4. Flashcards
Diagnostic Studies/Cardiology Which diagnostic study is considered to be the strategy of choice for symptomatic patients with recurrent ischemia, hemodynamic instability or impaired left ventricular dysfunction? A. Stress echocardiography B. Exercise treadmill testing C. Coronary angiography D. Cardiac magnetic resonance imaging
Explanations
(h) A. Stress echocardiography should not be performed in the setting of a patient who is acutely symptomatic.
(h) B. Exercise treadmill testing should not be performed in the setting of an unstable patient with ongoing cardiac symptoms.
(c) C. Coronary or cardiac catheterization is the gold standard technique in the evaluation of patients with significant cardiac symptoms. Anatomical information along with degree of coronary artery blockages are provided and patients may be able to undergo coronary revascularization during or after this procedure.
(u) D. Cardiac magnetic resonance imaging has limited availability and is not part of national guidelines for evaluation of the cardiac patient.
History & Physical/Cardiology Which of the following is a systemic manifestation of infective endocarditis? A. Hemarthrosis B. Petechiae C. Cafe au lait spots D. Bronzing of the skin
Explanations
(u) A. Hemarthrosis is most commonly a consequence of a clotting disorder such as hemophilia.
(c) B. Petechiae, splinter hemorrhages, Janeway lesions, and Osler’s nodes are systemic manifestations of patients who have infective endocarditis.
(u) C. Cafe au lait spots are seen in Neurofibromatosis (von Recklinghausen’s syndrome).
(u) D. Bronzing of the skin is most commonly associated with hemochromatosis or Addison’s disease.
Diagnostic Studies/Cardiology A 76 year-old male presents after returning from a Safari in Africa. Seven days ago he experienced chest pressure lasting one hour that did not respond to three sublingual nitroglycerin tablets. There was no ability to have lab work or an EKG. The pain has not returned. If the patient had a non-STEMI myocardial infarction, which of the following studies will still be positive? A. Electrocardiogram B. Myoglobulin C. CK-MB index D. Troponin I
Explanations
(u) A. Patients suffering from a non-STEMI myocardial infarction will not develop Q waves and most likely will have a normal EKG five days after an acute event.
(u) B. Myoglobulin is a nonspecific enzyme that is released into the circulation after any skeletal muscle damage, including a myocardial infarction. It is the first enzyme that becomes positive in the setting of acute myocardial infarction but its non-specific measurement makes it less useful in the setting of acute myocardial infarction. It returns to baseline within 24 hours after infarction.
(u) C. CK-MB index has improved sensitivity for myocardial muscle damage that occurs with acute myocardial infarction but it returns to baseline within 2-3 days after injury.
(c) D. Troponin I levels will stay positive for at least one week following myocardial infarction and is the preferred enzyme to measure in this setting.
Clinical Intervention/Cardiology A 52 year-old patient with episodes of syncope has an electrocardiogram which shows a consistently prolonged PR interval with a missing QRS every two beats. Which of the following is the most effective management? A. Permanent pacing B. Beta-blocker C. ACEInhibitor D. Defibrillation
Explanations
(c) A. This is consistent with ECG findings of a Mobitz type II AV block. Since the patient is symptomatic this type of AV block requires a permanent pacing to prevent total AV disassociation.
(u) B. Beta-blockers will slow conduction from the AV node and is not indicated with this type of AV block. (u) C. There is no indication for ACE Inhibitors in Mobitz Type II heart block.
(u) D. Defibrillation is not indicated in a person with AV block.
Health Maintenance/Cardiology According to the Joint National Commission VII Guidelines, blood pressure targets are lower in patients with diabetes mellitus and what other condition? A. Liver disease B. Renal disease C. Thyroid disease D. Peripheral vascular disease
Explanations
(u) A. See B for explanation.
(c) B. Blood pressure targets for hypertensive patients at the greatest risk for cardiovascular events, particularly those with diabetes and chronic kidney disease, are lower (less than 130/80) than for those individuals with lower cardiovascular risk (goal is less than 140/90).
(u) C. See B for explanation.
(u) D. See B for explanation.
Diagnosis/Cardiology A patient presents to the office following a syncopal episode. The patient claims that the syncope occurs when he changes position such as rolling over in bed or when he bends over to tie his shoes. Which of the following is the most likely explanation for this presentation? A. Carotid sinus hypersensitivity B. Vasovagal episode C. Subclavian steal syndrome D. Atrial myxoma
Explanations
(u) A. Carotid sinus hypersensitivity may present with syncope but is usually related to tight collars or when excessively turning the head.
(u) B. Vasovagal episodes may occur with syncope as its manifestation but it is not caused by changes in position.
(u) C. Subclavian steal syndrome may present with syncope that is related to exercise of the affected arm which results in a decreased pulse when the Adson maneuver is performed.
(c) D. Atrial myxoma most commonly presents with sudden onset of symptoms that are typically positional in nature due to the effect that gravity has on the tumor. Myxomas are the most common type of primary cardiac tumor in all age groups and are most commonly found in the atria.
