Practice Questions Flashcards
A previously healthy 33-year-old woman comes to the emergency department because she could feel her heart racing intermittently for the past 2 hours. Each episode lasts about 10 minutes. She does not have any chest pain. Her mother died of a heart attack and her father had an angioplasty 3 years ago. She has smoked a half pack of cigarettes daily for 14 years. She drinks one to two beers daily. She appears anxious. Her temperature is 37.0°C (98.6°F), pulse is 190/min, and blood pressure is 104/76 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. ECG is shown. What is the most appropriate initial step in management?
An ECG showing regular narrow QRS complexes without P waves indicates AV nodal reentrant tachycardia (AVNRT), a type of paroxysmal supraventricular tachycardia (PSVT).
Vagal maneuvers are the initial step in the management of a stable patient with PSVT because they are quick, can be performed by the patient, and have no side effects. Common maneuvers are the Valsalva maneuver and carotid massage. The stimulated vagus nerve then acts on the sinoatrial and atrioventricular nodes, which slows the heart rate and reduces conduction velocity. Should vagal maneuvers fail, other options in the acute management phase include adenosine, beta blockers, and calcium channel blockers.
A previously healthy 22-year-old woman comes to the emergency department because of several episodes of palpitations that began 5 days ago. The palpitations are intermittent in nature, with each episode lasting 5–10 seconds. She states that during each episode she feels as if her heart is going to “spin out of control.” She has recently been staying up late to study for her final examinations. She does not drink alcohol or use illicit drugs. She appears anxious. Her temperature is 37.0°C (98.6°F), pulse is 75/min, and blood pressure is 110/75 mm Hg. Physical examination shows no abnormalities. ECG shows normal P wave morphology with intermittent doublets of broad, monomorphic QRS complexes. What is the most appropriate next step in management?
This patient’s ECG findings suggest benign premature ventricular contractions (PVCs).
PVCs are often asymptomatic but can manifest with a feeling of “skipped beats.” If PVCs are frequent, symptoms such as palpitations, lightheadedness, dizziness, and irregular heartbeat can occur. The PVCs in this healthy young patient are most likely triggered by lack of sleep and stress due to studying. Other common triggers include caffeine, alcohol, or nicotine consumption. In patients with frequent or long episodes of PVCs, further diagnostic studies (e.g., echocardiography) are indicated to assess for underlying heart disease.
Because this is the first incident of PVCs in this patient, no treatment is necessary at this time; however, observation and rest are recommended to monitor for and potentially reduce the frequency of episodes.
A 64-year-old woman is brought to the emergency department 1 hour after the onset of acute shortness of breath and chest pain. The chest pain is retrosternal in nature and does not radiate. She feels nauseated but has not vomited. She has type 2 diabetes mellitus, hypertension, and chronic kidney disease. Current medications include insulin, aspirin, metoprolol, and hydrochlorothiazide. She is pale and diaphoretic. Her temperature is 37.0°C (98°F), pulse is 136/min, and blood pressure is 80/60 mm Hg. Examination shows jugular venous distention and absence of a radial pulse during inspiration. Crackles are heard at the lung bases bilaterally. Cardiac examination shows distant heart sounds.
What is the most appropriate next step in management?
Pericardiocentesis
Severe pericardial effusion and subsequent cardiac tamponade are life-threatening conditions that require immediate decompression with pericardiocentesis. Pericardiocentesis is indicated for hemodynamic stabilization and symptom relief before treatment of the underlying condition (e.g., with hemodialysis) can be started. This patient with diabetes has a history of chronic kidney disease (CKD), likely as a result of inadequately managed hyperglycemia.
A 14-year-old girl is brought to the physician because of a 1-week history of fever, malaise, and chest pain. She describes the pain as 6 out of 10 in intensity and that it is more severe if she takes a deep breath. The pain is centrally located in the chest and does not radiate. She had a sore throat 3 weeks ago that resolved without treatment. She has no personal history of serious illness. She appears ill. Her temperature is 38.7°C (101.7°F). Examination shows pale conjunctivae. There are several subcutaneous nodules on the elbows and wrist bilaterally. Lungs are clear to auscultation. A soft early systolic murmur is heard best at the apex in the left lateral position. Abdominal examination is unremarkable. Laboratory studies show:
Erythrocyte sedimentation rate 40 mm/h
Antistreptolysin O titer 327 U/mL (N < 200 U/mL)
She is treated with aspirin and penicillin and her symptoms resolve. Echocardiography performed 14 days later shows no abnormalities. Which of the following is the most appropriate recommendation for this patient?
