2nd Cardiovascular USMLE

A 54-year-old woman presents for a routine physical. She has no complaints. She has no history of hypertension, diabetes, hypercholesterolemia, or heart disease, and she does not use tobacco, alcohol or drugs. On physical examination, her pulse is irregular. There are no murmurs. Her lungs are clear to auscultation and her legs are free of edema. An EKG shows atrial fibrillation with a heart rate of 72 beats per minute. An echocardiogram is unremarkable except for evidence of atrial fibrillation. What is the most appropriate management of this patient?

A middle-aged man was recently diagnosed with hypertension. The antihypertensive medication prescribed to him enhances natriuresis, decreases serum angiotensin II concentration, and decreases aldosterone production. This medication most likely belongs to which of the following drug classes?

A 32-year-old man develops severe nausea and vomiting after returning from a party. He also complains of chest pain that is more intense than any pain he has previously experienced. His past medical history is significant for HIV infection, alcohol abuse, and alcoholic hepatitis. He admits to using cocaine regularly. His temperature is 37.8C (100.F), pulse is 120/min, respirations are 24/min, and blood pressure is 100/60 mmHg. Examination reveals injected conjunctivae and bilateral dilated pupils. Chest X-ray demonstrates a widened mediastinum and left-sided pleural effusion. EKG is unremarkable. The pleural fluid is found to have an elevated amylase content. Which of the following is the most likely diagnosis in this patient?

A 45-year-old male is brought to the ER with sudden onset palpitations and chest tightness. His past medical history is significant for hypertension, gout and diabetes mellitus. Cardiac monitoring shows atrial fibrillation at a rate of 120-140/min. As the nurse is attempting to establish IV access, the patient becomes unresponsive. There is no palpable pulse over the carotids or femoral arteries. The cardiac monitor still shows atrial fibrillation at the same rate. What is the best next step in management?

A 24-year-old male experiences syncope while shoveling snow. He regained consciousness within one minute. He has been having some shortness of breath and chest pains recently, mostly related to exercise. He denies any illicit drug use. His temperature is 37.2 C (98.9 F), and blood pressure is 126/76 mm Hg, pulse is 76/min and respirations are 14/min. Physical examination shows a well-built male in no apparent distress. Lungs are clear. A crescendo-decrescendo systolic murmur is heard along the left sternal border without carotid radiation. Chest X-ray is normal. Which of the following is the most likely cause of his syncopal episode?

A 54-year-old overweight man wakes up in the middle of the night with substernal discomfort that he describes as a burning sensation. He also complains of left-sided neck pain and feels sweaty and short of breath. He has never had similar pain before. Prior to going to bed he had eaten a big meal. His past medical history is significant for diabetes and hypertension. Which of the following physical findings is most consistent with this patient's clinical presentation?

A 56-year-old male is hospitalized following an acute anterior wall myocardial infarction that was treated with thrombolytic therapy 4 days ago. On day 4 of his hospitalization, he develops recurrent chest pain, similar in quality and severity to his previous pain. Sublingual nitroglycerin is administered but does not help. His blood pressure is now 140/90 mmHg and his heart rate is 82/min. S 1 and S2 are normal, and there are no cardiac murmurs or rubs. Lungs are clear to auscultation. Which of the following laboratory tests would be most useful to send in this setting?

A 33-year-old woman is undergoing an elective, open cholecystectomy after 2 episodes of acute calculous cholecystitis. She suddenly becomes hypotensive, and a generalized rash is noted. Her past medical history is significant for a hypotensive episode 8 weeks ago while having protected sex with her new partner. Which of the following is the most probable cause of this patient's condition?

A 68-year-old man presents to the emergency department complaining of left lower extremity pain. He says that he first noticed a tingling sensation in his leg 3 hours ago, and since that time it has become increasingly painful. Over the past hour, he says, the skin on his leg has started to change color. His medical history is significant for hypertension, diabetes mellitus, atrial fibrillation, and major depressive disorder. He cannot remember his medication list at this time. On physical examination, his blood pressure is 127/74 mm Hg and his heart rate is 102/min. His left lower extremity is cool and pale below the level of the knee. Neither the posterior tibial nor the dorsalis pedis pulse is palpable. Which medication could have prevented this acute problem?

A 75-year-old patient presents to the ER after a syncopal episode. He is again alert and in retrospect describes occasional substernal chest pressure and shortness of breath on exertion. His blood pressure is 110/80 and lungs have a few bibasilar rales. Which auscultatory finding would best explain his findings?

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 at the apex. What is the most likely cause of the murmur?

You are helping with school sports physicals and see a 16-year-old boy who has had trouble keeping up with his peers. Which of the following auscultatory findings suggests a previously undiagnosed ventricular septal defect?

