Cardio Flashcards
History & Physical/Cardiology Which of the following conditions would cause a positive Kussmaul's sign on physical examination? Answers A. Left ventricular failure B. Pulmonary edema C. Coarctation of the aorta D. Constrictive pericarditis
Explanations
(u) A. Left ventricular failure results in the back-up of blood into the left atrium and then the pulmonary system so it would not be associated with Kussmaul’s sign.
(u) B. Pulmonary edema primarily results in increased pulmonary pressures rather than having effects on the venous inflow into the heart.
(u) C. Coarctation of the aorta primarily affects outflow from the heart due to the stenosis resulting in delayed and decreased femoral pulses; it has no effect on causing Kussmaul’s sign.
(c) D. Kussmaul’s sign is an increase rather than the normal decrease in the CVP during inspiration. It is most often caused by severe right-sided heart failure; it is a frequent finding in patients with constrictive pericarditis or right ventricular infarction.
History & Physical/Cardiology
Anginal chest pain is most commonly described as which of the following?
Answers
A. Pain changing with position or respiration
B. A sensation of discomfort
C. Tearing pain radiating to the back
D. Pain lasting for several hours
Explanations
(u) A. Pain changing with position or respiration is suggestive of pericarditis.
(c) B. Myocardial ischemia is often experienced as a sensation of discomfort lasting 5-15 minutes, described as dull, aching or pressure.
(u) C. Tearing pain with radiation to the back represents aortic dissection.
(u) D. Chest pain lasting for several hours is more suggestive for myocardial infarction.
History & Physical/Cardiology
Eliciting a history from a patient presenting with dyspnea due to early heart failure the severity of the dyspnea should be quantified by
Answers
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.
Explanations
(c) A. The amount of activity that precipitates dyspnea should be quantified in the history.
(u) B. Orthopnea or paroxysmal nocturnal dyspnea can be quantified by how many pillows a patient needs to sleep on to be comfortable.
(u) C. How long dyspnea takes to resolve or associated comorbidities has no bearing on quantifying the severity of dyspnea.
(u) D. See answer C above.
History & Physical/Cardiology A 25 year-old female presents with a three-day history of chest pain aggravated by coughing and relieved by sitting. She is febrile and a CBC with differential reveals leukocytosis. Which of the following physical exam signs is characteristic of her problem? Answers A. Pulsus paradoxus B. Localized crackles C. Pericardial friction rub D. Wheezing
Explanations
(u) A. Pulsus paradoxus is a classic finding for cardiac tamponade.
(u) B. Localized crackles are associated with pneumonia and consolidation, not pericarditis.
(c) C. Pericardial friction rub is characteristic of an inflammatory pericarditis.
(u) D. Wheezing is characteristic for pulmonary disorders, such as asthma
History & Physical/Cardiology
A 65 year-old white female presents with dilated tortuous veins on the medial aspect of her lower extremities. Which of the following would be the most common initial complaint?
Answers
A. Pain in the calf with ambulation
B. Dull aching heaviness brought on by periods of standing
C. Brownish pigmentation above the ankle
D. Edema in the lower extremities
Explanations
(u) A. Patients with deep venous thrombosis (DVT) may present with complaints of pain in the calf with ambulation. Secondary varicosities may result from DVT’s.
(c) B. Dull aching heaviness or a feeling of fatigue brought on by periods of standing is the most common complaint of patients presenting initially with varicosities.
(u) C. Stasis Dermatitis and edema are most suggestive of chronic venous insufficiency.
(u) D. See C for explanation
History & Physical/Cardiology A 22 year-old male received a stab wound in the chest an hour ago. The diagnosis of pericardial tamponade is strongly supported by the presence of Answers A. pulmonary edema. B. wide pulse pressure. C. distended neck veins. D. an early diastolic murmur.
Explanations
(u) A. Pulmonary edema may result with low output states as seen with myocardial contusions, but it is not strongly suggestive of tamponade.
(u) B. Wide pulse pressure is seen in conditions of high stroke volume such as aortic insufficiency or hyperthyroidism. Narrow pulse pressure is seen with cardiac tamponade.
(c) C. Cardiac compression will manifest with distended neck veins and cold clammy skin.
(u) D. The onset of diastolic murmur is suggestive of valvular disease, not tamponade
Diagnostic Studies/Cardiology Cardiac nuclear scanning is done to detect Answers A. electrical conduction abnormalities. B. valvular abnormalities. C. ventricular wall dysfunction. D. coronary artery patency/occlusion
Explanations
(u) A. An EKG is used to determine electrical conduction abnormalities.
(u) B. An echocardiogram is a non-invasive test used to determine valvular abnormalities and wall motion.
