528 : random cardiology ?s

A patient presents for a follow-up visit for chronic hypertension. Which of the following findings may be noted on the fundoscopic examination of this patient? Cherry-red fovea Boxcar segmentation of retinal veins Papilledema Arteriovenous nicking

AV nicking

An xanthoma would most likely be seen on a physical exam for which of the following patients? A. 89-year-old man with an LDL level of 200 mg/dL B. 22-year-old-man with a triglyceride level of 1600 mg/dL C. 50-year-old-woman with an HDL level of 10 mg/dL D. 25-year-old-woman with a total cholesterol level of 250 mg/dL E.72-year-old-man with an HDL ratio of 5:1

B. 22-year-old-man with a triglyceride level of 1600 mg/dL

You are seeing a 60-year-old man for the first time. He has untreated hypertension (168/106 mm Hg and blood pressure has been elevated on at least 3 occasions→ stage 2). There is currently no evidence of target organ dysfunction (heart, neurological, or eyegrounds).From a therapeutic perspective, what is the best initial approach? A. Initiate treatment with 25 mg of hydrochlorothiazide. B. Consider initiating treatment with a 2-agent combination pill. C. Delay pharmacologic intervention and treat with salt restriction.

B. Consider initiating treatment with a 2-agent combination pill.

A diabetic patient with secondary dyslipidemia has a triglyceride level not at goal. Which of the following medications offers the highest reduction in serum triglyceride levels? And why? A. Atorvastatin B. Gemfibrozil C. Lovastatin D. Sitagliptin

B. Gemfibrozil→ lowers triglycerides, increases HDL, lowers LDL levels. PPAR-α activation by fibrates results in numerous changes in lipid metabolism that act together to decrease plasma triglyceride levels & increase plasma HDL.

A 42-year-old woman presents with complaints of a sharp, stabbing pain in her chest upon coughing and inhalation. She says that the pain started acutely 2 days ago and has progressively worsened. Her past medical history is significant for a rash on her face, joint pains, and fatigue (SLE) for the past few weeks. The patient is afebrile and her vital signs are within normal limits. On physical examination, there is a malar macular rash that spares the nasolabial folds. There is a friction rub at the cardiac apex that does not vary with respiration. Which of the following additional physical examination signs would most likely be present in this patient? Mid-systolic click Pain improvement with inspiration Displaced apical impulse High-pitched diastolic murmur Breakthrough pain that improves with leaning forward

Breakthrough pain that improves with leaning forward - pericarditis

An 80-year-old man presents to the emergency department because of gnawing substernal chest pain that started an hour ago and radiates to his neck and left jaw. A 12-lead ECG is obtained and shows ST-segment elevation with newly developing Q waves. He is admitted for treatment. 4 days after hospitalization he suddenly develops altered mental status, and his blood pressure falls from 115/75 mm Hg to 80/40 mm Hg. Physical examination shows jugular venous distention, pulsus paradoxus, and distant heart sounds. What is the most likely cause of this patient's condition? Acute pulmonary edema causing right heart failure Arrhythmia caused by ventricular fib Compression of heart chambers by blood in the pericardial space Pericardial inflammation Rupture of papillary muscle

Compression of heart chambers by blood in the pericardial space - cardiac tamponade resulting from pericardial effusion

You hear a diastolic murmur on the right 2nd intercostal space. Pulmonic stenosis Aortic prolapse Mitral prolapse Tricuspid stenosis

aortic prolapse

Which of the following are considered to cause Diastolic Murmurs? Mitral prolapse Tricuspid prolapse Aortic stenosis Aortic prolapse Mitral stenosis

aortic regurge mitral stenosis

Which of the following are considered Systolic Murmurs? Aortic stenosis Pulmonic stenosis Aortic regurge Mitral regurge Mitral stenosis

aortic stenosis pulmonic stenosis mitral regurge

Which of the following population groups represent the greatest risk for developing primary hypertension? White non-Hispanic Hispanic Mediterranean Black non-Hispanic

black non-hispanic

Which of the following valves are closed during Systole? Aortic Mitral Tricuspid Pulmonic

mitral & tricuspid

A 27-year-old woman, who recently immigrated from Bangladesh, presents to her primary care physician to discuss birth control. During a review of her past medical history, she reports that as a child she had a recurrent sore throat and fever followed by swollen and aching hip and knee joints. These symptoms returned every season and were never treated but went away on their own only to return with the next typhoon season. When asked about any current complaints, the patient says that she sometimes has shortness of breath and palpitations that do not last long. A physical exam is performed. In which of the auscultation sites will a murmur most likely be heard in this patient? Point 1 Point 2 Point 3 Point 4 Point 5