A. Intramuscular benzathine penicillin every 4 weeks for 10 years
B. Low-dose prednisone therapy for a month
C. Oral penicillin V before dental procedures
D. Intramuscular benzathine penicillin every 4 weeks until the age of 40
Intramuscular benzathine penicillin every 4 weeks for 10 years (or until 21 years of age, whichever is longer) is recommended for secondary prophylaxis of recurrent acute rheumatic fever in patients with manifestations of carditis but no permanent valvular damage.
A 14-year-old boy is brought to the physician because of fever, malaise, and severe right knee joint pain and swelling for 3 days. He has also had episodes of abdominal pain and epistaxis during this period. Five days ago, he had swelling and pain in his left ankle joint which has since resolved. He reports having a sore throat 3 weeks ago while he was camping in the woods, for which he received symptomatic treatment. His immunizations are up-to-date. His temperature is 38.7°C (101.6°F), pulse is 119/min, and blood pressure is 90/60 mm Hg. Examination shows a swollen, tender right knee; range of motion is limited. There are painless 3 to 4-mm nodules over the elbow. Cardiopulmonary examination is normal. His hemoglobin concentration is 12.3 g/dL, leukocyte count is 11,800/mm3, and erythrocyte sedimentation rate is 63 mm/h. Arthrocentesis of the right knee joint yields clear, straw-colored fluid. Analysis of the synovial fluid shows a leukocyte count of 1350/mm3 with 17% neutrophils; no organisms are identified on Gram stain. Which of the following is the most likely diagnosis?
Migratory polyarthritis, subcutaneous nodules, and fever following an upper respiratory tract infection are suggestive of an immune-mediated sequela of rheumatic fever.
To diagnose ARF, two major or one major plus two minor revised Jones criteria are required. Major criteria include arthritis (migratory polyarthritis primarily involving the large joints), subcutaneous nodules, carditis (pancarditis, including valvulitis), Sydenham chorea (CNS involvement), and erythema marginatum. Minor criteria include polyarthralgia, fever, elevated acute phase reactants (ESR, CRP), and a prolonged PR interval on ECG. This patient meets 2 major and 3 minor criteria, which is sufficient to establish the diagnosis of ARF.
A 12-year-old girl is brought to the physician by her mother because of a 2-day history of high fever and swelling of the left ankle and knee. She had a sore throat 3 weeks ago. There is no family history of serious illness. Her immunizations are up-to-date. She developed an episode of breathlessness and generalized rash when she received dicloxacillin for a skin infection 2 years ago. She appears ill. Her temperature is 38.8°C (102.3°F), pulse is 87/min, and blood pressure is 98/62 mm Hg. Examination shows swelling and tenderness of the left ankle and knee; range of motion is limited. Lungs are clear to auscultation. A grade 3/6 holosystolic murmur is heard best at the apex. Abdominal examination shows no abnormalities. Which of the following is the most appropriate pharmacotherapy?
A. Vancomycin
B. Azithromycin
C. Amoxicillin
D. Benzylpenicillin
E. Ciprofloxacin
Macrolides such as clarithromycin are the antibiotics of choice for ARF in patients with hypersensitivity to beta-lactam antibiotics. In addition to group A streptococcal eradication therapy, patients with ARF also require symptomatic treatment with NSAIDs for arthritis and fever.
Additionally, an echocardiogram should be performed to evaluate for the presence of rheumatic valvulitis. This patient’s apical holosystolic murmur is consistent with mitral regurgitation (likely due to rheumatic valvulitis).
