Cardio Block 2 Review
Continue high-dose statin and add ezetimibe
A 45-year-old man with a history of diabetes mellitus and hyperlipidemia has been hospitalized for an acute coronary syndrome. His serum LDL cholesterol prior to admission on high-dose atorvastatin (80 mg daily) was 82 mg/dL. Which of the following lipid-lowering regimens would be most appropriate following discharge? a. Continue high-dose statin only. b. Continue high-dose statin and add ezetimibe. c. Continue high-dose statin and add a PCSK9 inhibitor. d. Continue high-dose statin and add niacin.
Admit to the hospital for workup of left ventricular dysfunction
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? A Send him home on 20 mg furosemide (Lasix) p.o. every day and recheck in one week B Send him home on clarithromycin (Biaxin) 500 mg p.o. BID and recheck in 1 week C Admit to the hospital for workup of left ventricular dysfunction D Admit to the hospital for workup of pneumonia
Furosemide
A 58-year-old man ran out of his congestive heart failure medications. He presents with significant dyspnea and altered mental status. Examination reveals bibasilar crackles and jugular venous distension. An electrocardiogram shows sinus rhythm with low voltage complexes. Which of the following is most appropriate at this time? a.Amiodarone b.Disopyramide c.Furosemide d.Ventricular assist device
Atrial fibrillation
A 76-year-old woman with a history of hypertension comes to the office because of palpitations and dizziness for the past week. An electrocardiogram is obtained, and the rhythm strip is shown. What finding is shown in this electrocardiogram that most likely explains this patient's symptoms? A. Atrial fibrillation B. Atrial flutter C. First degree atrioventricular block D. Mobitz I (Wenckebach) second-degree atrioventricular block E. Sinus node dysfunction
Transcutaneous pacing
An 85-year-old woman presents to the emergency department after a syncopal episode. She is still moderately confused and complains of severe chest pain and dyspnea. The emergency team states that her medications include beta blockers and digitalis. Cardiac monitor is below. Blood pressure is 80/40. The patient's ECG is below. Which of the following is the best treatment strategy at this time? A. Discontinue beta blocker therapy B. Adenosine C. Epinephrine D. Transcutaneous pacing E. Thrombolic therapy
Give atropine 0.5 mg IV
An IV has been established. The patient is showing clear signs of poor perfusion with the following rhythm. What should be your next intervention? 1. observe and monitor 2. give adenosine 6mg rapid IV push 3. give atropine 0.5mg IV 4. begin CPR
Labetolol
An active 19-year-old male presents with dyspnea on exertion and pre-syncopal episodes. He has a positive family history of sudden cardiac death. Echocardiography demonstrates significant left ventricular hypertrophy. Which pharmacotherapeutic agent is the most appropriate initial therapy for this patient? A. Labetolol B. Nifedipine C. Aspirin D. Atropine E. Adenosine
Ventricular fibrillation
As you finish up with the first cycle of CPR and give the first dose of epinephrine (1mg IVP), the rhythm changes. The rhythm below is what you now see on the monitor. The patient remains unresponsive. What is this rhythm? 1. artifact 2. ventricular tachycardia 3. atrial fibrillation 4. ventricular fibrillation
amount of activity that precipitates it
Eliciting a history from a patient presenting with dyspnea due to early heart failure the severity of the dyspnea should be quantified by A amount of activity that precipitates it. B how many pillows they sleep on at night. C how long it takes the dyspnea to resolve. D any associated comorbidities.
Renal artery stenosis
A 23-year-old asymptomatic woman comes to your office for routine follow-up on an elevated blood pressure reading taken one week prior. She has no significant past medical history besides an appendectomy at age 14. On physical examination today, the patient again has an elevated blood pressure. Which of the following is the most likely cause of secondary hypertension in this patient? A. Coarctation of the aorta B. Cushing syndrome C. Diabetes D. Obstructive sleep apnea E. Renal artery stenosis
rapid ventricular filling during early dyastole
In congestive heart failure the mechanism responsible for the production of an S3 gallop is? A contraction of atria in late diastole against a stiffened ventricle. B rapid ventricular filling during early diastole. C vibration of a partially closed mitral valve during mid to late diastole. D secondary to closure of the mitral valve leaflets during systole.
give amiodarone 300mg IV/IO
The epinephrine is given, and after the cycle of CPR is completed a rhythm check reveals continued ventricular fibrillation. You give a third shock (300 J) and resume CPR. What is your next intervention during CPR? 1. give lidocaine 2 to 2.5 mg/kg IV/IO 2. give magnesium 2 to 4 grams IV/IO 3. give atropine 1mg IV/IO 4. give amiodarone 300mg IV/IO
Amiodarone
The third shock is delivered and you restart CPR (5 cycles). What medication should be given after the 3rd shock during CPR? 1. Amiodarone 2. Lopressor 3. Atropine 4. Dopamine
both epinephrine or dopamine
Transcutaneous pacing is attempted. You set the pacing rate for 60/min and attempt capture. After trying for about 30-40 seconds, you are unable to achieve capture. What other medication may now be considered for use in the bradycardia algorithm? 1. epinephrine 2. dopamine 3. amiodarone 4. both epinephrine or dopamine 5. both dopamine or amiodarone
Tobacco
Use of which of the following substances accounts for the leading causes of preventable death in the United States? A. Alcohol B. Heroin C. Marijuana D. Prescription narcotics E. Tobacco
Give adenosine 6 mg rapid IV push. If no conversion, give 12 mg rapid IV push.