point 5 - apex/mitral valve - rheumatic fever

A 73-year-old woman arrives at the emergency department due to intense central chest pain for 30 minutes this morning. She says the pain was cramping in nature and radiated down her left arm. She has a history of atrial fibrillation and type 2 diabetes mellitus. Her pulse is 98/min, respiratory rate is 19/min, temperature is 36.8°C (98.2°F), and blood pressure is 160/91 mm Hg. Cardiovascular examination shows no abnormalities. ECG is shown below. Which of the following biochemical markers would most likely be elevated and remain elevated for a week after this acute event? Alanine aminotransferase Aspartate transaminase Creatinine-kinase MB LDH Troponin I

troponin I

A 31-year-old woman presents to the clinic with shortness of breath, palpitations, and fatigue. She has had these symptoms over the last several weeks. She had been tolerating these symptoms until last night when she could not fall asleep due to palpitations. She has a past medical history of infective endocarditis 6 months ago that was successfully treated with antibiotics. She does not smoke or drink alcohol. Her blood pressure is 138/89 mm Hg and her pulse is 76/min and regular. The cardiac exam reveals a soft S1, S3 gallop, a hyperdynamic apex beat, and a pansystolic murmur that radiates to the axilla on auscultation. Echocardiography reveals incompetence of one of the valves. Which of the following sites is the best position to auscultate this defect? Right lower end of the body of the sternum 4th intercostal space at the midclavicular line on the left side Medial end of 2nd intercostal space on right side 5th intercostal space at the midclavicular line on the left side Medial end of the 2nd intercostal space on the left side

5th intercostal space at the midclavicular line on the left side - mitral valve regurg so listen to apex

You see a patient whose previous physician has retired. The patient's blood pressure is not controlled on a regimen of hydralazine 20 mg three times a day, atenolol 50 mg daily, and 12.5 mg of hydrochlorothiazide daily. The patient has stage 3 chronic kidney disease (GFR 38 mL/min). You should (choose all that apply): A. Switch the diuretic to chlorthalidone. (this is a diuretic/antihypertensive combo drug) B. Consider other medications in lieu of hydralazine and atenolol. (reports of renal injury w/ these) C. Add clonidine D. Increase hydrochlorothiazide to 25 mg.

A. Switch the diuretic to chlorthalidone. (this is a diuretic/antihypertensive combo drug) B. Consider other medications in lieu of hydralazine and atenolol. (reports of renal injury w/ these)

A 70-year-old man presents to a physician's office with shortness of breath for 1 month. He is "easily winded" and is unable to keep up with his grandchildren when playing in the park. Over the last few weeks, he had to increase the number of pillows under his head to sleep comfortably. He denies a cough and fever. The medical history includes hypercholesterolemia and hypertension. His current medications are aspirin, carvedilol, and rosuvastatin. The vital signs are as follows: blood pressure 150/90 mm Hg, pulse 90/min, and respiratory rate 14/min. The physical examination reveals distended jugular veins, bilateral pitting edema of the lower limbs, and fine crackles at the base of the lungs. An echocardiogram reveals an ejection fraction of 40%. Inhibition of which of the following hormones would be most beneficial for this patient? Angiotensin II Prostaglandin E1 Aldosterone Epinephrine ADH

Angiotensin II - want to decrease compensatory mechanism of increases RAAS

You evaluate a woman with chronic hypertension whose blood pressure remains above target despite a daily regimen of benazepril 20 mg, chlorthalidone 25 mg, and amlodipine 10 mg. Your next step should be: A. Add an agent from another class, such as hydralazine or clonidine. B. Characterize the patient as having resistant hypertension and initiate therapy with 25 mg of spironolactone (potassium levels permitting). C. Add an ARB. D. Switch from amlodipine to verapamil.

B. Characterize the patient as having resistant hypertension and initiate therapy with 25 mg of spironolactone (potassium levels permitting). **Explanation : "Spironolactone is commonly known as a potassium-sparing diuretic, which means in exchange for relieving the body of sodium and water, it makes the body retain potassium. This is how spironolactone works to protect the heart, lower blood pressure, and help with any leg swelling that a weak heart can cause."

A total lipid panel should be ordered for which of the following patients? A. 80-year-old African American man with no risk factors B. 34-year-old African American woman with no risk factors C. 37-year-old Caucasian man with no risk factors D. 20-year-old Asian man with no risk factors E.76-year-old Middle Eastern man with no risk factors

C. 37-year-old Caucasian man with no risk factors

A 53-year-old white man presents to the emergency department because of progressive fatigue, shortness of breath on exertion, and a sensation of his heart pounding for the past 2 weeks. He has had high blood pressure for 8 years for which he takes hydrochlorothiazide. He denies any history of drug abuse or smoking, but he drinks alcohol socially. His blood pressure is 145/55 mm Hg, his radial pulse is 90/min and is bounding, and his temperature is 36.5°C (97.7°F). On physical examination, an early diastolic murmur is audible over the left sternal border. His chest X-ray shows cardiomegaly and echocardiography shows chronic, severe aortic regurgitation. If left untreated, which of the following is the most common long-term complication for this patient's condition? Arrhythmias CHF Infective endocarditis Sudden death Myocardial ischemia