A 53-year-old male presents to your office with a two-day history of right calf pain and swelling. He describes the pain as constant and states that it is exacerbated by knee flexion. He has a history of past IV drug abuse, endocarditis, and stroke. He is currently wheelchair-bound secondary to stroke-related left-sided hemiparesis. On physical examination, his blood pressure is 140/90 mmHg and his heart rate is 100/min. There is no jugular venous distention or hepatojugular reflux. His chest is clear to auscultation but his abdomen is enlarged with shifting dullness and a fluid wave, suggestive of ascites. His liver is palpable 3 cm below the right costal margin. His spleen is also palpable. On examination of his lower extremities, you note right-sided calf swelling and tenderness. Which of the following is the most likely cause of this patient's ascites?

A 64-year-old male presents to the ER with chest pain. His history is significant for a hospitalization 2 weeks ago for an acute myocardial infarction. The patient reports that he is afraid his heart attack is recurring. He localizes the pain to the middle of the chest, and says that he can only take shallow breaths because deep breaths make the pain worse. Leaning forward in his chair makes the pain somewhat better. He notes some associated neck pain and general malaise, but denies shortness of breath, palpitations, syncope or cough. His temperature is 36.7C (98.F), blood pressure is 135/84 mmHg and heart rate is 90/min. EKG shows ST segment elevations in all limb and precordial leads except in aVR, where ST depression is seen. Which of the following is the best next step in the management of this patient?

A 15-year-old female, who has recently emigrated from Asia, is found to have a heart murmur during her routine physical examination. She has no current complaints. She had a febrile illness with joint swelling and pain approximately one year ago. She plays table tennis and swims every weekend. Her blood pressure is 120/70 mmHg and her heart rate is 70/min, regular. Cardiac auscultation shows a loud first heart sound and mid-diastolic rumble at the apex. Her lungs are clear to auscultation. Which of the following is the best treatment for this patient at this point?

A 60-year-old white man comes into the Emergency Room with intensive retrosternal pain that began ten minutes ago. He has never had such pain before. His past medical history is significant for diabetes mellitus, type 2, controlled with diet His blood pressure is 150/95 mmHg and HR is 80/min. You give him one chewable tablet of aspirin and two sublingual tablets of nitroglycerin with a 5-minute interval. After the second tablet of nitroglycerin, the pain is greatly relieved. What is the most important mechanism responsible for pain relief in this patient?

A 34-year-old male who recently immigrated from Brazil presents with a 5-month history of exertional dyspnea without associated chest pain, palpitations, dizziness, or syncope. His past medical history is significant for an episode of megacolon, which was treated 2 years ago. On physical examination, there is 1+ pedal edema and mild jugular venous distention. Cardiac exam is significant for the presence of an S3, but no murmurs are heard. Chest x-ray reveals prominent cardiomegaly. Based on these findings, which of the following is most likely causing his symptoms?

A 54-year-old male with a past medical history of type 2 diabetes mellitus comes to the emergency department complaining of shortness of breath. His blood pressure is 146/92 mmHg, respiratory rate is 26/min, and oxygen saturation is 87% on room air. Cardiac auscultation findings over the apex are given below. Based on the physical findings, which of the following is the best initial therapy for this patient?

Neighbors find a 65-year-old male unconscious in his garden and immediately call EMS. The man is intubated at the scene. In the ER, he develops sustained ventricular tachycardia and requires cardioversion. He is started on an antiarrhythmic agent and, once recovered, is discharged to home. Three months later he returns to his physician complaining of dyspnea on exertion. Chest-x ray reveals bilateral lung fibrosis. All cultures are negative and lung biopsy reveals lipoid pneumonitis. Which of the following medications is most likely responsible for his current condition?

A 12-year-old African American male is found to have a murmur during a routine sports physical. He has a family history of sudden death at a young age. It is a harsh crescendo-decrescendo murmur that begins after S1 and is best heard at the left lower sternal border. Valsalva maneuver intensifies the murmur. Which of the following is the most likely mitral valve abnormality in this patient?

A 36-year-old female presents to the emergency room complaining of chest pain that started suddenly while she was shopping at the mall. She also reports shortness of breath, palpitations and diaphoresis. The pain is retrosternal and radiates to the left arm. There are no aggravating or relieving factors. On review of systems, the patient reports having had a runny nose, sore throat and dry cough for the past 3 days. Her past medical history is significant for panic attacks, for which she takes paroxetine, and dysfunctional uterine bleeding, for which she takes estrogen. Her family history is significant for the sudden death of her father at age 44 from a heart attack. Social history reveals that she has smoked one pack of cigarettes per day for the past 15 years. Which of the following is the most appropriate initial therapy for this patient?

A 65-year-old female is admitted to the hospital with increasing shortness of breath, weight gain and lower extremity edema. She has a history of hypertension, nonischemic cardiomyopathy with an ejection fraction of 30%, and hyperlipidemia. Her home medications include oral aspirin, digoxin, furosemide, metoprolol, lisinopril and atorvastatin. She is started on intravenous furosemide. On day three of hospitalization telemetry reveals six beats of wide complex ventricular tachycardia. Physical examination now shows decreased leg edema and clear lungs. Which of the following is the most appropriate next step in the management of this patient's tachycardia?

