Exam Master Cardio ?'s

You transfuse 3 units of whole blood to a gun shot victim. Unknown to you, there was a shortage of blood, and the units you gave to your patient were from the bottom of the freezer and about to expire. Within 2 days, the transfused cells are breaking down, and your patient's ECG is beginning to show high T waves and an increased PR interval. You recognize that he is becoming hyperkalemic and that the excess potassium is affecting the electrical conduction system of the heart. What best describes the resting membrane potential of a sinus nodal fiber under normal conditions?

-55 mV Normal resting potential is -70 mV.

A 72-year-old woman is admitted to the hospital following a syncopal episode. She began having dizziness and palpitations approximately 2 days ago. She admits to episodes of intermittent palpitations and dizziness over the last 3 months. EKG reveals atrial fibrillation. She is started on warfarin. Cardiology is consulted and recommends electrical cardioversion. When is the most appropriate time for electrical cardioversion to be performed?

4 weeks

A 40-year-old man presents with atrial flutter with 2:1 atrioventricular (AV) conduction, giving him a pulse of 150 per minute, which is perfectly regular. His blood pressure is 70/40 mmHg. He takes no medications regularly. You plan to provide him with urgent direct current cardioversion with conscious sedation. What would be an appropriate level of energy for cardioversion in order to restore sinus rhythm in this patient?

50 Joules

A 70-year-old woman presents with shortness of breath at rest over the past 3 days. She has found it difficult to walk short distances due to shortness of breath. Additionally, she is experiencing confusion, orthopnea, nocturnal dyspnea, and lightheadedness. She denies cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, cough, nausea, abdominal pain, vomiting, diarrhea, rashes, and syncope. On physical examination, the patient is short of breath, requiring numerous pauses during conversation. She is afebrile; however, she is tachycardic, diaphoretic, and her extremities are cool. There is a diminished first heart sound, S3 gallop, laterally displaced PMI, bibasilar rales, and dullness to percussion and expiratory wheezing noted. An elevated JVD and 2+ pitting edema of the lower extremities is evident. What statement regarding this patient's condition is correct?

Activation of the renin-angiotensin-aldosterone system occurs which leads to CHF and further increasing peripheral vascular resistance and left ventricular afterload.

A 66-year-old man with a past medical history of myocardial infarction 2 years ago, angina pectoris, aortic regurgitation, congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease is presently being monitored in the hospital status-post admission for chest pain 1 day ago. Myocardial infarction has been ruled out. An EKG performed upon admission revealed a prolonged Qt interval and significant Q waves in the anterior leads. A diagnostic echocardiogram confirms moderate aortic and mitral valve regurgitation and a left-ventricular ejection fraction of 30%. He denies any complaints upon bedside evaluation. His physical exam reveals a blood pressure of 105/70 and tachycardia. Continuous bedside ECG monitoring notes wide, monomorphic QRS complexes with a heart rate of 160 beats per minute that spontaneously resolve within 20 seconds, reverting to the pattern identified upon admission. What antiarrhythmic agent is considered to be the pharmacologic treatment of choice for management of this patient?

Amiodarone Pt presents with V tach

A 56-year-old man presents with a 1-week history of palpitations and shortness of breath. He has a long-standing history of poorly controlled hypertension. Physical examination reveals an elevated blood pressure of 190/98 mm Hg, elevated jugular venous pressure (JVP), mild hepatomegaly, bilateral pedal edema, and rales at the lung bases. Diagnostic studies reveal concentric left ventricular hypertrophy without significant valvular abnormalities on echocardiogram. What drug is beneficial in the treatment of the patient's condition by virtue of both afterload and preload reduction?

Angiotensin-converting enzyme inhibitor (eg Enalapril)

A 64-year-old woman with a past medical history of hyperthyroidism presents with new-onset palpitations. The patient states that she has intermittent palpitations, and she is worried about heart disease. She is currently asymptomatic and reports no chest pain or shortness of breath. An EKG is obtained. Vital signs reveal a T 98.6° F, BP 134/88 mm Hg, P 119 beats/min R 12/min. The pulse is noted to be irregular. What arrhythmia does this patient most likely have?