CHF

A 63-year-old woman presents with dyspnea on exertion. She reports that she used to work in her garden without any symptoms, but recently she started to note dyspnea and fatigue after working for 20-30 minutes. She has type 2 diabetes mellitus diagnosed 2 years ago but she does not take any medications preferring natural remedies. She also has arterial hypertension and takes torsemide (loop diuretic) 20 mg daily. The weight is 88 kg and the height is 164 cm. The vital signs include: blood pressure is 140/85 mm Hg, heart rate is 90/min, respiratory rate is 14/min, and the temperature is 36.6℃ (97.9℉). Physical examination is remarkable for increased adiposity, pitting pedal edema, and present S3. Echocardiography shows a left ventricular ejection fraction of 51%. The combination of which of the following medications would be a proper addition to the patient's therapy? Metoprolol & indapamide Spironolactone & fosinopril Enalapril & bisoprolol Indapamide & amlodipine Valsartan & spironolactone

Enalapril & bisoprolol - ACEI & beta-blocker

A 75-year-old man presents to his primary care provider with malaise and low-grade fever after he underwent a cystoscopy for recurrent cystitis and pyelonephritis two weeks ago. His past medical history is significant for coronary artery disease and asthma. His current medications include aspirin, metoprolol, atorvastatin, and albuterol inhaler. His temperature is 37.2°C (99.0°F), blood pressure is 110/70 mm Hg, pulse is 92/min, and respiratory rate is 14/min. On physical examination, there are painless areas of hemorrhage on his palms and soles. Cardiac auscultation reveals a new pansystolic murmur over the apex. An echocardiogram shows an echogenic endocardial vegetation on a leaflet of the mitral valve. Which of the following pathogens is most likely responsible for his condition? Staph aureus Staph epidermidis Strep gallolyticus Enterococcus Pseudomonas aeruginosa

Enterococcus - infective endocarditis

A 65-year-old man presents to a physician with a cough and dyspnea on exertion for 1 week. His symptoms worsen at night and he has noticed that his sputum is pink and frothy. He has a history of hypertension for the past 20 years and takes losartan regularly. There is no history of fever or chest pain. The pulse is 124/min, the blood pressure is 150/95 mm Hg, and the respirations are 20/min. On physical examination, bilateral pitting pedal edema is present. Chest auscultation reveals bilateral fine crepitations over the lung bases. A chest radiograph showed cardiomegaly, absence of air bronchograms, and presence of Kerley lines. The physician prescribes a drug that reduces preload and schedules the patient for follow-up after 2 days. During follow-up, the man reports significant improvement in symptoms, including the cough and edema. Which of the following medications was most likely prescribed by the physician? Captopril Carvedilol Digoxin Furosemide Tolvaptan

Furosemide - loop diuretic! Captopril - ACEI decreases afterload and would worsen cough Carvedilol - beta-blocker decreases afterload Digoxin - short-term use/last resort Tolvaptan - ARB decreases afterload

A 55-year-old man presents with complaints of exertional dyspnea and dry cough. He reports using extra pillows at night to sleep and two nighttime awakenings to catch his breath in the last month. The patient lives in a homeless shelter and has not seen a doctor in the last 20 years. He has been drinking 5-8 drinks of alcohol per day for the last 20 years. Family history is non-significant, and the patient does not take any medications. His temperature is 37.1°C (98.9°F), blood pressure is 135/115 mm Hg, pulse is 85/min, and respiratory rate is 24/min. Physical examination reveals 2+ bilateral pitting edema. Chest auscultation reveals bibasilar crackles. Which of the following is associated with this patient's condition? Decreased GFR Decreased vascular smooth muscle tone Decreased ECF volume Increased renal blood flow Increased renal tubular sodium reabsorption

Increased renal tubular sodium reabsorption

A 60-year-old man presents to the emergency department with progressive dyspnea for the last 3 weeks. He complains of shortness of breath while lying flat and reports nighttime awakenings due to shortness of breath for the same duration. The patient has been a smoker for the last 30 years. Past medical history is significant for myocardial infarction 7 months ago. Current medications include metoprolol, aspirin, and rosuvastatin, but the patient is noncompliant with his medications. His temperature is 37.2°C (98.9°F), the blood pressure is 150/115 mm Hg, the pulse is 110/min, and the respiratory rate is 24/min. Oxygen saturation on room air is 88%. Chest auscultation reveals bilateral crackles and an S3 gallop. On physical examination, the cardiac apex is palpated in left 6th intercostal space. Bilateral pitting edema is present, and the patient is in moderate distress. Which of the following is the best next step in the management of the patient? IV beta blockers Echocardiography Cardiac stress testing IV diuretics IV inotropes