What is your next step? 1. Give adenosine 6mg rapid IV push. If no conversion, give 12mg rapid IV push 2. Give adenosine 12mg rapid IV push. If no conversion, give another 12mg rapid IV push. 3. Give Amiodarone 150mg over 10 minutes. May repeat as needed 4. Continue to attempt vagal maneuvers until the patient converts to a regular sinus rhythm
All of the above
What should be checked to ensure that this is true asystole? 1. loose leads or leads not connected to the patient 2. signal gain 3. ensure that the patient is pulseless 4. all of the above
Loud murmur associated with a thrill
Which description corresponds to a heart murmur that is classified as a grade 4/6? A. Quiet, but clearly audible with the stethoscope B. Heard with the stethoscope entirely off the chest, obvious thrill C. May be heard with the stethoscope partially off the chest, obvious thrill D. Loud murmur associated with a thrill E. Moderately loud murmur
assist breathing and give oxygen, monitor ECG & VS, establish IV access
Which is the correct order for treatment in this scenario? 1. assist breathing and give oxygen, monitor ECG & VS, establish IV access 2. give oxygen, monitor ECG & VS, establish IV access, assist breathing 3. monitor ECG & VS, assist breathing and give oxygen, establish IV access 4. establish IV access, Give oxygen, monitor ECG & VS, assist breathing
Stage C
Which of the following American College of Cardiology (ACC) and American Heart Association (AHA) stages do the majority of patients with heart failure fall under? A Stage A B Stage B C Stage C D Stage D
Crescendo-decrescendo systolic ejection murmur
Which of the following best describes the murmur associated with aortic stenosis? A. Crescendo-decrescendo diastolic murmur B. Holosystolic murmur best heard at the apex C. Late diastolic ejection murmur D. Crescendo-decrescendo systolic ejection murmur E. Machine-like rough continuous murmur
Afterload
Which of the following best describes the pressure against which the heart must work to eject blood during systole? A. Afterload B. Ejection fraction C. Preload D. Pulmonary capillary wedge pressure E. Stroke volume
Pericardial effusion
Which of the following best represents the abnormality shown in this chest radiograph? A. Enlarged aortic knob B. Pleural effusion C. Hilar adenopathy D. Pericardial effusion E. Solitary pulmonary nodule
Restrictive cardiomyopathy
Which of the following cardiomyopathies has diastolic dysfunction as a hallmark finding? A. Dilated cardiomyopathy B. Congestive heart failure C. Alcoholic cardiomyopathy D. Restrictive cardiomyopathy E. Peripartum cardiomyopathy
Papilledema
Which of the following characteristic physical examination findings is most likely to be seen in a patient with malignant hypertension? A. Diastolic murmur B. Jugular venous distention C. Papilledema D. Peripheral edema E. Precordial thrill
Thyrotoxicosis
Which of the following is a cause of high output heart failure? A myocardial ischemia B complete heart block C aortic stenosis D thyrotoxicosis
Renal ultrasound
Which of the following is not indicated in the initial evaluation of a patient with suspected essential hypertension? A. Serial blood pressure measurements B. ECG C. Basic metabolic panel D. Urinalysis E. Renal ultrasound
Dyspnea on exertion
Which of the following is the earliest sign or symptom of congestive heart failure? A. Dyspnea on exertion B. Paroxysmal nocturnal dyspnea C. Distended neck veins D. Bibasilar rales E. Pitting lower extremity edema
Amyloidosis
Which of the following is the most common cause of restrictive cardiomyopathy? A. Hemochromatosis B. Scleroderma C. Sarcoidosis D. Amyloidosis E. Carcinoid heart disease
Isoproterenol
Which of the following is the most potent positively chronotropic agent? A. Isoproterenol B. Dobutamine C. Norepinephrine D. Epinephrine E. Diltiazem
Diltiazem
Which of the following medications is used for rate control in patients who have an irregularly irregular rhythm on ECG? A. Isoproterenol B. Digitalis C. Atropine D. Amiodarone E. Diltiazem
Chest pain that occurs at rest
Which of the following meets the definition of unstable angina? A. Chest pain that occurs at rest B. Chest pain that occurs with exertion C. Chest pain that is pleuritic in nature D. Chest pain that is associated with leg edema E. Chest pain lasting less than 5 minutes
Calcium channel blockers
Which of the following should be avoided in patients with heart failure? A Diuretics B Digoxin C Anticoagulants D Calcium channel blockers
Cardiac CT scanning
Which of the following studies is not usually required in the routine diagnosis and management of heart failure? A Cardiac CT scanning B ECG C Chest radiography D Echocardiography
establish IV access
You are caring for a 50-year-old female. She is 2 days post-op. from a total hip replacement. 6L/min by nasal cannula. When you enter the patient's room, she appears to be unconscious and you note that her nasal cannula is laying beside her bed. Your initial assessment reveals: SKIN: ashen, diaphoretic, warm CVS: Carotid pulse only, HR 25, unable to obtain blood pressure RESP: sporadic and shallow CNS: Unresponsive Monitor: See below You have called for help. Being an in-hospital setting emergency, your first priority is to: 1. give epinephrine 2. begin chest compressions 3. secure the airway and ventilate with BVM (bag valve mask) 4. establish IV access
Echocardiography
You are examining a two-week-old infant that was brought in for his well child checkup. You note a systolic murmur at the left chest, as well as diminished pulses of the femoral arteries bilaterally. Which of the following is considered to be diagnostic for this patient's suspected condition? A. Electrocardiography B. Brain natriuretic peptide level C. Echocardiography D. Chest radiography E. CT scan of the chest
begin CPR immediately
You confirm that this is true asystole and that the patient has no pulse. You begin the cardiac arrest algorithm. Your first step is to? 1. give 1 shock (120-200 J) 2. give epinephrine 1 mg 3. begin CPR immediately 4. continue transcutaneous pacing
