EXAM POSSIBILITIES Flashcards
A 60-year old male patient on aspirin, an angiotensin-converting enzyme inhibitor, nitrates, and a beta blocker, who is being followed for chronic stable angina, presents to the ER with a history of two or three episodes of more severe and long-lasting anginal chest pain each day over the past 3 days. His ECG and cardiac enzymes are normal. Which of the following is the best course of action?
A. Admit the patient and begin IV digoxin.
B. Admit the patient and begin IV heparin.
C. Admit the patient and give prophylactic thrombolytic therapy
D. Admit the patient for observation with no change in meds
E. Increase the doses of current medications and follow closely as an outpatient.
Admit the patient and begin IV heparin.
You are seeing in your office a patient with the chief complaint of relatively sudden onset of shortness of breath and weakness, but no chest pain, ECG shows nonspecific ST-T changes. You should be particularly attuned to the possibility of painless, or silent, myocardial infarction in which of the following patients?
A. Unstable angina patient on multiple medications. B. Elderly diabetic C. Premenopausal female D. Inferior MI patient E. MI patient with PVCs
. Elderly diabetic
A 45-year old white female smoker is admitted to the hospital for observation after presenting to the emergency department with vague chest pain. There is no past history of cardiac disease, diabetes, hypertension, or hyperlipidemia. Later that night while in bed she has a recurrence of pain, at which time cardiac monitoring shows a transient elevation of precordial ST segments. The pain is promptly relieved by sublingual nitroglycerin. Physical exam is unremarkable. Which of the following is the best follow-up management plan?
A. Echocardiography and anti-inflammatory therapy
B. EGD and proton pump inhibitor therapy
C. Exercise stress testing: treatment depending on results
D. Coronary angiography; likely treatment with nitrates and calcium channel blockers
E. Chest CT scan; likely treatment with IV heparin
. Coronary angiography; likely treatment with nitrates and calcium channel blockers
. Two weeks after hospital discharge for documented myocardial infarction, a 65-year-old returns to your office very concerned about low-grade fever and pleuritic chest pain. There is no associated shortness of breath. Lungs are clear to auscultation and heart exam is free of significant murmurs, gallops, or rubs. ECG is unchanged from the last one in the hospital. Which of the following therapies is likely to be most effective?
A. Antibiotics B. Anticoagulation with warfarin C. An anti-inflammatory agent D. An increase in antianginal medication E. An antianxiety agent
. An anti-inflammatory agent
. A 55-year-old patient presents to you with a history of having recently had a 3-day hospital stay for gradually increasing shortness of breath and leg swelling while away on a business trip. He report being told he had congestive heart failure then, but is asymptomatic now, with normal vital signs and physical exam. An echocardiogram is obtained that estimates an ejection fraction of 38%. The patient likes to keep medications to a minimum. He is currently on just aspirin plus a statin. Other than remaining on those, which of the following would be the most appropriate medication recommendation at this time?
A. Begin an ACE inhibitor and then add a B-blocker on a scheduled basis.
B. Begin digoxin plus furosemide on a scheduled basis
C. Begin spironolactone on a scheduled basis
D. Begin hydralazine plus nitrates on a scheduled basis
E. Just use furosemide plus nitroglycerin if shortness of breath and swelling recur
F. Given his preferences, since he is doing well, no other medication is needed.
Begin an ACE inhibitor and then add a B-blocker on a scheduled basis.
A 32-year-old female is referred to you from an OB-GYN colleague due to the onset of extreme fatigue and dyspnea on exertion 1 month after her second vaginal delivery. By history, physical exam, and echocardiogram, which shows systolic dysfunction, you make the diagnosis of peripartum (postpartum) cardiomyopathy. Which of the following statements is correct?
A. Postpartum cardiomyopathy may occur unexpectedly years after pregnancy and delivery.
B. About half of all such patients will recover completely.
C. The condition is idiosyncratic; the risk of recurrence in a future pregnancy is no greater than average.
D. The postpartum state will require a different therapeutic approach than typical dilated cardiomyopathies.
About half of all such patients will recover completely.
A 75-year-old patient presents to the ER after a sudden syncopal episode. He is again alert and in retrospect describes occasional substernal chest pressure and shortness of breath on exertion. His lungs have a few bibasilar rales, and his blood pressure is 110/80. Which of the following classic findings should you expect to hear on cardiac auscultation?
A. A harsh systolic crescendo-decrescendo murmur heard best at the upper right sternal border.
B. A diastolic decrescendo murmur head at the mid-left sternal border.
C. A holosystolic murmur heard best at the apex.
D. A Midsystolic click.
A harsh systolic crescendo-decrescendo murmur heard best at the upper right sternal border.
. A 72-year-old male comes to the office with intermittent symptoms of dyspnea on exertion, palpitations, and cough occasionally productive of blood. On cardiac auscultation, a low-pitched diastolic rumbling murmur is faintly heard toward the apex. The origin of the patient’s problem probably relates to which of the following?
