Soal Dewasa Seri 5 dari 5

Question 1

Total coronary blood flow is increased in severe AR

Answer 1

Ramipril

Question 2

A 43 year old man complains of dyspnea on exertion and exertional chest pain. An echocardiographic demonstrates an aortic valve orifice area of less than 0.70 cm2, making it most appropriate to schedule the patient for which of the following?

Answer 2

Coronary angiography

Question 3

A 45 year old woman with history of mitral valve prolapse presents with the acute onset of shortness of breath and fever. Physical examination reveals an early systolic murmur at the apex and bilateral pulmonary rales. Chest x-ray demonstrates bilateral pulmonary edema but not cardiomegaly. In addition to blood cultures, the next test that should be performed is which of the following?

Answer 3

Echocardiography

Question 4

A 60-year-old man is hospitalized after he is taken to the emergency department because of dyspnea and leg edema. He has a longstanding history of essential hypertension that is treated with a thiazide diuretic and amlodipine. Coronary angiography performed 1 year ago because of chest pain was normal, but left ventriculogram showed an ejection fraction of 45%. On admission, blood pressure is 180/100 mm Hg and heart rate is 110/min and regular. Jugular venous distension
is 10 cm while the patient is lying on a stretcher with his head elevated at 45 degrees. He has a positive hepatojugular reflex, 2+ pitting leg edema to the knees, soft S1 and S2, an S3 gallop, and diffuse pulmonary crackles. No heart murmurs are auscultated. Echocardiogram shows left ventricular ejection fraction of 20% and left ventricular end-diastolic dimension in diastole of 7 cm. He has 1+ mitral and 1+ tricuspid regurgitation with an estimated right ventricular systolic pressure of 40 mm Hg. Electrocardiogram shows a left bundle branch block. Serum electrolytes and hepatic and renal function measurements are normal. Acute ischemic syndrome is excluded by repeated measurements of cardiac enzymes. He receives furosemide, three boluses of 60 mg intravenously, and nesiritide over a 24-hour period and improves rapidly with diuresis of 2200 mL. Which of the following drugs should be initiated before discharge to improve long-term survival in this patient?

Answer 4

Lisinopril

Question 5

Which of the following statements regarding ACE inhibitors is true?

Answer 5

Captopril has been shown to reduce systemic arterial pressures and lower ventricular filling pressure

Question 6

Captopril has been shown to reduce systemic arterial pressures and lower ventricular filling pressure

Answer 6

Clopidogrel, enoxaparin, tirofiban.

Question 7

Which of the following is a feature of spironolactone?

Answer 7

It has been associated with reduced mortality in CHF, possibly by reducing arrhythmic death

Question 8

Digoxin is of limited value for right sided heart failure

Answer 8

T

Question 9

Which of the following statements regarding treatments for chronic stable angina is true?

Answer 9

A combination of β adrenergic blocking agents and nitrates is more effective than treatment with β adrenergic blocking agents alone

Question 10

A 29-year-old woman in the 28th week of pregnancy has sudden onset of severe anterior chest pain radiating to her back. The pain began 2 hours earlier and increased in severity. It was not associated with shortness of breath, nausea or vomiting, or diaphoresis. The patient has a history of mitral valve prolapse that was diagnosed on echocardiogram 10 years earlier. Her only medication is a prenatal vitamin. Her family history is unremarkable. On physical examination, blood pressure is 105/78 mm Hg, heart rate is 110/min, and respiration rate is 18/min while the patient is lying still. The patient is afebrile. Examination of the head, eyes, ears, nose, and throat shows a high, arched palate. Carotid pulses are normal bilaterally, with no jugular venous distension. The lungs are clear to auscultation. Cardiac examination shows a nondisplaced apical impulse, diminished S1, physiologically split , and a soft blowing murmur in early diastole along the right sternal border. A midsystolic click and a late systolic murmur are noted. Abdominal examination shows a gravid uterus that is appropriate for gestational age. Trace pedal edema and intact symmetrical pulses are noted throughout. Fetal heart sounds are normal. An electrocardiogram shows mild T-wave flattening. Laboratory
findings include hematocrit of 32% and platelet count of 170,000/μL. Fetal monitoring is instituted, and morphine is administered for pain control. Which of the following is the most appropriate diagnostic test?