give 1 shock (120-200 J)
You determine that this rhythm is ventricular fibrillation, and you begin the VF cardiac arrest algorithm (left branch). What is your first intervention? 1. give 1 shock (120-200 J) 2. give 3 stacked shocks 3. continue CPR (5 cycles) 4. give epinephrine 1mg IV/IO
perform immediate synchronized cardioversion
You give 6mg Adenosine rapid IV push with no effect. 12mg Adenosine rapid IV push is then given. The patient develops severe chest pain and his vital signs are: HR 220, BP (not obtainable), and weak pulse. The patient also has LOC changes. Your next step should be? 1. perform immediate defibrillation 2. give 2nd dose of 12mg adenosine rapid IV push 3. perform immediate synchronized cardioversion 4. perform precordial thump
attempt transcutaneous pacing
You give atropine 0.5mg IV push. There is no change in the patients rhythm/rate. What will be your next intervention? 1. attempt transcutaneous pacing 2. increase atropine to 1mg IVP 3. adenosine 1mg IVP 4. norepinephrine 1mg IVP
shock (360 J)
You give the amiodarone 300 mg IV and after completing the 5 cycles of CPR you check the rhythm: What is your next step? 1. give amiodarone 150 mg IV 2. consider giving atropine 0.5mg IV 3. shock (360 J) 4. check a pulse
300 Joules
You have given the epinephrine and completed the 5 cycles of CPR. A rhythm check reveals no change. You attempt a third defibrillation. What will be your defibrillator setting? A. 300 Joules B. 150 Joules C. 120 Joules D. 50 Joules
Give 5 cycles of CPR
You perform defibrillation with 120 J. What is your next intervention? A. Deliver a second shock (120-200 J) B. Give 1mg Epinephrine IV push (repeat the epinephrine every 3-5 minutes) C. Give 5 cycles of CPR D. Check the rhythm and the pulse
Amiodarone
You shock the patient and complete 5 cycles of CPR. After the CPR, you see the following rhythm on the monitor. You perform a pulse check. The patient now has a palpable pulse. VS are: HR 60; BP 105/65; RR 5-8 You have corrected the ventricular fibrillation and the patient is stabilizing but has had several short runs of ventricular tachycardia post-arrest. You now consider maintenance antiarrhythmic therapy that can be started if any arrhythmias persist in the post-arrest phase. Which is the best drug of choice in this scenario? 1. amiodarone 2. lidocaine 3. epinephrine 4. magnesium sulfate
give 1 shock
You shock the patient with 120 J and continue CPR immediately. After 5 cycles of CPR, your rhythm check reveals continued ventricular fibrillation. What is your next step? 1. give epinephrine 1mg IV/IO 2. check to see that your leads are still connected 3. give 1 shock 4. give atropine 0.5mg IV/IO
Start CPR, beginning with chest compressions
Your patient collapses. You see this on the monitor. After providing a shock with an AED you should? a.Start CPR, beginning with chest compressions b.check a pulse c.give a rescue breath d.let the AED reanalyze the rhythm
Serum BNP levels
Your patient with a MI diagnosis may progress to CHF. Which of the following laboratory tests would yield results most indicative of congestive heart failure? A. Complete blood count B. Serum BNP levels C. Erythrocyte sedimentation rate D. Troponin E. Arterial blood gas
Atrial septal defect
A 28 month old infant is brought into your office by her parents. They have noticed that she is not playing as much as she used to, and now spends much of the day asking to be held. Physical exam shows a systolic ejection murmur with associated heave at the left-lower sternal border. You are also able to discern that there is fixed splitting of the S2 heart sound. Which of the following is this patient's most likely diagnosis? A. Mitral valve prolapse B. Ventricular septal defect C. Aortic stenosis D. Atrial septal defect E. These are normal findings in this patient population
ASD
1) What is RBBB associated with? A) ASDB) VSDC) Paradoxical split S2
VSD and Paradoxical split S2
2) What is LBBB most likely associated with? A) ASD B) Mitral Regurgitation C) Paradoxical split S2
Dilated cardiomyopathy
A 28 year old female presents to the urgent care complaining of a cough that has been ongoing for two weeks. She has been more fatigued than usual since delivering her first child 4 weeks earlier. When questioned, she states that she has to sleep on three or four pillows now to feel comfortable. Chest x-ray reveals cardiomegaly, but is otherwise non-specific. Which of the following is the most likely diagnosis? A. Viral pneumonia B. Bacterial pneumonia C. Cardiac ischemia D. Pulmonary embolism E. Dilated cardiomyopathy
AED
A 58-year-old man collapses suddenly while attending a sporting event. He is pulseless and apneic. What can you do to save his life? A)Airway management B)AED C)IV Access D)Epinephrine
Renal artery stenosis
A 29-year-old woman who is otherwise healthy is seen in the office by her primary care provider for evaluation of throbbing, frontal headaches for the past two months. She states that she gets mild symptomatic relief from using over-the-counter ibuprofen, but the headaches always return. There is no aura. She takes no regular medications, and specifically denies recent steroid or oral contraceptive pill use. She does not use recreational drugs or smoke cigarettes. She has 2-3 alcoholic drinks per month in a social setting. Temperature is 37.0°C (98.6°F), pulse rate is 88/min, and blood pressure is 164/98 mmHg in both arms. On examination, bruits are heard bilaterally over the flanks. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis? A. Aortic aneurysm B. Essential hypertension C. Pheochromocytoma D. Primary hyperaldosteronism E. Renal artery stenosis
Pulmonary stenosis