IV diuretics - most effective tx for mild-moderate CHF sx

Which lipid measurement is considered at goal for a patient with cardiovascular disease? A. Total Cholesterol 210 mg/dl B. LDL 80 mg/dL C. LDL 69 mg/dL D. HDL 40 mg/dL E.HDL Ratio 6:1

LDL 69 mg/dL

A 75-year-old man presents to the emergency department with a 4-month history of difficulty breathing which forces him to sleep in a chair at night. He had a myocardial infarction 18 months ago but was lost to follow-up. He currently takes no medications. His blood pressure is 156/88 mm Hg and pulse is 100/min and regular. Physical examination shows bilateral lower extremity edema and jugular venous distention. His point of maximal impulse is displaced to the left. There are bibasilar crackles in the lung fields. Cardiac auscultation at the apex reveals the following sound. ECG findings are non-specific. If cardiac catheterization is performed, which of the following would be the most likely findings?

LV EDV : increased; systemic vascular resistance : increased; cardiac index : decreased

A 65-year-old woman presented to the emergency room due to progressive dyspnea. She is a known hypertensive but is poorly compliant with medications. The patient claims to have orthopnea, paroxysmal nocturnal dyspnea, and easy fatigability. On physical examination, the blood pressure is 80/50 mm Hg. There is prominent neck vein distention. An S3 gallop, bibasilar crackles, and grade 3 bipedal edema were also detected. A 2d echo was performed, which showed a decreased ejection fraction (32%). Which of the following drugs should not be given to this patient? Furosemide Nesiritide Metoprolol Digoxin Dobutamine

Metoprolol - don't give in decompensated CHF

A 64-year-old man presents to his primary care physician for 4 weeks of recurrent fever, night sweats, malaise, and fatigue. Associated with shortness of breath and orthopnea. Family and personal history are unremarkable. Upon physical examination, he is found with a blood pressure of 100/68 mm Hg, a heart rate of 98/min, a respiratory rate of 20/min, and a body temperature of 38.5°C (101.3°F). Cardiopulmonary auscultation reveals a high-pitched holosystolic murmur over the lower end of the left sternal border and that radiates to the left axilla. Skin lesions are found on the patient's palms seen in the picture below. Which of the following entities predisposed this patient's condition? Rheumatic heart disease Systemic lupus erythematosus Mitral valve prolapse Bicuspid aortic valve Pulmonary stenosis

Mitral valve prolapse - MC risk factor associated with infective endocarditis

A 21-year-old man presents to his physician for a routine checkup. His doctor asks him if he has had any particular concerns since his last visit and if he has taken any new medications. He says that he has not been ill over the past year, except for one episode of the flu. He has been training excessively for his intercollege football tournament, which is supposed to be a huge event. His blood pressure is 110/70 mm Hg, pulse is 69/min, and respirations are 17/min. He has a heart sound coinciding with the rapid filling of the ventricles and no murmurs. He does not have any other significant physical findings. Which of the following best describes the heart sound heard in this patient? Opening snap S3 S4 Mid systolic click

S3

A 48-year-old man is brought to the emergency department for sudden onset of difficulty breathing 6 hours ago. For the past several months, he has had shortness of breath on exertion and while lying down on the bed, frequent headaches, and swelling of his feet. He does not take any medications despite being diagnosed with hypertension 10 years ago. His pulse is 90/min, respirations are 20/min, blood pressure is 150/110 mm Hg, and temperature is 37.0°C (98.6°F). Physical examination shows an overweight male in acute distress with audible wheezes. Crackles are heard bilaterally and are loudest at the lung bases. Which of the following findings on cardiac auscultation will most likely be present in this patient? Fixed split S2 Loud P2 S3 gallop Absent S4 Loud S1

S3 gallop

Which of the following valves are closed during Diastole? Aortic Mitral Tricuspid Pulmonic

aortic & pulmonic

A 40-year-old man presents with substernal chest pain for the past hour. He describes the chest pain as severe, squeezing in nature, diffusely localized to the substernal area and radiating down his left arm. He also has associated nausea, dizziness, and diaphoresis. He denies any recent history of fever, chest trauma, palpitations, or syncope. Past medical history is significant for gastroesophageal reflux disease (GERD), managed medically with a proton pump inhibitor for the last 3 months. He also has uncontrolled diabetes mellitus type 2 and hypercholesterolemia diagnosed 10 years ago. His last HbA1c was 8.0. The vital signs include: blood pressure 140/90 mm Hg, pulse 100/min, respiratory rate 20/min, temperature 36.8°C (98.3°F) and oxygen saturation 98% on room air. He is administered sublingual nitroglycerin which lessens his chest pain. Chest radiograph seems normal. Electrocardiogram (ECG) shows ST-segment elevation in anterolateral leads. Which of the following is the most likely diagnosis of this patient? Acute coronary syndrome GERD Diffuse esophageal spasm Pulmonary embolism Pneumothorax