A 34-year-old male presents with palpitations for the past 4 hours without associated chest pain, shortness of breath, fevers, or chills. His medical history is significant for Wolff-Parkinson-White syndrome for the past ten years and three prior episodes of supraventricular tachycardia. He does not smoke cigarettes, and drinks alcohol on social occasions. He does report having had five cans of beer while at a party last night. On examination, his blood pressure is 120/80 mmHg and his pulse is irregularly irregular. EKG shows atrial fibrillation with a rate of 160/min. What is the best next step in the management of this patient?

A 21-year-old man comes to the ER with palpitations and dizziness that began suddenly one hour ago. He notes having similar past episodes provoked by fatigue or strong emotions. He says he can usually stop the episodes by putting his head into cold water or squatting and taking a deep breath. However, these techniques are not working this time. Presently, his blood pressure is 60/30 mmHg and his heart rate is 240/min. He is diaphoretic with cold extremities. An EKG rhythm strip shows a regular, narrow complex tachycardia. Which of the following is the best next step in managing his condition?

A 64-year-old Caucasian male presents to the Emergency Room with a sharp, left-sided chest pain. He says that the pain is worse when he takes deep breaths, but he gets relief with leaning forward. He had an acute non-ST elevation myocardial infarction six months ago and had undergone angioplasty for the right coronary artery. His other medical problems include: diabetes, hypertension, hyperlipidemia, peripheral neuropathy, diabetic retinopathy, paroxysmal atrial fibrillation, hypothyroidism, and chronic renal insufficiency. His vital signs are BP 142/86 mmHg, PR 78/min, RR 16/min, and T 36.1 C (97F). On examination, you find a pericardial rub. EKG shows diffuse ST elevation. Lab results are: Hb 9.0 g/dl WBC 8,000/cmm Platelets 210,000/cmm Blood Glucose 248 mg/dl Serum Na 135 mEq/L Serum K 5.8 mEq/L Bicarbonate 17 mEq/L BUN 86 mg/dl Serum Creatinine 4.4 mg/dl Which of the following is the most appropriate management of this patient?

A 63-year-old woman with a long history of hypertension faints after experiencing the sudden onset of severe chest pain that radiates to her back. She is rushed to the emergency room. Upon arrival she is agitated and demands quick pain relief. Her heart rate is 110/min and blood pressure is 90/50 mmHg. Jugular veins are distended. An intraarterial catheter shows significant variation of systolic blood pressure related to the respiratory cycle. Chest x-ray reveals widening of the mediastinum. Which of the following is the most likely cause of this patient's syncope?

A 32-year-old woman is brought to the emergency department with excruciating chest and neck pain. She is 6'2" and has long extremities. Her hand joints show significant extensibility. Which of the following additional findings is also likely in this patient?

A 53-year-old Caucasian woman comes to the physician for a routine health maintenance examination. Recently, she noticed a mild hand tremor while performing some fine tasks, like pouring out the tea. She says that the tremor disappears for a while after drinking a glass of wine. Her past medical history is insignificant. Her blood pressure is 160/90 mmHg and heart rate is 80/min. Physical examination is insignificant. Which of the following medications is the best choice to treat this patient's hypertension?

A 47-year-old male was brought to the emergency room with chest pain of acute onset. The pain was associated with nausea, vomiting, and diaphoresis. He has a history of diabetes, hypertension, and hyperlipidemia. ECG reveals ST segment elevation in the anterolateral leads and ventricular premature beats (VPBs). The patient dies within the first hour after the arrival to emergency room. What is the most likely pathophysiologic mechanism responsible for this patient's death?

A 60-year-old Caucasian man presents to the office with a 2-week history of worsening shortness of breath and decreased exercise tolerance. His breathlessness is worse at night. He thinks his legs are swelling up. He has hypertension, coronary artery disease and chronic obstructive pulmonary disease. He used to drink heavily and smoke 1 pack of cigarettes daily but has quit recently, although he still reports occasionally drinking a "few beers." He currently denies any chest pain, palpitations or cough. His temperature is 37.5C (99.5 F), blood pressure is 110/70 mm Hg, pulse is 96/min and respirations are 22/min. The pertinent physical findings are an S3, bibasilar crackles, JVP 10 cm above the sternal angle, mild hepatomegaly, and 4+ pitting lower extremity edema. The patient is immediately treated with oxygen, intravenous furosemide, and nitrates Which of the following markers is most likely elevated in this patient?

A 69-year-old male presents to the emergency department with severe pain in the back of his chest that began suddenly 6 hours ago, and 2 hours of difficulty walking due to leg weakness. He has never had such symptoms before. His past medical history is significant for hypertension, bleeding peptic ulcers, and deep vein thrombosis requiring inferior vena cava filter placement. He drinks 6-8 cans of beer each weekend and does not smoke cigarettes or use illicit drugs. Blood pressure taken from his right arm is 210/120 mmHg. His heart rate is 120/min and regular. Chest x-ray reveals a right-sided pleural effusion. EKG shows sinus tachycardia. What is the most likely diagnosis?