Answer 10

Transesophageal echocardiography

Question 11

A 25-year-old pregnant woman is referred to you for evaluation of a heart murmur that was noted during the second trimester of this pregnancy, which is her first. The patient has no history of cardiovascular disease, and the murmur was not heard during previous medical evaluations. She is asymptomatic. Examination shows a mildly displaced apical impulse and lower extremity edema. S1 and S2 are normal, and S3 is noted at the apex. A grade 2/6 early to mid-peaking systolic murmur is audible at the left sternal border. Based on the patients history and physical findings, which of the following is the most likely cause of the murmur?

Answer 11

Physiologic murmur related to pregnancy

Question 12

For which of the following patients should primary PCI be considered over thrombolytic therapy?

Answer 12

A 58 yar old with blood pressure on presentation of 190/ 110 mmHg

Question 13

A 47-year-old woman is evaluated for palpitations that occur intermittently during the day, vary in severity, and cause a sensation of skipped beats. She has no other associated symptoms. She had a similar episode 2 years ago while undergoing a stressful job relocation, but did not seek medical attention at that time. She is now under pressure at work, and her son is leaving for college in 1 week. On physical examination, her blood pressure is 160/90 mm Hg and her heart rate is 80/min. Cardiac examination shows normal heart sounds and no murmurs. Electrocardiogram shows sinus rhythm with premature atrial contractions, and a 24-hour ambulatory monitor shows 5673 premature atrial contractions, 127 premature ventricular contractions, and no runs of arrhythmias. Results of laboratory tests, including thyroid function tests and complete blood count, are normal. The patient remains highly symptomatic, despite reassurance.
Which of the following is the most appropriate next step in the management of this patient?

Answer 13

Start β-blocker therapy

Question 14

Vasodilators are useful in the management of patient with acute AR

Answer 14

T

Question 15

Total coronary blood flow is increased in severe AR

Answer 15

T

Question 16

Which of the following statements regarding the management of patients with chronic aortic regurgitation is true?

Answer 16

Vasodilators are of short term benefit in patients in functional classes III and IV heart failure

Question 17

Diuretic therapy is recommended for every patient with acute and chronic heart failure with signs and/or symptoms of fluid overload. This recommendation is based on :

Answer 17

Diuretic’s rapid induction of diuresis and reduction of fluid and sodium overload

Question 18

â blocker therapy is recommended for all patients with stable heart failure and reduced ejection fraction, unless there is a specific contraindication, or a specific patient is unable to tolerate treatment. Therapy should be commenced upon diagnosis. However only certain â blockers are recommended by guidelines for managing heart failure. Which of the following is not a guideline-recommended â blocker for heart failure?

Answer 18

Immediate –release metoprolol (tartrate)

Question 19

Successful beta blocker therapy is dependent on correct dosing. The recommended dosing strategy for beta blocker therapy is :

Answer 19

Up[titration (as tolerated) until the dosages shown effective in clinical trials are achieved

Question 20

A 63 year old man with a history of acute myocardial infarction received an index diagnosis of heart failure following a 3-day hospitalization for fluid overload. At the time of presentation, the patient was already taking aspirin, enalapril and metoprolol. During hospitalization, the dosage of ACEi and beta blocker were adjusted and oral furosemide was added to the drug regimen. In several trials, aspirin was associated with reduction in the efficacy of ACEi in patients with heart failure and the attending physician considered discontinuing aspirin therapy. For this patient, the ACCF/AHA heart failure guidelines recommend :