acute coronary syndrome

A 44-year-old man presents to the emergency department due to sudden chest pain and difficulty breathing for the past 3 hours. The pain is felt in the retrosternal area and radiates up to his left shoulder and arm; it worsens on inspiration, and is relieved when he is leaning forward. His heart rate is 61/min, respiratory rate is 16/min, temperature is 36.5°C (97.7°F), and blood pressure is 115/78 mm Hg. Physical examination shows no abnormalities. Pericardial friction rub is heard on auscultation. Laboratory results show elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels. An ECG is performed. Which of the following is the most likely diagnosis? Acute pericarditis Angina pectoris Aortic stenosis Infective endocarditis MI

acute pericarditis

A 55-year-old obese female with a history of hypertension, tobacco abuse, and hyperlipidemia presents for routine follow-up. Which of her risk factors for coronary atherosclerosis is not modifiable? Age High LDL Hypertension Obesity

age

A 58-year-old man presents to the emergency department with severe chest pain and uneasiness. He says that symptoms onset acutely half an hour ago while he was watching television. He describes the pain as being 8/10 in intensity, sharp in character, localized to the center of the chest and retrosternal, and radiating to the back and shoulders. The patient denies any associated change in the pain with breathing or body position. He says he has associated nausea but denies any vomiting. He denies any recent history of fever, chills, or chronic cough. His past medical history is significant for hypertension, hyperlipidemia, and diabetes mellitus for which he takes lisinopril, hydrochlorothiazide, simvastatin, and metformin. He reports a 30-pack-year smoking history and has 1-2 alcoholic drinks during the weekend. Family history is significant for hypertension, hyperlipidemia, and an ST elevation myocardial infarction in his father and paternal uncle. His blood pressure is 220/110 mm Hg in the right arm and 180/100 mm Hg in the left arm. On physical examination, the patient is diaphoretic. Cardiac exam reveals a grade 2/6 diastolic decrescendo murmur loudest over the left sternal border. Remainder of the physical examination is normal. The chest radiograph shows a widened mediastinum. The electrocardiogram (ECG) reveals non-specific ST segment and T wave changes. Intravenous morphine and beta-blockers are started. Which of the following is the most likely diagnosis in this patient? Aortic dissection Pulmonary embolism Acute myocardial infarction Myocarditis Aortic regurgitation

aortic dissection

A 59-year-old woman presents to the outpatient clinic for worsening symptoms of congestive heart failure. She states that while she used to be able to go for short walks, she is no longer able to do so. Now, even simple tasks like getting ready in the morning have become burdensome for her. When she gets tired, sitting down helps to alleviate her symptoms. Her blood pressure is 136/92 mm Hg and heart rate is 76/min. On physical examination, she has regular heart sounds but does have 1+ pitting edema to her bilateral lower extremities. What is her New York Heart Association Functional Classification for congestive heart failure? Class I Class IIa Class IIb Class III Class IV

class III

A 71-year-old man develops worsening chest pressure while shoveling snow in the morning. He tells his wife that he has a squeezing pain that is radiating to his jaw and left arm. His wife calls for an ambulance. On the way, he received chewable aspirin and 3 doses of sublingual nitroglycerin with little relief of pain. He has borderline diabetes and essential hypertension. He has smoked 15-20 cigarettes daily for the past 37 years. His blood pressure is 172/91 mm Hg, the heart rate is 111/min and the temperature is 36.7°C (98.0°F). On physical examination in the emergency department, he looks pale, very anxious and diaphoretic. His ECG is shown in the image. Troponin levels are elevated. Which of the following is the best next step in the management of this patient condition? Oral nifedipine Fibrinolysis Clopidogrel, atenolol, anticoagulation & monitoring Echocardiography CT scan of chest with contrast

clopidogrel, atenolol, anticoagulation & monitoring

A 46-year-old woman presents with a 5-month history of worsening dry cough, occasional shortness of breath, and fatigue. She says she is now having trouble walking a full block. For the past week, she also has noticed bilateral swelling of the lower legs. She denies chest pain, fever, chills, syncope, or bloody sputum. Current vitals include: temperature 37.0°C (98.6°F), pulse 63/min, blood pressure 128/91 mm Hg and respiratory rate 15/min. On physical examination, there is elevated jugular venous pressure, decreased breath sounds bilaterally at the lung bases, and 1+ non-pitting edema bilaterally in the lower extremities. A chest X-ray demonstrates a slightly enlarged cardiac silhouette. Which of the following is the most appropriate next step in the diagnosis of this patient? Bronchoalveolar wash Pulmonary function studies Echocardiography Chest CT Biopsy of the heart

