Cardiovascular

Question 1

1.

A 66-year-old retired carpenter presents with

chronic shortness of breath upon exertion. He

has smoked one pack of cigarettes per day for

the past 5 years and drinks alcohol regularly.

Physical examination reveals a displaced point

of maximal impulse and hepatosplenomegaly.

His medications include pantoprazole for gas-

troesophageal refl ux and sertraline for depres-

sion. Echocardiogram reveals an ejection frac-

tion of 30% and dilated left and right ventricles.

Laboratory tests show:

Na+: 129 mEq/L

K+: 5.2 mEq/L

Cl−: 101 mEq/L

Blood urea nitrogen: 45 mg/dL

Creatinine: 1.3 mg/dL

Glucose: 134 mg/dL

Aspartate aminotransferase: 220 U/L

Alanine aminotransferase: 140 U/L

Alkaline phosphatase: 280 U/L

Which of the following is the most likely cause

of his cardiac findings?

(A)Borrelia burgdorferi

(B) Cigarette smoking

(C) Coxsackie B virus

(D) Ethanol

(E) Pantoprazole toxicity

(F)Trypanosoma cruzi

Answer 1

1. The correct answer is D.

Dilated cardiomy-

opathy (DCM) is a common cause of conges-

tive heart failure (CHF). It is usually due to

causes such as ische mic heart disease or hyper-

tension, but in this case, it is likely due to the

toxic effects of chronic alcohol consumption.

The liver function tests and physical examina-

tion results are consistent with chronic alcohol-

ism and alcoholic cirrhosis.

Question 2

2.

A 52-year-old man presents to his primary care

physician’s offi ce for routine care. He has hy-

pertension, hypercholesterolemia, and type 2

diabetes mellitus, and has smoked one pack of

cigarettes per day for the past 30 years. Medica-

tions include hydrochlorothiazide, atorvastatin,

and glipizide. There is a family history of myo-

cardial infarction in the maternal grandfather

at age 60. The patient has undergone screen-

ing for colon and prostate cancer. Physical ex-

amination reveals a pleasant, obese man who is

175 cm (5′9′′) tall and weighs 108 kg (238 lb).

His blood pressure is 155/81 mm Hg, heart rate

is 78/min, respiratory rate is 14/min, and tem-

perature is 36.8°C (98.3°F). What one action

would most reduce the patient’s stroke risk?

(A) Blood glucose reduction

(B) Blood pressure reduction

(C) Serum cholesterol reduction

(D) Smoking cessation

(E) Weight loss

Answer 2

2. The correct answer is B.

Hypertension is the

most important controllable risk factor for

stroke, and the stroke risk attributable to this

patient’s high blood pressure is larger than any

other factor. The other answers, although im-

portant for improving the patient’s health and

longevity, are less tightly correlated to reducing

stroke risk.

Question 3

3.

A 36-year-old man presents to the clinic with

complaints of a genital sore. The patient is a

sexually active heterosexual involved with

three partners and practices unprotected inter-

course. Fours days ago he noted a painless sore

on his penis. He is afebrile, with a heart rate of

80/min and blood pressure of 120/77 mm Hg.

Physical examination reveals a solitary ulcer-

ated lesion located on the lateral aspect of his

penis. The lesion is nontender and associated

with bilateral inguinal lymphadenopathy. Phys-

ical examination is otherwise normal. If left

untreated, this man is at increased risk for

which of the following?

(A) Ascending aortic aneurysm

(B) Coronary artery aneurysm

(C) Endocarditis

(D) Mitral valve stenosis

(E) Rupture of ventricular free wall

Answer 3

3. The correct answer is A.

The patient presents

with primary syphilis. The lesion is typically a

single painless papule that rapidly becomes

eroded and indurated. Chancres are usually lo-

cated on the penis in heterosexual males but in

homosexual males may be found in the anal

canal, mouth, or external genitalia. In females

they may be seen on the cervix or labia. Serol-

ogy or dark fi eld microscopy can be used to

confi

rm the diagnosis. If left untreated, the pa-

tient may progress to secondary and tertiary

syphilis. Tertiary syphilis causes disruption of

the vasa vasorum or the aorta and consequent

dilation of the aorta, often involving the aortic

root or ascending aorta. This can result in an-

eurysm of the ascending aorta and aortic valve

incompetence.

Question 4

4.

An 81-year-old man is hospitalized for acute

onset of shortness of breath and lower extrem-

ity edema. Although he lives by himself, it is

very difficult for him to move around his apart-

ment without experiencing fatigue. He has not

seen his physician in years but was told in the

past that he had high blood pressure. On physi-

cal examination his jugular venous pulse is pal-

pated 9 cm above his sternal notch, inspiratory

crackles are heard at his lung bases, and there

is 3+ lower extremity edema. Which of the fol-

lowing will confirm the most likely diagnosis?

(A) Cardiac angiography

(B) Echocardiography

(C) Electrocardiogram

(D) Endomyocardial biopsy

(E) Pulmonary function tests

(F) X-ray of the chest

Answer 4

4. The correct answer is B.

The patient most

likely has an acute CHF exacerbation with the

underlying etiology being hypertension.

Echocardiography is an essential test in all pa-

tients with newly diagnosed heart failure and is

an excellent, noninvasive method of assessing

chamber size, function, and ejection fraction.

Question 5

5.

A 42-year-old man presents to the clinic for routine evaluation. His medical history is significant for gallstones. The patient denies smoking and drinks alcohol occasionally. His mother had a heart attack at the age of 63 years. His blood pressure is 134/77 mm Hg. The patient is overweight with well-healed laparoscopic cholecystectomy scars. Fasting laboratory tests show:

Aspartate aminotransferase: 37 U/L

Alanine aminotransferase: 28 U/L

Alkaline phosphatase: 88 U/L

Total cholesterol: 268 mg/dL

LDL cholesterol: 183 mg/dL

HDL cholesterol: 46 mg/dL

Triglycerides: 166 mg/dL

What is the most appropriate next step in management?

(A) A trial of lifestyle modification alone (diet,

exercise, and weight loss)

(B) A trial of lifestyle modification combined with statin and niacin therapy

(C) A trial of lifestyle modification combined with statin therapy

(D) Niacin therapy

(E) Statin therapy

Answer 5

5. The correct answer is A.

You should be famil-

iar with the goals of cholesterol-adjusting ther-

apies. This patient has only one risk factor

(family history) and his goal of LDL choles-

terol is 160 mg/dL or less. Therapeutic lifestyle

changes in the form of a 12-week trial of diet,

exercise, and weight loss should be attempted

given his current LDL cholesterol level.

Question 6

6.

Two and a half weeks after coronary artery by-

pass grafting, a 63-year-old man returns to the

emergency department acutely short of breath.

The patient states that he began having chest

pain and shortness of breath approximately 1

hour earlier. He has a history of hypertension,

diabetes, and two myocardial infarctions. On

examination he is hypoxic with an oxygen satu-

ration of 86% on room air. Other vital signs

and results of a physical examination are nor-

mal. ECG shows no interval change from his

most recent ECG. CT of the chest is shown in

the image. What is the most likely etiology of

this patient’s shortness of breath?

A) Aortic dissection

(B) Exacerbation of chronic obstructive pulmonary disease

(C) Myocardial infarction

(D) Pleural effusion

(E) Pulmonary embolus

Answer 6

6. The correct answer is E.

Recent surgery and

likely limited mobility in the postoperative pe-

riod are two risk factors for pulmonary em-

bolus. The enhanced CT scan of the chest

shows a fi lling defect within the right pulmo-

nary artery consistent with pulmonary em-

bolus. The patient should be treated with anti-
coagulation. Other common risk factors for

deep venous thrombosis and pulmonary em-

bolus include malignancy, pregnancy, and hy-

percoagulable states.

Question 7

7.

A 72-year-old man with coronary artery disease

and hypertension is hospitalized after suffering

a myocardial infarction 5 days ago. He sud-

denly complains of severe chest pain. His

blood pressure is 90/60 mm Hg and heart rate

is 65/min. Auscultation reveals no murmurs or

rubs. An ECG reveals sinus rhythm with an

acute ST-segment elevation in the anteroseptal

area. Urgent bedside echocardiography showed

anteroseptal, lateral, and apical akinesis, mild

left ventricular systolic dysfunction, and severe

pericardial effusion. Within 20 minutes he is

unconscious with undetectable pulses and

blood pressure. What is the most likely cause

of the patient’s sudden decompensation?

(A) Free wall rupture

(B) Left ventricular thrombus

(C) Mitral regurgitation

(D) Pericarditis

(E) Ventricular septal rupture

Answer 7

7. The correct answer is A.

Myocardial rupture is

a sudden postinfarction complication that typi-

cally occurs 5–10 days after an MI (peak at 7

days). During this time the integrity of the car-

diac wall is compromised by macrophage and

mononuclear infiltration, fi brovascular re-

sponse, and other infl ammatory mediators, as

they replace necrotic tissue with scar tissue.

Old age, fi rst MI, and a history of hypertension

are risk factors. The clinical manifestations, as

seen here, are a sudden loss of heart rate, blood

pressure, and consciousness, while the ECG

continues to show a sinus rhythm. Measures to

prevent cardiac rupture include the administration of

β-blockers, angiotensin-converting en-

zyme (ACE) inhibitors, and the avoidance of

steroidal and nonsteroidal anti-inflammatory

agents such as ibuprofen and indomethacin.

Question 8

8.

A 56-year-old woman was recently started on

medication for high blood pressure. At her next

office visit her hypertension is under good control, but

she now complains of “feeling strange”

since she started the medication. On further

questioning, she reports feeling chest tightness

several times over the past 2 weeks, and has

also noticed pain in her elbows and knees. Her

blood pressure is 124/78 mm Hg (146/82 mm

Hg on last visit), heart rate is 102/min, and respiratory

rate is 14/min. Her examination is notable for

several erythematous plaques on the

malar distribution of the face, arms, and upper

torso. What medication was she most likely

started on during her last visit?

(A) Captopril

(B) Furosemide

(C) Hydralazine

(D) Metoprolol

(E) Verapamil

Answer 8

8. The correct answer is C.

This patient displays

symptoms of angina, tachycardia, rash, and

joint pains. This lupus-like syndrome is a well-

described adverse effect of hydralazine therapy.

The vasodilatory action of hydralazine can re-

sult in refl ex tachycardia and decreased oxygen

delivery to the myocardium in patients with ex-

isting CAD. Other agents known to cause a sys-

temic lupus erythematosus-like syndrome in-

clude isoniazid, procainamide, and phenytoin.

Question 9

9.

A 19-year-old woman was attacked while com-

ing home from a party and is brought to the

emergency department. She recalls being

punched in the side of the head and stabbed in

the left flank. Her speech is slow and she com-

plains of a bad headache. Her pulse is 110/

min, blood pressure is 90/50 mm Hg, and re-

spiratory rate is 25/min. On examination she

has a stab wound at the left costal margin in

the midaxillary line. Two large-bore intrave-

nous lines are inserted, and after infusion of

2 L of lactated Ringer’s solution her blood

pressure rises to 95/55 mm Hg. What is the

most appropriate next step in management?