Atrial fibrillation

A 70-year-old African-American man presents with gradual but progressive dyspnea and fatigue on exertion. He notes difficulty in climbing stairs; there is associated lightheadedness, increased abdominal girth, and swollen bilateral lower extremities. He admits to chronic alcohol use, but he denies any heart disease, chest pain or pressure, diaphroesis, palpitations, a history of diabetes, cigarette smoking, or claudication. His physical exam reveals sinus tachycardia, bibasilar rales, a laterally-displaced PMI, an elevated JVP, an S3 gallop, a mitral regurgitation murmur, peripheral edema, and abdominal ascites. A bedside echocardiogram noted four-chamber dilatation, increased left ventricle end-diastolic diameter and volume, thinning left ventricle walls, left atrial enlargement, and limited mitral and aortic valve opening. What is correct regarding this patient?

Atrophy and hypertrophy of myocardial fibers occurs histologically Patient has dilated cardiomyopathy

A 52-year-old man presents with onset of palpitations accompanied by a complaint of "feeling ill." He has a past medical history of hypertension that is currently untreated. The patient is not experiencing dyspnea, orthopnea, paroxysmal nocturnal dyspnea, chest pain, heat intolerance, or tremor. He does not drink coffee or smoke. He drinks a glass of wine occasionally. On physical exam, his blood pressure is 159/64 mmHg, his pulse is 109/minute, respirations 16/minute, and temperature is 98 Fahrenheit. His thyroid examination is normal; he has no raised jugular venous pressure. His heart sounds and lung exam are normal. He has no hepatomegaly, and his peripheral pulses are present. His chest X-ray appears normal. An echocardiogram demonstrates mitral stenosis with a left atrial size of 7.0 centimeters. After establishing airway, breathing, and circulation, what is the next step?

Begin Diltiazem Pt presents with V tach

A 28-year-old African-American man presents with dyspnea; it is associated with mild substernal chest pain and dizziness. Symptoms are provoked by sporting activities, and they are relieved with rest. His physical exam reveals a harsh murmur best heard at the left lower sternal border; it decreases in intensity upon squatting. There is also an S4 gallop. A bedside electrocardiogram was remarkable for left ventricular hypertrophy and septal Q waves in the anterolateral leads. An echocardiogram noted asymmetric LVH and a septum that was 2 times the thickness of the posterior wall. What would be the next most appropriate step in the management of this patient?

Begin this patient on a -adrenergic blocker (initial drug of choice) Patient has hypertrophic cardiomyopathy

A 20-year-old man presents after experiencing an attack of syncope while playing soccer. It is the 1st time he has experienced such an attack, although he has felt a little bit dizzy while exercising before. He had a cousin who died suddenly at the age of 20. Except for a small cut-wound on his forehead, the patient looks healthy. He has normal vitals and a pansystolic murmur heard at the apex that propagates to the axilla. In addition, a short systolic murmur is heard inside the apex. ECG shows left ventricular hypertrophy. Echocardiography shows asymmetrical septal hypertrophy. Systolic anterior motion of the mitral valve SAM, moderate mitral regurge, and left ventricular outflow tract obstruction gradient=88mmhg. What is the best management of this patient?

Beta-blocker Patient has hypertrophic cardiomyopathy Use BB for following effects: 1) Negative inotropic (decreases gradient across the LVOT) 2) Improves diastolic dysfunction (improves dyspnea) 3) Improves angina (slows HR and decreases myocardial oxygen consumption) (Antiarrhythmic effect)

A 74-year-old Caucasian man presents with progressive exertional shortness of breath, lower extremity edema, and lightheadedness over the previous 7 months. He has a past medical history of HIV, hepatic cirrhosis secondary to chronic alcohol abuse and hemochromatosis, obesity, and thiamine deficiency. His symptoms are improved with rest. The physical examination reveals rales, an elevated JVP, cardiomegaly, S3 gallop rhythm, a high-pitched, blowing holosystolic murmur at the apex, peripheral edema, and abdominal distension suggestive of ascites. A bedside EKG noted sinus tachycardia with nonspecific ST-T wave changes and Q waves. What is correct regarding the clinical intervention for this patient?

