Cardio

A 53 yo Caucasian male arrives at your naturopathic medicine clinic seeking alternatives to statin drugs. He has read about harmful side effects on the internet and is concerned. His cardiologist prescribed atorvastatin (Lipitor) 80 mg po QD after the patient underwent catheterization and stent placement for a coronary artery blockage. You provide health teaching about the pleiotropic effects of Statins which includes all EXCEPT:

SB, a 60 yo Asian female, has average ambulatory home monitoring BPs in the 140’s/90’s mm Hg. PE is negative for signs of end organ damage. Her ASCVD score is 4.8%. Your diagnosis is Stage 1 HTN. An initial trial of diet and lifestyle intervention may include:

An 80 yo African American female presents for her annual exam. She appears frail, with slow gait and appears out of breath as she reaches the exam room. Vital signs are T98.8, P110, R22, BP 160/94, O2 Sats 89%. She states she feels tired all the time and anxious but thinks it’s because her husband passed last winter. Your next step includes:

A 46 yo Hispanic male presents with blurred vision and severe headache (pain 8/10; 10 worst) not relieved by acetaminophen (Tylenol). Vital signs are T98.4, P90, R20, BP 210/120, O2 Sats 98%. Fundoscopic exam reveals papilledema and cotton wool spots. SHx includes recreational cocaine and methamphetamine use. Abdominal exam is positive for mild TTP, negative hepatosplenomegaly. UA is positive for blood and protein. You suspect ___ and your plan includes ____.

A 19 yo male was resuscitated on the field during a college soccer match. He was diagnosed with hypertrophic cardiomyopathy (aka Idiopathic Hypertrophic Subaortic Stenosis or IHSS). He comes to you after hospital discharge because he doesn’t want to take “heart drugs” for the rest of his life and would prefer diet and lifestyle management so he can play soccer professionally. He reports feelings of depression. Your recommendations include:

XX is a 72 year old African American female coming to you looking for natural ways to treat her atrial fibrillation. Her onset occurred after a MI 6 years ago and required a pacemaker implant. She has been recently placed on Warfarin. She is seeking your help because she feels lightheaded, tired, weak, and shaky. She is currently taking carvedilol and amiodarone. Her cardiologist has suggested CoQ10 supplementation. Her PE is remarkable for a soft S1 with an irregular rhythm, increased JVP, hepatomegaly and pulmonary rales, bilaterally. She keeps saying, “I just feel so tired, can you make me feel not tired anymore?” Your suggestion for her would be:

TG is a 48 year old male seeing you because he just doesn’t feel right lately. He can’t pinpoint what doesn’t feel right and says he would feel better if the doc would give him a clean bill of health so his mind can rest. He currently smokes cigarettes occasionally, drinks 2 beers every night and eats “his good ole meat and potatoes diet”. ROS was pertinent for intermittent heartburn, frequent urination with burning, and “needs to go to the eye doc because his eyes are getting old”. PE: BP: 190/120, funduscopic exam, cardiovascular, respiratory, abdominal exam is WNL. UA shows glucose, WBC and nitrites. You decide that this is a hypertensive emergency and instruct the patient to go the ER. What should happen next?

KL is a 39 year old Caucasian male who is seeking help for natural ways to deal with his cholesterol. His recent labs showed the following: TGL: 200 mg/dl, LDL- 220 mg/dl, HDL: 31 mg/dl. He has no history of diabetes. His vitals in office were: HR 68, weight: 202 lbs, ht: 6’4”, BP: 138/78. His family history includes: father passed away from MI at 53, grandfather had a stroke at 58. With all of this information you have, you decide you are going to determine his ASCVD risk percentage. Which of these values is not needed to calculate his risk for his case?

ABC is a 86 year old female coming in for a ROC for weight gain concerns. Her weight gain started about 3 months ago. She reports being cold, tired, nauseated, constipated, having a nasty dry cough, and feels the need to use two pillows instead of one at night for her head as it helps her sleep better. PE shows a respiratory rate of 24, skin pallor as well as cool to touch, pitting edema of her feet. Her cardiac exam reveals S3 sounds. Which of these labs are the most appropriate to order:

DT is a 5 year old male who is in your office with his mother for his well child exam. He was playing soccer with his pee wee team and fell pretty hard to the ground, yesterday. Since then, he has been holding his chest and told his dad his heart hurts really bad. His mother tells you he has been turning “blue” because he is holding his breath due to the pain. In office the child is alert, holding on to his mother’s waist. His blood pressure is in the 89th percentile for his age and height. His cardiac exam revealed a systolic, diamond shaped, blowing murmur in the 2nd left intercostal space. Skin, respiratory exams are WNL. The most likely diagnosis from your differential diagnosis is:

A 67 year old African American male presents to office complaining of a “fluttering feeling” in his chest for the last several hours. He is slightly anxious in office. He denies feeling dizzy or faint. He has experienced 4-5 of these episodes over the last several months. He was diagnosed with hypertension 6 years ago, but has not taken the medications prescribed. He has never smoked and drinks 2-3 drinks on the weekends with friends. On physical exam you find that he is afebrile, with a pulse of 110 bpm with an irregularly irregular rhythm and a blood pressure of 168/98. He is alert and oriented. You note that he wearing shorts and flip-flops despite it being quite cold out. What are your next step(s) with this patient?