A. Rheumatic fever as a youth
B. Long-standing hypertension
C. A silent MI within the past year
D. A congenital condition
Rheumatic fever as a youth
You are helping with school sports physicals and see a 13-year-old boy who has had some trouble keeping up with his peers. He has a cardiac murmur, which you correctly diagnose as a ventricular septal defect based on which of the following auscultatory findings?
A. A systolic crescendo-decrescendo murmur heard best at the upper right sternal border with radiation to the carotids; the murmur is augmented with transient exercise.
B. A systolic murmur at the pulmonic area and a diastolic rumble along the left sternal border.
C. A holosystolic murmur at the mid-left sternal border
D. A diastolic decrescendo murmur at the mid-left sternal border
E. A continuous murmur through systole and diastole at the upper left sternal border
A holosystolic murmur at the mid-left sternal border
A 40-year-old male in generally good health presents to the office with a history of palpitations that last for a few seconds and occur two or three times a week. There are no other symptoms. ECG shows a rare single unifocal premature ventricular contraction (PVC). Which of the following is the most likely cause of this finding?
A. Underlying coronary artery disease B. Valvular heart disease C. Hypertension D. Apathetic hyperthyroidism E. Idiopathic or unknown
Idiopathic or unknown
An active 78-year-old female has been followed for hypertension but presents with new onset of mild left hemiparesis and the finding of atrial fibrillation on ECG, which persists throughout the hospital stay. She has been in sinus rhythm on checkup 3 months earlier. Optimal management by the time of hospital discharge includes review of antihypertensive therapy (aspirin), a ventricular rate control agent if needed, plus which of the following?
A. Automated implanted cardioverter-defibrillator (AICD)/permanent pacemaker placement to avoid the need for anticoagulation.
B. Waiting for anticoagulation therapy until the ability to ambulate without falls is established.
C. Antiplatelet therapy such as aspirin, without warfarin.
D. Warfarin with a target INR of 1.5 plus antiplatelet therapy
E. Warfarin with a target INR of 2.5 ( Coumadin)
Warfarin with a target INR of 2.5 ( Coumadin)
During a new-patient history and physical exam this asymptomatic 67-year old male was found to have a palpable, pulsatile, but nontender abdominal mass just above the umbilicus. On follow-up ultrasound, an infrarenal abdominal aortic aneurysm is confirmed, measuring 3.0x3.5 cm. The patient’s other medical conditions include hypertension, hyperlipidemia, and tobacco abuse. Which of the following is an accurate, evidence-based recommendation for the patient to consider?
A. Watchful waiting is the best course until the first onset of abdominal pain
B. Surgery would be indicated except for the excess operative risk represented by the patient’s risk factors
C. Serial follow-up with ultrasound, CT, or MRI is indicated, with the major determinant for surgery being aneurysmal size greater than 5 to 6cm
D. Serial follow-up with ultrasound, CT, or MRI is indicated, with the major determinant for surgery being involvement of a renal artery
E. Unlike stents in the setting of coronary artery disease, endovascular stent grafts have proven unsuccessful in the management of AAAs.
Serial follow-up with ultrasound, CT, or MRI is indicated, with the major determinant for surgery being aneurysmal size greater than 5 to 6cm
. A 70-year-old female has been relatively healthy (but allergic to PCN), treated only for hypertension, on a thiazide diuretic. She comes to the hospital due to the sudden onset of a severe, tearing chest pain, which radiates through to the back, associated with dyspnea and diaphoresis. Blood pressure is 165/80. Lung auscultation reveals bilateral basilar rales. A faint murmur of aortic insufficiency is heard. The BNP level is elevated at 550pg/mL. ECG shows nonspecific ST-T changes. A chest x-ray suggests a widened mediastinum. Which of the following choices represents the most prudent emergent management?
A. IV furosemide plus IV loading dose of digoxin
B. Emergent percutanous coronary intervention with consideration of angioplasty and/or stenting
C. Blood cultures followed by rapid initiation of vancomycin plus gentamicin, then echocardiography
D. IV beta-blocker therapy plus echocardiography; consideration of nitroprusside
E. IV heparin followed by chest CT scan; consideration of thrombolytic therapy
IV beta-blocker therapy plus echocardiography; consideration of nitroprusside
A 55-year-old African American female presents to the ER with lethargy and blood pressure of 250/150. Her family members indicate that she was complaining of severe headache and visual disturbance earlier in the day. They report a past history of asthma but no known kidney disease. On PE, retinal hemorrhages are present. Which of the following is the best approach?
A. IV labetalol therapy
B. Continuous-infusion nitroprusside
C. Clonidine by mouth to lower BP slowly
D. Nifedipine sublingually to lower BP rapidly
E. Further history about recent home antihypertensive before deciding current therapy
Continuous-infusion nitroprusside
A 35-year-old male complains of substernal chest pain aggravated by inspiration and relieved by sitting up. He has a history of tuberculosis. Lung fields are clear to auscultation, and heart sounds are somewhat distant. CXR shows and enlarged cardiac silhouette. Which of the following is the best next step in evaluation?
A. Right lateral decubitus film B. Cardiac catheterization C. Echocardiogram D. Serial ECGs E. Thallium stress test
Echocardiogram
