Practice Flashcards
For the past three weeks, a 47-year-old man has had the feeling of heaviness in his chest while
pushing his lawn mower. He says he has never been treated before and is having no symptoms
now. He smoked one pack of cigarettes daily for 20 years but quit smoking seven years ago.
Findings on physical examination are normal. Electrocardiogram shows no abnormalities. Which
of the following is the most appropriate initial diagnostic study?
(A) Coronary arteriography (B) Echocardiography (C) Exercise stress test (D) 24-Hour Holter monitoring (E) Myocardial perfusion scan
C - exercise stress test, is the most
appropriate initial step in the work-up of a patient with recent chest pain because the test is
noninvasive, inexpensive, convenient, and sensitive in this type of patient.
*The most definitive diagnostic test for a patient with coronary artery disease is Option (A),
coronary arteriography, but this test is not the most appropriate initial test in an asymptomatic
patient with no abnormal findings on electrocardiogram.
A 68 year old male presents complaining of fever, fatigue and loss of appetite. While taking his history his wife tells you that he had to have some heart surgery about a year ago, but she doesn’t know what they did. On physical exam you hear a slight murmur. You also notice nontender macular lesions on the palms of his hands. He doesn’t recall seeing them before. What should your next course of action be?
A) Observation
B) Blood cultures
C) Empiric antibiotics
D) Call the operating room
B - obtain blood cultures. The description leads you to think endocarditis.
Jaw claudication =
A) Giant cell arteritis
B) Peripheral vascular disease
C) Superficial thrombophlebitis
D) Endocarditis
A - Giant cell arteritis
An 23 year old female presents to your office four weeks after an ORIF of her left ankle complaining of severe swelling in her left leg. You not in her chart that she has been taking wellbutrin and an oral contraceptive in addition to percocet for her pain. She also had stated that she drinks occasionally and smokes 10 cigarettes per day. She has tried elevation and ice over the past two days, but it has continued to increase in severity. What is your next course of action?
A) Remove her cast and send her for an U/S
B) Send her for a D-dimer blood test
C) Have her continue to decrease her activity and keep the leg elevated for another day.
D) Add aspirin 81mg daily to her medications
A - OCP + smoking + surgery + immobilization + severe swelling = DVT until proven otherwise. You can prove it with an U/S (the cast can be exchanged for a splint in the short term)
*A D-dimer can only rule out an DVT and is not nearly as helpful as an u/s
Although aspirin may be a good idea to help prevent a DVT once the patient has one adding it alone to her medications is not going to be enough.
List the six P’s of arterial occlusion.
pain, pallor, pulselessness, paresthesias, poikilothermia (cold), paralysis
Which of the following is for diagnosing endocarditis according to the Duke criteria Either
A) One major criteria
B) Two major criteria and one minor criteria
C) One major criteria and two minor criteria
D) Five minor criteria
D - According to the Duke criteria you must have either two major criteria, one major criteria and three minor criteria or five minor criteria.
Which of the following CV disorders is most likely associated with abnormal pupillary response?
A) Aortic regurgitation
B) Coarctation of the aorta
C) Thoracic aortic aneurysm
D) Myocarditis
C - The “Argyll Robertson pupil” (a pupil that constricts with accommodation but not in response to light) is characteristic of a CNS syphilis that often results in a thoracic aortic aneurysm!
Which of the following CV disorders is most likely associated w/JVD and exopthalmoses?
A) Massive tricuspid regurgitation
B) Coarctation of the aorta
C) Thoracic aortic aneurysm
D) Myocarditis
A - Tricuspid regurgitation produces elevated venous pressure. If this is SEVERE –> exophthalmoses.
A pt arrives with short stature, webbed neck, low-set ears, and epicanthal fold. Which of the following is he most likely suffering from?
A) Tricuspid regurgitation
B) Cardiomegaly
C) Coarctation of the aorta
D) Myocarditis
B - Coarctation of the aorta. This is a common presentation of an individual w/congenital coarctation.
A 16yo asymptomatic girl had a blood pressure of 150/94 in both arms and 120/94 in her left leg. Radial-femoral pulse lag is noted. Which is the most likely diagnosis?
Coarctation of the aorta!