A 67 year old African American male presents to office complaining of a “fluttering feeling” in his chest for the last several hours. He is slightly anxious in office. He denies feeling dizzy or faint. He has experienced 4-5 of these episodes over the last several months. He was diagnosed with hypertension 6 years ago, but has not taken the medications prescribed. He has never smoked and drinks 2-3 drinks on the weekends with friends. On physical exam you find that he is afebrile, with a pulse of 110 bpm with an irregularly irregular rhythm and a blood pressure of 168/98. He is alert and oriented. You note that he wearing shorts and flip-flops despite it being quite cold out. What is the best explanation for this patient’s symptoms?

A 67 year old African American male presents to office complaining of a “fluttering feeling” in his chest for the last several hours. He is slightly anxious in office. He denies feeling dizzy or faint. He has experienced 4-5 of these episodes over the last several months. He was diagnosed with hypertension 6 years ago, but has not taken the medications prescribed. He has never smoked and drinks 2-3 drinks on the weekends with friends. On physical exam you find that he is afebrile, with a pulse of 110 bpm with an irregularly irregular rhythm and a blood pressure of 168/98. He is alert and oriented. You note that he wearing shorts and flip-flops despite it being quite cold out. The patient returns to office 2 weeks later and wants your help to get his blood pressure under control. He does not have CDK or diabetes. What is his target blood pressure and what medications are recommended for this patient according to the JNC-8?

A 63 year old female presents to office with nausea and some SOB that began last night (8 hours ago). She tells you she just wanted to come see you because she “feels like something is really off”. She is anxious and diaphoretic in office. You decide to send her to the ER to rule out MI. In the ER they run an ECG. Which of the following ECG findings is NOT suggestive of an MI?

A 63 year old female presents to office with nausea and some SOB that began last night (8 hours ago). She tells you she just wanted to come see you because she “feels like something is really off”. She is anxious and diaphoretic in office. You decide to send her to the ER to rule out MI. The ECG is ran 9 hours after the onset of symptoms and is found to be normal. At this time they also decide to run cardiac enzymes. At this time, which of the following findings would rule out an MI?

(True Story) A 62yo woman with a history of angina experiences crushing chest pains, sweating, and tachycardia while driving to the airport. She pulls over, takes a sublingual nitroglycerine (NG), and then continues to drive. The pain is not improved so she pulls over twice more and takes more NG. Still feeling chest pain, she boards her 5 hour flight and chews four aspirin. After she gets to her destination she goes to the ER and she is diagnosed with an MI. The doctor tells her the aspirin probably saved her life. Which of the following cardiac enzymes is least likely to be elevated in the ER (>8 hrs after event)?

A 34-year-old African American female presents with recent-onset headaches, blurred vision, and dyspnea. On physical examination, she appears very ill and has difficulty concentrating and answering questions. Her blood pressure reading in office is 190/130. What is the appropriate management for this patient?

Ranjit is a 54yo Indian male who comes to see you for fatigue, SOB, peripheral edema, bloating, low appetite and a history of hemochromatosis. You strongly suspect Restrictive Cardiomyopathy (RCM). Which test is diagnostic for RCM?

Joan brings in her 4yo daughter, Ella, concerned because she keeps saying her “heart hurts”. Which of the following is lowest on your ddx?

Roberta is a 55yo Caucasian female presenting for annual physical. Aside from occasional DOE and a history of rheumatic fever, there are no pertinent subjective findings. On PE, you palpate a small volume pulse, S1 and S2. On auscultation, you note the first heart sound (S1) is accentuated and you think you hear a low pitch diastolic rumble. As you set up the ECG, which of the following is highest on your ddx?

A 64 year-old male, with a long history of COPD, presents with increasing fatigue over the last three months. The patient has stopped playing golf and also complains of decreased appetite, chronic cough and a bloated feeling. Physical examination reveals distant heart sounds, questionable gallop, lungs with decreased breath sounds at lung bases and the abdomen reveals RUQ tenderness with the liver two finger-breadths below the costal margin, the extremities show 2+/4+ pitting edema. Labs reveal the serum creatinine level 1.6 mg/dl, BUN 42 mg/dl, liver function tests mildly elevated and the CBC to be normal. Which of the following is the most likely diagnosis?

A 55 year-old male is seen in follow-up for a complaint of chest pain. Patient states that he has had this chest pain for about one year now. The patient further states that the pain is retrosternal with radiation to the jaw. "It feels as though a tightness, or heaviness is on and around my chest". This pain seems to come on with exertion however, over the past two weeks he has noticed that he has episodes while at rest. If the patient remains non- active the pain usually resolves in 15-20 minutes. Patient has a 60-pack year smoking history and drinks a martini daily at lunch. Patient appears overweight on inspection. Based upon this history what is the most likely diagnosis?

Which of the following ECG findings is consistent with hyperkalemia?

You’re evaluating a 35-year-old man who presents to your office with a headache. On physical examination, his blood pressure is 240/120 mmHg. On fundoscopic examination, you note the presence of papilledema. What’s this person’s underlying diagnosis?

You’re evaluating a 25-year-old woman who presents with palpitations. On examination, you hear a midsystolic click. Which one of the following would you recommend concerning evaluation of her heart condition?

Mrs. Jones is a 68 y/o female that presents to office today for an annual wellness exam. Past medical history is positive for gallbladder surgery when she was 38, diabetes (12 year history, well controlled) and cataracts. Her blood pressure at this visit is 170/100mmHg. She was seen on a homeopathy visit one week ago and her blood pressure was 165/98mmHg at that visit. Which of the following is NOT true about the management of her care?

A six year old boy presents to the office today with a chief complaint of chest pain. When he is asked where the pain is, he points very specifically to his left sternal border, around the level of T5. Which of the following is NOT an appropriate next step?