A 32-year-old man comes to the emergency department because of sharp chest pain for 3 days. The pain is retrosternal, 8 out of 10 in intensity, increases with respiration, and decreases while sitting upright and leaning forward. He has nausea and myalgia. He has not had fever or a cough. He has asthma and was treated for bronchitis 6 months ago with azithromycin. His mother has hypertension. He uses an over-the-counter inhaler. His temperature is 37.3°C (99.1°F), pulse is 110/min, and blood pressure is 130/84 mm Hg. Breath sounds are normal. Cardiac examination shows a high-pitched grating sound between S1 and S2. The remainder of the examination shows no abnormalities. Serum studies show:
Urea nitrogen 16 mg/dl
Glucose 93 mg/dL
Creatinine 0.7 mg/dL
Troponin I 0.23 ng/mL
An ECG shows diffuse ST elevations in all leads. The patient is at increased risk for which of the following conditions?
A. Pulmonary embolism
B. Cardiac tamponade
C. Mediastinitis
D. STEMI
The patient’s 3-day history of chest pain that increases with respiration and decreases while sitting up, in conjunction with a friction rub on cardiac auscultation, nausea, and myalgia, is suggestive of acute pericarditis. The ECG finding of ST elevations in all leads with a mild increase in troponin I further support the diagnosis.
Pericarditis is a common cause of cardiac tamponade; it may occur in cases in which the pericardium becomes scarred and less elastic, while increased amounts of inflammatory fluids are secreted into the pericardial space. Cardiac tamponade can lead to hemodynamic compromise; therefore, treatment with pericardiocentesis is indicated.
A 72-year-old man comes to the physician for medical clearance for a molar extraction. He feels well. He reports he is able to climb 3 flights of stairs without experiencing any shortness of breath. He has hypertension, type 2 diabetes mellitus, and ischemic heart disease. He underwent an aortic valve replacement for severe aortic stenosis last year. Twelve years ago, he underwent a cardiac angioplasty and had 2 stents placed. Current medications include aspirin, warfarin, lisinopril, metformin, sitagliptin, and simvastatin. His temperature is 37.1°C (98.8°F), pulse is 92/min, and blood pressure is 136/82 mm Hg. A grade 6/6 systolic ejection click is heard at the right second intercostal space. Which of the following is the most appropriate next step in management?
Administer oral amoxicillin 1 hour before the procedure
Antimicrobial prophylaxis for the prevention of IE is recommended for high-risk patients (e.g., patients with prosthetic heart valves, a history of IE, or an unrepaired cyanotic congenital heart defect) who undergo procedures that are likely to result in bacteremia with common pathogens of IE. These procedures include certain dental procedures (e.g., tooth extraction, routine dental cleaning), procedures of the respiratory tract that involve incision of the respiratory mucosa, and cardiac surgery with prosthetic material (e.g., prosthetic heart valves). The most commonly used antibiotic regimen is oral amoxicillin administered 30–60 minutes prior to a high-risk procedure.
A 43-year-old man with HIV comes to the physician because of fever and night sweats over the past 15 days. During this period, he has also had headaches and generalized weakness. He has no cough or shortness of breath. He has hypertension controlled with lisinopril and is currently receiving triple antiretroviral therapy. He has smoked one pack of cigarettes daily for the past 15 years and drinks one to two beers on weekends. He is a known user of intravenous drugs. His temperature is 39°C (102°F), pulse is 115/min, respirations are 15/min, and blood pressure is 130/80 mm Hg. Examination shows several track marks on the forearms. The lungs are clear to auscultation. A holosystolic murmur that increases on inspiration is heard along the left lower sternal border. The remainder of the physical examination shows no abnormalities. Laboratory studies show a leukocyte count of 12,800/mm3 and an erythrocyte sedimentation rate of 52 mm/h. His CD4+ T-lymphocyte count is 450/mm3. This patient is at greatest risk for developing which of the following?
Pulmonary embolism
Septic pulmonary embolism is a common and severe complication of right-sided IE and is caused by bacterial thromboemboli that form on the affected heart valve and dislodge into the lung. Patients present with cough, pleuritic chest pain, and nodular pulmonary infiltrates. While tricuspid valve IE is rare, nonsterile injections (e.g., in individuals who use IV drugs) leading to bacteremia as well as indwelling intravascular devices increase the risk for this condition.