Clinical Therapeutics/Cardiology Which of the following is the optimal therapy for a 76 year-old patient with no allergies who has chronic atrial fibrillation? A. Aspirin B. Clopidogrel (Plavix) C. Warfarin (Coumadin) D. Low molecular weight heparin
Explanations
(u) A. Aspirin’s role to prevent thromboembolism in atrial fibrillation is limited to patients with no risk factors who are under age 65.
(u) B. Clopidogrel is not the optimal therapy for patients with atrial fibrillation.
(c) C. Patients older than age 75 who have chronic atrial fibrillation should be anticoagulated with warfarin to maintain an INR between 2.5 and 3.0 for optimum therapy unless a contraindication to therapy exists.
(u) D. Due to the increased costs and need for parenteral therapy, daily subcutaneous heparin is not first line therapy unless warfarin therapy is contraindicated.
Clinical Intervention/Cardiology Patients who undergo percutaneous angioplasty or who have coronary artery revascularization often are treated with glycoprotein IIb/IIIa inhibitors. What is the major side effect associated with these agents? A. Hypotension B. Bleeding C. Coronary vasospasm D. Acute renal failure
Explanations
(u) A. See B for explanation.
(c) B. Glycoprotein IIb/IIa inhibitors have their activity in the final stages of platelet bridging and are associated with bleeding when used in the management of acute myocardial infarction. Since they are effective at treating and preventing new clot formation, bleeding is the main concern and complication with the use of these agents.
(u) C. See B for explanation.
(u) D. See B for explanation.
Health Maintenance/Cardiology
Which of the following is an absolute contraindication for the performance of exercise stress testing for patients who wish to start an exercise program?
A. Second degree heart block type 1
B. Severe aortic stenosis
C. Atrial fibrillation with controlled ventricular response
D. Recent diagnosis of lung cancer
Explanations
(u) A. See B for explanation.
(c) B. Contraindications to stress testing include rest angina within the last 48 hours, unstable cardiac rhythm, hemodynamically unstable patient, severe aortic stenosis, acute myocarditis, uncontrolled heart failure, and active infective endocarditis.
(u) C. See B for explanation.
(u) D. See B for explanation.
History & Physical/Cardiology A 23 year-old male with recent upper respiratory symptoms presents complaining of chest pain. His pain is worse lying down and better sitting up and leaning forward. Electrocardiogram shows widespread ST segment elevation. Which of the following is the most likely physical examination finding in this patient? A. Elevated blood pressure B. Subungual hematoma C. Diastolic murmur D. Pericardial friction rub
Explanations
(u) A. Acute pericarditis is usually not associated with elevated blood pressure. One would expect to see hypertensive pressures in the setting of an aortic dissection.
(u) B. Subungual hematomas are usually seen in endocarditis not pericarditis.
(u) C. A diastolic murmur in a patient with chest pain would likely be associated with acute aortic regurgitation in the setting of an aortic dissection.
(c) D. This patient has symptoms consistent with acute pericarditis and would most likely have a pericardial friction rub on examination.
Diagnostic Studies/Cardiology A 53 year-old male with history of hypertension presents complaining of recent 4/10 left-sided chest pain with exertion that is relieved with rest. He states the pain usually lasts approximately 4 minutes and is relieved with rest. Heart examination reveals regular rate and rhythm with no S3, S4, or murmur. Lungs are clear to auscultation bilaterally. Electrocardiogram reveals no acute changes. Which of the following is the most appropriate initial step in the evaluation of this patient? A. Cardiac catheterization B. CT Angiogram of the chest C. Echocardiogram D. Nuclear stress test
Explanations
(u) A. This patient has signs and symptoms consistent with stable angina. Noninvasive diagnostic testing is preferred in this patient.
(u) B. CT angiogram may be useful for the evaluation of chest pain, however its role in routine practice has not been established.
(u) C. This patient has signs and symptoms of stable angina. There are no signs of valvular heart disease on examination. While an echocardiogram may be performed at some point, it is not the best initial diagnostic step to determine the etiology of the patient’s angina.
(c) D. Nuclear stress testing is the most appropriate initial diagnostic study in the evaluation of a patient with signs and symptoms consistent with stable angina.
Clinical Therapeutics/Cardiology A 48 year-old male with diabetes mellitus presents for routine physical examination. Of note his blood pressure each of his last two follow-up visits was 150/90 mmHg. Today the patient's BP is 148/88 mmHg. The patient denies complaints of chest pain, change in vision, or headache. Which of the following is the most appropriate management for this patient? A. Atenolol (Tenormin) B. Nifedipine (Procardia) C. Hydralazine (Apresoline) D. Lisinopril (Zestril)
Explanations
(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. ACE inhibitors are the first line treatment of choice in a patient with hypertension and diabetes.
Health Maintenance/Cardiology
A 36 year-old female presents for a routine physical. She has no current complaints and her only medication is oral contraceptives. The patient is preparing for a trip to Australia and is worried about the long flight as her mom has a history of deep vein thrombosis after a long trip several years ago. Physical examination reveals BP 110/60 mmHg, HR 66 bpm, regular. Heart is regular rate and rhythm without murmur, lungs are clear to auscultation bilaterally and extremities are without edema. Which of the following is the most appropriate recommendation for your patient?