A 3-month-old male infant is brought to the emergency department because he has had sudden crying spells during the past three weeks, and he is getting progressively harder to console. His parents noticed that today while crying, the patient's lips and fingernails turned visibly blue. On physical examination, a crescendo-decrescendo harsh systolic ejection murmur is heard on auscultation. A ventricular septal defect is noted on echocardiography. Which of the following additional findings is most likely to be noted on echocardiography? A. A single great vessel arising from the heart B. Pulmonary stenosis C. Transposition of the aorta and pulmonary artery D. Tricuspid valve atresia E. aortic stenosis
Mid-systolic click heard best at the apex
A 30 year old female presents with chest pain and palpitations. Patient undergoes echocardiography which reveals mitral valve prolapse. What physical exam finding would most likely be found in this patient? A. Systolic ejection murmur heard best over the 2nd and 3rd intercostal space left of the sternum B. Low frequency diastolic murmur heard best at the apex C. Holosystolic murmur heard best at the apex D. Diastolic rumble heard best in the left 4th intercostal space E. Mid-systolic click heard best at the apex
Have the patient hold his breath and bear down
A 31-year-old man comes to the clinic for routine screening. He states that he has noticed that during exercise he feels his heart racing, has mild chest pain, and lightheadedness. He seems very concerned because one of his uncles died at an early age from an unknown heart condition. On physical examination you note a mild, systolic ejection murmur. Which of the following would be likely to increase this type of murmur? A. Have the patient hold his breath and bear down B. Assuming the lateral decubitus position C. Squatting D. Hand grip for 30 seconds E. Putting the patient in the reverse Trendelenburg position
Tricuspid valve
A 32-year-old woman, with a significant history of IV drug use, presents to the emergency department with complaint of muscle aches and pains, hot and cold flashes, fever, and painful nodes on the pads of her fingers. She has also noticed weight loss over the past four weeks. During physical examination, a new murmur is noted on auscultation. Given this patient's presentation and history, which of the following valves is most likely affected? A. Mitral valve B. Tricuspid valve C. A bicuspid aortic valve D. Pulmonic valve E. A tricuspid aortic valve
Wolff-Parkinson-White Syndrome
A 36-year-old man with history of hypertension well controlled with monotherapy, comes to the clinic with episodes of palpitations that are occurring more frequently than they have in the past. The patient denies diaphoresis, chest pain, or history of anxiety. Given this patient's electrocardiogram findings, what is the most likely diagnosis? A. Lown-Ganong-Levine Syndrome B. Wolff-Parkinson-White Syndrome C. Paroxysmal supraventricular tachycardia D. Sick sinus syndrome E. Brugada syndrome
Heart failure
A 36-year-old patient with cardiomyopathy secondary to viral myocarditis develops fatigue, increasing dyspnea, and lower extremity edema over the past 3 days. He denies fever. A chest x-ray shows no significant increase in heart size but reveals prominence of the superior pulmonary vessels. Based on these clinical findings, which of the following is the most likely diagnosis? A Heart failure B Subacute bacterial endocarditis C Pulmonary embolus D Pneumonia
Restrictive cardiomyopathy
A 38-year-old African American woman comes to the cardiology office because she has had fatigue and worsening shortness of breath that has limited her ability to exercise for the past month. She also has had trouble breathing when lying down. She does not have chest pain but has experienced palpitations. The patient has had a 10-lb weight loss over the past three months and also has had right upper quadrant abdominal pain. Physical examination shows a violaceous rash on the cheeks. There are tender nodular lesions over the shins bilaterally and pitting edema of the lower extremities. Lung sounds are decreased bilaterally. S1 and S2 are normal with a loud diastolic S3 and a blowing pansystolic murmur; no pericardial knock is heard. Chest x-ray study shows bilateral hilar lymphadenopathy with a normal sized heart. Echocardiography shows dilation of both atria with an ejection fraction of 60%; ventricular wall thickness and volume are normal. Which of the following is the most likely diagnosis? A. Cardiac tamponade B. Constrictive pericarditis C. Dilated cardiomyopathy D. Hypertrophic cardiomyopathy E. Restrictive cardiomyopathy
Attempt vagal maneuvers
A 40-year-old man arrives at the ER accompanied by his family. He is complaining of palpitations after working outside for several hours. The assessment is as follows: SKIN: Hydrated, pale, warm and dry CVS: Strong peripheral pulses and a BP of 125/80 CNS: Fully intact RESP: RR is 22, no resp. difficulties, lungs CTA You start an IV on the patient. The monitor shows a narrow complex SVT (160). What is your next intervention? 1. Give adenosine 6mg rapid IV push 2. Attempt vagal maneuvers 3. Perform immediate synchronized cardioversion 4. Give epinephrine 1mg IV push
Calcium channel blocker
A 44-year-old woman with a history of hypertension comes to the office with a six-week history of episodes of dizziness, fatigue, and palpitations. During the episodes, which last no longer than five minutes each, the patient's pulse rate has been as low as 46/min and as high as 118/min and has felt irregular. She says she has had three episodes over the past six weeks. She is asymptomatic currently. Electrocardiography is nonspecific. Sick sinus syndrome is suspected. Which of the following types of drugs is most likely responsible for this patient's symptoms? A. Alpha blocker B. Angiotensin II receptor blocker C. Angiotensin-converting enzyme inhibitor D. Calcium channel blocker E. Diuretic
Basic metabolic panel to assess electrolytes
