary vasc. resistance

A 63-year-old woman comes to the ER complaining of chest pain. The patient states that the pain began during her morning walk. It started as a dull pressure over her breastbone and then radiated to her left arm. Over the next few minutes it escalated in intensity and was not relieved by rest. She called 911 and was brought to the ER. Her medications included atenolol and simvastatin daily. On Physical examination her BP is 190/100 mm Hg, and pulse is 60/minute. Which of the following is the most appropriate agent to lower her BP?

Intravenous NTG

Pulmonary capillary wedge pressure indirectly measures which of the following?

Left atrial filling pressure

A 77-year old man has an acute STEMI myocardial infarction complicated by pulmonary edema. Blood pressure 130/90 mm Hg; pulse 130/min. Which of the following is contraindicated?

Metoprolol

A patient presents with complaints of headaches during strenuous exercise. Twenty-four hour ambulatory blood pressure readings indicate he is hypertensive with exercise. A chest radiograph reveals mild cardiomegaly. An echocardiogram shows an ejection fraction of 75% with interventricular septal hypertrophy. Which of the following is the most appropriate initial choice of medications for this patient?

Metoprolol (Lopressor)

Which of the following valvular heart abnormalities will most likely be seen on echocardiography as a complication of acute myocardial infarction?

Mitral regurgitation

"A 26-year-old female comes into the emergency room with complaints of dyspnea on exertion. On further questioning, she gives a history of increasing cough over the last week and limitation of her daily activities. She also gives a history of breathlessness at night after going to bed. Her past medical history is significant for a bout of rheumatic fever at age 15. Examination shows a female in distress. There is peripheral and facial cyanosis. There are prominent 'a' waves in the jugular venous pulse. Palpation yields a diastolic thrill at the apex in the left lateral position. Auscultation shows the presence of a mid-diastolic murmur best heard in the mitral area. What is the MOST likely diagnosis?"

Mitral stenosis

A 71 year-old male with a history of diabetes and dyslipidemia presents to the emergency department with complaints of exertional chest pain for the past two hours. He gets some relief with rest but admits to associated nausea and leftsided jaw pain. On examination he appears diaphoretic and tachypnic. Electrocardiogram (ECG) is unchanged from a previous ECG 1 year ago. His cardiac enzymes are within normal limits. Which of the following is the most appropriate next step?

Monitor with repeat enzymes and ECG in 4-6 hours

A 24-year-old man with a recent history of a viral illness comes to the emergency department complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. On physical examination, the patient's temperature is 39°C, blood pressure is 135/78, with a pulse of 85 bpm, and a pericardial friction rub is noted. Laboratory findings demonstrate elevated serum creatine kinase levels and normal serial troponin levels. His EKG demonstrates diffuse ST segment elevation in the precordial leads. His CXR demonstrates no acute process. Which of the following is the most appropriate treatment for this patient?

NSAID's

A patient has the following rhythm strip & is asymptomatic. Which of the following is the best management? (AVB 2 Type 1- Wenkebach)

No treatment is indicated

A 80-year-old with a past history of myocardial infarction is found to have left bundle branch block on ECG. He is asymptomatic with blood pressure 130/80, lungs clear to auscultation, and no leg edema. On cardiac auscultation, the most likely finding is

Paradoxical (reversed) split S2

A 59-year-old diabetic woman had suffered an acute AWMI. Five days later she gets into an argument with her husband and complains of chest pain. Her initial EKG shows no ischemic changes, but serum cardiac troponin levels are drawn and return mildly elevated at this time. Which of the following is the best next therapy?

Perform serial ECGS and obtain CK-MB

A 25 year-old female presents with a three day history of chest pain aggravated by coughing and relieved by sitting and leaning forward. She is febrile and a CBC with differential reveals leukocytosis. Which of the following physical examination signs is characteristic of her problem?

Pericardial friction rub

A 80 year-old female presents with syncope and recent fatigue and lightheadedness over the past month. She denies chest pain or dyspnea. Physical examination reveals BP 130/70 mmHg, HR 40 bpm, regular, and RR 16. Electrocardiogram reveals two p waves before each QRS complex. Which of the following is the treatment of choice for this patient?

Permanent dual chamber pacemaker insertion

Which of the following is not a typical sign of chronic right sided heart failure ?