(A) Abdominal ultrasound

(B) Diagnostic peritoneal lavage

(C) Exploratory laparotomy

(D) Noncontrast CT of the head

(E) Peritoneal laparoscopy

Answer 9

The correct answer is C.

A stab wound in a

patient who is hemodynamically unstable re-

quires immediate exploratory laparotomy. This

patient is in shock, and the source of bleeding

should be found.

Question 10

10.

A 48-year-old man presents to the emergency

department complaining of crushing subster-

nal chest pain. He is diaphoretic, anxious, and

dyspneic. His pulse is 110/min, blood pressure

is 175/112 mm Hg, respiratory rate is 30/min,

and oxygen saturation is 94%. Aspirin, oxygen,

sublingual nitroglycerin, and morphine are

given, but they do not relieve his pain. ECG

shows ST-segment elevation in leads V2 to V4.

The duration of symptoms is now approxi-

mately 30 minutes. What is the most appropriate

treatment for this patient at this time?

(A) Calcium channel blocker

(B) Intravenous angiotensin-converting enzyme inhibitor

(C) Intravenousβ-blocker

(D) Magnesium sulfate

(E) Tissue plasminogen activator

Answer 10

10. The correct answer is E.

This patient is pre-

senting with a classic acute MI, and he has ful-

fi lled all indications for fibrinolytic therapy:

acute chest pain suggesting MI, time to ther-

apy <12 hours, and ST-segment elevation >2–3

mm in the chest leads and 1 mm in the limb

leads. Contraindications to fibrinolytic therapy,

however, must still be ruled out; these include

a history of intracranial hemorrhage, acute

ischemic stroke within the past 3 months, cere-

brovascular malformation or brain metastasis,

suspicious aortic dissection, active internal

bleeding or bleeding diathesis, and significant

head trauma within the past 3 months.

Question 11

11.

A 70-year-old woman presents to the emer-

gency department complaining of dizziness.

She is disoriented to the date and her location

and it is difficult to gather an accurate history.

Her pulse is 48/min, blood pressure is 84/60

mm Hg, and respiratory rate is 12/min. On

examination her extremities are cool and

clammy. Her capillary refi ll time is 5 seconds.

What is the most appropriate therapy?

(A) Adenosine

(B) Amiodarone

(C) Atropine

(D) Isoproterenol

(E) Metoprolol

Answer 11

11. The correct answer is C.

This patient has symp-

tomatic bradycardia as evidenced by her altered

mental status and hypoperfusion. In an elderly

patient, it is most likely caused by an inferior

wall MI or sick sinus syndrome, but certain

medications like nitroglycerin,

β-blockers, ACE

inhibitors or barbiturates can mimic a shock-like

state. Atropine is the drug of choice for symp-

tomatic bradycardia.

Question 12

12.

A 77-year-old man, complaining of abdominal

pain, anorexia, and nausea and vomiting over

the past 24 hours, presents to the clinic with

his son. The son reveals that his father has also

complained of blurred vision. The patient’s vi-

tal signs are stable and his abdomen is soft, but

he appears to be somewhat confused. He is

currently taking metoprolol, digoxin, and hy-

drochlorothiazide for ischemic congestive

heart failure. His son says that sometimes his

father confuses his medications. The patient

also has renal insuffi ciency with a baseline se-

rum creatinine of 2.6 mg/dL. The ECG reveals

a widened QRS complex and a new first-degree heart

block. Which of the following is the most

likely cause of this patient’s symptoms?

(A) Digoxin toxicity

(B) Gastroenteritis

(C) Hypocalcemia

(D) Hypovolemia secondary to thiazide diuretic overuse

(E) Myocardial infarction

Answer 12

12. The correct answer is A.

Digoxin toxicity often

presents with vague abdominal complaints, ac-

companied by neurologic (headache, delir-

ium) complaints; visual (altered color percep-

tion, scotomata) complaints; and, most notably,

cardiac arrhythmias. This patient may have

taken too many digoxin pills. Measurement of

the plasma digoxin level will help confirm the

diagnosis (therapeutic range is 0.5–2 ng/mL).

However, toxicity can also exist at normal lev-

els, particularly in persons who are elderly. Be-

cause digoxin is renally excreted, the patient

may have acute renal failure precipitating his

toxicity; this must be investigated. Note that

digoxin levels taken within 6–8 hours of inges-

tion do not refl ect the steady state and are not

reliable predictors of prognosis. Antidigoxi-

genin antibody Fab fragments are first-line

therapy in the setting of life-threatening arrhythmia.

Question 13

13.

A 35-year-old woman presents to the clinic be-

cause of visual problems. She states that she

has always had diffi culty looking up, and over

the past few years her overall vision has be-

come blurry. Review of symptoms is notable

for several recent episodes of “near fainting.”

She takes no medication and has no other

medical history, and has not seen a physician

for 7 years. Because she was adopted as a child,

she does not know her family history, but her

son has required special tutoring at school. The

patient also remarks that her son seems to have

been dropping objects lately. Physical exami-

nation reveals bilateral ptosis. Her extraocular

movements are intact and the pupils are equal,

round, and reactive. Her corrected visual acu-

ity is 20/100 in the right eye and 20/120 in the

left eye. The view of the fundus is obscured.

On ambulation she raises her knees and makes

a slapping sound on the fl oor as she walks.

ECG indicates heart block. What is the patho-

genesis of this patient’s disorder?

(A)

Borrelia burgdorferi

infection

(B) Deletion mutation in dystrophin

(C) Frameshift mutation in dystrophin

(D) Trinucleotide repeat expansion

(E) X-linked emerin defi

ciency

Answer 13

13. The correct answer is D.

This patient is suffer-

ing from myotonic dystrophy, a muscular dys-

trophy caused by multiple CTG nucleotide re-

peats within the myotonin protein kinase gene.

With successive generations, the number of

CTG sequences increases parallel with earlier

onset of symptoms and more severe disease (ge-

netic anticipation). This accounts for the likely

onset of weakness already in the patient’s son.

Patients often present with ptosis and weakness

of the facial muscles, giving a characteristic

“hatchet face” appearance. Another common

presentation is weakness and atrophy of the in-

trinsic hand muscles and forearm extensors.

Cardiac abnormalities, particularly disease of

the conduction system, can lead to syncopal epi-

sodes or even sudden death. Heart block can be

progressive, sometimes necessitating placement

of a pacemaker. The hallmark of disease is myo-

tonia, which is tonic spasm of affected muscles.

Pharmacologic therapy for myotonia includes

phenytoin, procainamide, or quinine sulfate,

but this does not improve the weakness, cardiac

abnormalities, or overall course of the disease.

Question 14

14.

A college sophomore is found by his roommate

to be poorly responsive and brought to the

emergency department. After resuscitation, the

man complains of a severe headache and pho-

tophobia that is accompanied by dizziness,

nausea, vomiting, and neck pain. Physical ex-

amination is noteworthy for positive Kernig’s

and Brudzinski’s signs as well as petechiae on

the trunk and mucocutaneous bleeding. Labo-

ratory studies show:

WBC count: 17,000/mm³

Hemoglobin: 11 g/dL

Platelet count: 70,000/mm³

Bleeding time: 10 min

Prothrombin time: 17 sec

Activated partial thromboplastin time: 47 sec

Thrombin time: 18 sec

A peripheral blood smear is shown in the im-

age. Which of the following is the most likely

diagnosis?

(A) Disseminated intravascular coagulation

(B) Factor V Leiden

(C) Immune thrombocytopenic purpura

(D) Protein C deficiency

(E) Thrombotic thrombocytopenic purpura

Answer 14

14. The correct answer is A.

Disseminated intra-

vascular coagulation (DIC) is a consumptive

coagulopathy that has been associated with a

number of clinical conditions, including bacte-

rial infections such as meningococcemia. DIC

involves activation of the coagulation pathways,

excessive fi brin formation, and platelet activa-

tion. Subsequent bleeding results because of

the depletion of coagulation factors and plate-

lets in the circulation. Because of the con-

sumption of coagulation factors and activation

of platelets, patients present with prolonged

bleeding time, prothrombin time, activated

partial thromboplastic time, and thrombin

time; thrombocytopenia; and schistocytes on

peripheral blood smear. Although not specific,

the presence of D-dimer and fibrinogen degra-

dation products supports a diagnosis of DIC.

Question 15

15.

A 60-year-old man with coronary artery disease,

peptic ulcer disease, and gout presents to the

emergency department with a 24-hour history

of abdominal pain. The pain, which is most in-

tense in the upper abdomen, was sudden in

onset and has become progressively more se-

vere. Free air in the abdomen is detected on

x-ray fi lms. The patient is in an agitated state.

His extremities are cool and capillary refi

ll

time is 3 seconds. His blood pressure is 80/40

mm Hg and heart rate is 130/min. The neck

veins are fl at and the lungs are clear to auscul-

tation. His hemoglobin is 13.8 g/dL. A urinary

catheter is inserted and 10 mL of urine is

drained. What is the most appropriate treat-

ment for this patient at this time?

(A) Broad-spectrum antibiotics for presumed

sepsis

(B) Infusion of isotonic fl

uid

(C) Infusion of norepinephrine

(D) Inotropic support with dopamine, vaso-

pressin, or dobutamine

(E) Transfuse with 1 unit packed RBCs

Answer 15

15. The correct answer is B.

This patient is most

likely suffering from hypovolemic shock sec-

ondary to perforation of a peptic ulcer, which

is confi rmed by the fi nding of free air in the

abdomen. Initial resuscitation requires rapid

reexpansion of the effective blood volume

along with interventions to control ongoing

losses. This is best accomplished with a rapid

infusion of isotonic saline or lactated Ringer’s

solution through two large-bore intravenous

lines.

Question 16

16.

A 29-year-old woman presents to the emer-

gency department with a 3-week history of be-

ing awakened by a dull, prolonged chest pain

that occurs 3–4 times a week. She is a smoker

but has never suffered a myocardial infarction

(MI) or had chest pain before and has no fam-

ily history of early MI. Results of a 12-lead

ECG are normal. Her fi rst set of cardiac en-

zyme measurements (creatine kinase, creatine

kinase-MB fraction, troponin I) are negative. If

coronary angiography were taken at the time of

her chest pain, which of the following fi

ndings

is most like?

(A) Coronary artery spasm

(B) Greater than 80% stenosis in at least two

coronary arteries

(C) No abnormal fi

ndings

(D) Plaque rupture and thrombosis

Answer 16

16. The correct answer is A.

This patient most

likely suffers from Prinzmetal’s angina, which

is caused by coronary artery spasm. This type

of angina usually occurs in smokers younger

than those with unstable angina (UA) due to

atherosclerotic disease. The pain is intermit-

tent and can wake them up in the morning.

During chest pain, an ECG will show multi-

lead ST-segment elevations that can resolve

with the administration of nitroglycerin.