Beta-blockers have demonstrated reductions in cardiovascular mortality Patient has dilated cardiomyopathy

A 68-year-old man with a history of hypertension, hyperlipidemia, and myocardial infarction presents to the emergency room with a 3-day history of shortness of breath at rest. He has found it difficult to walk short distances due to shortness of breath. Additionally, he complains of orthopnea, nocturnal dyspnea, and generalized abdominal discomfort. He denies cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, cough, nausea, vomiting, diarrhea, rashes, lightheadedness, and syncope. Upon physical examination, the patient is acutely dyspnic. He is afebrile, but tachypnic and diaphoretic. There is a diminished first heart sound, S3 gallop, laterally displaced PMI. The abdominal exam reveals distension with hepatomegaly in the right upper quadrant. There is 2+ pitting edema of the lower extremities to the level of the mid calf. What additional finding is expected to occur in this patient? What health maintenance statement is correct regarding this patient's condition?

Bibasilar rales (Patient is in Heart failure) Routine monitoring of hypertension and valvular dysfunction should occur

A 72-year-old man with a past medical history of hyperlipidemia, inferior wall myocardial infarction 6 months ago, and congestive heart failure has presented to his local medical office with complaints of increased tiredness and fatigue upon ambulation over the past several weeks. He denies edema, syncope, lightheadedness, dizziness, chest pain, palpitations, cough, shortness of breath, abdominal pain, fever, or chills. What is the most likely physical exam finding expected in this patient?

Blowing apical diastolic murmur Pt presents with a 1st degree AV block.

A 70-year-old woman presents with a 3-day history of shortness of breath at rest. She has been finding it difficult to walk short distances due to shortness of breath. Additionally she is experiencing orthopnea and nocturnal dyspnea. Her past medical history is significant for hypertension, hyperlipidemia, and myocardial infarction. The patient denies cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, cough, nausea, abdominal pain, vomiting, diarrhea, rashes, lightheadedness, and syncope. Upon physical examination, the patient is short of breath; she requires numerous pauses during conversation. She is afebrile but tachycardic, diaphoretic, and her extremities are cool. The exam reveals a diminished first heart sound, S3 gallop, laterally displaced PMI, bibasilar rales, dullness to percussion, and expiratory wheezing. There is no JVD noted; however, 2+ pitting edema of the lower extremities to the level of the mid-calf is evident. Diagnosis?

CHF

A 62-year-old man collapses in the emergency department. The patient is connected to a cardiac monitor that shows the presence of an irregular waveform with wandering baseline and no identifiable P waves or QRS complexes. What intervention has the greatest impact on this patient's survival?

Defibrillation

A 72-year-old man presents with double vision, weakness, fatigue, nausea, and abdominal discomfort. He describes seeing everything greenish. He suffers from congestive heart failure and is treated for that with digoxin, furosemide, and potassium. He has been taking acetylsalicylic acid since a TIA 2 years ago. He also takes amoxicillin for a urinary tract infection. What medication can cause his symptoms?

Digoxin

A 74-year-old Caucasian woman with a history of hypertension, hyperlipidemia, and myocardial infarction presents with shortness of breath upon exertion, lightheadedness, increased fatigue, and palpitations for 3 days. She has found it difficult to walk short distances due to shortness of breath. She denies any orthopnea, nocturnal dyspnea, abdominal pain cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, cough, nausea, vomiting, diarrhea, rashes, or syncope. She is well nourished and afebrile, but tachypnic. Her cardiac exam reveals an irregularly irregular pulse, hypotension, diminished first heart sound, S3 gallop, and laterally displaced PMI. Her lung, peripheral vascular, and abdominal exams are normal. An echocardiogram is remarkable for a left ventricular ejection fraction of 25%. EKG shows Atrial fibrillation. What agent would be most appropriate in the management of this patient at this time?

Digoxin

A 62-year-old woman with past medical history of hyperlipidemia presents due to shortness of breath. She is a nonsmoker and drinks a pint of vodka daily. Chest X-ray reveals severe cardiomegaly. She is ultimately diagnosed with cardiomyopathy. What type of cardiomyopathy does the patient likely have?

Dilated cardiomyopathy

A 57-year-old woman presents with progressive dyspnea and lower extremity edema. She has noticed the symptoms occurring over the last 3 months and also notes increasing fatigue over the last year. Past medical history is significant for diabetes and hypertension. Past social history is significant for previous alcohol abuse; patient has been sober for approximately 5 years. On physical examination, an S3 gallop is heard. Electrocardiogram reveals ST-T changes. Echocardiogram reveals left ventricular dilatation with an ejection fraction of 35%. Diagnosis?