A 51-year-old man who is otherwise healthy comes to the office for follow-up appointment regarding hypertension. On two previous visits his blood pressure had been elevated. He was resistant to beginning medication, and wanted to try lifestyle modification first. He states that he has cut back on smoking, but has not quit completely. He has not been successful in losing weight, and current BMI is 38. His blood pressure measurement today is 162/94 mmHg. After discussing his options, the patient agrees to try medication while continuing to work on lifestyle changes. You prescribe chlorthalidone 12.5 mg once daily. Which of the following tests should be done within 4-6 weeks of initiating this medication? A. Basic metabolic panel to assess electrolytes B. Complete blood count to assess for neutropenia C. Electrocardiogram to assess for prolongation of QT interval D. Hepatic panel to assess liver function E. Serum uric acid level
Calcium channel blocker
A 52-year-old African American woman has had three elevated blood pressure readings in the past three months. Today her blood pressure is 158/96 mm Hg. She denies peripheral edema, chest pain, shortness of breath, dizziness, palpitations, headache, or muscle aches. Physical examination shows no abnormalities. Baseline laboratory studies reveal no underlying kidney or liver disease. After discussing the importance of weight loss, exercise, and a low-fat, low-sodium diet, the patient decides that she would like to begin an antihypertensive medication. Which of the following classes of antihypertensive medications is recommended as initial treatment for this patient? A. Angiotensin converting enzyme inhibitor B. Angiotensin receptor blocker C. Beta-adrenergic blocker D. Calcium channel blocker E. Aldosterone receptor antagonist
Myocarditis
A 52-year-old woman returns to your clinic for follow up after recovering from a recent viral illness. She comes in with increasing fatigue, decreased exercise tolerance and chest discomfort. Temperature is 98.7, blood pressure is 128/72 mmHg, pulse is 67 beats per minute, and respirations are 14 breaths per minute. Physical examination reveals a muffled S1 heart sound, peripheral edema, and jugular venous distention. Electrocardiogram reveals non-specific ST and T wave changes. Chest x-ray is without cardiopulmonary changes. Which of the following is the most likely diagnosis? A. Acute myocardial infarction B. Heart failure C. Myocarditis D. Pericarditis E. Sick sinus syndrome
Angiotensin converting enzyme inhibitor
A 54-year-old African-American man is seen in the office for follow-up visit after being diagnosed with hypertension three months ago. He is otherwise healthy. A trial of dietary modification and exercise has been only modestly successful, and a mutual decision has been made to introduce pharmacotherapy. Of the following classes of antihypertensive agents, which has a relative contraindication as a first line agent for this individual? A. Angiotensin converting enzyme inhibitor B. Beta-blocker C. Calcium-channel blocker D. Loop diuretic E. Thiazide diuretic
Statins
A 54-year-old African-American man is seen in the office for follow-up visit after being diagnosed with hypertension three months ago. He is otherwise healthy. A trial of dietary modification and exercise has been only modestly successful, and a mutual decision has been made to introduce pharmacotherapy. Of the following classes of antihypertensive agents, which has a relative contraindication as a first line agent for this individual? A. Angiotensin converting enzyme inhibitor B. Beta-blocker C. Calcium-channel blocker D. Loop diuretic E. Thiazide diuretic
Thiazide diuretic
A 54-year-old African-American man is seen in the office for follow-up visit after being diagnosed with hypertension three months ago. He is otherwise healthy. A trial of dietary modification and exercise has been only modestly successful, and a mutual decision has been made to introduce pharmacotherapy. Which of the following is the most appropriate initial therapy for this patient's hypertension? A. Angiotensin converting enzyme inhibitor B. Angiotensin receptor blocker C. Beta-blocker D. Loop diuretic E. Thiazide diuretic
Dental procedures involving manipulation of gingival tissue
A 54-year-old woman has a prosthetic cardiac valve. Administration of antibiotics is recommended for endocarditis prophylaxis if this patient were to undergo which of the following? A. Bronchoscopy B. Dental procedures involving manipulation of gingival tissue C. Excisional biopsy of uninfected skin lesion D. Gastrointestinal tract procedures E. Genitourinary procedures
Cough
A 55-year-old man, diagnosed with primary hypertension, is being treated with an angiotensin converting enzyme inhibitor. Which of the following is the most likely adverse effect associated with this class of medications? A. Cough B. First dose syncope C. Hypokalemia D. Lupus-like syndrome E. Migraine headache
Metolazone
A 55-year-old woman has a history of myocardial infarction and heart failure with reduced ejection fraction (HFrEF). She presents to the hospital with increasing exertional dyspnea after eating fried chicken, seasoned turkey, and canned soup over the Thanksgiving holiday. Her physical exam is notable for prominent jugular venous distention and crackles on pulmonary exam halfway up both posterior lung fields. Labs are notable for elevated serum potassium level of 5.8 mEq/L (normal range = 3.5-5.0 mEq/L). She is treated with intravenous furosemide but demonstrates poor diuresis. Which of the following diuretics acts at the distal convoluted tubule and would be appropriate therapy to further facilitate diuresis in this patient? a. Lisinopril b. Metolazone c. Spironolactone d. Bumetanide
Esmolol
A 56-year-old man with a history of hypertension is brought by ambulance to the emergency department because of sudden onset severe chest pain described as a tearing sensation that started one hour ago. Temperature is 37.2°C (99°F), pulse rate is 96/min, respirations are 22/min, blood pressure is 190/122 mmHg. Physical examination shows decreased peripheral pulses bilaterally. Chest x-ray study is shown. Which of the following is the most appropriate initial treatment for this patient's blood pressure? A. Esmolol B. Furosemide C. Nicardipine D. Nitroglycerin E. Nitroprusside
Lateral wall myocardial infarction