Pulmonary edema

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 is seen below. Which of the following is the treatment of choice in this patient? (WPW)

Radiofrequency catheter ablation

A 60 year-old male complains of progressive fatigue and dyspnea. On examination his lungs are clear to auscultation bilaterally, heart exam reveals regular rate and rhythm without S3, S4 or murmur, and extremities show 1+ edema bilaterally. Chest x-ray reveals cardiomegaly. Electrocardiogram shows low voltage, and echocardiogram shows an ejection fraction of 55% with a small, thickened left ventricle that has rapid early filling with diastolic dysfunction. Which of the following is the most likely underlying etiology of this patient's cardiomyopathy?

Restrictive cardiomyopathy from Amyloidosis

A 72-year-old male comes to the office with intermittent symptoms of dyspnea on exertion, palpitations, and cough occasionally productive of blood. On cardiac auscultation, a low-pitched diastolic rumbling murmur is faintly heard toward the apex. The origin of the patient's problem probably relates to

Rheumatic fever as a youth

What type of chest pain is most commonly associated with a dissecting aortic aneurysm?

Ripping, tearing

Examination of the heart in chronic heart failure frequently reveals

S3

Which of the following indicates EKG changes consistent with a suspected pulmonary embolus?

Sinus tachycardia with a right ventricular strain pattern, prominent S in lead I, Q wave and inverted T in lead III

A 14 year-old male is scheduled for a physical examination before football tryouts. During examination of the heart, a systolic murmur is heard over the left upper sternal border. Hypertrophic Obstructive Cardiomyopathy (HOCM) is of concern. Which of the following maneuvers will INCREASE the intensity of this murmur?

Standing

The following patient is in the emergency department and has the below rhythm. He does not have a pulse. What is the best management? (VT)

Unsyncronized cardioversion 200J (biphasic)/defibrillation

A 68-year-old man with a history of hypertension, diabetes, and urinary retention awoke feeling nauseated and light-headed. He did not respond to questions from his wife. When the emergency medical technicians arrived, his blood pressure was 60 by palpation. IV fluids and oxygen were administered. Vital signs obtained in the ER were blood pressure 60, heart rate 120 and regular, temperature 38.9°C (102°F), and respiratory rate 30. A brief physical examination revealed coarse rales approximately halfway up in the chest bilaterally and inaudible heart sounds An indwelling urinary catheter was placed with drainage of 10 to 20 mL of dark urine. ECG was unremarkable except for sinus tachycardia. Antibiotics were administered, and the patient was transferred to the ICU, where a right heart catheterization was performed. Pulmonary capillary wedge pressure was 28 mm Hg. Cardiac output was 1.9 L/min. Right atrial mean pressure was 10 mmHg. These findings are most consistent with which of the following types of shock

cardiogenic

A 75-year-old male with chronic hypertension is assessed in the office for routine evaluation. His hypertension is well-controlled with thiazide diuretics. EKG reveals U waves. Which of the following is the most likely cause for U waves?

hypokalemia

A 68 year-old patient presents after a syncopal episode. The patient has a history of coronary artery disease and ischemic cardiomyopathy. Echocardiogram shows an ejection fraction of 20%. Electrophysiology study reveals inducible sustained ventricular tachycardia from the left ventricle. Which of the following is the most appropriate therapy in this patient?

implantable defibrillator

This patient was admitted to the general medical ward with a history of alcoholism. A code is in progress and he has recurrent episodes of this rhythm. You review his chart. Notes about the 12-lead ECG say that his baseline QT interval is high normal to slightly prolonged. He has received 2 doses of epinephrine 1 mg and 1 dose of amiodarone 300 mg IV so far. What would you order for his next medication? (Torsades)

magnesium sulfate

A mother rushes her 3-year-old daughter to your office. The little girl, who had been diagnosed with Tetralogy of Fallot at 6 months, got up from her nap and was restless and hyperventilating. There was an increase of cyanosis at first, which turned to extreme paleness, and she lost consciousness for about 1 minute. What is the most important first measurement to take?

oxygen

Post-infarction syndrome (Dressler's syndrome) occurs after acute myocardial infarction presenting as

pericarditis and pleuritis.

A 55 year-old male with a syncope episode is found to have a late systolic ejection murmur that radiates to the carotids on physical exam. After an echocardiogram, how should the patient be managed?

should be referred to cardiovascular surgery