A 24-year-old man is brought to the emergency department 15 minutes after he sustained a stab wound to the left chest. On arrival, he has rapid, shallow breathing and appears anxious. His pulse is 135/min, respirations are 30/min and shallow, and palpable systolic blood pressure is 80 mm Hg. Examination shows no active external bleeding. There is a 2.5-cm single stab wound to the left chest at the 4th intercostal space at the midclavicular line. Cardiovascular examination shows muffled heart sounds and jugular venous distention. Breath sounds are normal. Further evaluation of this patient is most likely to show which of the following findings?
A. Tracheal deviation to the right side
B. Drop in SBP of 14mmHg during inspiration
C. Paradoxical motion of part of chest with breathing
D. Herniation of the stomach into the chest
B. Drop in SBP of 14mmHg during inspiration
In cardiac tamponade, outward expansion of the ventricles is limited because of fluid in the pericardial space. During inspiration, increased venous return leads to increased right ventricular volume. As outward expansion is limited, the right ventricle expands via the interventricular septum, which bulges into the left ventricle. This effect leads to further reduction in left ventricular filling during inspiration, resulting in decreased stroke volume and a subsequent drop in blood pressure. A drop in systolic blood pressure > 10 mm Hg during inspiration is known as pulsus paradoxus, a sign characteristically seen in moderate and severe cardiac tamponade but also in some cases of severe asthma, tension pneumothorax, and constrictive pericarditis.
A 69-year-old man is scheduled to undergo a total pancreatectomy in one month. He has a history of chronic pancreatitis, diabetes mellitus, hyperlipidemia, and severe osteoarthritis in both knees. He is unable to climb the stairs because of knee pain and only walks indoors around his house. He has severe abdominal pain due to chronic pancreatitis but does not report any chest pain, shortness of breath, or dizziness. He had smoked one pack of cigarettes and consumed 4–6 beers daily for 25 years but quit smoking and alcohol consumption 5 years ago. Current medications include insulin, metoprolol, lisinopril, rosuvastatin, ibuprofen, and pregabalin. His temperature is 36.4°C (97.5°F), pulse is 90/min, and blood pressure is 136/88 mm Hg. Cardiopulmonary examination and a 12-lead ECG show no abnormalities. What is most appropriate next step for assessing this patient’s perioperative cardiac risk?
For assessing this patient’s perioperative cardiac risk, the most appropriate next step would be to perform a cardiac stress test.
Patients with a history of chronic pancreatitis, diabetes mellitus, hyperlipidemia, and smoking are at increased risk of developing cardiovascular disease. The patient’s current medications, including metoprolol and lisinopril, suggest a history of hypertension, which is another risk factor for cardiovascular disease.
Since the patient is scheduled to undergo a major surgery, a cardiac stress test can help assess his cardiovascular function and identify any underlying coronary artery disease. This will help the healthcare team in deciding the appropriate anesthetic and surgical approach and planning postoperative management.
However, given the patient’s severe osteoarthritis and limited mobility, it may be challenging to perform a standard treadmill stress test. Alternative options, such as pharmacologic stress testing, may need to be considered. The final decision regarding the type of stress test should be made in consultation with a cardiologist.
A 25-year-old man is brought to the emergency department because of a 6-day history of fever and chills. During this period, he has had generalized weakness, chest pain, and night sweats. He has a bicuspid aortic valve and recurrent migraine attacks. He has smoked one pack of cigarettes daily for 5 years. He does not drink alcohol. He has experimented with intravenous drugs in the past but has not used any illicit drugs in the last 2 months. Current medications include propranolol and a multivitamin. He appears ill. His temperature is 39°C (102.2°F), pulse is 108/min, respirations are 14/min, and blood pressure is 150/50 mm Hg. On pulmonary examination, diffuse crackles are heard. A grade 3/6 high-pitched, early diastolic, decrescendo murmur is best heard along the left sternal border. An S3 gallop is heard. The remainder of the physical examination shows no abnormalities. Laboratory studies show:
Hemoglobin 13.1 g/dL
Leukocyte count 13,300/mm3
Platelet count 270,000/mm3
Serum
Glucose 92 mg/dL
Creatinine 0.9 mg/dL
Total bilirubin 0.4 mg/dL
AST 25 U/L
ALT 28 U/L
Three sets of blood cultures are sent to the laboratory. Transthoracic echocardiography confirms the diagnosis. In addition to antibiotic therapy, which of the following is the most appropriate next step in management?