A 34-year-old male with a history of mitral valve prolapse and mitral regurgitation presents with one week of intermittent fevers and increasing fatigue. He was punched in the face during a street fight two weeks ago. On admission he receives empiric intravenous vancomycin and gentamicin. Three days later, three out of four blood cultures grow Streptococcus viridans highly sensitive to penicillin. Which of the following is the best next step in managing this patient?

A 10-year-old boy is brought to the ER by his mother because he has lost consciousness, while playing in the yard. He regained his consciousness quickly without following confusion. He never had such an episode before. His past medical history is significant for impaired hearing since birth and one episode of pneumonia three years ago, which required hospitalization. The family history is significant for a sudden cardiac death, in his cousin, at the age of 13. Physical examination is unremarkable. Blood pressure is 110/70 mmHg. Heart rate is 70/min, regular. Which of the following medication is most appropriate for this patient?

A 57-year-old male presents to the emergency department with recent-onset dyspnea and cough. He reports that his symptoms began earlier this morning while he was jogging, when he suddenly started feeling short of breath and very weak. In the emergency department, laboratory analysis reveals a markedly elevated serum b-type natriuretic peptide level. Which of the following clinical signs best correlates with this finding?

A 68-year-old Caucasian male presents to the emergency room with a three-week history of progressive dyspnea, orthopnea, and lower extremity edema. His past medical history is significant for hypertension, type 2 diabetes mellitus, myocardial infarction experienced eight years ago, and congestive heart failure. His current medications include metoprolol, digoxin, enalapril, furosemide, spironolactone, and aspirin. His blood pressure is 145/90 mmHg, and heart rate is 75/min. Symmetric 2+ pitting edema of the lower extremities is present. Point of maximal impulse is displaced to the left and soft holosystolic murmur is heard on the apex. Bilateral crackles are present over the lower lobes. His laboratory values are: Hemoglobin 11.0 g/dl Leukocyte count 7,500/cmm Platelets 300,000/cmm Serum sodium 128 mEq/L Serum potassium 5.3 mEq/L Serum calcium 9.0 mg/dl Serum phosphorus 4.0 mg/dl Serum creatinine 1 .9 mg/dl ECG does not reveal acute ischemic changes. Which of the following is most likely correct concerning this patient's condition?

A 76-year-old man presents to your office with progressively worsening fatigue over the past several months. He denies associated chest pain, dyspnea, nausea, cough, or ankle swelling. He has smoked a pack of cigarettes per day for the past 30 years. His past medical history is significant for hypertension for which he takes hydrochlorothiazide and type 2 diabetes mellitus controlled with metformin. He had a medical check-up five months ago which did not uncover any new abnormalities or medical issues. On physical examination today, his blood pressure is 130/80 mmHg and his heart rate is 110 and irregularly irregular. His lab values are: Hematocrit 41% WBC count 4,700/mm3 Platelets 200,000/mm3 Sodium 137 mEq/L Potassium 4.1 mEq/L Creatinine 0.8 mg/dl Fasting glucose 85 mg/dl Which of the following is the best treatment for this patient?

A 70-year-old male is brought to the ER, by his wife, because he lost consciousness while getting up in the morning. The syncopal episode lasted for several minutes, and the patient rapidly recovered consciousness. He had diarrhea and a decreased appetite one day earlier, which resolved spontaneously. His past medical history is significant for hypertension that is effectively controlled with the combination of hydrochlorothiazide/amiloride. His blood pressure is 120/70 mm Hg, while supine, and 98/50 mm Hg, while standing. The physical examination revealed a mucosal dryness. The EKG is normal. Which of the following laboratory values is the most sensitive indicator of the patient's underlying condition?

A 65-year-old man complains of lower leg swelling, fatigue and poor appetite. His past medical history is significant for recurrent chest infections, wheezing, cough, recent pyelonephritis, and arterial hypertension. He smokes 1 pack of cigarettes a day but denies alcohol or intravenous drug use. His physical examination reveals a barrel-shaped chest with bilateral scattered wheezes. His abdomen is distended and his liver edge is palpated 4 cm below the right costal margin. You note pitting edema and dilated, tortuous, superficial veins over the bilateral lower extremities. Manual pressure on the abdomen causes persistent distention of the jugular veins. The patient's serum sodium level is 135 mEq/L and his creatinine concentration is 1.2 mg/dl. An abnormality of which of the following is most likely to explain his edema?

A 60-year-old male presents to the emergency room with the chief complaint of progressive exertional dyspnea and fatigue. He denies any chest pain, syncope, cough, or edema. He suffered an acute anterior wall myocardial infarction one month ago. Chest auscultation reveals bilateral crackles in his lower chest. Cardiac auscultation reveals a pansystolic murmur at the apex with radiation to the axilla. ECG shows previously present unchanged Q waves and a persistent ST segment elevation in the anterior leads. Based on these findings, what is the most likely underlying cause of his symptoms?