Question 17

17.

A 42-year-old man presents to the emergency

department with a complaint of increasing

shortness of breath when walking to get his

newspaper, diffi culty breathing while lying fl

at,

and a 4.5-kg (10-lb) weight gain over the past

month. He is afebrile, his pulse is 75/min, and

his blood pressure is 98/50 mm Hg. On exami-

nation he smells of alcohol and has 2+ pitting

edema in the lower extremities and a third

heart sound. X-ray of the chest reveals cardio-

megaly. What additional fi ndings must be pres-

ent to confi rm this man’s underlying diagnosis?

(A) Hepatojugular refl

ux and pulmonary con-

gestion

(B) Left ventricular dilation and aortic insuffi

-

ciency

(C) Left ventricular dilation and systolic dys-

function

(D) Myocardial thickening and diastolic dys-

function

(E) Pulmonary congestion and diastolic dys-

function

Answer 17

17. The correct answer is C.

The patient has

DCM, a diagnosis that requires evidence of LV

dilation and systolic dysfunction with LV ejec-

tion fraction (LVEF) <40% on echocardiogra-

phy. Dilation of the LV results in decreased

ability to contract and eject blood from the

chamber, resulting in a decreased LVEF. Pa-

tients usually present with symptoms of heart

failure, arrhythmias, or even sudden death.

Fifty percent of cases are of idiopathic etiology

but the most common known causes are isch-

emic cardiomyopathy due to CAD, myocardi-

tis, and infi ltrative disease. Alcohol is a poorly

understood but signifi cant risk factor for DCM,

and abstinence can result in remarkable recov-

ery of cardiac function.

Question 18

18.

A 69-year-old man with rheumatic heart dis-

ease presents to the emergency department

complaining of a fever and weakness on his left

side. On physical examination the patient is

weak in his left upper extremity and he draws

only the right half of a clock. Shortly after his

presentation, the patient dies, and an autopsy

is performed. A gross view of the patient’s heart

is shown in the image. Which of the following

is a risk factor for the type of lesion pictured?

(A) Coronary artery disease

(B) Hypertension

(C) Mitral valve prolapse

(D) Prolonged bedrest

(E) Prosthetic valve replacement

Answer 18

18. The correct answer is C.

The photograph de-

picts a vegetative growth on a native mitral

valve. Mitral valve prolapse (MVP), particu-

larly as a complication of rheumatic heart dis-

ease, is a risk factor for native valve infective

endocarditis. This is because altered blood flow

around a damaged valve provides the opportu-

nity for a clot to develop and harbor bacteria,

which gain access to the blood through a

wound, dental work, surgery, or intravenous

drug use. It can be prevented by replacing the

valve with a prosthetic valve.

Question 19

19.

A 28-year-old man with a history of intravenous

drug abuse presents to the emergency depart-

ment with a 2-day history of fever, chills, and

shortness of breath. On physical examination

the patient has a new heart murmur, small reti-

nal hemorrhages, and subungual petechiae.

Which of the following is the most likely caus-

ative organism?

(A) Group A Streptococcus

(B) Mycobacterium tuberculosis

(C) Staphylococcus aureus

(D) Staphylococcus epidermidis

(E) Streptococcus viridans

Answer 19

19. The correct answer is C.

In patients with in-

fective endocarditis and a history of intravenous drug

abuse, Staphylococcus aureus is the

causative agent in the vast majority of cases

and is more likely to cause acute rather than

subacute endocarditis. If the patient has a pros-

thetic valve, then coagulase-negative staphylo-

coccus is the predominant organism. Bacterial

endocarditis is an infectious process of the en-

dothelial surface of the heart. Symptoms in-

clude fever, fatigue, malaise, vascular phenom-

ena such as Janeway lesions, and immunologic

phenomena such as Osler nodes. Diagnosis is

usually based on the Duke criteria, and labora-

tory studies include blood culture and echocar-

diography. Treatment is through intravenous

antibiotics and surgery for valve repair or re-

placement, if necessary.

Question 20

20.

A boy is delivered at 37 weeks’ gestation via

spontaneous vaginal delivery. He is the prod-

uct of a normal pregnancy and was delivered

without complications. Prenatally the mother

was blood type B and was rubella immune and

negative for Rh antibody, group B streptococci,

rapid plasma reagin, hepatitis B surface anti-

gen, gonorrhea, and chlamydia. The patient

appears cyanotic. He is breathing at a rate of

60/min and his heart rate is 130/min. He has a

normal S1 and S2. There is a harsh holosys-

tolic murmur that is loudest at the left lower

sternal border. His examination reveals palpa-

ble nonbounding peripheral pulses bilaterally.

Which of the following is the most likely diag-

nosis?

(A) Coarctation of the aorta

(B) Dextraposed transposition of the great ar-

teries

(C) Patent ductus arteriosus

(D) Tetralogy of Fallot

(E) Truncus arteriosus

Answer 20

20. The correct answer is B.

Dextraposed transpo-

sition of the great arteries (D-TGA) is the most

common cause of cyanotic heart disease in neonates.

It accounts for 5% of congenital heart

defects. With this defect, the aorta arises from

the right ventricle and the pulmonary artery

arises from the LV. This leads to pulmonary

and systemic circuits that are in parallel as op-

posed to in series. The deoxygenated blood is

therefore recirculated through the body in the

systemic circulation, while the oxygenated

blood only fl ows through the pulmonary circu-

lation. A lesion, such as an atrial septal defect

(ASD), ventricular septal defect (VSD), or pa-

tent ductus arteriosus (PDA), is therefore re-

quired for mixing of the systemic and pulmo-

nary circulations for survival. D-TGA usually

presents at birth with cyanosis and tachypnea.

Plain fi lm radiographs demonstrate an egg-

shaped silhouette due to the absent main pul-

monary artery stem and small heart base. Pros-

taglandin E1 is used to keep the PDA open and

increase mixing of deoxygenated and oxygen-

ated blood. Balloon atrial septostomy can also

be used if necessary. An arterial switch surgical

procedure is used to repair the defect.

Question 21

21.

A 32-year-old man is stabbed in the left chest

and presents to the emergency department in

distress. His pulse is 130/min, blood pressure is

70/50 mm Hg, and respiratory rate is 39/min.

The stab wound is in the left fifth intercostal

space in the midaxillary line. On examination

his trachea is deviated to the right, jugular

veins are distended bilaterally, and he has ab-

sent breath sounds and hyperresonance to per-

cussion on the left side. Subcutaneous emphy-

sema is palpated on the left thoracic wall.

What is the best next step in management?

(A) Chest tube thoracotomy

(B) Diagnostic peritoneal lavage

(C) Needle thoracostomy

(D) Pericardiocentesis

(E) Surgical exploration

Answer 21

21. The correct answer is C.

This patient pre-

sented with a tension pneumothorax, which re-

sults from a parenchymal wound that acts as a

one-way valve that allows free air into the pleu-

ral space but prevents its escape, causing col-

lapse of the lung on the affected side. It is a

medical emergency, as the building pressure in

the pleural space causes shifting or displace-

ment of the mediastinum to the contralateral

side and subsequently compromises cardiopul-

monary function. Compression of the opposite

lung impairs proper gas exchange while im-

pingement on the heart impairs proper cardiac

function. The most common mechanisms of

this type of injury are blunt or penetrating in-

juries, or secondary to medical procedures. A

large-bore needle should be inserted in the sec-

ond intercostal space in the midclavicular line

to facilitate decompression and reestablish car-

diopulmonary function. The needle is left in

place until a thoracostomy tube can be inserted.

Question 22

22.

A 75-year-old man comes into the emergency

department with a 10-minute history of crush-

ing substernal chest pain radiating to his left

arm. This man is well known to the staff due to

his long history of chest pain. His creatine

phosphokinase level is elevated and his tro-

ponin T level is 0.4 ng/mL. Which of the fol-

lowing is the most likely diagnosis?

(A) Acute myocardial infarction

(B) Hypochondriasis

(C) Prinzmetal’s angina

(D) Stable angina

(E) Unstable angina

Answer 22

22. The correct answer is A.

This man has a car-

diac enzyme leak of specifi c myocardial mark-

ers that suggests acute MI. UA is defi ned as ei-

ther rest angina >20 minutes in duration,

new-onset angina, or increasing angina that is

more frequent, longer in duration, or occurs

with less exertion than previous angina. UA

and non-ST-segment elevation MI (NSTEMI)

are part of the continuum of acute coronary

syndromes, in which plaque rupture and coro-

nary thrombosis compromise blood fl ow to a

region of viable myocardium. In UA and

NSTEMI, ST-segment elevation and patho-

logic Q waves are absent. They are treated with

medical management (antiplatelet therapy, ni-

troglycerin, β-blockade, and morphine), and

considered for revascularization.

Question 23

23.

A 91-year-old woman presents to the emer-

gency department with a chief complaint of

shortness of breath over the past 2 days. She

has a history of hypertension and coronary ar-

tery bypass surgery 25 years earlier. Her blood

pressure is 178/92 mm Hg and she has jugular

venous distension, hepatomegaly, and 3+ lower

extremity edema. ECG is remarkable for left

ventricular hypertrophy, no ST-segment eleva-

tions or depressions, no Q waves, and no T-

wave abnormalities. Echocardiogram reveals

an ejection fraction of 60% and left atrial dila-

tation. There is universal left ventricular thick-
ening. No valvular regurgitation or stenosis was
noted. Which of the following underlying con-

ditions is the most likely cause of this patient’s

symptoms?

(A) Hypertensive heart disease

(B) Hypertrophic obstructive cardiomyopathy

(C) Ischemic heart disease

(D) Mitral valve prolapse

(E) Myocarditis

Answer 23

23. The correct answer is A.

You should be able to

recognize diastolic dysfunction as a cause of

heart failure. In diastolic heart failure, LVEF is

normal (>50%). Heart failure results from an

inability of the LV to fi ll during diastole rather

than an inability of the LV to eject blood into

systemic fl ow. Hypertensive heart disease is one

of the most common causes of diastolic heart

failure. This patient’s medical history of hyper-

tension, in-offi ce measurement indicating high

blood pressure, and the ECG showing LVH is

consistent with this diagnosis.

Question 24

24.

A 39-year-old white man with essential hyper-

tension presents for a routine health mainte-

nance visit. He has no complaints and reports

compliance with his hydrochlorothiazide. His

pulse is 70/min, blood pressure is 145/92 mm

Hg, and respiratory rate is 16/min. His body

mass index is 24 kg/m². His physical examina-

tion is within normal limits. For which condi-

tion is the patient at increased risk?

(A) End-stage renal disease

(B) Hypercholesterolemia

(C) Hypertrophic cardiomyopathy

(D) Second-degree Mobitz I atrioventricular

block

(E) Type 2 diabetes mellitus

Answer 24

24. The correct answer is A.

Hypertension is a risk

factor for both chronic renal insufficiency and

end-stage renal disease. Hypertension can di-

rectly cause renal disease and accelerate the

progression of underlying renal pathology. In

addition, hypertension increases a patient’s risk

of premature cardiovascular disease, heart fail-

ure, stroke, and intracerebral hemorrhage.