Dilated cardiomyopathy (occurs when left ventricle becomes dilated and weakened. Heart is unable to efficiently pump blood leading to fluid overload)

How do you best describe dilated cardiomyopathy?

Dilation and impaired contraction of one or both ventricles

A 32-year-old man with no significant past medical history presented with dyspnea, palpitations, feelings of anxiety, and dizziness, all of which occurred earlier in the morning following a brisk walk. He denied any prior episodes, illicit drug use, alcohol or cigarette use, skipping meals, or caffeine intake. He further denied fever, chills, chest pain, history of murmurs, cough, edema, rashes, syncope, headache, psychiatric, or focal neurological complaints. The physical examination demonstrated a fast, regular pulse with a constant-intensity first heart sound, but was otherwise normal. An EKG was performed, which revealed a short PR interval plus a slurred upstroke at the beginning of the QRS complex. What is the most likely mechanism responsible for this patient's presentation?

Early excitation due to accessory pathways between the atria and ventricles

An 8-year-old girl, who weighs 70 lbs and is 52 inches tall, has been diagnosed with stage I HTN. Physical examination and lab studies are normal. Which additional test is most likely to detect target-organ damage abnormalities in this child?

Echocardiogram

A 37-year-old woman with a recent onset of atrial fibrillation presents with new symptoms of fatigue and dyspnea on exertion that 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). A loud systolic ejection murmur is heard in the second and third interspaces parasternally. The patient's past medical history is significant for a mumur diagnosed during childhood. What diagnostic test will identify the most likely etiology of the patient's symptoms?

Echocardiogram CHF due to atrial septal defect.

A 63-year-old woman with a 3-day history of hypertension, hyperlipidemia, and myocardial infarction presents to the emergency room with shortness of breath at rest. She has found it difficult to walk short distances due to shortness of breath. Additionally, she complains of orthopnea, nocturnal dyspnea, and generalized abdominal discomfort. She denies cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, cough, nausea, vomiting, diarrhea, rashes, lightheadedness, and syncope. She is well nourished and afebrile, but tachypnic and diaphoretic. There is a diminished first heart sound, S3 gallop, laterally displaced PMI, bibasilar rales and dullness to percussion, and expiratory wheezing noted. The abdominal exam reveals distension, with hepatomegaly in the right upper quadrant. There is 2+ pitting edema of the lower extremities to the level of the mid calf, and the extremities are cool. What additional finding is expected in this patient?

Elevated jugular venous distension Patient has CHF

A 35-year-old Caucasian woman presents with a 5-day history of nervousness and palpitations. She has had diarrhea for most of the previous month and has had a 3 kg weight loss despite an increased appetite. She also reports increased fatigue and sweating. Her vital signs are an irregular pulse of 114 BPM, blood pressure of 125/75 mm Hg, respirations of 18/min, and a temperature of 37.8°C. Physical exam reveals exophthalmos, a mass in the midline of her neck that moves with deglutition, fine resting tremor, and hyperactive reflexes. Her thyroid stimulating hormone (TSH) level is low. An ECG is performed, revealing atrial fibrillation with an atrial rate of 420/min, and a ventricular response ranging between 110 and 130/min. What would be the most appropriate initial intervention regarding her arrhythmia?

Esmolol Short acting Beta blocker preferred for emergency use...

A 66-year-old man has a past medical history of amyloidosis, hyperlipidemia, and hypereosinophilic syndrome; he presents with a 1-year history of progressive dyspnea upon exertion. Currently, he is only able to walk 3 blocks before having to stop to catch his breath. Additionally, he has noticed increased lower extremity swelling, abdominal "bloating", and a loss of appetite. Despite not eating as much, he has noticed a 15-pound weight gain over the past 6 weeks. His physical exam reveals bipedal pedal edema, increased jugular venous pressure (with Kussmaul's sign noted), abdominal distension with shifting dullness, and hepatosplenomegaly. The precordium is without any heaves, lifts, or thrills. An EKG demonstrates a normal sinus rhythm without abnormalities. What pharmacotherapeutic agent would be most beneficial to this patient at this time?