A 65-year-old male presents to your office with a six-month history of periodic substernal pain. The pain episodes are experienced during strong emotion, last for 10-15 minutes, and resolve spontaneously. He has a long history of hypertension and diabetes mellitus, type 2. His right foot was amputated two years ago due to diabetes-related complications. You suspect angina pectoris and decide to perform myocardial perfusion scanning. It reveals uniform distribution of isotope at rest, but inhomogenesity of the distribution after dipyridamole injection. You conclude that the patient has ischemic heart disease. Which of the following effects of dipyridamole helped you in making the diagnosis?

A 37-year-old healthy Caucasian male is seen in your office for a routine physical examination. He denies any symptoms or illness. He says he smokes a pack a day and drinks one to two beers every weekend. He has no allergies. Examination is unremarkable. The EKG reveals normal sinus rhythm with a heart rate of 72; there are frequent premature atrial beats present. The blood pressure is 120/65mm Hg. The next step in his management is:

A 56-year-old white male presents with dyspnea for the last 3 months. His dyspnea was initially exertional but it has worsened progressively and now he is breathless even at rest. He denies any chest pain or ankle swelling. He has been smoking one-pack/day cigarettes for the last 30 years and has been drinking alcohol heavily for the last 10 years. He is not taking any medication. His mother died of breast cancer at 57. His vitals are, PR 86/min, BP 113/76mm of Hg; Temperature 37.1C (98.9F); RR 13/min. On auscultation of his precordium an S3 is heard, but there are no murmurs. Chest auscultation reveals bilateral basal crepitations. Chest x-ray shows marked cardiac silhouette enlargement and pulmonary venous congestion. EKG shows non-specific ST-T wave changes. Echocardiography shows a dilated left ventricle and systolic dysfunction (EF of 25-30%). CBC shows hematocrit of 32%, WBC count of 6,000/microl, and platelet count of 60,000/microl. Peripheral blood smear shows MCV of 101 fl. LFTs show AST of 180U/L and AL T of 66 U/L. The findings of cardiac catheterization and coronary angiography are not compatible with the diagnosis of ischemic cardiomyopathy. Which of the following measures is most likely to reverse his heart failure?

A 55-year-old Caucasian male presents to your office for a routine check-up. His past medical history is significant for gout, hypertension, and hypercholesterolemia. His current medications include enalapril and pravastatin. He does not smoke or consume alcohol. His blood pressure is 156/94 mmHg and heart rate is 80/min. Physical examination reveals that the patient is moderately overweight (BMI = 27 kg/m2) with increased waist-to-hip ratio. You consider adding hydrochlorothiazide to the treatment regimen to improve the control of hypertension. Which of the following metabolic effects do you expect to emerge after this correction?

An imaging study detects a 3.5 cm abdominal aortic aneurysm in a 60-year-old male. He has no associated symptoms. His past medical history is significant for hypertension, type 2 diabetes, hypercholesterolemia and hypothyroidism. His medications include aspirin, metformin, glipizide, hydrochlorothiazide, lisinopril, low dose atorvastatin and levothyroxine. He has smoked 1-2 packs of cigarettes daily for the past 40 years, and he drinks 1-2 glasses of wine daily. On physical examination, his blood pressure is 160/90 mmHg and his pulse is 80/min. Heart sounds are normal and his lungs are clear. Laboratory studies show: Serum creatinine 1.7 mg/dL Low density lipoprotein (LDL) 150 mg/dL HbA1C 8.5% Serum TSH 3.0 Which of the following interventions would most reduce the likelihood of his aortic aneurysm enlarging?

A 68-year-old white female presents to the ER complaining of sudden onset chest pain associated with two episodes of vomiting. She has hypertension for which she takes atenolol and hydrochlorothiazide. Her pulse is 60/min, blood pressure is 80/50 mmHg and respirations are 14/min. Examination shows elevated jugular venous pressure and a positive Kussmaul's sign. Her lungs are clear to auscultation. Her EKG shows 2 mm ST segment elevation in leads II, Ill and aVF and 1 mm ST segment depression in leads I and aVL. Which of the following is the most likely cause of this patient's hypotension?

A 53-year-old man presents to your office complaining of weakness and exertional dyspnea over the last week. He denies chest pain and palpitations. He has no other past medical history. His father died of a myocardial infarction at age 55. On exam, his heart rate is 100/min and blood pressure is 90/60 mmHg. Internal jugular venous pulsation is observed 7 cm above the sternal angle. Lungs are clear to auscultation. Heart sounds are muffled. Which of the following is the most likely cause of this patient's complaints?

56-year-old man presents to your office complaining of progressively worsening fatigue. He also reports difficulty concentrating and increasing forgetfulness over the past several weeks. On review of systems, the patient reports having unintentionally gained 6 pounds over the last three months. His past medical history is significant for hypertension and atrial fibrillation. On physical examination, he has a blood pressure of 140/90 mmHg and a heart rate of 75/min. His lung fields are clear to auscultation. There is no ankle edema. His skin is dry. Which of the following drugs is most likely responsible for this patient's complaints?