Question 25

25.

An 83-year-old woman is being evaluated for

confusion. She was admitted 3 days ago after

having an acute MI. Her hospital course has

been complicated by narrow-complex ventricu-

lar tachycardia, which has fi nally been stabi-

lized on an antiarrhythmic medication. She

was also started on a post-MI protocol and an

antidepressant. One day after beginning these

medications, she begins to develop confusion

and slurred speech. Her temperature is 36.7°C

(98.1°F), blood pressure is 138/60 mm Hg,

pulse is 88/min, and respiratory rate is 14/min.

She is alert and oriented to person, but she

does not realize she is in the hospital. Addition-

ally, she exhibits diffi culty with word articula-

tion, although she speaks fl uently, and she

demonstrates a mild resting tremor. The re-

mainder of her examination is normal. Which

of the following medications is most likely to

cause these central nervous system effects?

(A) Aspirin

(B) Enalapril

(C) Fluoxetine

(D) Lidocaine

(E) Metoprolol

Answer 25

25. The correct answer is D.

Lidocaine is an im-

portant agent used for the acute treatment of

ventricular arrhythmias, especially those after

acute MI. It is a class IB antiarrhythmic agent

and thus acts on the ventricular myocardium

by mildly blocking sodium channels, slowing

repolarization in Purkinje cells, and increasing

the fi ring threshold in pacemaker cells. It has

relatively few serious adverse effects; however,

patients taking lidocaine may experience significant

neurologic complications. This patient

is displaying the classic neurologic adverse ef-

fects of lidocaine, including slurred speech and

confusion. Other common adverse effects in-

clude tremor, personality and mood changes,

and hallucinations. These effects are entirely

reversible with the removal of therapy.

Question 26

26.

A 43-year-old woman presents to the emer-

gency department because of chest pain, short-

ness of breath, and worsening fatigue for the

past day. The chest pain initially worsened with

lying down and improved with leaning for-

ward, but now it seems equal in intensity over

all positions. On physical examination she has

labored, fast breathing and appears to be in

pain. She has jugular venous distention. She is

tachycardic, has a regular rhythm, and has dis-

tant heart sounds with a friction rub. Her lungs

are clear to auscultation bilaterally, her abdom-

inal examination is benign, and she has no pe-

ripheral edema. Her temperature is 39.0°C

(102.2°F), pulse is 126/min, blood pressure is

89/66 mm Hg, respiratory rate is 32/min, and

oxygen saturation is 98% on room air. X-ray of

the chest is shown in the image. Which of the

following is the most likely diagnosis?

A) Cardiac tamponade

(B) Decompensated congestive heart failure

(C) Panic attack

(D) Pericarditis

(E) Tension pneumothorax

Answer 26

26. The correct answer is A.

This patient has the

characteristic symptoms and signs of cardiac

tamponade. She complains of chest pain, fa-

tigue, and dyspnea, all characteristic of tam-

ponade. On physical examination, she has

Beck’s triad, a group of signs characterized by

hypotension, distant heart sounds, and dis-

tended neck veins. The fluid accumulation

around the heart decreases the ventricular filling

pressure, which decreases cardiac output.

She also has tachycardia and tachypnea, both

found in patients with cardiac tamponade. Evi-

dence of cardiomegaly is due to a large pericar-

dial effusion, and the echocardiogram would

show a large pleural effusion with chamber

collapse, a characteristic echocardiographic

sign of tamponade.

Question 27

27.

An elderly man presents to the emergency de-

partment with chest pain. He has a history of

stable angina and recent onset diabetes melli-

tus, but now the chest pain comes on with less

exertion and takes longer to go away. An ECG

and cardiac enzymes are ordered. If this man

has unstable angina, what are the expected

fi ndings on ECG and cardiac enzyme testing?

(A) Delta waves on the ECG and elevated car-

diac enzyme levels

(B) Low voltage ECG and elevated cardiac en-

zyme levels

(C) No changes on ECG and elevated cardiac

enzyme levels

(D) ST-segment depressions on ECG and nor-

mal cardiac enzyme levels

(E) ST-segment elevations with Q waves and

normal cardiac enzyme levels

Answer 27

27. The correct answer is D.

UA is acute myocar-

dial ischemia without evidence of myocardial

necrosis, manifesting as angina that is new-on-

set, crescendos, or occurs at rest. It can present

with or without ECG changes, including ST-

segment depressions, but by definition cardiac

enzyme levels are normal. Treatment involves

relief of ischemic pain, assessment of hemody-

namic status, and antithrombotic therapy if

necessary. If this patient were having an acute

MI, we would expect to see ST-segment eleva-

tions and elevated cardiac enzyme levels.

Question 28

28.

A 19-year-old man complains of chest pain

while playing basketball on his high school

team. Paramedics are called and he is rushed

to the hospital. Physical examination reveals

moderate mitral regurgitation and a crescendo-

decrescendo systolic ejection murmur that gets

louder with Valsalva maneuver. Echocardiog-

raphy reveals thickened left ventricular walls

and dynamic left ventricular outfl ow tract ob-

struction. What is the best first step in management?

(A)β-Blockers

(B) Calcium channel blockers

(C) Partial excision of the interventricular septum

(D) Warfarin

Answer 28

28. The correct answer is A.

Idiopathic hypertro-

phic subaortic stenosis (IHSS) is the most com-

mon cause of sudden death in young athletes

in the United States. IHSS results in LV out-

fl ow tract obstruction, impaired LV unloading,

LVH, and diastolic dysfunction (impaired LV

relaxation and fi lling). Patients may be asymp-

tomatic, but can present with dizziness, dysp-

nea, angina, and sudden death. Physical examination

often reveals mitral insufficiency, an

S4 gallop (due to a stiffened LV), and a cre-

scendo-decrescendo ejection murmur that

gets louder with Valsalva maneuver (decreased

preload). Both echocardiography and ECG

show signs of LVH, and x-ray of the chest may

reveal left atrial dilation due to mitral insufficiency.

The first step in management is symp-

tomatic control with β-blockade.

Question 29

29.

A 47-year-old woman who is 2 weeks post triple

bypass surgery presents to the emergency de-

partment with a chief complaint of sudden on-

set, sharp chest pain for several hours. She is

fatigued and short of breath. On physical ex-

amination she has distended neck veins that

grow more distended on inspiration. Muffl

ed

heart sounds are heard. Her temperature is

37.0°C (98.6°F), pulse is 133/min, blood pres-

sure is 70/50 mm Hg, respiratory rate is 30/

min, and oxygen saturation is 100% on room

air. An echocardiogram shows a large pericar-

dial effusion and chamber collapse; therefore,

pericardiocentesis is performed. Although a

large amount of blood is aspirated, the patient’s

clinical picture acutely worsens. Her pain level

increases substantially; pulse is 150/min, blood

pressure is 60/41 mm Hg, respiratory rate is 30/

min, and oxygen saturation is 100%. Repeat

echocardiography shows an even larger peri-

cardial effusion with chamber collapse. Which

complication of pericardiocentesis is most

likely in this patient?

(A) Acute left ventricular failure with pulmo-

nary edema

(B) Aspiration of 10 mL air into the pericar-

dium

(C) Laceration of a coronary vessel

(D) Pneumothorax

(E) Puncture of the left ventricle

Answer 29

29. The correct answer is C.

Laceration of a coro-

nary vessel is the most dangerous complication

of pericardiocentesis. It can lead to worsened

cardiac tamponade, MI, and even death. This

patient has worsening chest pain and hemody-

namics during pericardiocentesis, the most

likely cause of which is laceration of a coronary

vessel.

Question 30

30.

A 57-year-old man presents to the emergency

department with worsening substernal chest

pain occurring over the past 20 minutes. He

has a medical history signifi cant for a 2-pack-

per-day smoking history, gout, obesity, hyper-

cholesterolemia, hypertension, osteoarthritis of

both knees, infl ammatory bowel disease, and

recently diagnosed type 2 diabetes mellitus that

is well controlled on oral antiglycemics (hemoglobin

A1c of 7.8%). On physical examination

he is in moderate distress, diaphoretic, and

nauseous. His temperature is 37.5°C (99.5°F),

pulse is 112/min, blood pressure is 142/85 mm

Hg, and respiratory rate is 22/min. He tests pos-

itive for MI by serial cardiac enzymes. He is

started on the appropriate therapy and is ready

for discharge the following evening. What is

the number one preventive measure this pa-

tient can take to decrease his immediate risk

for a second MI?

(A) Decrease the amount of cholesterol in his diet

(B) Exercise three times a week

(C) Lower his blood pressure to the 120/80mm Hg range

(D) Lower his blood sugar levels to achieve a hemoglobin A1c level <7%

(E) Quit smoking

Answer 30

30. The correct answer is E.

The patient can best

decrease his risk of a second MI by quitting

smoking. In some studies, patients who already

had an initial coronary event and subsequently

quit smoking decreased their risk of a second

coronary event by 50%.

Question 31

31.

A 37-year-old woman with sarcoidosis presents

to her primary care physician complaining of

progressive fatigue and shortness of breath over

the past 3 months. She also reports that her

socks and shoes do not fi t the way they used to

and that she fainted a few weeks ago for the

fi rst time in many years. She denies any recent

illness and only takes medications to control

her sarcoid. She states that she is more com-

fortable sitting than lying down. She has jugu-

lar venous distension, which increases with in-

spiration. Her blood pressure is 134/87 mm

Hg, respiratory rate is 17/min, pulse is 96/min,

and temperature is 37.2°C (98.9°F). She also

has decreased breath sounds bilaterally at the

bases. ECG shows decreased QRS voltage. An

echocardiogram shows a thick left ventricle.

Which of the following is the most likely diag-

nosis?

(A) Aortic stenosis

(B) Cardiac tamponade

(C) Hypertensive heart disease

(D) Pericarditis

(E) Restrictive cardiomyopathy

Answer 31

31. The correct answer is E.

This is a classic de-

scription of RCM. RCM is almost always asso-

ciated with infi ltrative diseases such as amyloi-

dosis, sarcoidosis, or hemochromatosis. These

conditions restrict LV fi lling, causing decreased

output and compliance, and increased filling

pressure. Consequently, patients begin to expe-

rience CHF symptoms. Here, this patient com-

plains of dyspnea (positional and with exer-

tion), syncope, and peripheral edema. She also

has the classic Kussmaul’s sign (increased jug-

ular venous distension with inspiration) that,

although it is not specifi c for this condition,

contributes to making the diagnosis. The com-

bination of the echocardiogram and ECG

signs listed are also classic for making the diag-

nosis. Treatment of RCM is to control the un-

derlying cause (e.g., iron chelation for hemo-

chromatosis), diuretics, ACE inhibitors, and nitrates.

Question 32

32.