A 57-year-old man is brought to the emergency department by ambulance because of chest pain, nausea, and sweating that started 45 minutes ago after mowing his lawn. He describes the pain as an "elephant sitting on his chest." During transport to the hospital, paramedics administered aspirin, nitroglycerin, morphine, and oxygen. A 12-lead ECG obtained in the emergency department shows ST segment elevation in leads I, aVL, V5, and V6. Which of the following is the most likely diagnosis? A. Anterior wall myocardial infarction B. Inferior wall myocardial infarction C. Lateral wall myocardial infarction D. Posterior wall myocardial infarction E. Septal myocardial infarction
Congestive heart failure
A 62-year-old man is brought to the office by his wife because he has had fatigue, and shortness of breath for the past week. He has also had a nonproductive cough which is made worse by lying down. Temperature is 37.4°C (99.3°F), pulse rate is 94/min, respirations are 24/min, and blood pressure is 152/94 mmHg. Physical examination shows scattered bibasilar crackles. Chest x-ray study shows mild cephalization of the pulmonary vasculature, and peribronchial cuffing. Which of the following is the most likely diagnosis? A. Bacterial pneumonia B. Chronic obstructive pulmonary disease C. Congestive heart failure D. Idiopathic pulmonary fibrosis E. Pulmonary embolism
S3 gallop
A 62-year-old man with a history of hypertension and myocardial infarction presents for follow-up with his primary care physician assistant. He says that he has shortness of breath and has to stop and catch his breath more frequently when chasing his grandchildren around the yard. The patient also has to sleep propped up with two pillows and occasionally wakes up feeling short of breath. Temperature is 36.9 C (98.4 F), pulse rate is 90/min, respirations are 24/min, and blood pressure is 142/92 mmHg. On physical examination, the skin is pale and dusky. Bibasilar crackles are noted on lung auscultation. Laboratory studies ordered at his most recent visit showed a brain natriuretic peptide of 150 pg/mL. Chest x-ray study showed small pleural effusions, and echocardiography showed an ejection fraction of 40%. Which of the following additional physical examination findings is most likely on auscultation of this patient's heart? A. Distant heart sounds B. Pericardial rub C. S2 opening snap D. S3 gallop E. S4 gallop
Additional antihypertensive drug therapy
A 62-year-old man with a history of poorly controlled hypertension comes to the office for follow-up visit to review laboratory results. Past medical history also includes hyperlipidemia. He has a 10-pack year history of smoking cigarettes during his twenties. Current medications include hydrochlorothiazide, metoprolol, and rosuvastatin. Pulse rate is 72/min, and blood pressure is 168/106 mmHg. BMI is 32 kg/m². Blood test results show serum creatinine of 1.7 mg/dL, and eGFR of 42 mL/min/1.73 m². Duplex ultrasonography and magnetic resonance angiography confirm a diagnosis of bilateral renal artery stenosis with a blockage of 50% on the left, and 45% on the right. Which of the following is the most appropriate next step in management? A. Additional antihypertensive drug therapy B. Nephrectomy C. Percutaneous nephrostolithotomy D. Percutaneous renal artery angioplasty E. Renal artery bypass surgery
Restrictive cardiomyopathy
A 62-year-old man with a history of sarcoidosis presents with dyspnea, fatigue, and signs of right-sided heart failure. Physical exam shows elevated jugular venous pressure and hepatomegaly. Echocardiogram shows reduced diastolic filling. Magnetic resonance imaging shows gadolinium hyperenhancement. Which of the following is the most likely diagnosis? a.Dilated cardiomyopathy b.Hypertrophic cardiomyopathy c.Restrictive cardiomyopathy d.Takotsubo cardiomyopathy
Right bundle branch block
A 63-year-old man comes to the emergency department after a syncopal episode. The emergency team stated that the patient had sustained monomorphic ventricular tachycardia. The patient is currently feeling better and not complaining of either chest pain or shortness of breath. Physical examination reveals splitting of the second heart sound. The patient's ECG is shown above. Which of the following is the most likely diagnosis? A. Left bundle branch block B. Right bundle branch block C. Left anterior fascicular block D. Bifascicular block E. Left posterior fascicular block
Aortic dissection
A 63-year-old man with a longstanding history of hypertension, presents to the emergency department with sudden onset of severe chest pain which the patient describes as a tearing sensation. The patient appears distressed. Blood pressure in left arm is 140/90 mmHg and in the right arm is 110/60 mmHg. What is the most likely diagnosis? A. Subclavian steal syndrome B. Aortic aneurysm C. Aortic dissection D. Acute myocardial infarction E. Toxic shock syndrome
Right ventricular failure
A 64 year-old male, with a long history of COPD, presents with increasing fatigue over the last three months. The patient has stopped playing golf and also complains of decreased appetite, chronic cough and a bloated feeling. Physical examination reveals distant heart sounds, questionable gallop, lungs with decreased breath sounds at lung bases and the abdomen reveals RUQ tenderness with the liver two finger-breadths below the costal margin, the extremities show 2+/4+ pitting edema. Labs reveal the serum creatinine level 1.6 mg/dl, BUN 42 mg/dl, liver function test's mildly elevated and the CBC to be normal. Which of the following is the most likely diagnosis? A Right ventricular failure B Pericarditis C Exacerbation of COPD D Cirrhosis
Furosemide