(c) C. Visualization of the cardiac wall can be done with cardiac nuclear scanning. This is done to determine hypokinetic areas from akinetic areas.
(u) D. Patency or occlusion is assessed with cardiac catheterization (invasive)
Diagnostic Studies/Cardiology A 72 year-old male with a new diagnosis of congestive heart failure and atrial fibrillation, develops episodes of hemodynamic compromise secondary to increased ventricular rate. A decision to perform elective cardioversion is made and the patient is anticoagulated with heparin. Which test should be ordered to assess for atrial or ventricular mural thrombi? Answers A. Electrocardiogram B. Chest x-ray C. Transesophageal Echocardiogram D. C-reactive protein
Explanations
(u) A. Electrical conduction will not assess for mural thrombi.
(u) B. A chest x-ray will not visualize the left atria and ventricles to assess for mural thrombi.
(c) C. Transesophageal echocardiography allows for determination of mural thrombi that may have resulted from atrial fibrillation.
(u) D. C-reactive protein is not going to give you any information regarding thrombi. This test is used to identify the presence of inflammation
Diagnostic Studies/Cardiology A 64 year-old patient with known history of type 1 diabetes mellitus for 50 years has developed pain radiating from the right buttock to the calf. Patient states that the pain is made worse with walking and climbing stairs. Based upon this history which of the following would be the most appropriate test to order? Answers A. Venogram B. Arterial duplex scanning C. X-ray of the right hip and L/S spine D. Venous Doppler ultrasound
Explanations
(u) A. See B for explanation.
(c) B. Given the patient’s long history of type 1 diabetes mellitus the patient most likely has vascular occlusive disease. Evaluation of arterial blood flow is assessed using the duplex scanner. X-ray of the L/S spine and right hip while not harmful may give information regarding bony structures. Venous Doppler ultrasound will not give information of arterial perfusion.
(u) C. See B for explanation.
(u) D. See B for explanation
Diagnostic Studies/Cardiology A 36 year-old male complains of occasional episodes of "heart fluttering". The patient describes these episodes as frequent, short-lived and episodic. He denies any associated chest pain. Based on this information, which one of the following tests would be the most appropriate to order? Answers A. Holter monitor B. Cardiac catheterization C. Stress testing D. Cardiac nuclear scanning
Explanations
(c) A. Holter monitoring is a non-invasive test done to obtain a continuous monitoring of the electrical activity of the heart. This can help to detect cardiac rhythm disturbances that can correlate with the patient symptoms. Cardiac catheterization is an invasive procedure done to assess coronary artery disease. Stress testing and cardiac nuclear scanning are non-invasive testing maneuvers done to assess coronary artery disease.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
Diagnostic Studies/Cardiology A patient with a mitral valve replacement was placed post-operatively on warfarin (Coumadin) for anticoagulation prophylaxis. To monitor this drug for its effectiveness, what test would be used? Answers A. PTT B. PT-INR C. Platelet aggregation D. Bleeding time
Explanations
(u) A. PTT is a reflection of the intrinsic clotting system and is used to monitor heparin administration.
(c) B. PT-INR is a reflection of the extrinsic and common pathway clotting system. Coumadin interferes with Vitamin K synthesis which is needed in the manufacture of factors II, VII, IX, X which are part of the extrinsic clotting pathway.
(u) C. Platelet aggregation tests are utilized to assess platelet dysfunction.
(u) D. Bleeding time is used to assess platelet function.
Diagnosis/Cardiology 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? Answers A. Right ventricular failure B. Pericarditis C. Exacerbation of COPD D. Cirrhosis
Explanations
(c) A. Signs of right ventricular failure are fluid retention i.e. edema, hepatic congestion and possibly ascites.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation
Diagnosis/Cardiology A 56 year-old male with a known history of polycythemia suddenly complains of pain and paresthesia in the left leg. Physical examination reveals the left leg is cool to the touch and the toes are cyanotic. The popliteal pulse is absent by palpation and Doppler. The femoral pulse is absent by palpation but weak with Doppler. The right leg and upper extremities has 2+/4+ pulses throughout. Given these findings what is the most likely diagnosis? Answers A. Venous thrombosis B. Arterial thrombosis C. Thromboangiitis obliterans D. Thrombophlebitis
Explanations
(u) A. See B for explanation.
(c) B. Arterial thrombosis has occurred and is evidenced by the loss of the popliteal and dorsalis pedis pulse. This is a surgical emergency. Venous occlusion and thrombophlebitis do not result in loss of arterial pulse.
(u) C. See B for explanation.
(u) D. See B for explanation.