Furosemide (Lasix) Patient likely has restrictive cardiomyopathy.

A 68-year-old woman presents with shortness of breath, fatigue, dry cough, and swelling in her ankles. Symptoms started around the time of her son's wedding 6 weeks ago, and she dismissed them as stress-related, but symptoms have worsened in intensity and frequency. Now she becomes very short of breath with any exertion, such as climbing stairs in her home. She feels like she may pass out and has to sit when she gets lightheaded. Her breathing is more difficult when lying down. She denies productive cough, fever, or chest pain. She has had no medical care for several years. Her past medical history is unremarkable, with no known medical conditions and no surgeries. She is menopausal and does not take any medications, nor does she have any allergies. She denies the use of tobacco, alcohol, and drugs. Vitals are: Pulse 101, BP 158/98, temperature 97.9 F, and BMI 28.5. BNP was elevated, Chest X-ray shows signs of perivascular edema/slightly enlarged cardiac shadow, EKG shows mild left ventricular hypertrophy. Echo is pending. What physical exam findings would be expected given this patient's history and test results? Once this patient is stabilized and educated about her diagnosis and treatment, she asks what she could have done to prevent her condition. What represents the greatest modifiable contributing factor to this condition on a population basis? What medication is recommended for this patient and, in large trials, has been shown to increase survival, reduce hospital admissions, and improve quality of life for patients with her current condition?

Hepatojugular reflux (acute exacerbation of heart failure). Hepatojugular reflux is an observation of filling of the jugular vein when pushing on the liver of a patient placed in a semi-reclined position. Untreated hypertension Angiotensin-converting-enzyme inhibitor

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

Hypertrophic Cardiomyopathy

A 70-year-old woman with a history of hypertension, hyperlipidemia, and myocardial infarction presents with a 3-day history of shortness of breath at rest. She has found it difficult to walk short distances due to shortness of breath and is experiencing orthopnea and nocturnal dyspnea. She denies cough, fever, chills, nausea, abdominal pain, vomiting, diarrhea, rashes, or edema. Upon physical examination, the patient is short of breath, requiring numerous pauses during conversation. She is tachycardic, diaphoretic, and extremities are cool. There is a diminished first heart sound, S3 gallop, laterally displaced PMI, bibasilar rales and dullness to percussion, and expiratory wheezing noted. There is no JVD noted, and 2+ pitting edema of the lower extremities to the level of the mid calf. What intervention will provide the greatest symptomatic relief to this patient? What diagnostic test result would be considered most useful in differentiating a cardiac from noncardiac cause of this patient's presentation?

IV diuretic Elevations of B-type natriuretic peptide

An ECG shows a LBBB. What are the 4 underlying conditions associated with increased risk of cardiovascular morbidity and mortality rates?

Impaired left ventricle function, hypertension, aortic valve disease, and cardiomyopathy.

A 68-year-old man with a past medical history of diabetes mellitus type II, hyperlipidemia, myocardial infarction 1 year ago, and congestive heart failure with left ventricular ejection fraction of 35% is rushed to his local emergency room by his wife after he collapsed and became unresponsive at their residence. He admitted to her that he had been experiencing severe chest pain and pressure, fatigue, palpitations, diaphoresis, and lightheadedness for several minutes prior to his collapse. His present medications include aspirin, atorvastatin, lisinopril, glipizide, and carvedilol. Upon physical exam, he is found to have a blood pressure of 60/palpable, is pulseless, and has gasping respirations. His troponin T level was found to be elevated at 0.2 ng/ml, and troponin I level elevated and measured to be 0.25 ng/ml. The admission ECG revealed bizarre, irregular, random waveform, no clearly identifiable QRS complexes or P waves, and a wandering baseline. Following appropriate stabilization, what is best next step for this patient?

Implantable cardioverter-defibrillator (ICD) implantation

A 78-year-old man with known left-sided congestive heart failure presents with a complaint of cough, worsening dyspnea with exertion, and orthopnea. What is the most direct cause of his symptoms?