A. Mechanical valve replacement of the tricuspid valve
B. Mechanical valve replacement of the aortic valve
C. Porcine valve replacement of the aortic valve
D. Surgical repair of the mitral valve
B. Mechanical valve replacement of the aortic valve
The patient has acute aortic regurgitation and subsequent left-sided heart failure from IE, which together are an indication for surgical intervention. Further indications for surgical treatment of IE include uncontrolled infection, systemic embolization, prosthetic valve endocarditis, or fungal endocarditis. Mechanical valve replacement is the treatment of choice in a young (< 65 years of age) patient without contraindications for anticoagulation. Patients with current bleeding, history of intracranial hemorrhage, coagulopathy, or severe thrombocytopenia (< 50,000/μL) should be evaluated for porcine valve replacement as mechanical valves require lifelong anticoagulation.
A 52-year-old man comes to the physician for a routine medical check-up. The patient feels well. He has hypertension, type 2 diabetes mellitus, and recurrent panic attacks. He had a myocardial infarction 3 years ago. He underwent a left inguinal hernia repair at the age of 25 years. A colonoscopy 2 years ago was normal. He works as a nurse at a local hospital. He is married and has two children. His father died of prostate cancer at the age of 70 years. He had smoked one pack of cigarettes daily for 25 years but quit following his myocardial infarction. He drinks one to two beers on the weekends. He has never used illicit drugs. Current medications include aspirin, atorvastatin, lisinopril, metoprolol, fluoxetine, metformin, and a multivitamin. He appears well-nourished. Temperature is 36.8°C (98.2°F), pulse is 70/min, and blood pressure is 125/75 mm Hg. Lungs are clear to auscultation. Cardiac examination shows a high-frequency, mid-to-late systolic murmur that is best heard at the apex. The abdomen is soft and nontender. The remainder of the physical examination shows no abnormalities. Which of the following is the most likely diagnosis?
A. Mitral valve regurgitation
B. Mitral valve prolapse
C. Aortic stenosis
D. Pulmonary valve regurgitation
Mitral valve prolapse is the most common valvular abnormality in the US and is usually asymptomatic, as in this patient. It typically manifests as a high-frequency, midsystolic click combined with a high-frequency, mid-to-late systolic murmur heard best at the apex, which is consistent with this patient’s auscultatory findings. Mitral valve prolapse is most often idiopathic, but can also be secondary to conditions such as rheumatic heart disease, infectious endocarditis, connective tissue disorders, or myocardial infarction (MI).
A 56-year-old man is brought to the emergency department because of severe back pain for the last 2 hours. He describes a stabbing pain between the scapulae that is 9 out of 10 in intensity. He has vomited once during this period. He has hypertension and type 2 diabetes mellitus complicated by diabetic nephropathy. Current medications include lisinopril and metformin. He is diaphoretic. Temperature is 37.3°C (99.1°F), pulse is 110/min, respirations are 20/min, and blood pressure is 210/130 mm Hg. He is not oriented to person, place, or time. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. The radial pulse is decreased on the left side. Laboratory studies show:
Hemoglobin 13.5 g/dL
Leukocyte count 10,000/mm3
Platelet count 230,000/mm3
Serum
Na+ 139 mEq/L
K+ 4.1 mEq/L
Cl- 103 mEq/L
Creatinine 2.6 mg/dL
Glucose 230 mg/dL
Alkaline phosphatase 55 U/L
Urine toxicology screening is positive for opiates and cocaine. An ECG shows sinus tachycardia with no evidence of ischemia. An x-ray of the chest shows a widened mediastinum. Which of the following is the most appropriate next step in management?
Severe stabbing interscapular pain combined with asymmetrical pulse readings between the upper extremities and a widened mediastinum on chest x-ray suggests aortic dissection.