A 64-year-old man in the surgical intensive care

unit goes into rapid atrial fi brillation on postop-

erative day one after a decortication for a locu-

lated pulmonary empyema. He is given an ap-

propriate loading dose of digoxin, but 4 hours

after his second dose, the patient complains of

increased palpitations and dizziness. The patient

is conscious and hemodynamically stable. STAT

serum blood tests show a potassium level of 5.0

mEq/L; all other electrolytes, including diva-

lents, are in the normal range. The digitalis level

is above the therapeutic range at 4 ng/mL (thera-

peutic range 0.5-2 ng/mL). Results of cardiac te-

lemetry are shown in the image. Which of the

following should be administered immediately?

(A) Calcium

(B) Furosemide

(C) Magnesium

(D) Potassium

(E) Sodium polystyrene sulfonate

Answer 32

32. The correct answer is C.

Nearly any dysrhyth-

mia may be precipitated by acute digitalis tox-

icity, but atrial tachycardia with 2:1 block, ac-

celerated junctional rhythm, and bidirectional

ventricular tachycardia (torsade de pointes) are

frequently seen, due to the combination of de-

creased atrioventricular node conduction and

increased automaticity. Magnesium sulfate is

the drug of choice for treating torsades de

pointes, including in the setting of digitalis tox-

icity, since it decreases calcium infl ux and thus

reduces the early afterdepolarizations that per-

petuate this dysrhythmia. A therapeutic level is

4–5 mEq/L. Additional treatment for torsades

in the setting of digoxin overdose include anti-

digitalis Fab fragments, lidocaine, and direct

current cardioversion.

Question 33

33.

A 1-week-old infant presents to her general pe-

diatrician’s offi ce for a well-child visit. She was

born at 37 weeks’ gestation without complica-

tions. Her temperature is 37.0°C (98.6°F),

pulse is 130/min, blood pressure is 72/54 mm

Hg, and respiratory rate is 28/min. She is cur-

rently at the 50th percentile for weight and

75th percentile for height. She is acyanotic and

has a wide, fi xed split S2, with a 2/6 systolic

ejection murmur at the left upper sternal bor-

der. The remainder of the examination is unre-
markable. Which of the following is the most

likely diagnosis?

(A) Atrial septal defect

(B) Coarctation of the aorta

(C) Dextratransposition of the great arteries

(D) Tetralogy of Fallot

(E) Ventricular septal defect

Answer 33

33. The correct answer is A.

ASDs are often as-

ymptomatic and cause acyanotic heart disease.

As described in this patient, physical examina-

tion may be remarkable for a wide, fixed, split

S2 with a systolic ejection murmur at the left

upper sternal border. Some patients also have a

mid-diastolic rumble at the left lower sternal

border. Both murmurs represent increased

blood fl ow across the pulmonic and tricuspid valves.

Question 34

34.

A 26-year-old white nonsmoking woman re-

turns for a follow-up appointment with her pri-

mary care provider. At a routine health mainte-

nance visit 8 months earlier, her blood pressure

was 179/97 mm Hg. Since then she has ad-

hered to a low-fat diet and exercises regularly.

On repeat measurement 1 month later, her

blood pressure was still elevated, despite her

compliance with the prescribed hydrochloro-

thiazide and lisinopril. She has no complaints

and denies headaches, chest pain, or mental

status changes. On physical examination she is

a slender woman in no apparent distress. An

abdominal bruit that lateralizes to the left is

heard. Her blood pressure is 178/99 mm Hg in

her left arm and 181/95 mm Hg in her right

arm. A basic metabolic panel and complete

blood count are within normal range. Which

of the following is the most appropriate next

step in patient care?

(A) Add a statin to the patient’s current drug

regimen to decrease fatty arterial plaques

(B) Admit patient to the hospital and start in-

travenous nitroprusside

(C) Increase the dosage of her antihypertensive

regimen

(D) Order duplex imaging of the renal arteries

and proceed to percutaneous transluminal

angioplasty if renal artery stenosis is found

(E) Order duplex imaging of the renal arteries

and proceed to surgical revascularization if

renal artery stenosis is found

Answer 34

34. The correct answer is D.

This patient most

likely has fibromuscular dysplasia leading to re-

nal artery stenosis. She has early onset hyper-

tension that is refractory to pharmacotherapy.

In addition, she has an abdominal bruit, sug-

gestive of renal artery stenosis. Young women

with early onset of hypertension refractory to

pharmacotherapy are the most common patient

population for fibromuscular dysplasia.

Fibromuscular dysplasia can be diagnosed by

duplex imaging of the renal arteries, and per-

cutaneous transluminal angioplasty is the treat-

ment of choice in young patients with this dis-

ease and refractory hypertension.

Question 35

35.

A 49-year-old man presents to the clinic for a

health maintenance visit. He has no com-

plaints, but he requests a prescription for his

“pressure pills,” as he lost his original prescrip-

tion. On physical examination his blood pres-

sure is 220/130 mm Hg. Physical examination

is otherwise within normal limits. Laboratory

tests show:

Na

+

: 142 mEq/L

K

+

: 3.8 mEq/L

Cl

−

: 105 mEq/L

Carbon dioxide: 25 mEq/L

Blood urea nitrogen: 20 mg/dL

Creatinine: 1.0 mg/dL

Glucose: 133 mg/dL

Urinalysis is within normal limits, and his

ECG is normal. Which of the following is the

most effective management?

(A) Administer intravenous nitroprusside for

management of hypertensive emergency

(B) Administer intravenous nitroprusside for

management of hypertensive urgency

(C) Administer oral furosemide for manage-

ment of hypertensive emergency

(D) Administer oral metoprolol for manage-

ment of hypertensive urgency

(E) Administer sublingual nifedipine for man-

agement of hypertensive emergency

Answer 35

35. The correct answer is D.

This patient is in hy-

pertensive urgency: he has a diastolic blood

pressure >130 mm Hg but has no signs of end-

organ damage. His ECG, laboratory values,

and physical examination results are all nor-

mal. Initial management of hypertensive

urgency involves administration of an oral anti-

hypertensive. β-blockers, loop diuretics, ACE

inhibitors, or calcium channel blockers are

recommended, and two agents should be

started if initial treatment fails to lower pres-

sures to a safe level in 3–6 hours. Therefore

oral metoprolol would be appropriate manage-

ment for this patient in hypertensive urgency.

Question 36

36.

A 58-year-old man is admitted to the coronary

care unit for telemetric monitoring after an ep-

isode of bradycardia. While in the unit, he sud-

denly loses consciousness. His pulse is unde-

tectable and his blood pressure drops to 40

mm Hg. His airway is clear and patent, and he

is still breathing on his own. An ECG shows

electrical activity. Chest compressions are

started and he is quickly given a bolus of intra-

venous sodium bicarbonate and atropine.

When his tracing does not improve, the bo-

luses are repeated twice, and fi nally his tracing

returns to normal sinus rhythm. Moments

later, when he regains consciousness, he com-

plains of a dry mouth, blurred vision, and feel-

ing fl ushed. What is the most appropriate next

step in the management of this patient?

(A) This patient has atropine toxicity and re-

quires urgent administration of a cholin-

ergic agonist

(B) This patient has atropine toxicity and re-

quires urgent administration of a musca-

rinic agonist

(C) This patient has bicarbonate toxicity and

requires urgent administration of calcium

citrate

(D) This patient is experiencing transient ad-

verse effects of atropine and requires only

supportive measures

(E) This patient is experiencing transient ad-

verse effects of bicarbonate and requires

only supportive measures

Answer 36

36. The correct answer is D.

Pulseless electrical

activity (PEA) is an important reversible brady-

arrhythmia. It often represents an underlying

disorder such as pulmonary embolism, tam-

ponade, or severe acidosis. Advanced cardiac

life support recommends initial basic life sup-

port stabilization of a patient with demon-

strated PEA. Once airway and breathing have

been secured, several medications can be ad-

ministered to address the PEA. These include

several doses each of empiric bicarbonate, epi-

nephrine, and atropine. After the administra-

tion of each medication, reassessment of the

ECG is important. Atropine works on the heart

by antagonizing muscarinic receptors and re-

leasing the vagal stimulus on the heart. As an

anticholinergic agent, it has several character-

istic and uncomfortable adverse effects. Al-

though they are rarely life threatening, they

can be quite concerning to a patient experienc-

ing them. They include blurry vision (blind as

a bat), cutaneous fl ushing (red as a beet, hot as

a hare), confusion (mad as a hatter), and dry

mucous membranes (dry as a bone). Because

these adverse effects are uncomfortable, they

should be treated supportively.

Question 37

37.

A 62-year-old man with a history of benign pros-

tatic hyperplasia and hypertension presents to

his primary care provider for a routine health

maintenance visit. He reports that he feels

“better than ever” and explains that his daugh-

ter made him come in for his annual visit. He

takes prazosin daily and occasionally some

acetaminophen. He has no drug allergies and

denies smoking, drinking, or the use of illicit

drugs. His physical examination is within nor-

mal range except for his rectal examination,

which revealed an enlarged prostate. His tem-

perature is 36.8°C (98.2°F), respiratory rate is

13/min, pulse is 82/min, and blood pressure is

138/86 mm Hg. Which of the following is the

most likely adverse effect of

α1-adrenergic blockade in this patient?

(A) Decreased urine flow

(B) Increased blood pressure

(C) Increased sexual drive

(D) Irritability

(E) Orthostatic hypotension

Answer 37

37. The correct answer is E.

When patients stand,

baroreceptors in the carotids and aorta typi-

cally sense decreased blood fl ow as blood pools

in the venous system due to gravity. This leads

to a sympathetic response which stimulates α1-

adrenergic receptors, causing a reflexive vaso-

constriction and increased resistance in order

to maintain blood pressure. If a patient is taking an α1

-adrenergic blocking agent, this re-

flexive vasoconstriction and increased resis-

tance is blocked, and patients often experience

orthostatic hypotension.

Question 38

38.

A 2-year-old girl is referred to the hospital for

evaluation of her inability to gain weight. She

is well fed by her parents, but appears to tire

during feedings and has been losing weight de-

spite frequent high-calorie meals. There is no

family history of developmental delay or short

stature. She is well dressed, her hair is brushed,

and she is playful but tires quickly. Her tem-

perature is 36.5°C (97.7°F), pulse is 110/min,

blood pressure is 90/50 mm Hg, and respira-

tory rate is 24/min. She has a harsh 2/6 holosys-

tolic murmur that is best heard at the left ster-

nal border, which is unchanged and has been

present since birth. Which of the following is

the most appropriate next step in management?

(A) Continue to monitor the patient for increased weight loss and increased shunting

(B) pH probe for gastroesophageal reflux disease

(C) Refer for evaluation and possible closure of ventricular septal defect

(D) Skeletal survey

(E) Stool culture

Answer 38

38. The correct answer is C.

Feeding is a strenu-

ous activity for many infants and can lead to

failure to thrive in children with congenital

heart disease. Most small VSDs close sponta-

neously during the fi rst few years of life; how-

ever, this child’s VSD is still present given the

unchanged murmur, and is leading to weight

loss. A high-calorie intake has not led to resolu-

tion of the failure to thrive. Therefore referral

for possible closure of the VSD is the correct choice.