Diagnosis/Cardiology A 48 year-old male with a known history of hypertension is brought to the ED complaining of headache, general malaise, nausea and vomiting. The patient currently takes nifedipine (Procardia)90mg XL every day and atenolol (Tenormin) 50 mg every day. Vital signs reveal temperature 98.6°F, pulse 72/minute, respiratory rate 20/minute, and the blood pressure is 168/120 mmHg. BP reading taken every 15 minutes from the time of admission reveal the systolic to run from 176 to 186 mmHg and the diastolic to run from 135 to 150 mmHg. Physical examination reveals papilledema bilaterally. There are no renal bruits noted. The EKG is normal. Based upon this presentation, what is the most likely diagnosis? Answers A. Meningitis B. Secondary hypertension C. Pseudotumor cerebri D. Malignant hypertension
Explanations
(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. Pseudotumor cerebri presents with papilledema, but not hypertension and is more common in young females.
(c) D. Malignant HTN is characterized by diastolic reading greater than 140 mm Hg with evidence of target organ damage
Diagnosis/Cardiology A 55 year-old male is seen in follow-up for a complaint of chest pain. Patient states that he has had this chest pain for about one year now. The patient further states that the pain is retrosternal with radiation to the jaw. "It feels as though a tightness, or heaviness is on and around my chest". This pain seems to come on with exertion however, over the past two weeks he has noticed that he has episodes while at rest. If the patient remains non- active the pain usually resolves in 15-20 minutes. Patient has a 60-pack year smoking history and drinks a martini daily at lunch. Patient appears overweight on inspection. Based upon this history what is the most likely diagnosis? Answers A. Acute myocardial infarction B. Prinzmetal variant angina C. Stable angina D. Unstable angina
Explanations
(u) A. Pain does not resolve in an acute MI, it gradually gets worse.
(u) B. Pain typically occurs at rest is one of the hallmarks of Prinzmetal variant angina. This patient has just started to develop pain at rest.
(u) C. Pain in stable angina is relieved with rest and usually resolves within 10 minutes. angina does not have pain at rest.
(c) D. Pain in unstable angina is precipitated by less effort than before or occurs at rest
Diagnosis/Cardiology Stable A 60 year-old male is brought to the ED complaining of severe onset of chest pain and intrascapular pain. The patient states that the pain feels as though "something is ripping and tearing". The patient appears shocky; the skin is cool and clammy. The patient has an impaired sensorium. Physical examination reveals a loud diastolic murmur and variation in blood pressure between the right and left arm. Based upon this presentation what is the most likely diagnosis? Answers A. Aortic dissection B. Acute myocardial infarction C. Cardiac tamponade D. Pulmonary embolism
Explanations
(c) A. The scenario presented here is typical of an ascending aortic dissection. In an acute myocardial infarction the pain builds up gradually. Cardiac tamponade may occur with a dissection into the pericardial space; syncope is usually seen with this occurrence. Pulmonary embolism is usually associated with dyspnea along with chest pain.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation
Diagnosis/Cardiology
A 42 year-old male is brought into the ED with a complaint of chest pain. The pain comes on suddenly without exertion and lasts anywhere from 10-20 minutes. The patient has experienced this on three previous occasions. Today the patient complains of light- headedness with the chest pain lasting longer. Vital signs T-99.3°F oral, P-106/minute and regular, R-22/minute, BP 146/86 mm Hg. EKG reveals sinus rhythm with a rate of 100. Intervals are PR = 0.06 seconds, QRS = 0.12 seconds. A delta wave is noted in many leads. Based upon this information what is the most likely diagnosis?
Answers
A. Sinus tachycardia
B. Paroxysmal supraventricular tachycardia
C. Wolff-Parkinson-White syndrome
D. Ventricular tachycardia
Explanations
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. Wolff-Parkinson-White syndrome hallmarks on EKG include a shorten PR interval, widened QRS, and delta waves. Sinus tachycardia has a normal PR interval and no delta waves. PSVT usually has a retrograde P wave or it may be buried in the QRS complex.
(u) D. Ventricular tachycardia has a widened QRS as it originates in the ventricles
Diagnosis/Cardiology A 63 year-old male is admitted to the hospital with an exacerbation of COPD. The electrocardiogram shows an irregularly, irregular rhythm at a rate of 120/minute with at least three varying P wave morphologies. These electrocardiogram findings are most suggestive of Answers A. atrial fibrillation. B. multifocal atrial tachycardia. C. atrioventricular junctional rhythm. D. third degree heart block.
Explanations
(u) A. Atrial fibrillation is an irregularly, irregular rhythm with no definable P waves.