A. Discontinue oral contraceptives
B. Recommend walking frequently during the flight
C. Begin daily aspirin therapy
D. Increase fluid intake 2-3 days prior to the flight
Explanations
(u) A. See B for explanation.
(c) B. The risk of deep vein thrombosis after air travel increases with flight duration. Preventive measures for patients include using support hose and performing in-flight exercises and walking.
(u) C. See B for explanation.
(u) D. See B for explanation.
Diagnostic Studies/Cardiology A 3 month-old female presents with her mom for physical examination. The patient's mom denies any complaints. On examination you note a well-developed, well-nourished infant in no apparent distress. There is no cyanosis noted. Heart examination reveals a normal S1 with a physiologically split S2. There is a grade III/VI high-pitched, harsh, pansystolic murmur heard best at the 3rd and 4th left intercostal spaces with radiation across the precordium. Which of the following is the initial diagnostic study of choice in this patient? A. CT angiogram B. Electrocardiogram C. Echocardiogram D. Cardiac catheterization
Explanations
(u) A. This patient has signs and symptoms consistent with a ventricular septal defect (VSD). CT angiogram and electrocardiogram are not indicated in establishing the diagnosis of a VSD.
(u) B. See A for explanation.
(c) C. Echocardiogram is the initial diagnostic study of choice in the diagnosis of a VSD.
(u) D. Cardiac catheterization may be necessary to accurately measure pulmonary pressures or if a VSD can not be well localized on echocardiogram, but it is not the initial diagnostic study of choice.
Clinical Intervention/Cardiology A 20 year-old male presents with complaint of brief episodes of rapid heart beat with a sudden onset and offset that have increased in frequency. He admits to associated shortness of breath and lightheadedness. He denies syncope. Electrocardiogram reveals a delta wave prominent in lead II. Which of the following is the most appropriate long-term management in this patient? A. Implantable cardio defibrillator B. Radiofrequency ablation C. Verapamil (Calan) D. Metoprolol (Lopressor)
Explanations
(u) A. Implantable cardio defibrillators are indicated in the treatment of ventricular arrhythmias, not Wolf-Parkinson- White (WPW) syndrome.
(c) B. Radiofrequency ablation is the procedure of choice for long-term management in patients with accessory pathways (WPW) and recurrent symptoms.
(u) C. Calcium channel blockers and beta-blockers are not the best options for the long-term management of WPW. They may decrease the refractoriness of the accessory pathway or increase the refractoriness of the AV node in patients with atrial fibrillation or atrial flutter who have an antegrade conducting bypass tract. This may lead to faster ventricular rates.
(u) D. See C for explanation.
Diagnosis/Cardiology A 60 year-old female recently discharged after an 8 day hospital stay for pneumonia presents complaining of pain and redness in her right arm. The patient thinks this was the area where her IV was placed. The patient denies fever or chills. Examination of the area reveals localized induration, erythema and tenderness. There is no edema or streaking noted. Which of the following is the most likely diagnosis? A. Acute thromboembolism B. Thrombophlebitis C. Cellulitis D. Lymphangitis
Explanations
(u) A. Acute thromboembolism is usually associated with edema of the extremity and warm temperature. Thromboembolism is unusual after thrombophlebitis.
(c) B. This patient’s signs and symptoms are consistent with thrombophlebitis. Short-term venous catheterization of a superficial arm vein is commonly the cause and thrombophlebitis characterized by dull pain, induration, redness and tenderness along the course of the vein.
(u) C. Cellulitis is usually associated with fever, increased warmth over the affected area and associated edema. (u) D. Lymphangitis is associated with fever, malaise, chills, and streaking.
History & Physical/Cardiology A patient with a history of chronic venous insufficiency presents for routine follow-up. Which of the following findings is most likely on physical examination? A. Cold lower extremities B. Diminished pulses C. Lower extremity edema D. Palpable cord
Explanations
(u) A. Cold lower extremities are more commonly seen in peripheral arterial, not venous, disease.
(u) B. Diminished pulses are seen in peripheral arterial disease.
(c) C. Patients with chronic venous insufficiency will commonly have lower extremity edema.
(u) D. A palpable cord is more common in superficial thrombophlebitis.
Diagnostic Studies/Cardiology A 29 year-old female with history of IV drug abuse presents with ongoing fevers for three weeks. She complains of fatigue, worsening dyspnea on exertion and arthralgias. Physical examination reveals a BP of 130/60 mmHg, HR 90 bpm, regular, RR 18, unlabored. Petechiae are noted beneath her fingernails. Fundoscopic examination reveals exudative lesions in the retina. Heart examination shows regular rate and rhythm, there is a grade II-III/VI systolic murmur noted, with no S3 or S4. Lungs are clear to auscultation bilaterally, and the extremities are without edema. Which of the following is the diagnostic study of choice in this patient? A. Electrocardiogram B. CT angiogram of the chest C. Cardiac catheterization D. Transesophageal echocardiogram
Explanations
(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. This patient’s signs and symptoms are consistent with infective endocarditis. The diagnostic study of choice would be a transesophageal echocardiogram.