echocardiography

A 57-year-old man presents to his primary care provider because of chest pain for the past 3 weeks. The chest pain occurs after climbing more than 2 flights of stairs or walking for more than 10 minutes and resolves with rest. He is obese, has a history of type 2 diabetes mellitus, and has smoked 15-20 cigarettes a day for the past 25 years. His father died from a myocardial infarction at 52 years of age. Vital signs reveal a temperature of 36.7 °C (98.06°F), a blood pressure of 145/93 mm Hg, and a heart rate of 85/min. The physical examination is unremarkable. Which of the following best represents the most likely etiology of the patient's condition? Multivessel atherosclerotic disease w/ or w/out a nonocclusive thrombus Intermittent coronary vasospasm w/ or w/out coronary atherosclerosis Sudden disruption of an atheromatous plaque with a resulting occlusive thrombus Fixed, atherosclerotic coronary stenosis Hypertrophy of the interventricular septum

fixed, atherosclerotic coronary stenosis (ischemic heart disease)

A 23-year-old man presents with sudden loss of consciousness while pitching in a baseball game. There is no history of injury. Consciousness is regained after cardiopulmonary resuscitation. Past medical history is negative for any neurological and cardiovascular problems. Physical examination reveals a prominent A wave on the jugular venous pulse and a double apical impulse. There are no audible murmurs. An S4 is present. What is the most likely diagnosis? Dilated cardiomyopathy Hypertrophic cardiomyopathy Aortic stenosis Takotsubo cardiomyopathy Restrictive cardiomyopathy

hypertrophic cardiomyopathy

A 70-year-old man presented to a medical clinic for a routine follow-up. He has had hypertension for 20 years and is currently on multiple anti-hypertensive medications. The blood pressure is 150/100 mm Hg. The remainder of the examinations were within normal limits. Echocardiography showed some changes in the left ventricle. What is the most likely reason for the change? Disordered growth of cardiac cells Replacement of cardiac cells into stronger red fiber skeletal cells Decrease in cardiac cell size Increase in cardiac cell size Increase in # of normal cardiac cells

increase in cardiac cell size

A 27-year-old man from Southern California presents with progressive chest pain, non-productive cough, and shortness of breath for the past 24 hours. He denies any similar symptoms in the past. He denies any family history of cardiac disease, recent travel, or exposure to sick contacts. His temperature is 38.5°C (101.3°F), pulse is 105/min, blood pressure is 108/78 mm Hg, and the respiratory rate is 32/min. On physical examination, patient is cachectic and ill-appearing. Bilateral pleural friction rubs are present on pulmonary auscultation. Antecubital track marks are noted bilaterally. An echocardiogram is performed and results are shown below. Which of the following is the most likely diagnosis in this patient? Histoplasmosis Hypertrophic cardiomyopathy Infective endocarditis Pulmonary embolism TB

infective endocarditis - IV drug use

A 38-year-old woman presents to her physician's clinic for recurrent episodes of chest pain that wakes her from her sleep. While usually occurring late at night, she has also had similar pains during the day at random times, most recently while sitting at her desk in her office and at other times while doing the dishes at home. The pain lasts 10-15 minutes and resolves spontaneously. She is unable to identify any common preceding event to pain onset. The remainder of her history is unremarkable and she takes no regular medications. She works as an accountant. There is no history of smoking or drug use, however, she does consume 5 alcoholic drinks per week. Examination reveals: pulse 70/min, respirations 16/min, and blood pressure 120/70 mm Hg. A physical examination is unremarkable. Which of the following would be effective in reducing her symptoms? Aspirin Clopidogrel Digoxin Isosorbide dinitrate - nitrate Heparin Propranolol Rosuvastatin

isosorbide dinitrate

What is the EKG manifestation of cardiac end-organ damage due to hypertension? Right bundle branch block Left ventricular hypertrophy Right ventricular hypertrophy ST segment elevation in lateral precordial leads

left ventricular hypertrophy

A 23-year-old active college student has a sudden loss of consciousness 40 minutes after he was playing basketball with his team. Cardiopulmonary resuscitation is administered by bystanders. On arrival of emergency medical professionals, he regains his consciousness. He has no past medical history. He does not smoke or drink alcohol. His family history is positive for a cousin who died suddenly in his youth. On physical examination, a systolic ejection murmur is audible on the left lower sternal border. ECG shows left ventricular hypertrophy and echocardiography shows asymmetric septal hypertrophy. Which of the following decreases the pressure gradient between the aorta and the left ventricle in this patient? High-dose diuretics Digoxin Nitroglycerin Metoprolol Forceful attempted exhalation against a closed airway

metoprolol

You hear a Systolic murmur at the left 5th intercostal space? Mitral stenosis Mitral prolapse Aortic stenosis Aortic prolapse

mitral prolapse

You hear a diastolic murmur at the left 5th intercostal space. Aortic regurge Mitral regurge Aortic stenosis Mitral stenosis