Answer 20

None of the above

Question 21

A 70 year old man with hypertension and history of myocardial infraction (10 years prior) presented to his cardiologist for a routine evaluation. On physical examination, the patient’s BPwa 130/90 mmHg, and respiration and HR were normal. He reported maintaining a low-sodium diet, exercising and regular adherence to his losartan prescription. He had developed a cough in response to
previous ACEi therapy. Despite the patient’s good health practices, an ECG revealed evidence of left ventricular hypertrophy. However, the patient reported no signs or symptoms of heart failure. As per the guideline recommendations, the physician decided to add beta blocker to the patient’s current medications. In terms of renin-angiotensin suppression, the physician should ;

Answer 21

Continue the ARB with beta blocker

Question 22

A 66 year old man with NYHA class IV/stage D heart failure presented, with dyspnea at rest, congestion and fatigue. His BP was 106/ 70 mmHg, HR 72 bpm and respiratory rate 24 bretahs/minute. The patient had a history of coronary artery disease, prior myocardial infarction, hypertension, hypercholesterolemia, type 2 diabetes and tobacco use. Laboratory results revealed a BUN of 43 mg/dL and serum creatinine 2.5 mg/dL. Catheterization showed three vessel disease with an occluded LAD artery. The patient was recommended for coronary revascularization with planned cardiopulmonary bypass (CPB). Surgery is associated with a variety of complication including bleeding, stroke, myocardial infarction and infection. CPB also introduces the unique risk of :

Answer 22

Maladaptive neurohormonal activation

Question 23

According to current guidelines, digoxin is :

Answer 23

An add-on to beta blocker and ACEi therapy

Question 24

A 72-year-old man is hospitalized because of precordial discomfort radiating to his left arm and neck for 3 hours. He has a history of longstanding diabetes, hypertension, and chronic renal insufficiency (serum creatinine 2.8 mg/dL). His medications include aspirin, 325 mg daily; atenolol, 100 mg daily; and insulin. On physical examination, his pulse rate is 60/min, and blood pressure is 170/90 mm Hg. There is no jugular venous distention, and his chest is clear. An S1 is present without any murmurs. An electrocardiogram shows diffuse 1-mm ST-segment depression, and a troponin I level is elevated (3 ng/mL). Which of the following medications may require dose adjustment because of this patients renal insufficiency?

Answer 24

Enoxaparin

Question 25

Which of the following statements regarding the treatment of mitral regurgitation (MR) is true?

Answer 25

The risk of surgery is much greater for patients in their sixth decade and above as compared to younger patients

Question 26

Which of the following statements regarding mitral valve prolapse (MVP) is true?

Answer 26

Infective endocarditis is a serious complication

Question 27

An inactive overweight 43-year-old man with a strong family history of type 2 diabetes mellitus seeks advice to help prevent diabetes. His blood pressure is 138/86. His fasting plasma glucose is 104 mg/dL. Which of the following interventions is associated with a decreased incidence of new-onset diabetes mellitus?

Answer 27

Ramipril therapy

Question 28

A 28-year-old woman who is 29 weeks pregnant is referred to you for evaluation of progressive dyspnea. She has mitral valve stenosis and a history of rheumatic fever. Over the last 4 weeks, she has had progressive dyspnea with minimal activity, but no palpitations. Cardiovascular examination shows elevated jugular venous pressure and a heart rate of 100/min. The apical impulse is prominent (tapping), and a parasternal impulse is present. An opening snap and a grade 2 diastolic rumble with presystolic accentuation are noted. The S2 opening snap interval is approximately 60 msec. No systolic murmur is noted. S2 is somewhat accentuated. An electrocardiogram shows sinus tachycardia, left atrial enlargement, and right axis deviation. Which of the following agents would you recommend for use in this patient?