A 33-year-old Russian male reports concern over recurrent episodes of a "pounding" and "racing" heart over the last several months. He says his symptoms are worst while lying supine and while lying on his left side. On physical examination, his blood pressure is 150/55 mmHg and heart rate is 73/min. Which of the following is most likely responsible for his symptoms?

A 34-year-old man rushes into the ER complaining of severe substernal chest pain that began abruptly 30 minutes ago. He says that he also feels as though his heart 'is racing,' but denies any shortness of breath, cough or fever. He has never experienced pain like this before. His past medical history is significant for an appendectomy one year ago. The patient reports that his father died at age 64 due to "some heart problem" and his mother died of ovarian cancer. On physical examination, the patient is agitated and sweating profusely. His pulse is 110/min, blood pressure is160/100 mm Hg, and respirations are 14/min. Physical examination is normal except for dilated pupils and a small amount of blood at the external nares. EKG shows ST elevations in leads v1_v4. What is the most likely explanation for his symptoms?

A 40-year-old male presents to the Emergency Room with a two-month history of occasional severe headache and blurring of vision. His past medical history is significant for hypertension controlled with hydrochlorothiazide for two years. His family history is significant for hypertension and diabetes. He smokes two packs a day and occasionally consumes alcohol. His blood pressure is 200/140 mmHg and heart rate is 75/min. Which of the following is most consistent with a diagnosis of malignant hypertension in this patient?

A 62-year-old man visits his family physician because of generalized aches and pains. He denies associated fevers, headaches, chest pain, or abdominal discomfort. His past medical history is significant for an inferior wall myocardial infarction 6 years ago. His other medical problems include hypertension, diabetes, hypercholesterolemia, and gout. His current medications are aspirin, losartan, naproxen, atenolol, glipizide, colchicine, and simvastatin. On physical exam today, he is afebrile, with blood pressure 130/90 mm Hg, pulse 80/min and respirations 18/min. Lab results are as follows: Sodium 140 mEq/L Potassium 4.2 mEq/L Bicarbonate 21 mEq/L Chloride 100 mEq/l BUN 30 mg/dl Creatinine 1.6 mg/dl AST 113 IU/L ALT 120 IU/L Creatine phosphokinase 14,998 mg/dl What is the most appropriate next step in the management of this patient?

A 50-year-old white male comes into your office for a routine check-up. He has no present complaints. His past medical history is significant for hypertension controlled with a low-dose thiazide diuretic. His family history reveals non-fatal myocardial infarction in his father at the age of 47. The patient does not smoke or consume alcohol. His blood pressure is 130/75 mmHg and his heart rate is 70/min. His previous records show that his HDL level is persistently low in spite of acceptable total cholesterol and LDL levels. You prescribe niacin to raise HDL level. The patient returns in a week complaining of intensive generalized pruritis and flushing. What is the most probable cause of the patient's complaint?

A 74-year-old woman presents to your office complaining of diarrhea and decreased appetite over the past week as well as increasing fatigue and occasional palpitations over the last few days. Her past medical history is significant for chronic atrial fibrillation for which she takes metoprolol, digoxin and warfarin. She smokes cigarettes and has for the past several years. On physical examination, her blood pressure is 140/90 mmHg and her heart rate is 70/min and irregular. Lung auscultation reveals scattered wheezes. Her abdomen is soft and non-tender. The liver span is 8 cm and the spleen is not palpable. There is no ankle edema. Her last measured INR was 2.3 two weeks ago. Which of the following is the best initial test in this patient?

A 43-year-old male complains of frequent epigastric burning not relieved by antacids. The sensation is typically brought on by heavy lifting at work and takes 10-15 minutes to go away. He denies having associated arm or neck pain, cough, shortness of breath or difficulty swallowing. His past medical history is significant for systemic lupus erythematosus (SLE) diagnosed five years ago, for which he takes low-dose prednisone daily. On physical examination, his blood pressure is 140/90 mmHg and pulse is 80/min and regular. Heart, lung, and abdomen exams are unremarkable. EKG is normal. Which of the following is the best next step in managing this patient?

A 64-year-old white female presents for evaluation of two weeks of decreased appetite and nausea. She also notes occasional palpitations, which have been especially prominent over the past two days. Her medical history is significant for an anterior wall myocardial infarction one year ago and secondary congestive heart failure with left ventricular systolic dysfunction. Her current medications include aspirin, digoxin, furosemide, enalapril and metoprolol. On physical examination, her blood pressure is 120/80 mm Hg, pulse is 106/min and respirations are 15/min. The remainder of her exam is unremarkable. Chest x-ray shows an enlarged cardiac silhouette and normal lung fields. On laboratory testing, her digoxin level is twice the upper limit of normal. You order an EKG. Which of the following arrhythmias is most specific for digitalis toxicity?

A 34-year-old female presents to your office complaining of pressure-like, substernal chest pain that has been affecting her recently when she plays active sports. Resting consistently alleviates the pain. She denies any associated nausea, vomiting, diaphoresis, dyspnea, palpitations or syncope. Family history is non-contributory. On physical examination, her pulse is 79/min and blood pressure is 130/70 mmHg. Cardiac auscultation reveals a high-pitched 3/6 systolic murmur best heard at the second right intercostal space. The lungs are clear to auscultation. Chest x-ray shows a normal sized heart and clear lung fields. What is the most likely cause of this patient's chest pain?