Question 39

39.

A 72-year-old man presents with shortness of

breath and increased home oxygen require-

ment. The patient has coronary artery disease,

he has had two previous myocardial infarc-

tions, and he has a history of chronic obstruc-

tive pulmonary disease requiring 2 L of contin-

uous home oxygen. The patient has a

45-pack-year history of smoking. He is unable

to walk more than a block and the swelling in

his legs has worsened. The physician suggests

measuring a brain natriuretic peptide (BNP)

level to distinguish a cardiac from a pulmonary

cause of his symptoms. Which of the following

statements regarding BNP is true?

(A) BNP acts to decrease venous capacitance

and increase preload

(B) BNP is decreased in the setting of left ven-

tricular dysfunction

(C) BNP is secreted by the cardiac atria

(D) BNP is secreted in response to hypovo-

lemia

(E) BNP levels cannot differentiate systolic

and diastolic dysfunction

(F) BNP secretion results in pressure overload

Answer 39

39. The correct answer is E.

BNP levels are in-

creasingly utilized in the management of heart

failure. It is often used in the setting of short-

ness of breath when differentiating between a

pulmonary and a cardiac etiology. Levels can

predict heart failure from a systolic and dia-

stolic cause with approximately equal accu-

racy; however, BNP cannot differentiate be-

tween the two. Note that N-pro-BNP (a peptide

cleaved in BNP release) is often tested because

levels rise higher in patients with LV dysfunction.

Question 40

40.

A 77-year-old man with a history of hyperten-

sion, hypercholesterolemia, chronic obstruc-

tive pulmonary disease, and a 90-pack-year

smoking history presents to the emergency de-

partment with lethargy and abdominal pain.

His temperature is 36.9°C (98.5°F), blood

pressure is 82/54 mm Hg, pulse is 125/min,

and respiratory rate is 16/min. A pulsatile ab-

dominal mass is palpable just superior to the

umbilicus. There is diffuse abdominal tender-

ness, although rebound tenderness and guard-

ing are absent. There is also slight skin discol-

oration noted in the left lower back. Which of

the following is the most likely diagnosis?

(A) Aortic dissection

(B) Mesenteric ischemia

(C) Perforated gastric ulcer

(D) Ruptured abdominal aortic aneurysm

(E) Stroke

Answer 40

40. The correct answer is D.

This patient presents

with the classic triad of symptoms for the diag-

nosis of a ruptured abdominal aortic aneurysm

(AAA): abdominal pain, pulsatile abdominal

mass, and hypotension. In addition, this patient

has several risk factors for an AAA rupture in-

cluding hypertension and chronic obstructive

pulmonary disease. The skin discoloration

along the left lower back may be due to a retro-

peritoneal hematoma that is associated with a

ruptured AAA. Patients with AAA diameters be-

tween 5–7 cm have a 5-year risk of rupture of

about 33%. A ruptured AAA can be lethal and

demands immediate surgical attention. When

ruptured AAA is highly suspected, he patient

should be taken immediately to the operating

room for surgical repair without further diagnostic tests.

Question 41

41.

A 52-year-old African-American man with a

history of smoking and asthma presents to the

emergency department complaining of short-

ness of breath. He has alcohol on his breath

and admits to drinking 3–4 beers each night

plus an occasional “mixed drink.” He denies

drug use and states that he has been feeling

well until recently, when he began to sleep

with more pillows and to become out of breath

when walking. His blood pressure is 143/89

mm Hg, respiratory rate is 21/min, pulse is

112/min, and he is afebrile. On physical exam-

ination he has a laterally displaced point of

maximal impulse and an S3 gallop, as well as

rales over his right lung base. X-ray of the chest

shows cardiomegaly and a pleural effusion.

Echocardiogram reveals an ejection fraction of

25%. Which of the following is the most likely

diagnosis?

(A) Asthma exacerbation

(B) Delirium tremens

(C) Dilated cardiomyopathy

(D) Endocarditis

(E) Hypothyroidism

Answer 41

41. The correct answer is C.

DCM may be caused

by a number of factors, one of the most impor-

tant of which is alcohol. Other causes include

chronic CAD, myocarditis, doxorubicin toxic-

ity, and viral infection. The dilated pericar-

dium leads to decreased contractility and the

symptoms of CHF. The physical exam and di-

agnostic test fi ndings are classic for this malady.

Question 42

42.

A cardiologist is called to consult on the care of

a 2-day-old girl delivered at 33 weeks’ gesta-

tion. The infant is lying supine in her isolette.

She is acyanotic, but has a heart rate of 192/

min and a respiratory rate of 60/min. She has a

nonradiating continuous machinery murmur

at the left upper sternal border that remains the

same with compression of the ipsilateral, then

contralateral jugular veins. S1 and S2 are nor-

mal. Her peripheral pulses are bounding.

Which of the following is the most likely diagnosis?

(A) Aortic stenosis with aortic regurgitation

(B) Patent ductus arteriosus

(C) Systemic arteriovenous fistula

(D) Venous hum

(E) Ventricular septal defect

Answer 42

42. The correct answer is B.

PDA is a vascular

connection that exists between the aorta and

main pulmonary artery. It causes acyanotic

congenital heart disease. PDAs account for

10% of congenital heart disease, occurring with

a high incidence in preterm infants and a 2:1

female:male predominance. Small PDAs are

asymptomatic, while large ones may cause

CHF, failure to thrive, and recurrent lower re-

spiratory tract infections. On physical examina-

tion, a continuous machinery murmur heard

best at the left upper sternal border, and

bounding peripheral pulses may be present.

There may also be a prominent apical impulse

and a thrill. X-ray of the chest may show cardi-

omegaly and increased pulmonary vascular

markings. PDAs usually close within the first

month of life. In preterm infants, indometha-

cin may be administered to close the PDA.

PDAs also may be surgically ligated or coil embolized if

necessary.

Question 43

43.

A 64-year-old white man with type 2 diabetes

mellitus presents to the emergency department

after “passing out.” While climbing the stairs,

he felt dyspneic and lost consciousness as he

reached the top. Before the event he experi-

enced no palpitations or change in vision.

When he awoke he felt alert and called for

help immediately. He reports dyspnea on exer-

tion for the past year. He has no history of chest

pain, seizures, or recent illnesses. Medications

include calcium and vitamin D supplements,

glyburide, and synthroid. He is allergic to peni-

cillin. Family history is noncontributory. He

drinks wine socially and does not smoke or use

illicit substances. His blood pressure is 136/92

mm Hg, heart rate is 88/min, respiratory rate is

14/min, and temperature is 36.5°C (97.7°F).

Physical examination reveals a systolic crescendo-

decrescendo murmur best heard in the second

right intercostal space with a soft S2. ECG shows

nonspecifi

c ST-segment changes and left ven-

tricular hypertrophy with a normal heart rate

and rhythm. Which of the following interven-

tions will most likely reveal the cause of this syn-

copal event?

(A) ECG

(B) Echocardiography

(C) Electroencephalography

(D) Exercise stress test with echocardiogram

(E) Sublingual nitroglycerin and serial cardiac enzymes

(F) Tilt test

Answer 43

43. The correct answer is B.

The most likely diag-

nosis is AS. Approximately 80% of patients who

are symptomatic with AS are male. In the

United States, senile calcifi c stenosis is the

most common cause of AS and presents be-

tween 60 and 80 years of age. Risk factors for

age-related degenerative calcifi c AS are the

same as those for atherosclerosis (age, male,

smoking, hypertension, decreased HDL, diabe-

tes mellitus), and the pathology of the valves is

similar to that of atherosclerotic vessels. Aortic

valves can also be congenitally abnormal (e.g.,

bicuspid) and thus more prone to stenosis.

Rheumatic endocarditis tends to cause fusion

of the commissures, forming a bicuspid valve;

then the valve fi broses and calcifi es. AS of

rheumatic origin is highly associated with mi-

tral valve disease. When AS develops gradually,

the LV responds with concentric hypertrophy

to maintain cardiac output, and thus the trans-

valvular pressure gradient increases. Because of

this compensation, AS can exist for years with-

out symptoms. When the valve orifice de-

creases to <1 cm² symptoms may develop. Pa-

tients present with dyspnea on exertion

(because of increased pulmonary capillary

wedge pressure), angina (due to the increased

myocardial oxygen requirements), and exer-

tional syncope (because exercising muscles va-

sodilate and arterial pressure drops in the face

of a fi xed carbon dioxide level). Echocardio-

gram reveals LVH and calcifi cations (if pres-

ent). Doppler echocardiogram also allows esti-

mation of the transaortic valvular gradient and

of the valvular orifi ce, which are measures of

disease severity. Other valve function can be

assessed concurrently, and HCM causing ob-

struction can be ruled out.

Question 44

44.

A 56-year-old woman with a history of chronic

renal disease presents to the emergency depart-

ment because of severe, sharp, retrosternal

chest pain that radiates to her jaw. The pain

worsens when the patient lies down, and she is

most comfortable leaning forward and hugging

her knees. She takes erythropoietin, furo-

semide, calcitriol, and sodium polystyrene sul-

fonate. She is scheduled for dialysis three times

per week, but she admits to sometimes missing

sessions. She stopped drinking and smoking 20

years ago, and she has no family history of

heart or renal problems. Auscultation of the

heart reveals a friction rub. Laboratory tests show:

WBC count: 12,000/mm3

Hemoglobin: 10.0 g/dL

Hematocrit: 30.0%

Platelet count: 150,000/mm3

Na+: 141 mEq/L

K+: 4.8 mEq/L

Cl−: 101 mEq/L

HCO3−: 22 mEq/L

Blood urea nitrogen: 63 mg/dL

Creatinine: 3.2 mg/dL

Glucose: 111 mg/dL

The emergency medicine physician urges the

patient to be more compliant with her dialysis,

but the patient complains that she is too tired

to go to dialysis all of the time and that it is ru-

ining her life. Which of the following is the

most likely complication if the patient’s condi-

tion remains untreated?

(A) Cardiac tamponade

(B) Decreased jugular venous pressure

(C) Mitral regurgitation

(D) Restrictive cardiomyopathy

(E) Septic shock

Answer 44

44. The correct answer is A.

This patient has symptoms consistent with pericarditis,

or inflammation of the pericardial sac. The condi-

tion is most often idiopathic (84% of cases),

with other major causes being neoplasia, tuber-

culosis, infection, and collagen vascular dis-

eases. Uremia in patients with chronic renal

failure can cause pericarditis, and uremic peri-

carditis is an indication for emergent dialysis.