mitral stenosis

A healthy 20-year-old African American man presents to the clinic for pre-participation sports physical for college football. He has no health complaints at this time. He has no recent history of illness or injury. He denies chest pain and palpitations. He reports no prior syncopal episodes. He had surgery 2 years ago for appendicitis. His mother is healthy and has an insignificant family history. His father had a myocardial infarction at the age of 53, and his paternal uncle died suddenly at the age of 35 for unknown reasons. His temperature is 37.1°C (98.8°F), the heart rate is 78/min, the blood pressure is 110/66 mm Hg, and the respiratory rate is 16/min. He has a tall, proportional body. There are no chest wall abnormalities. Lungs are clear to auscultation. His pulse is 2+ and regular in bilateral upper and lower extremities. His PMI is nondisplaced. Auscultation of his heart in the 5th intercostal space at the left midclavicular line reveals a systolic murmur. What type of murmur does he most likely have? Mitral valve stenosis Mitral valve prolapse Aortic regurge Tricuspid stenosis

mitral valve prolapse

A 37-year-old woman is being evaluated for difficulty with swallowing that has worsened over the past few months. She explains that she experiences difficulty swallowing solid foods only. Her medical history is relevant for hypothyroidism and migraines. Her current medications include daily levothyroxine and acetaminophen as needed for pain. Her blood pressure is 110/90 mm Hg, pulse rate is 55/min, and respiratory rate is 12/min. On physical examination, her abdomen is nontender. Her voice is hoarse, but there is no pharyngeal hyperemia on oral examination. On cardiac auscultation, an opening snap followed by an early to mid-diastolic rumble is heard over the apex. A barium swallow X-ray is performed and is unremarkable. Echocardiography shows an enlarged left atrium and abnormal blood flow through 1 of the atrioventricular valves. What is the most likely valve abnormality seen in this patient? Mitral valve stenosis Mitral valve regurgitation Aortic valve stenosis Aortic valve regurgitation Mitral valve prolapse

mitral valve stenosis

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

primary aldosteronism

A 39-year-old man presents to the emergency department because of progressively worsening chest pain and nausea that started at a local bar 30 minutes prior. The pain radiates to the epigastric area. He has a 5-year history of untreated hypertension. He has smoked 1 pack of cigarettes daily for the past 5 years and started abusing cocaine 2 weeks before his emergency room visit. The patient is diaphoretic and in marked distress. What should be the first step in management? Diltiazem Labetalol Nitroglycerin Propranolol Reassurance & continuous monitoring

reassurance & continuous monitoring

Which of the following is the most common cause of secondary hypertension? Renal parenchymal disease Primary aldosteronism Oral contraceptive use Cushing's syndrome

renal parenchymal disease

A 53-year-old businessman is rushed to the emergency department with sudden onset, severe crushing chest pain radiating to his left arm and jaw. He has a history of episodic chest pain on exertion for which he uses nitroglycerin sublingually, but his medication did not relieve the pain today. His blood pressure is 141/97 mm Hg, pulse is 130/min, respiratory rate is 18/min, and temperature is 37°C (98.6°F). Physical examination reveals an uncomfortable and diaphoretic man with mildly labored breathing. Cardiac auscultation reveals tachycardia with a regular rhythm. A bedside electrocardiogram shows ST-segment elevation in leads II, III, and aVF. Blood is drawn and sent to the lab which shows elevated cardiac troponins. The ECG shown in the image was obtained from the patient. The patient is sent to the catheterization lab for evaluation for angioplasty with stent placement. The coronary catheterization will most likely reveal blockage of which of the following arteries? Left marginal artery Right coronary artery Left anterior descending artery Right marginal artery

right coronary artery

A 67-year-old man comes to the physician due to exertional dyspnea and lower extremity swelling for the last 4 weeks. The patient has been a smoker for the last 45 years and has been diagnosed with COPD. He has no history of diabetes mellitus or ischemic heart disease. He is non-compliant with his medications for COPD. The patient is a retired social worker and spends most of his time at home. His temperature is 37.2°C (98.9°F), blood pressure is 135/115 mm Hg, pulse is 90/min, and respirations are 22/min. Oxygen saturation on room air is 92%. Physical examination reveals a barrel-shaped chest, distension of neck veins, and 3+ bilateral pitting edema of his lower extremities. The liver is palpated 6 cm below the costal margin and is tender to palpation. Application of pressure on the upper abdomen causes persistent distension of jugular veins. Lungs are clear to auscultation. Chest X-ray shows enlarged main pulmonary arteries. ECG shows right bundle branch block and right ventricular hypertrophy. Which of the following is the gold standard test for diagnosing this patient's condition? Pulmonary capillary wedge pressure Right heart catheterization Coronary angiography Abdominal paracentesis Ultrasound of liver