A 64-year-old woman with a history of hypertension and myocardial infarction comes to the emergency department because she has had worsening shortness of breath and productive cough over the past eight hours. She also has had painless swelling in her lower legs bilaterally. The patient says she has never had similar symptoms. She used to be physically active, but over the past six months she has had increasing difficulty breathing and has had to stop to rest after she walks two blocks. Pulse rate is 84/min, respirations are 24/min, and blood pressure is 164/92 mmHg. Oxygen saturation is 97%. Physical examination shows diffuse bilateral wheezes and crackles. Laboratory studies, electrocardiography, and chest x-ray studies are ordered. Which of the following is the most appropriate initial drug therapy? A. Cardizem B. Furosemide C. Lisinopril D. Methylprednisolone E. Metoprolol
Furosemide
A 65-year-old man with a history of hypertension, hyperlipidemia, and type II diabetes is admitted to the hospital with worsening shortness of breath, especially with exertion or lying flat. He has also noticed edema in both lower extremities in recent months. The ECG shows normal sinus rhythm and no change compared with 6 months earlier. Transthoracic echocardiography shows a left ventricular ejection fraction of 30%. Which of the following medications has NOT been shown to improve survival in such a patient? a. Metoprolol succinate b. Captopril c. Spironolactone d. Furosemide
Stress-induced cardiomyopathy
A 65-year-old woman presented to the emergency department with sub-sternal chest pain and dyspnea. Her cardiac biomarkers were mildly elevated and there was ST-segment elevation in the anterior leads. Apical ballooning was seen on echocardiography and coronary angiography revealed normal coronary arteries. She has no past medical history and takes no medications. Recently the patient lost her husband of 40 years. What is the most likely diagnosis? a.Non-ST-elevation myocardial infarction b.Pericarditis c.ST-elevation myocardial infarction d.Stress-induced cardiomyopathy
Decreased intensity
A 66-year-old man is being evaluated in the office for a murmur that was found incidentally two weeks ago when he was seen at a local urgent care clinic for an unrelated problem. Physical examination shows a grade II-III systolic murmur best heard over the second intercostal space adjacent to the right border of the sternum. Aortic stenosis is suspected. You ask the patient to perform a Valsalva maneuver, then re-auscultate over this same area. Which of the following effects upon the murmur is most likely to occur as a result of performing the Valsalva maneuver? A. Conversion of the systolic murmur to a machinery-type murmur B. Decreased intensity C. Increased intensity D. No change in intensity E. Reversal of the systolic murmur to a diastolic murmur
Measurement of B-type natriuretic peptide
A 67-year-old man comes to the emergency department because of worsening dyspnea and fatigue over the past 36 hours. Past medical history includes emphysema, and myocardial infarction with three vessel bypass surgery performed two years ago. Temperature is 37°C (98.6°F), pulse rate is 92/min, respirations are 20/min, blood pressure is 162/90 mmHg, and oxygen saturation is 95% on room air. Physical examination shows a thin man who apperas dyspneic. Auscultation of the lungs shows diminished breath sounds with bibasilar crackles. Auscultation of the heart shows a regular rate and rhythm, a S4 gallop, but no murmurs. There is no jugular venous distension, but he does have bilateral pitting edema in the lower extremities. Which of the following diagnostic studies best determines if his dyspnea is due to heart failure? A. Arterial blood gas B. Electrocardiogram C. Measurement of B-type natriuretic peptide D. Measurement of serum electrolyte levels E. Spirometry
Inhibition of activated factor X
A 67-year-old woman with a history of hypertension, diabetes mellitus, hypothyroidism, and coronary artery disease comes to emergency department with a 3-day history of palpitations. The ECG in the emergency department shows an irregular rhythm without discernable P waves, with a ventricular rate of 94 beats/min. She has no history of mitral stenosis. The serum creatinine is normal. She is initially prescribed metoprolol (β-blocker) and enoxaparin (a low molecular weight heparin). At the time of discharge, she is converted from enoxaparin to oral apixaban therapy. By what mechanism does apixaban exert its anticoagulant effect? a. Inhibition of platelet cyclooxygenase-1 b. Reversible inhibition of the platelet P2Y12 receptor c. Direct inhibition of activated factor II (thrombin) d. Inhibition of activated factor X
Ultrasound of the abdominal aorta
A 70-year-old man with a history of well-controlled hypertension and osteoarthritis comes to the office for routine visit. He has a 40 pack-year history of smoking, but quit 10 years ago. Temperature is 37°C (98.6°F), pulse rate is 78/min, respirations are 16/min, and blood pressure is 118/76 mmHg. Physical examination shows slight kyphosis, and Heberden nodes at the distal interphalangeal joints of both hands. Which of the following screening tests is recommended for this patient? A. Carotid ultrasound B. Chest x-ray study C. DEXA scan of the hip and lumbar spine D. Echocardiogram E. Ultrasound of the abdominal aorta
D. Mitral regurgitation
A 70-year-old woman comes to her primary care provider for a routine checkup. On physical examination, a holosystolic murmur heard best at the apex and radiates to the left axilla is auscultated. Which heart murmur is most often associated with this description? A. Aortic regurgitation B. Tricuspid stenosis C. Aortic stenosis D. Mitral regurgitation E. Mitral stenosis
Aortic valve regurgitation
A 71-year-old man comes to the office because of progressively worsening exertional dyspnea and fatigue over the past year. He occasionally experiences a "forceful" heartbeat, but denies chest pain, dizziness or syncope. Blood pressure is 140/40 mmHg. Pulses are bounding. Palpation of the precordium shows laterally displaced point of maximal impulse. Auscultation of the heart shows a grade III/VI diastolic murmur at the lower left sternal border, and a S3 gallop. The lungs do not have any adventitious sounds. There is no peripheral edema. An electrocardiogram demonstrates left ventricular hypertrophy. Which of the following is the most likely diagnosis? A. Aortic valve regurgitation B. Aortic valve stenosis C. Mitral valve regurgitation D. Mitral valve stenosis E. Tricuspid valve regurgitation