Increased pulmonary venous pressure (predominant features are low cardiac output and elevated pulmonary venous pressure resulting in dyspnea)

A 58-year-old man who is a long standing patient of yours is experiencing worsening symptoms and signs of his dilated cardiomyopathy; symptoms include fatigue, dyspnea with mild exertion, paroxysmal nocturnal dyspnea, severe lower extremity edema, clubbing, an S3 gallop, and jugulovenous distention. Medications that this patient is taking on a daily basis include a β-blocker, adult dose aspirin, and an ACE inhibitor. What intervention would be the most logical next step in helping resolve his current symptoms?

Initiation of a diuretic

A long-standing patient of yours is experiencing acutely worsening symptoms and signs of his dilated cardiomyopathy; symptoms include fatigue, dyspnea with mild exertion, paroxysmal nocturnal dyspnea, severe lower extremity edema, clubbing, an S3 gallop, and jugulovenous distention. Medications this patient is taking daily include a β-blocker, adult dose aspirin, and an ACE inhibitor. What clinical intervention would be the most logical next step in helping resolve his current symptoms?

Initiation of a diuretic

A 26-year-old African-American man with no significant past medical history presents with a history of dyspnea on exertion, which occurs after running. The dyspnea is associated with mild substernal chest pain. All symptoms are relieved with rest. He denies fever, chills, cough, wheezing, pleurisy, calf pain, abdominal complaints, peripheral edema, cigarette, drug, or alcohol use, sick contacts, or travel. His physical exam reveals a harsh murmur best heard at the left lower sternal border and an S4 gallop. A bedside electrocardiogram was remarkable for left ventricular hypertrophy and septal Q waves in the inferolateral leads. An echocardiogram noted asymmetric LVH, anterior motion of the mitral valve during systole, a small and hypercontractile LV, and delayed relaxation and filling of the LV during diastole. The septum was 2 times the thickness of the posterior wall. What is expected to be true regarding the murmur in this patient?

It decreases with squatting Patient has hypertrophic cardiomyopathy. It is enhanced with standing and valsalva maneuver. It is decreased with squatting, sustained handgrip, lying down, or straight leg raises.

A 48-year-old man is brought to the ER complaining of difficulty breathing, fatigue, and intermittent chest pain for the past month. On further questioning, he states that the breathing seems to worsen when lying down. On physical exam, you note elevated respiratory and heart rates and pale, sweaty skin. On auscultation, rales are noted as well as a 3rd heart sound. Which of the following is the most likely diagnosis?

Left Ventricular Failure (clinical presentation is dyspnea, orthopnea, and Paroxysmal nocturnal dyspnea)

A 70-year-old man with a history of hyperlipidemia, hypothyroidism, osteoarthritis, and hypertension presents for a routine evaluation. He denies any complaints today and otherwise has no significant past medical history. His physical examination is remarkable for a pulse rate of 44 beats per minute and a blood pressure of 150/94. An EKG assessment reveals sinus bradycardia and a type II Mobitz heart block. What antihypertensive should be avoided in the management of this patient?

Metoprolol

A 70-year-old African American man presents to his primary care provider with a complaint of gradual but progressive dyspnea and fatigue on exertion. He notes difficulty in climbing stairs with associated lightheadedness, increased abdominal girth, and swollen bilateral lower extremities. He admits to chronic alcohol use, but denies any heart disease, chest pain or pressure, diaphroesis, palpitations, a history of diabetes, cigarette smoking, or claudication. His physical exam reveals sinus tachycardia, bibasilar rales, a laterally-displaced PMI, an elevated JVP, an S3 gallop, a mitral regurgitation murmur, peripheral edema, and abdominal ascites. What is the next appropriate step in the management of this patient?

Obtain an echocardiogram (for diagnosis of cardiomyopathy)

A 65-year-old African-American man presents in your office for a follow-up for hypertension. Three months earlier you prescribed furosemide. He checks his blood pressure daily and states that it is markedly lower since he has been on the medication. However, it feels like his heart is skipping a beat once in a while. What deficiency is most likely?

Potassium

An 80-year-old man was treated for ventricular arrhythmias. He presents 1 month later with joint pain. He also has an unusual mask-like rash over his face and body. Discontinuation of drug therapy causes the symptoms to abate. What drug was most likely administered to this patient?