Answer 28

Metoprolol

Question 29

The following about myocardial infarction is true, except :

Answer 29

The occurrence of bradycardia may be serious

Question 30

A 48-year-old woman comes to your office as a new patient. She weighs 82 kg (180 Ib) and has an abdominal girth of 91 .5 cm (36 inches). Her body mass index is 30. She has a family history of diabetes and premature coronary artery disease. She smokes one pack of cigarettes a day. Her chest radiograph is normal, and blood pressure is 135/86 mm Hg. Which of the following is the most important screening laboratory test to use to evaluate this patient’s vascular risk?

Answer 30

Fasting lipid profile (serum total cholesterol, LDL and HDL cholesterol, and triglycerides)

Question 31

Fasting lipid profile (serum total cholesterol, LDL and HDL cholesterol, and triglycerides)

Answer 31

Spironolactone

Question 32

A 53-year-old woman with hypertension and a 12-year history of type 2 diabetes mellitus is evaluated. She is overweight but has lost 4.4 kg (10 Ib) on a heart-healthy, low-sodium diet. Her blood pressure is 158/90 mm Hg. Her hemoglobin Al c is 8.6%, serum creatinine is 1.4 mg/dL, and blood urea nitrogen level is 28 mg/dL. Which of the following agents should be included in this patient’s initial drug therapy?

Answer 32

Ramipril

Question 33

The following about systemic hypertension is true :

Answer 33

Hyperkalemia occurs with the use of ACE Inhibitors, spironolactone and ARB

Question 34

A 67-year-old man has persistent exertional angina despite treatment with a β-blocker and a calcium channel blocker. He also has well-controlled diabetes. Echocardiography shows an old anterior myocardial infarction and a left ventricular ejection fraction of 35%. Physical examination shows a blood pressure of 130/80 mm Hg, heart rate of 62/min, and no signs of heart failure. Cardiac catheterization shows 95% narrowing of the proximal left anterior descending coronary artery, 70% lesion of the proximal circumflex artery, 90% narrowing of the obtuse marginal artery, and 85% lesion of the proximal posterior descending artery. Which of the following is the most appropriate next step in the management of this patient?

Answer 34

Perform coronary artery bypass surgery.

Question 35

The following signs are indicative of massive pericardial effusion, except

Answer 35

Harsh pericardial rub

Question 36

Stokes-Adams attack is characterized by the following except

Answer 36

Rapid weak pulse

Question 37

Orthostatic hypotension is characterized by the following except :

Answer 37

Change < 20 mmHg in SBP in supine and standing

Question 38

If a patient with mitral stenosis develops atrial fibrillation :

Answer 38

The patient should receive lifetime anticoagulant

Question 39

Graham Steel murmur is :

Answer 39

An early diastolic murmur

Question 40

Pericarditis is an early and a late complication of myocardial infarction

Answer 40

T

Question 41

Beta blockers in heart failure ;

Answer 41

Can be prescribed with ACE inhibitors in class II and III heart failure

Question 42

All of the following about pulmonary embolism etiology is true, except

Answer 42

Heart Failure

Question 43

All of the following about neck veins is true, except :

Answer 43

Occasional cannon waves occur in Tricuspid regurgitation

Question 44

The following about heart failure is true :

Answer 44

Pleural effusion may occur in right and left sided heart failure

Question 45

Pleural effusion may occur in right and left sided heart failure

Answer 45

Aortic stenosis

Question 46

A 70 year old woman suffers an anterolateral MCI. Two weeks later, she develops sudden right hemipharesis and difficulty in talking. What is the most probable MCI complication in this patient?

Answer 46

Mural thrombus

Question 47

A 60 year old man id hospitalized for an inferior MCI. Despite appropriate management, he dies six days later. Post mortem examination shows massive distension of the pericardial sac by organizing hematoma. What is the most probable MCI complication in this patient?

Answer 47

Ventricular wall rupture

Question 48

Current guidelines from the American College of Cardiology Foundation and the American Heart Association (ACCF/AHA) define heart failure as :

Answer 48

A syndrome resulting from any structural or functional cardiac disorder that impairs the ventricles’ ability to fill or eject blood