(c) B. Multifocal atrial tachycardia is seen most commonly in patients with COPD. Electrocardiogram findings include an irregularly, irregular rhythm with a varying PR interval and various P wave morphologies (Three or more foci).
(u) C. Atrioventricular junctional rhythm is an escape rhythm, because of depressed sinus node function, with a ventricular rate between 40-60/minute.
(u) D. Third degree heart block presents with a wide QRS at a rate less than 50/minute and blocked atrial impulses
Health Maintenance/Cardiology
A 72 year-old female is being discharged from the hospital following an acute anterolateral wall myocardial infarction. While in the hospital the patient has not had any dysrhythmias
or hemodynamic compromise. discharge medications?
Answers
A. Warfarin (Coumadin)
B. Captopril (Capoten)
C. Digoxin (Lanoxin)
D. Furosemide (Lasix)
Which of the following medications should be a part of her
Explanations
(u) A. Warfarin is not indicated since there is no role for anticoagulation in this patient.
(c) B. ACE inhibitors have been shown to decrease left ventricular hypertrophy and remodeling to allow for a greater ejection fraction.
(u) C. The patient does not have any dysrhythmias so Lanoxin is not indicated.
(u) D. The patient does not have any hemodynamic compromise or indicators of CHF
Health Maintenance/Cardiology
A 44 year-old male with a known history of rheumatic fever at age 7 and heart murmur is scheduled to undergo a routine dental cleaning. The murmur is identified as an opening snap murmur. Patient has no known drug allergies. What should this patient receive for antibiotic prophylaxis prior to the dental cleaning?
Answers
A. This patient does not require antibiotic prophylaxis for a routine dental cleaning.
B. This should receive Pen VK 250 mg p.o. QID for 10 days after the procedure.
C. This patient should receive Amoxicillin 3.0 gms. p.o. 1 hour before the procedure and then 1.5 gm. 6 hours after the procedure.
D. This patient should receive Erythromycin 250 mg QID for 1 day before the procedure and then 10 days after the procedure
Explanations
(h) A. See C for explanation.
(u) B. See C for explanation.
(c) C. These are the current recommendations from the American Heart Association if the patient is not allergic to penicillin.
(u) D. See C for explanation
Health Maintenance/Cardiology A 36 year-old female presents for a refill of her oral contraceptives. She admits to smoking one pack of cigarettes per day. She should be counseled with regard to her risk of Answers A. venous thrombosis. B. varicose veins. C. atherosclerosis. D. peripheral edema.
(c) A. Women over age 35 who smoke are at increased risk for the development of venous thrombosis.
(u) B. Varicose veins are the result of pressure overload on incompetent veins and not due to the use of oral contraceptives.
(a) C. The defined risks of atherosclerosis includes smoking, but does not include the use of oral contraceptives.
(u) D. There is no relationship between the use of oral contraceptives and the development of peripheral edema.
Health Maintenance/Cardiology A 68 year-old female comes to the office for an annual physical examination. Her past medical history is significant for a 40-pack year cigarette smoking history. She takes no medications and has not been hospitalized for any surgery. Family medical history reveals that her mother is living, age 87, in good health without medical problems. Her father is deceased at age 45 from a motor vehicle crash. She has two siblings that are alive and well. From this information, how many identifiable risk factors for cardiovascular heart disease exist in this patient? Answers A. 0 B. 1 C. 2 D. 3
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. This patient has 2 identifiable risk factors based upon the information provided. These include her age 68 and her history of cigarette smoking.
(u) D. See C for explanation
Clinical Intervention/Cardiology Following an acute anterolateral myocardial wall infarction two days ago, a patient suddenly develops hemodynamic deterioration without EKG changes occurring. What complication can explain this scenario? Answers A. Free wall rupture B. CVA C. Atrial fibrillation D. Sick sinus syndrome
Explanations
(c) A. Free wall rupture is a complication that occurs within 72 hours of infarction. It is seen mainly in Q wave transmural and lateral wall infarctions.
(u) B. See A for explanation.
(u) C. See A for explanation. Atrial fibrillation would have EKG evidence of irregularly, irregular rate and rhythm.
(u) D. Sick sinus syndrome would have EKG evidence of decreased rate and loss of P waves
Clinical Intervention/Cardiology
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?
Answers
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 work up of left ventricular dysfunction
D. Admit to the hospital for work up of pneumonia
Explanations
(h) A. See C for explanation.
(h) B. See C for explanation.
(c) C. An elevated BNP is seen in a situation where there is increased pressure in the ventricle during diastole. This is representative of the left ventricle being stretched excessively when a patient has CHF. Sending a patient home would be inappropriate in this case.
(u) D. See C for explanation.