Procainamide

A 67-year-old man presents with progressive shortness of breath, fatigue, and orthopnea. The patient cannot walk more than a few steps without taking a short rest, and he says his condition has deteriorated in the past 3 days. His blood pressure is 120/60 mm Hg, pulse is 84 BPM, respirations are 28/minute and labored, and his body temperature is 97.5° F. What is the most likely diagnosis?

Pulmonary edema Patient is in advanced heart failure.

A 72-year-old man presents for worsening shortness of breath, orthopnea, and chest pain for the last few weeks. He admits some chronic heart problems with fatigue, dyspnea, and non-productive cough, but feels like symptoms have worsened recently. He denies fever, chills, and productive cough. On physical exam, the man has mildly increased respiratory effort but does not appear in distress. He is barrel-chested. His breath sounds are diminished bilaterally, with dullness to percussion over right and left lower lungs. No pleural friction rub is noted. On cardiovascular exam, an S3 gallop and mild tachycardia (110 bpm) is noted. Clubbing of the fingers, dependent edema in the lower extremities, and jugular venous distention is also noted. His cardiac enzymes and electrocardiogram demonstrate no acute cardiac pathology. Pleural fluid and cardiomegaly are found on the chest x-ray. What explanation for this patient's dependent edema is most plausible, given his history and physical?

Renal sodium and fluid retention, leading to increased capillary pressure

A 73-year-old woman with a past medical history of diabetes mellitus type II, hypderlipidemia, migraine headaches, recurrent urinary tract infections, myocardial infarction 1 year ago, and congestive heart failure is rushed to a local emergency department by her son after she collapsed and became unresponsive at her residence. She admitted to him that she had been experiencing severe chest pain and pressure, fatigue, palpitations, diaphoresis, and lightheadedness for several minutes prior to her collapse. Her present medications include aspirin, sumatriptan, atorvastatin, lisinopril, albuterol, glipizide, and carvedilol. Upon physical exam, she is found to have a blood pressure of 60/palpable, is pulseless, and has gasping respirations. Her admission ECG revealed bizarre, irregular, random waveform, no clearly identifiable QRS complexes or P waves, and a wandering baseline. What statement is true concerning the health maintenance of this patient?

Serial cardiac enzymes and an echocardiogram should be performed. Patient is in Ventricular Fibrillation due to myocardial infarction.

A 43-year-old patient presents with an acute onset of palpitations and dyspnea for the past 3 hours. There is no other significant medical history. Chest X-ray and echocardiography are normal. EKG performed in the ED reveals absence of P wave with variable R-R interval with atrial rate of 300/min and ventricular rate of 120/min. Vitals: patient is afebrile, radial pulse- 90/min, BP- 110/70 mm Hg and RR- 18/min. A diagnosis of newly detected atrial fibrillation is made. What is the next course of action?

Start Diltiazem therapy Patient is in Atrial Fibrillation. Diltiazem helps control ventricular rate.

A 20-year-old male presents following a syncopal episode during football practice. The patient is conscious and is not in acute distress. He denies abusing alcohol or "street drugs." The patient says he did not have fatigue, dizziness, or palpitations. On auscultation, you identify a systolic murmur in late systole. The murmur increases when you try Valsalva's maneuver. Otherwise, the review of systems is unremarkable. The patient's BP is 125/70 mmHg and HR is 94 bpm. The ECG you obtained shows right bundle branch block with QT interval of 495 ms. You decide to proceed with the study of cardiac anatomy and function with cardiac MRI. What is the most probable complication that can result from this patient's condition?

Sudden death Patient has hypertrophic cardiomyopathy.

A 54-year-old man presents with a 6-month history of increasing intolerance to exercise. He describes "breathlessness" with exertion, as well as fatigue and 2 pillow orthopnea. He denies tobacco use but does admit to 4 or 5 whisky sours daily for the last 20 years. He is a businessman and often entertains clients, which "involves drinking alcohol." Chest x-ray reveals an enlarged cardiac silhouette, EKG reveals normal sinus rhythm. A surface echocardiogram reveals an ejection fraction or 35%, mild mitral regurgitation, and dilated left ventricle. Which of the following statements about this patient's illness is true and should be shared with the patient?