Pericarditis can be complicated by cardiac tam-

ponade, recurrent pericarditis, or pericardial

constriction if left untreated. In patients with

cardiac tamponade, ventricular fi lling is lim-

ited, which leads to decreased cardiac output

and can lead to shock. Pericarditis is diagnosed

by the presence of two of the following three

factors: pleuritic chest pain, pericardial friction

rub, or widespread ST-segment elevation on

ECG. Ten to thirty percent of patients with

acute pericarditis may go on to develop recur-

rent or incessant disease, termed chronic auto-

reactive pericarditis.

Question 45

45.

A 60-year-old man with a history of congestive

heart failure presents to his physician. He has a

5-year history of excessive daytime sleepiness

and snoring. He also admits to three drinks of

alcohol per day. His temperature is 36.6°C

(98.0°F), pulse is 85/min, blood pressure is

138/82 mm Hg, respiratory rate is 14/min, and

oxygen saturation is 99% on room air. His body

mass index is 31 kg/m². Physical examination

is signifi cant for macroglossia and a short neck.

Polysomnography is performed and is signifi

-

cant for multiple nocturnal episodes of airfl

ow

cessation at the nose and mouth, despite evi-

dence of continuing respiratory effort. Which

of the following is the most effective manage-

ment for this patient?

(A) Avoidance of alcohol

(B) Avoidance of supine posture

(C) Nasal continuous positive airway pressure

(D) Uvulopalatopharyngoplasty

(E) Weight reduction

Answer 45

45. The correct answer is C.

The definitive event

in obstructive sleep apnea (OSA) is closure of

the patient’s upper airway, usually at the level

of the oropharynx. OSA can occur at any age

but is more common in men 30–60 years old.

The defi nitive investigation is polysomnogra-

phy, and the key diagnostic fi nding is episodes

of airfl ow cessation at the nose and/or mouth,

despite evidence of continuing respiratory ef-

fort. Several approaches to the management of

OSA have been outlined. For patients with

ischemic heart disease or CHF who also have

OSA, treatment should begin with nasal con-

tinuous positive airway pressure (CPAP). This

is the only treatment modality that has been

tested and proved effi cacious for patients with

ischemic heart disease or CHF and OSA. Na-

sal CPAP prevents upper airway occlusion by

propping the airway open with positive pres-

sure delivered via face mask, with the air acting

as a pneumatic stent.

Question 46

46.

During a screening physical examination for

participating in high school sports, a 14-year-

old girl is found to have a late apical systolic

murmur preceded by a click. The rest of the

examination is unremarkable. Echocardiogra-

phy shows superior displacement of the mitral

leaflets of >2 mm during systole into the left

atrium, with a thickness of at least 8 mm. In

addition, she states that her father also has

some type of heart “murmur,” but she knows

nothing else about it. Which of the following is

the most appropriate management at this time?

(A) Digoxin

(B) Instruct the patient to avoid all forms of strenuous activity

(C) Metoprolol

(D) Mitral valve replacement

(E) Prophylactic antibiotics for dental procedures

Answer 46

46. The correct answer is E.

MVP occurs when

the leafl ets of the mitral valve bulge backwards

into the left atrium during systole, resulting in

a characteristic mid- to late-systolic murmur,

often associated with a preceding click. It is

caused by an underlying structural abnormality

of the mitral valve, and seems to be more com-

mon in adolescent girls. Consider antibiotic

prophylaxis in patients with a mid-systolic click

and late-systolic mitral regurgitation murmur,

including those with increased leaflet thicken-

ing or redundancy, left atrial enlargement, and

LV dilatation, even in the absence of corre-

lated clinical fi ndings. Due to the transient

bacteremia following dental procedures, pro-

phylactic antibiotics are recommended since

the prolapsed valve can serve as a nidus for

colonization.

Question 47

47.

A 20-year-old woman arrives at the emergency

department actively seizing with QRS prolon-

gation on ECG per paramedics. The patient’s

roommate called emergency medical services

after the patient collapsed, was not responsive

to questioning, and began having clonic jerks

bilaterally in her upper extremities. The pa-

tient’s roommate denies any knowledge of the

patient consuming alcohol or illicit drugs. She

does not believe the patient had any plan of

harming herself, but does acknowledge that

the patient has seemed “down” lately and was

recently prescribed medication for generalized

anhedonia. Which of the following is the most

appropriate fi

rst-line treatment?

(A) Activated charcoal

(B) Diazepam

(C) Flumazenil

(D) Physostigmine

(E) Sodium bicarbonate and diazepam

Answer 47

47. The correct answer is E.

Tricyclic antidepres-

sant (TCA) overdose presents with sedation,

coma, anticholinergic effects, seizures, and

arrhythmias. First-line treatment includes so-

dium bicarbonate for QRS prolongation, diaz-

epam or lorazepam for seizures, and careful

cardiac monitoring for arrhythmias. Sodium bi-

carbonate is indicated for QRS widening >100

msec, ventricular arrhythmias, and/or hypoten-

sion. The benefi t of sodium bicarbonate is due

both to an increase in serum pH and extracel-

lular sodium. Elevated serum pH lowers free

drug concentrations and favors the neutral

form of the drug, making less available to bind

to sodium channels. Increasing extracellular

sodium increases the electrochemical gradient

across cardiac cell membranes, thus attenuat-

ing TCA-induced blockade of rapid sodium channels.

Question 48

48.

A 78-year-old woman presents to a nursing

home physician complaining of palpitations

over the past several months. Her episodes are

not associated with any chest pain, dizziness,

or loss of consciousness. The patient reports

that she spent several weeks in the hospital as a

child with rheumatic fever. ECG is shown in

the image. Which of the following is the most

likely diagnosis?

A) Atrial fibrillation

(B) Atrial flutter

(C) Multifocal atrial tachycardia

(D) Paroxysmal atrial tachycardia

(E) Paroxysmal supraventricular tachycardia

Answer 48

48. The correct answer is A.

This patient has per-

sistent atrial fi brillation. Her risk for the disor-

der is greatly increased by her history of rheu-

matic fever and presumed rheumatic heart

disease and is varied depending on the severity

of valvular disease. The ECG shown is charac-

teristic of atrial fi brillation, showing an irregu-

lar baseline, no clear P waves, and irregular

and varied QRS complexes. Rheumatic heart

disease can cause deformity of the valve cusps,

fusion of the commissures, and shortening and

fusion of the chordae tendineae. Stenosis of

the mitral valve is present in 50%–60% of the

cases, and combined aortic/mitral valve lesions

occur about 20% of the time. Therefore an as-

tute clinician should auscultate for a mitral

stenosis murmur (an diastolic opening snap fol-

lowed by a late rumbling diastolic murmur).

The increased pressure in the left atrium from

the mitral stenosis can cause atrial fibrillation

(which will need to be anticoagulated). This

patient should also receive prophylactic antibi-

otics for dental, urologic, and surgical proce-

dures to prevent endocarditis.

Question 49

49.

A 70-year-old man comes to his primary care

physician for his annual check-up. He has a

history of hypertension, hyperlipidemia, and

coronary artery disease, and had coronary ar-

tery bypass grafting 6 years ago. On examina-

tion the physician notes a right carotid bruit.

Which of the following is the most appropriate

next step?

(A) Carotid duplex ultrasound

(B) Carotid endarterectomy

(C) ECG

(D) Referral to a neurologist

(E) Transthoracic echocardiography

(F) Warfarin therapy

Answer 49

49. The correct answer is A.

This patient’s history

of hypertension and hyperlipidemia places him

at risk for atherosclerosis of the carotid arteries.

The carotid bruit arises from turbulent blood

flow caused by an atherosclerotic plaque. The

next appropriate step for this patient would be

a diagnostic test to assess the severity of carotid

artery stenosis. Although a traditional carotid

arteriogram remains the gold standard, it

comes with costs and risks that make it a less

likely fi rst choice for asymptomatic carotid artery

stenosis screening.

Question 50

50.

A 32-year-old man is brought to the emergency

department by paramedics after being found

wandering downtown, apparently delirious and

agitated. During transport to the hospital the

patient becomes diaphoretic and tremulous

and has a blood pressure to 163/100 mm Hg,

pulse of 102/min, and temperature of 39°C

(102.2°F). On examination the patient has di-

lated pupils and ulcerations of his nasal sep-

tum mucosa with the residue of a white pow-

der along the nasal alae in addition to his

tachycardia, hypertension, hyperthermia, and

agitation. Which of the following is the reason

why nonselective β-blockers should be avoided

in this patient?

(A) Increased risk of late vasospasm

(B) Risk of acutely worsening hypertension

through vasoconstriction

(C) Risk of causing acute hypotension

(D) Risk of causing dyspnea

(E) Risk of ventricular arrhythmia

Answer 50

50. The correct answer is B.

Cocaine toxicity pro-

duces a hyperadrenergic state which is identi-

fi ed by hypertension, tachycardia, tonic-clonic

seizures, dyspnea, and ventricular arrhythmias.

Cocaine produces vasoconstriction in coronary

arteries, resulting in hypertension and bradycardia.

Nonselective β-adrenergic blockade may

worsen this effect, suggesting that this vasocon-

striction may be mediated by

α-adrenergic receptors and antagonized by

β-adrenergic receptor-mediated vasodilatation.

Question 51

51.

A 59-year-old man presents to his internist for a

routine visit. He has no complaints, and review

of symptoms is negative. His past medical his-

tory is signifi cant for poorly controlled hyper-

tension for 15 years due to noncompliance

with antihypertensive medications. He takes

hydrochlorothiazide 25 mg orally four times a

day. His family history is signifi cant for hyper-

tension, heart failure, and stroke. He has a

30-pack-year smoking history and drinks two

beers a day. On physical examination he is a

mildly obese man in no acute distress. He has

a normal jugular venous pressure. He has a

prominent point of maximum impulse, regular

rate and rhythm, normal S1, loud S2, and au-

dible S4 with no murmurs. His lungs are clear

to auscultation bilaterally, and he has no signs

of edema. His abdominal and neurologic ex-

aminations are within normal limits. His tem-

perature is 37.0°C (98.6°F), pulse is 81/min,

respiratory rate is 12/min, blood pressure is

165/96 mm Hg, and oxygen saturation is 100%

on room air. His ECG shows normal sinus

rhythm with large amplitude of the S wave in

V1 and V2 and of the R wave in V5 and V6.

Also present are diffuse ST segment/T wave

changes, widened bifi d P waves, and prolonged

QRS waveforms. Which of the following is the

most likely diagnosis?

(A) Acute myocardial infarction

(B) Cerebrovascular accident

(C) Dilated cardiomyopathy

(D) Left ventricular hypertrophy

(E) Pericarditis

Answer 51

51. The correct answer is D.

LVH occurs as a con-

sequence of uncontrolled hypertension. In-

creased pressures lead to increased workload

for the heart and cardiac muscle hypertrophy.

Patients with LVH may have a prominent point

of maximum impulse, loud S2, and audible S4

from an atrial kick. In addition, there may be

signs of LVH on ECG; however, LVH can of-

ten be detected with echocardiography far ear-

lier than it can be detected on an ECG. On

this patient’s ECG, the large amplitude of the

S in V1 and V2, of the R in V5 and V6, the dif-

fuse ST/T wave changes, the widened bifid P

waves (indicating left atrial enlargement), and

the prolonged QRS all suggest LVH.