A 45-year-old mildly overweight smoker presents with occasional episodes of nocturnal substernal chest pain that wakes her up from sleep. The episodes last 15-20 minutes and resolve spontaneously. She denies any illicit drug use. She leads a sedentary lifestyle but states that she can climb two flights of stairs without any discomfort. Her pulse is 78/min and regular, blood pressure is 130/70 mmHg and respirations are 13/min. Auscultation of her heart and lungs is unremarkable. Extended ambulatory ECG monitoring reveals transient ST segment elevations in leads V4-V6 during the pain attack. The pathophysiology of this patient's condition is most similar to that of which of the following?

An 84-year-old Caucasian male is brought to the ER with severe chest pain, dyspnea and diaphoresis. His past medical history is significant for a long history of hypertension and diabetes mellitus, type 2. He experienced a severe myocardial infarction 6 months ago. His current medications are enalapril, metoprolol, aspirin, furosemide, potassium, glyburide and pravastatin, but he says that he has not been taking some of his medications recently. Physical examination reveals acrocyanosis and symmetric 3+ lower extremity edema. Point of maximal apical impulse is displaced to the left, and a holosystolic II/VI apical murmur is heard at the apex. Non-specific ST segment and T wave changes are present on ECG. The initial set of cardiac enzymes are positive. The patient continues to deteriorate, despite aggressive diuretic and vasodilator therapy. You perform an echocardiographic evaluation of left ventricular function and decide to proceed with pulmonary artery catheterization. Cardiac index (CI), total peripheral resistance (TPR) and left ventricular enddiastolic volume (LVEDV) are determined. Which of the following is most likely to present in this patient?

A 43-year-old man is hospitalized with chest pain, lightheadedness and nausea. He describes the pain as dull and non-radiating. He has never had chest pain before, but does report occasional episodes of dyspnea and coughing. His medical history is significant for eczema. He is not presently taking any medications. His family history is significant for prostate cancer in his father and rheumatoid arthritis in his mother. He does not smoke or consume alcohol. The patient is admitted to the hospital and is given aspirin, low-molecular weight heparin, metoprolol and captopril. On day 2 of his hospitalization he complains of shortness of breath. Physical examination reveals prolonged expirations and bilateral wheezes. There are no crackles. You estimate the jugular venous pressure to be 7 cm with the patient's head elevated at 45 degrees. Which of the following is most likely responsible for this patient's current respiratory symptoms?

A 53-year-old Caucasian male is admitted to the hospital with a 2-week history of fatigue and decreased exercise tolerance. He says he can hardly climb two flights of stairs without getting dyspneic. He denies palpitations or chest pain. His past medical history is insignificant, and a routine check-up 6 months ago was normal. He admits two episodes of binge drinking during the last month, but says that he 'got it under control'. He is currently not taking any medications. His blood pressure is 150/90 mmHg and heart rate is 130/min, irregular. Lungs are clear on auscultation. ECG does not reveal P waves. Echocardiography shows significant left ventricular dilation with an ejection fraction of 35% and mitral regurgitation (1+). Which of the following intervention will most likely improve the left ventricular function in this patient?

A 47-year-old Caucasian female presents with occasional episodes of nocturnal substernal chest pain that wakes her up during sleep. The pain episodes last 15-20 minutes and resolve spontaneously. She denies any illicit drug use. She leads a sedentary lifestyle but states that she can climb two flights of stairs without any discomfort. She has no history of hypertension or diabetes. Her pulse is 75/min and regular, blood pressure is 134/70 mmHg and respirations are 14/min. Extended ambulatory ECG monitoring reveals transient ST segment elevation in leads I, aVL, and V4-V6 during the episodes. Which of the following is the best treatment for this patient?

A 36-year-old male patient, who has a history of Marfan's syndrome, presents with sudden onset of severe central tearing chest pain radiating to his back. The pain is 9/10 in severity and is unrelated to exertion. He denies any history of alcohol or tobacco use. Measurement of his BP shows a difference of 35 mm Hg between his two arms. Chest auscultation reveals clear lung sounds and a mid-systolic click. What is the most appropriate next diagnostic step in the management of this patient?

A 55-year-old male presents to your office with a 6-month history of periodic substernal pressure. He experiences this pressure while walking uphill or climbing two flights of stairs. His past medical history is insignificant. He smokes 1 pack a day and consumes alcohol occasionally. His blood pressure is 160/90 mmHg and heart rate is 75/min. Resting ECG is normal. You suspect stable angina and order an ECG stress test that reveals horizontal ST segment depression in leads II, III, and aVF at submaximal heart rate. What is the best medication to treat this patient's condition?