Symptoms can significantly improve with alcohol cessation

A 15-year-old girl presents with a 1-hour history of rapid heartbeat, faintness, sweating, and nervousness. She is also experiencing shortness of breath and chest pain. The patient has no significant past medical history. There is no history of similar episodes. The patient is on no medications, and she denies illicit drug use. On exam, her vital signs are BP70/60 mmHg; pulse 200 bpm; RR 22/min, temperature afebrile. She looks pale, and her palms are slightly sweaty. She is not comfortable sitting up, so she prefers lying down. She looks slightly apprehensive. Her heart and lung exam are negative except for the tachycardia; except for cool sweaty hands, a brief abdominal and extremity exam are non-revealing. The physician quickly places the paddles on the patient's chest to record the rhythm; this shows a narrow-complex regular tachycardia at 210 bpm. He requests oxygen, IV line, and continuous monitoring. An EKG is in the process of being completed. At this point, what should be done?

Synchronized cardioversion

A 75-year-old African-American man presents with a 5-month history of gradually progressive dyspnea that is especially pronounced when climbing stairs. He also has been noticing that his ankles and lower legs have "gotten larger" over roughly the same time period, which no longer allows him to fit into his sneakers. He denies fever, chills, chest pain, palpitations, cough, pleurisy, calf pain, abdominal complaints, sick contacts, or travel. His psychosocial history is noteworthy for chronic alcohol use. His physical exam reveals bibasilar rales, JVD of 5cm, an S3 gallop, a holosystolic murmur at the apex that radiates to the left axilla, and 2+ pitting edema to the level of the mid-calves bilaterally. A bedside echocardiogram was remarkable for biventricular enlargement. What additional physical exam finding would be expected in this patient?

Tachycardia Pt has dilated cardiomyopathy.

A 72-year-old man with a history of poorly-controlled HTN and previous myocardial infarction presents with nocturnal cough, bilateral ankle swelling, and dyspnea on exertion. He denies any fever, chills, URI symptoms, chest pain, headache, N/V, diaphoresis, or syncope. He further denies smoking, alcohol, or drug use. Physical exam reveals bipedal edema and bibasilar crackles. Chest x-ray is remarkable for enlargement of the cardiac silhouette and interstitial infiltrates, while EKG analysis indicates deep S waves in lead V1 and tall R waves in lead V5. What is the most appropriate next step in the evaluation and management of this patient?

Transthoracic echocardiogram

You are called to the emergency department at 2 P.M. to see a 44-year-old male patient. He is a 3-pack-a-day, unfiltered cigarette smoker with crushing chest pains. He has a wide-complex, rapid, regular tachyarrhythmia at 160 beats per minute. When you reach his examination room, you note his monitor also reveals evidence of "P" waves at 75 beats per minute. What type of rhythm do his symptoms show?

Ventricular tachycardia

A 40-year-old man presents with irregular heartbeats lasting several days. His past medical history is significant for the presence of mitral valve stenosis and atrial fibrillation (AF). He takes beta blockers regularly. His ECG shows atrial fibrillation with an irregular heart rate around 80. To prevent further complications, you decide to restore his sinus rhythm by cardioversion and prescribe what treatment?

Warfarin

After successful cardioversion for atrial fibrillation (AF), a 65-year-old woman with rheumatic mitral valve disease patient feels better, with the exception of slight weakness in her left arm as a consequence of previous ischemic stroke. Her blood pressure is 120/80; her EKG is normal and shows sinus rhythm with rate 75. What chronic medical therapy is recommended?

Warfarin

A 78-year-old Caucasian man has a past medical history of HIV, hepatic cirrhosis secondary to chronic alcohol abuse and hemochromatosis, obesity, and thiamine deficiency; he presents with a 7-month history of progressive exertional shortness of breath, lower extremity edema, and lightheadedness. His symptoms are improved with rest. The physical examination reveals rales, an elevated JVP, cardiomegaly, S3 gallop rhythm, a high-pitched, blowing holosystolic murmur at the apex, peripheral edema, and abdominal distension that is suggestive of ascites. A bedside EKG notes sinus tachycardia, with nonspecific ST-T wave changes and Q waves. What is correct regarding this patient's health maintenance?

Water consumption should be limited as disease progresses Patient has dilated cardiomyopathy. Restrict salt to less than 2-4 g/day. And fluid restriction in very late stages of the disease.