Question 52

52.

A 60-year-old woman is transferred to a physi-

cian from an outside hospital following a mo-

tor vehicle collision. Her medical history is no-

table for Osler-Weber-Rendu syndrome. She is

otherwise healthy. Which of the following tri-

ads is most likely to characterize her medical

history prior to the collision?

(A) Hypertension, bradycardia, and irregular respirations

(B) Jaundice, fever, and right upper quadrant pain

(C) Symptoms of hypoglycemia, low blood

sugar, and relief with increase in blood sugar

(D) Telangiectasia, recurrent epistaxis, and positive family history

(E) Venous stasis, hypercoagulability, and endothelial damage

Answer 52

52. The correct answer is D.

Osler-Weber-Rendu

syndrome, also known as hereditary hemor-

rhagic telangiectasia, is an autosomal domi-

nant fi brovascular dysplasia in which vascular

lesions (telangiectasias, arteriovenous malfor-

mations, and aneurysms) are found throughout

the body, particularly in the lungs, brain, and

gastrointestinal tract.

Question 53

53.

A 65-year-old man presents to the emergency

department following the acute onset of palpi-

tations. His wife states that he was eating din-

ner when he noticed the palpitations, light-

headedness, and shortness of breath. The

patient has a history of treated hypertension,

but no other medical history. The patient is not

able to relate any meaningful history. Blood

pressure is 80/40 mm Hg, heart rate is 126/

min, respiratory rate is 20/min, and oxygen sat-

uration is 99% on room air; he is afebrile. His

heart rate is irregularly irregular with no mur-

murs, clicks, or rubs. Respiratory examination

is unremarkable. X-ray of the chest shows no

acute disease. ECG shows no discernible P

waves and an irregularly spaced QRS response.

Which of the following is the best first step in

management?

(A) Administration of adenosine

(B) Cardiac catheterization and stent placement

(C) Cardioversion to sinus rhythm

(D) Carotid massage

(E) Placement of dual lead pacemaker

Answer 53

53. The correct answer is C.

The patient presents

with atrial fibrillation and hemodynamic insta-

bility. He is hypotensive and tachycardic and

has altered mental status. The appropriate

treatment is immediate cardioversion.

Question 54

For each patient with chest pain, select the most

likely diagnosis.

54.

A 47-year-old man is brought to the emergency

department via ambulance. He was found un-

conscious and bleeding from a 4-cm penetrat-

ing wound over his lateral left chest. On admis-

sion he is in respiratory distress and he is

tachycardic and hypotensive, with a blood pres-

sure of 68/43 mm Hg. The jugular venous

pulse is elevated and heart sounds are difficult to

auscultate.

(A) Acute aortic dissection

(B) Acute myocardial infarction

(C) Angina pectoris

(D) Cardiac tamponade

(E) Compression fracture of the spine

(F) Coronary vasospasm

(G) Esophageal spasm

(H) Myocarditis

(I) Panic disorder

(J) Pericarditis

(K) Pneumonia

(L) Pulmonary embolus

(M) Rib fracture

(N) Tension pneumothorax

Answer 54

54. The correct answer is D.

The patient presents

with the classic triad of hypotension, jugular

venous distension, and distant heart sounds

(Beck’s triad), indicative of cardiac tamponade.

There is also a plausible mechanism given the

traumatic left chest wound.

Question 55

For each patient with chest pain, select the most

likely diagnosis.

55.

A 66-year-old woman presents to the emer-

gency department with chief complaints of

nausea, vague abdominal pain, and epigastric

discomfort. The pain began while she was

climbing stairs earlier in the day and increased

gradually. It was relieved after 10 minutes of

sitting down, but she remains concerned. Her

pulse is 105/min and blood pressure is 146/82

mm Hg.

(A) Acute aortic dissection

(B) Acute myocardial infarction

(C) Angina pectoris

(D) Cardiac tamponade

(E) Compression fracture of the spine

(F) Coronary vasospasm

(G) Esophageal spasm

(H) Myocarditis

(I) Panic disorder

(J) Pericarditis

(K) Pneumonia

(L) Pulmonary embolus

(M) Rib fracture

(N) Tension pneumothorax

Answer 55

55. The correct answer is C.

Symptoms of cardiac ischemia are often atypical in

women, the elderly, and patients with diabetes. Note

that the usual duration of angina is a few minutes to

half an hour, with pain gradually increasing

and improved with rest.

Question 56

For each of the following patients with fatigue, select the most appropriate pharmacologic intervention.

56.

A 36-year-old woman at 18 weeks’ gestation

presents with a chief complaint of fatigue. Her

history is signifi cant for leukemia 7 years ear-

lier that was treated successfully with a course

of doxorubicin chemotherapy. On physical ex-

amination she has bilateral rales throughout

her lung fi elds and 3+ pitting edema. Echocar-

diography reveals a dilated left ventricular

chamber and an ejection fraction of 40%.

(A) Candesartan

(B) Digoxin

(C) Erythropoietin

(D) Folate

(E) Heparin

(F) Isoniazid

(G) Lisinopril

(H) Metoprolol

(I) Warfarin

Answer 56

56. The correct answer is H.

This patient likely

suffered DCM as a result of doxorubicin toxic-

ity, which is now being exacerbated by the car-

diopulmonary stress of pregnancy. Any medical

intervention should take into account the pos-

sible teratogenic effects on the child. A

β-blocker such as metoprolol would be an ap-

propriate treatment for heart failure in this

case. Of note, this patient would also most

likely benefit from a loop diuretic given her

present volume status.

Question 57

For each of the following patients with fatigue, select the most appropriate pharmacologic intervention.

57.

A 75-year-old retired anesthesiologist with a

history of two previous myocardial infarctions

presents because of extreme fatigue upon exer-

tion. He is unable to walk more than two

blocks and requires three pillows to sleep com-

fortably at night. Physical examination reveals

jugular venous distension. He has previously

been unable to tolerate enalapril due to excessive

coughing.

(A) Candesartan

(B) Digoxin

(C) Erythropoietin

(D) Folate

(E) Heparin

(F) Isoniazid

(G) Lisinopril

(H) Metoprolol

(I) Warfarin

Answer 57

57. The correct answer is A.

ACE inhibitors and

angiotensin receptor blockers (ARBs) are the

most effective treatments for CHF. Since many

patients suffer from cough as an idiopathic ad-

verse effect of ACE inhibitors, one should be

familiar with ARBs as a possible alternative.

ARBs can have serious potential adverse effects

on a fetus.

Question 58

For each patient with pericardial disease, select the

most effective management.

58.

A 45-year-old man with chronic renal disease

on dialysis presents with a chief complaint of

sharp chest pain for several days that has not

improved with acetaminophen. He also notes

increasing fatigue and dyspnea over the past

few days with a bothersome cough. He nor-

mally is compliant with dialysis, but reports

that he has missed his last three dialysis treat-

ments. His temperature is 37.5°C (99.5°F),

pulse is 85/min, blood pressure is 100/72 mm

Hg, respiratory rate is 20/min, and oxygen satu-

ration is 99% on room air. On physical exami-

nation he appears in mild distress. He has

slightly distended neck veins. His heart sounds

are muffled and a pericardial friction rub is

heard. An echocardiogram shows a large pericardial

effusion.

(A) Antibiotics

(B) Chest tube placement

(C) Colchicine

(D) Corticosteroids

(E) Emergency cardiac catheterization

(F) Emergent pericardiocentesis

(G) Intravenous fluids

(H) Loop diuretics

(I) Morphine

(J) Multidrug antituberculous therapy

(K) Nitroglycerin

(L) Nonsteroidal anti-inflammatory drugs

(M) Renal dialysis

Answer 58

58. The correct answer is M.

The patient has car-

diac tamponade secondary to uremic pericardi-

tis. The usual treatment for cardiac tamponade

is pericardiocentesis. However, in relatively sta-

ble patients with cardiac tamponade secondary

to uremic pericarditis, the treatment of choice

is to initiate or intensify dialysis.

Question 59

For each patient with pericardial disease, select the

most effective management.

59.

A 58-year-old man with a history of angina and

a positive stress test presents for cardiac cathe-

terization. During the procedure, one of his

coronary arteries is lacerated. The patient de-

velops tachycardia and becomes hypotensive.

The anesthesiologist notices that his systolic

pressure falls even further on inspiration. A

bedside echocardiogram is performed and

shows a small pericardial effusion.

A) Antibiotics

(B) Chest tube placement

(C) Colchicine

(D) Corticosteroids

(E) Emergency cardiac catheterization

(F) Emergent pericardiocentesis

(G) Intravenous fluids

(H) Loop diuretics

(I) Morphine

(J) Multidrug antituberculous therapy

(K) Nitroglycerin

(L) Nonsteroidal anti-inflammatory drugs

(M) Renal dialysis

Answer 59

59. The correct answer is F.

The patient has car-

diac tamponade secondary to a hemopericar-

dium. If fluid is rapidly introduced into the

pericardium, it cannot stretch to accommodate

the additional volume; therefore, the intraperi-

cardial pressure rises quickly. A very small vol-

ume of fl uid in the pericardium can lead to

tamponade if introduced rapidly enough, as

seen in this patient. Emergent pericardiocente-

sis is recommended in the case of cardiac tam-

ponade in a hemodynamically unstable patient.

Question 60

For each patient with pericardial disease, select the

most effective management.

60.

An otherwise healthy 17-year-old girl presents

to the emergency department because of 2

weeks of chest pain. She describes the pain as

sharp, localized to the left side of her chest,

and radiating to her jaw and neck. The pain

worsens when she lies down and improves on

leaning forward. Her temperature is 37.5°C

(99.5°F), pulse is 81/min, blood pressure is

139/81 mm Hg, respiratory rate is 15/min, and

oxygen saturation is 100% on room air. Physi-

cal examination is signifi cant for a soft pericar-

dial friction rub. X-ray of the chest shows car-

diomegaly, and echocardiography shows a

moderate pericardial effusion.

A) Antibiotics

(B) Chest tube placement

(C) Colchicine

(D) Corticosteroids

(E) Emergency cardiac catheterization

(F) Emergent pericardiocentesis

(G) Intravenous fluids

(H) Loop diuretics

(I) Morphine

(J) Multidrug antituberculous therapy

(K) Nitroglycerin

(L) Nonsteroidal anti-inflammatory drugs

(M) Renal dialysis

Answer 60

60. The correct answer is L.

The patient has signs

and symptoms of viral pericarditis. Although

she has a moderate pericardial effusion seen on

x-ray of the chest and echocardiography, her

pericardium has stretched to accommodate the

excess fluid, so she is not experiencing cardiac

tamponade. High-dose nonsteroidal anti-infl

ammatory drugs (NSAIDs) are first-line therapy in

viral or idiopathic pericarditis. Her effusion

should resolve over time without pericardiocentesis.