A 45-year-old man presents to the emergency department because of dyspnea, fatigue, poor appetite and weight gain over the past several weeks. He says that about four weeks ago he began to develop worsening shortness of breath with exertion and more recently has been waking at night with breathlessness. He also notes that it is sometimes difficult for him to open his eyes in the morning due to facial edema. He has no significant past medical history and he takes no medications. On physical examination, his blood pressure is 200/120 mmHg and his heart rate is 100/min. You note generalized bodily edema and distention of his jugular veins while he is sitting upright. On lung auscultation you hear bibasilar rales. Urinalysis shows trace protein, no nitrites, trace leukocyte esterase, 50+ red blood cells and occasional neutrophils. Which of the following is the most likely cause of this patient's edema?

A 56-year-old man presents to the emergency department with dyspnea. He describes waking up during the night with difficulty breathing and chest pain that kept him from falling back to sleep. He has never had these symptoms before. His past medical history is significant for long-standing hypertension and non-compliance with his antihypertensive therapy. He has smoked a pack of cigarettes per day for the past 30 years. On physical examination, his blood pressure is 170/100 mmHg and his heart rate is 120/min and regular. Lung auscultation reveals bibasilar rales and scattered wheezes. Which of the following is most likely to relieve this patient's dyspnea?

A 56-year-old white male presents to his primary care physician for follow-up evaluation of high blood pressure noted on each of three prior visits over a period of 6 months (systolic blood pressure ranging 140-145, diastolic blood pressure ranging 90-96 mm Hg). He has smoked a pack of cigarettes per day for the past 20 years and takes 5-6 drinks of alcohol daily. He has no other medical problems and takes no medications. There is no family history of diabetes mellitus, coronary artery disease, hyperlipidemia or hypertension. On physical examination today, his blood pressure is 146/97 mm Hg and pulse is 80/min. The remainder of the exam is unremarkable. Which of the following nonpharmacologic interventions would be expected to have the greatest impact on his high blood pressure?

A 14-year-old African American male collapses and dies while playing basketball at a school tournament. He has no known past medical history. Which of the following is the most likely underlying disease in this patient?

A 63-year-old female presents to your office for a routine check-up. She has no present complaints. Her past medical history includes OM, type 2, and hypertension. Her current medications include glyburide and atenolol. She does not smoke. She drinks 2-3 glasses of wine 1-2 times a week. Three consecutive BP measurements were in the range of 138-142/87-90 mmHg. Physical examination is within normal limits. Her recent fasting glucose level was 250 mg/dl. ECG recorded 1 month ago showed left ventricular hypertrophy. Which statement about the BP control in this patient is the most accurate?

A 70-year-old patient presents to the ER with a 3-hour history of intensive retrosternal chest pain that radiates to the interscapular area. He states that he has never experienced this pain before. His past medical history is significant for a 20-year history of hypertension and a 10-year history of diabetes mellitus, type 2. His current medications include enalapril and hydrochlorothiazide. He does not smoke or consume alcohol. His vital signs are BP 180/110 mm Hg in the right arm and 178/110 mm Hg in the left arm, PR 85/min and RR 18/min. The physical examination revealed an early decrescendo-type diastolic murmur at the left sternal border. The EKG is normal. Which of the following is the best next step in the management of this patient?

A 46-year-old man complains of exertional dyspnea and dry cough. He also describes occasional episodes of a suffocating nighttime cough that is relieved only when he stands up. His medical history is significant for a myocardial infarction six months ago. His current medications are metoprolol, aspirin and simvastatin. He does not use tobacco but drinks alcohol on social occasions. His father died of a stroke and his mother suffers from diabetes mellitus. His blood pressure is 150/100 mmHg and his heart rate is 60/min. Chest examination reveals bibasilar rales. His cardiac apex is palpated in the sixth intercostal space. The liver span is 12 cm. Bilateral pitting leg edema is also present. Which of the following most likely contributes to his edema?

A 22-year-old white female is brought to your office by her mother because of the recurrent syncopal episodes. The first episode occurred about one year ago when her roommate committed suicide and then several similar episodes occurred usually provoked by a strong emotion. The episodes are preceded by lightheadedness, weakness, and blurred vision and last about three minutes with rapid recovery of consciousness. Past medical history is insignificant. She is not taking any medications and denies drug abuse. Her blood pressure is 110/70 mm/Hg while supine and 108/70 mmHg while standing. Physical findings are within normal limits. EKG performed one month ago was normal. Which of the following is the next best step in the management of this patient?

A 32-year-old man presents to the emergency department with a three-day history of fever, cough and weakness. His blood pressure is 120/80mmHg and his heart rate is 110/min. Physical examination reveals multiple needle tracks on his arms. ECG shows sinus tachycardia but is otherwise normal. Chest X-ray shows scattered round lesions in the peripheral lung fields bilaterally. Urinalysis is positive for 2+ protein. Which of the following accompanying findings is most likely in this patient?

A 54-year-old man with a 20-year history of chronic obstructive lung disease has a heave that is palpable at the lower left sternal border at the third, fourth, and fifth intercostal spaces. Which of the following best explains the etiology of the heave?