Transesophageal echocardiography (TEE) is a fast, portable test with high sensitivity and specificity for aortic dissection. TEE is the preferred initial study in hemodynamically unstable patients (it can be rapidly performed at the bedside or in the operating room) and patients with renal insufficiency (because of the increased risk of developing contrast-induced nephropathy with CT angiography) or contrast allergy. This imaging modality helps visualize intimal dissection flaps, true and false lumens, thromboses in false lumen, aortic regurgitation, and pericardial effusion, and it aids in determining whether surgical intervention is warranted. TEE cannot be used to assess dissections below the diaphragm; in such cases, CT angiography is preferred.
A 73-year-old woman is brought to the emergency department because of a 2-day history of diffuse abdominal pain, nausea, and vomiting. She has hypertension, congestive heart failure, atrial fibrillation, and osteoarthritis. She underwent an exploratory laparotomy for an ovarian mass a year ago where a mucinous cystadenoma was excised. Her medications include aspirin, nifedipine, lisinopril, metoprolol, warfarin, and acetaminophen as needed for pain. She does not drink alcohol or smoke cigarettes. She appears ill and disoriented. Her temperature is 37.9°C (100.3°F), pulse is 110/min and irregular, respirations are 16/min, and blood pressure is 102/60 mm Hg. Examination shows diffuse tenderness to palpation of the abdomen. The abdomen is tympanitic on percussion. Bowel sounds are hyperactive. The lungs are clear to auscultation bilaterally. There is a soft crescendo-decrescendo murmur best auscultated in the right second intercostal space. Laboratory studies show:
Hemoglobin 10.2 g/dL
Leukocyte count 14,000/mm3
Platelet count 130,000/mm3
Prothrombin time 38 seconds
INR 3.2
Serum
Na+ 132 mEq/dL
K+ 3.6 mEq/dL
Cl- 102 mEq/dL
HCO3- 19 mEq/dL
Urea nitrogen 44 mg/dl
Creatinine 2.1 mg/dL
Lactate 2.8 mEq/dL (N= 0.5–2.2 mEq/dL)
An x-ray of the abdomen shows multiple centrally located dilated loops of gas-filled bowel. There is no free air under the diaphragm. A nasogastric tube is inserted and IV fluids and empiric antibiotic therapy are started. An emergency exploratory laparotomy is planned. Which of the following is the next best step in management?
Diffuse abdominal pain, nausea, vomiting, abdominal tenderness, hyperactive bowel sounds, elevated serum lactate, leukocytosis, prerenal kidney injury, and multiple loops of gas-filled bowel on x-ray are consistent with small bowel obstruction with possible bowel ischemia. Although this patient requires immediate surgery, she has an increased bleeding risk, as indicated by prolonged prothrombin time (PT) and elevated INR.
Administer fresh frozen plasma and vitamin K
65%
Fresh frozen plasma and vitamin K can both be used for anticoagulation reversal in patients with decreased vitamin K-dependent coagulation factors (factors II, VII, IX, and X), e.g., due to warfarin intake. Administration of vitamin K alone would be insufficient, as it takes hours to days to produce further coagulation factors and take full effect. Additional administration of fresh frozen plasma is therefore indicated as it replaces those coagulation factors needed to immediately establish sufficient coagulation for surgery.
A 72-year-old man comes to the physician because of progressively worsening shortness of breath. The symptoms most commonly occur when lying flat at night. He also reports shortness of breath when walking up the two flights of stairs to his apartment. He reports no chest pain. Medical history is remarkable for myocardial infarction 2 years ago. The patient has smoked one pack of cigarettes daily for 40 years. He does not exercise. His medications include aspirin, lisinopril, bisoprolol, and atorvastatin. Pulse is 85/min and blood pressure is 124/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Examination shows an extra heart sound during early diastole on auscultation. Faint crackles are heard at both lung bases. There is 1+ ankle edema bilaterally. Cardiac ultrasonography shows a left ventricular ejection fraction of 0.35. Which of the following hemodynamic changes are most likely present in this patient?
In systolic heart failure, poor contractility leads to decreased stroke volume and cardiac output. In response to decreased cardiac output, there is compensatory activation of the RAAS and sympathetic nervous system, resulting in increased TPR. In addition, incomplete ventricular emptying during systole results in left ventricular volume overload, which results in increased LVEDV. Increased LVEDV and poor forward flow cause increased left ventricular pressure, which is transmitted to the left atrium, resulting in increased PCWP.