right heart catheterization

A 52-year-old man presents to the office complaining of a 2-week history of fatigue, progressively worsening shortness of breath, and swelling of his lower legs and feet. His past medical history is only significant for slightly elevated blood pressure. The patient denies tobacco use although he does admit to drinking 8-10 beers, daily, for the past 10 years. He takes a low dose of aspirin daily, ever since he had an anterior myocardial infarction 2 years ago. The patient works as a financial consultant and frequently travels for work. The current temperature is 36.8°C (98.3°F), the pulse rate is 68/min, the blood pressure is 152/84 mm Hg, and the respiratory rate is 16/min. His weight is 102 kg (224 lb) and height 180 cm (5 ft 9 in). Echocardiography demonstrates an ejection fraction of 35% and a thin left ventricular wall. What is the appropriate medication for this patient's condition? Nifedipine Atorvastatin Procainamide Ibuprofen Spironolactone

spironolactone

A 79-year-old man presents to his primary care physician complaining of progressive shortness of breath on exertion for the past 2 months. He was first aware of having to catch his breath while gardening, and he is now unable to walk up the stairs in his house without stopping. He has had type 2 diabetes mellitus for 30 years, for which he takes metformin and sitagliptin. His blood pressure is 110/50 mm Hg, the temperature is 37.1°C (98.8°F), and the radial pulse is 80/min and regular. On physical examination, there is a loud systolic murmur at the right upper sternal border with radiation to the carotid arteries. Which of the following will increase the intensity of this patient's murmur? Squatting Standing up Valsalva maneuver Isometric handgrip

squatting

A 44-year-old man presents for a routine check-up. He has a past medical history of rheumatic fever. The patient is afebrile, and the vital signs are within normal limits. Cardiac examination reveals a late systolic crescendo murmur with a mid-systolic click, best heard over the apex and loudest just before S2. Which of the following physical examination maneuvers would most likely cause an earlier onset of the click/murmur? Handgrip Inspiration Left lateral decubitus position Rapid squatting Standing

standing

A 65-year-old man is brought to the emergency department with central chest pain for the last hour. He rates his pain as 8/10, dull in character, and says it is associated with profuse sweating and shortness of breath. He used to have heartburn and upper abdominal pain associated with food intake but had never experienced chest pain this severe. He has a history of diabetes, hypertension, and hypercholesterolemia. His current medication list includes amlodipine, aspirin, atorvastatin, insulin, valsartan, and esomeprazole. He has smoked 1 pack of cigarettes per day for the past 35 years. Physical examination reveals: blood pressure 94/68 mm Hg, pulse 112/min, oxygen saturation 95% on room air, and BMI 31.8 kg/m2. His lungs are clear to auscultation. An electrocardiogram (ECG) is done and shown in the picture. The patient is discharged home after 3 days on aspirin, clopidogrel, and atenolol in addition to his previous medications. He is advised to get an exercise tolerance test (ETT) in one month. A month later at his ETT, his resting blood pressure is 145/86 mm Hg. The pre-exercise ECG shows normal sinus rhythm with Q waves in the inferior leads. After 3 minutes of exercise, the patient develops chest pain that is gradually worsening, and repeat blood pressure is 121/62 mm Hg. No ischemic changes are noted on the ECG. What is the most appropriate next step? Continue to exercise since ECG doesn't show ischemic changes Repeat exercise tolerance testing after one month Stop exercise and order coronary angiography Stop exercise and order a pharmacological stress test Stop exercise and order an echo stress test

stop exercise & order coronary angiography

A 50-year-old man presents the emergency department for intense chest pain, profuse sweating, and shortness of breath. The onset of these symptoms was 3 hours ago. The chest pain began after a heated discussion with a colleague at the community college where he is employed. Upon arrival, he is found conscious and responsive; the vital signs include a blood pressure of 130/80 mm Hg, a heart rate at 90/min, a respiratory rate at 20/min, and a body temperature of 36.4°C (97.5°F). His medical history is significant for hypertension diagnosed 7 years ago, which is well-controlled with a calcium channel blocker. The initial electrocardiogram (ECG) shows ST-segment depression in multiple consecutive leads, an elevated cardiac troponin T level, and normal kidney function. Which of the following would you expect to find in this patient? Ventricular pseudoaneurysm Transmural necrosis Subendocardial necrosis - NSTEMI Incomplete occlusion of a coronary artery Coronary artery spasm

subendocardial necrosis (NSTEMI)

A 43-year-old woman is brought to the emergency department by her brother for severe chest pain. The patient recently lost her husband in a car accident and is still extremely shocked by the event. On physical examination, her blood pressure is 105/67 mm Hg, the heart rate is 96/min and regular, breathing rate is 23/min, and the pulse oximetry is 96%. An S3 heart sound and rales in the lower right and left lung lobes are heard. A 12-lead ECG shows no significant findings. Echocardiography shows an enlarged left ventricle and left atrium. The patient is stabilized and informed about the diagnosis and possible treatment options. Which of the following is the most likely diagnosis? Aortic stenosis A fib Constrictive pericarditis Takotsubo cardiomyopathy Restrictive cardiomyopathy

takotsubo cardiomyopathy