A 63-year-old woman has the sudden onset of “knife-like” pain in the chest radiating to the back. She has been previously healthy except for a history of poorly controlled hypertension. She is transported to the hospital and on arrival she has a heart rate of 90/minute, respirations 20/minute, temperature 36.8°C, and blood pressure 150/100 mm Hg. No murmurs, rubs, or gallops are audible. A chest radiograph reveals a widened mediastinum. Laboratory findings include a total serum creatine kinase of 55 U/L, creatinine 0.9 mg/dL, and glucose 123 mg/dL. Which of the following is the most likely diagnosis?
A Fibrinous pericarditis B Aortic dissection C Infective endocarditis D Dilated cardiomyopathy E Myocardial infarction
B - Aortic dissection. The risk factors in most adults include atherosclerosis and hypertension. In Marfan syndrome, the risk for aortic dilation and dissection results from cystic medial necrosis, but this occurs at a much younger age.
A 45-year-old woman has had worsening shortness of breath for 3 years. She now has to sleep sitting up on two pillows. She has had difficulty swallowing for the past year. She has no history of chest pain. A month ago, she had a “stroke” with resultant inability to move her left arm. She is afebrile. A chest radiograph reveals a near-normal left ventricular size with a prominent left atrial border. Which of the following conditions is most likely to account for her findings?
A Essential hypertension B Cardiomyopathy C Mitral valve stenosis D Aortic coarctation E Patent foramen ovale
C - Mitral valve stenosis leads to left atrial enlargement, but the left ventricle is usually small. THere is typically a ‘fishmouth’ shaped mitral valve that has stenosis as well as insufficiency, since it does not close completely.
*Most mitral valvular disease in adults results from rheumatic valvulitis. The episode(s) of rheumatic fever occurred years before and the scarring of the valve developed slowly.
A 72-year-old woman has had no major illnesses throughout her life. She has had 3 syncopal episodes during the past 2 weeks. Over the past 2 days she has developed shortness of breath and a cough with production of frothy white sputum. On physical examination she is afebrile. Her blood pressure is 135/90 mm Hg. She has no peripheral edema. A chest radiograph reveals a prominent left heart border in the region of the left ventricle, but the other chambers do not appear to be prominent. There is marked pulmonary edema. Laboratory studies show a total serum cholesterol of 170 mg/dL. Which of the following is the most likely diagnosis?
A Acute rheumatic fever B Mitral valve insufficiency C Atherosclerotic aortic aneurysm D Calcific aortic stenosis E Infective endocarditis
D - Senile calcific aortic stenosis is a condition in which there is gradual calcification of an aortic valve with three cusps. The condition is seen in the elderly and is idiopathic.
Aortic valvular stenosis may not manifest itself clinically until there is critical narrowing of the outflow orifice to less than 1 square centimeter. Aortic valve disease can remain silent and then suddenly result in symptoms.
A 50-year-old man has the sudden onset of substernal chest pain. The pain persists for the next three hours. He then becomes short of breath and diaphoretic. He goes to the emergency department and on physical examination his vital signs include T 37°C, P 100/minute, RR 26/minute, and BP 130/90 mm Hg. A chest x-ray shows a slightly enlarged heart and mild pulmonary edema. An EKG shows ST segment elevation in anterior leads V1 - 6. Which of the following serum laboratory test findings is most likely to be present in this man?
A Urea nitrogen of 110 mg/dL B Sodium of 115 mmol/L C ALT of 876 U/L D Troponin I of 32 ng/mL E HDL cholesterol of 55 mg/dL
D - The findings suggest an early ischemic event as part of an acute coronary syndrome with developing myocardial infarction. The troponin I can be elevated within a few hours, similar to the CK-MB. The troponin I will remain elevated for 10 to 14 days, while the CK-MB will peak in a day and subside by 3 days.
A 44-year-old woman dies as a consequence of a “stroke”. At autopsy, she is found to have a large right basal ganglia hemorrhage. She has an enlarged 550 gm heart with predominantly left ventricular hypertrophy. Her kidneys are small, about 80 gm each, with cortical scarring, and microscopically they demonstrate small renal arterioles that have luminal narrowing from concentric intimal thickening. Which of the following is the most likely condition associated with her findings?
A Autosomal dominant polycystic kidney disease B Diabetes mellitus, type II C Hypercholesterolemia D Malignant hypertension E Monckeberg's sclerosis
D - The small arteries of the kidney are affected by hyperplastic arteriolosclerosis. Malignant hypertension with markedly elevated blood pressure is often preceded by chronic hypertension that leads to left ventricular hypertrophy. Hypertension is a risk for CNS hemorrhage.