Furosemide
A 71-year-old man comes to the primary care clinic because he has shortness of breath. He says he drove home from a family reunion two days ago and was feeling fine until he tried to lay down and go to sleep at home. During the interview, the patient explains that he forgot to bring one of his heart medications on the trip, but he does not remember which one he was missing, since he takes five different drugs. He also says he ate a lot of salty convenience store snacks while traveling. The patient is obese, and mildly increased respiratory effort is noted. Physical examination shows 2+ edema of both lower extremities to the knee. Cardiopulmonary examination shows a regular rate and rhythm and normal heart sounds. Fine expiratory rhonchi are noted at the lung bases bilaterally. Based on these findings, which of the following medications did this patient most likely forget to bring with him on his trip? A. Aspirin B. Atorvastatin C. Carvedilol D. Furosemide E. Lisinopril
Dobutamine
A 72 year old female presents to the emergency room with complaints of chest pain, dyspnea, palpitations, and a near-syncopal episode. Vital signs are BP 86/55, HR 115, RR 18, O2Sat 99% room air. Physical exam reveals altered mental status, weak peripheral pulses, jugular venous distention and 2+ pitting edema of bilateral lower extremities to the knees. Auscultation of bilateral lower lung bases reveals wet crackles. Which of the following is the drug of choice in the treatment of this patient? A. Labetolol B. Dobutamine C. Dopamine D. Diltiazem E. Atropine
Amiodarone
A 74-year-old man with a history of hypertension, coronary artery disease, supraventricular tachycardia, hyperlipidemia, and type 2 diabetes mellitus, seeks evaluation for a bluish-gray discoloration of his face and hands that has been progressively worsening over the past year. Which of the following medications in this patient's drug regimen is most likely to cause this discoloration? A. Amiodarone B. Atorvastatin C. Enalapril D. Metformin E. Metoprolol
Intravenous administration of atropine
A 76-year-old woman is brought to the emergency department by her niece because of chest discomfort, shortness of breath, dizziness, and weakness. She is hypotensive, and has a decreased level of consciousness. An electrocardiogram is perfromed, and shows sinus bradycardia at a rate of 38 beats per minute. Which of the following interventions is the most appropriate next step in management? A. Administer a shock at 200 joules B. Intravenous administration of adenosine C. Intravenous administration of atropine D. Intravenous administration of epinephrine E. Perform synchronized cardioversion
Daily weights
A 78 year-old male with history of coronary artery disease status post CABG and ischemic cardiomyopathy presents with complaint of progressive dyspnea and orthopnea. He also complains of lower extremity edema. The patient denies fever, chest pain, or cough. On physical examination, vital signs are BP 120/68, HR 75 and regular, RR 22, afebrile. You note the patient to have an S3 heart sound, jugular venous distention, and 2+ lower extremity edema. The patient is admitted and treated. Upon discharge from the hospital, the patient should be educated to monitor which of the following at home? A Daily weights B Daily spirometry C Daily blood glucose D Daily fat intake
You may cause cerebral ischemia
A 78-year-old man is brought to the emergency room by his wife who says that he has been complaining of a headache and acting strange all morning. Physical examination reveals a blood pressure of 225/132, an increased cup to disc ratio on fundoscopic exam, and altered mental status with disorientation. You order IV labetolol, but specify carefully the rate at which it should be administered. Why must you worry about decreasing the blood pressure too quickly in this patient? A. You may induce renal failure B. You may cause cerebral ischemia C. You may worsen the papilledema D. Your patient may experience nausea E. You may cause cerebral edema
Amiodarone
A 78-year-old woman with ischemic cardiomyopathy and left ventricular ejection fraction of 40% has recurrent episodes of symptomatic atrial fibrillation. Which of the following antiarrhythmic drugs is least likely to cause proarrhythmic effects (including sudden cardiac death) in her case? a. Sotalol b. Flecainide c. Propafenone d. Amiodarone
give 1 mg epinephrine while continuing CPR
A second shock is delivered at 200 J, and CPR is continued. Your next intervention is to: 1. seek expert consultation 2. consider giving antiarrhythmics 3. check a pulse for no more than 10 seconds 4. give 1 mg epinephrine while continuing CPR
Give Epinephrine 1 mg IV push (repeat every 3-5 minutes)
After completing 5 cycles of CPR, the rhythm is unchanged. You shock a second time with 200 J and resume CPR. While completing the cycle of CPR what else should be done? A. Give Epinephrine 1 mg IV push (repeat every 3-5 minutes) B. Vasopressin 40 U IV push to replace the 1st or 2nd dose of epinephrine C. Give Epinephrine 0.5mg IV push (repeat every 3-5 minutes) D. Either 1 or 2 is correct
Give one unsynchronized shock (120-200J)
After synchronized cardioversion is unsuccessful, the pt. continues to deteriorate. The patient is now unconscious with pulseless ventricular tachycardia. Below is what you see on the monitor: What is the first and most important intervention? 1. Begin CPR and give 5 cycles before shocking 2. Give Epinephrine 1mg IV push (repeat every 3-5 minutes) 3. Give one unsynchronized shock (120-200 J) 4. Place an advanced airway
give epinephrine 1 mg IV/IO
After you begin CPR for a pt in asystole, what is your next step? 1. give atropine 1 mg IV/IO 2. continue CPR, nothing else can be done 3. give 1 shock 4. give epinephrine 1 mg IV/IO
