3rd Cardiovascular USMLE

A 23-year-old woman who is an elementary school teacher is brought to the ED after syncopizing in her classroom while teaching. Prior to passing out, she describes feeling light-headed and dizzy and next remembers being in the ambulance. There was no evidence of seizure activity. She has no medical problems and does not take any medications. Her father died of a “heart problem” at 32 years of age. She does not smoke or use drugs. BP is 120/70 mm Hg, pulse rate is 71 beats per minute, RR is 14 breaths per minute, and oxygen saturation is 100% on room air. Her physical examination and laboratory results are all normal. A rhythm strip is seen below. Which of the following is the most likely diagnosis?

A 70-year-old male with a history of mild chronic kidney disease, diabetes mellitus, and CHF is admitted to your inpatient service with decreased urine output, weakness, and shortness of breath. He takes several medications but cannot remember their names. Labs are pending; his ECG is shown below. Based on the information available, what is the best initial step in management?

A 51-year-old man with a long history of hypertension presents to the ED complaining of intermittent chest palpitations lasting for a week. He denies chest pain, shortness of breath, nausea, and vomiting. He recalls feeling similar episodes of palpitations a few months ago but they resolved. His blood pressure (BP) is 130/75 mm Hg, heart rate (HR) is 130 beats per minute, respiratory rate (RR) is 16 breaths per minute, and oxygen saturation is 99% on room air. An ECG is seen below. Which of the following is the most appropriate next step in management? ?

A 63-year-old insurance agent is brought to the ED by paramedics for shortness of breath and an RR of 31 breaths per minute. The patient denies chest pain, fever, vomiting, or diarrhea. His wife says he ran out of his “water pill” 1 week ago. His BP is 185/90 mm Hg, HR is 101 beats per minute, oxygen saturation is 90% on room air, and temperature is 98.9°F. There are crackles midway up both lung fields and 2+ pitting edema midway up his legs. An ECG shows sinus tachycardia. The patient is sitting up and able to speak to you. After placing the patient on a monitor and inserting an IV, which of the following is the most appropriate next step in management?

A 15-year-old male presents to your office on the advice of his football coach. The patient started playing football this year and suffered a syncopal episode at practice yesterday. He reports that he was sprinting with the rest of the team and became lightheaded. He lost consciousness and fell to the ground, regaining consciousness within one or two minutes. He suffered no trauma during the event. He has no prior history of head injury or recent illness. He has had no prior episodes of syncope. The patient is adopted and family history unavailable. Physical examination is unremarkable. What is the best course of action regarding this patient’s syncopal episode?

An 82-year-old white female is admitted to the hospital for observation after presenting to the emergency department with dizziness. After being placed on a cardiac monitor in the ER, the rhythm strip below was recorded. There is no past history of cardiac disease, diabetes, or hypertension. With prompting, the patient discloses several prior episodes of transient dizziness and one episode of brief syncope in the past. Physical examination is unremarkable. Which of the following is the best plan of care?

A 29-year-old woman presents to the emergency department with a 3-week history of being awakened by a dull, prolonged chest pain that occurs 3–4 times a week. She is a smoker but has never suffered a myocardial infarction (MI) or had chest pain before and has no family history of early MI. Results of a 12-lead ECG are normal. Her first set of cardiac enzyme measurements (creatine kinase, creatine kinase-MB fraction, troponin I) are negative. If coronary angiography were taken at the time of her chest pain, which of the following findings is most like?

A 42-year-old man presents to the emergency department with a complaint of increasing shortness of breath when walking to get his newspaper, difficulty breathing while lying fl at, and a 4.5-kg (10-lb) weight gain over the past month. He is afebrile, his pulse is 75/min, and his blood pressure is 98/50 mm Hg. On examination he smells of alcohol and has 2+ pitting edema in the lower extremities and a third heart sound. X-ray of the chest reveals cardiomegaly. What additional findings must be present to confirm this man’s underlying diagnosis?

A 69-year-old man with rheumatic heart disease presents to the emergency department complaining of a fever and weakness on his left side. On physical examination the patient is weak in his left upper extremity and he draws only the right half of a clock. Shortly after his presentation, the patient dies, and an autopsy is performed. A gross view of the patient’s heart is shown in the image. Which of the following is a risk factor for the type of lesion pictured?

An 83-year-old woman is being evaluated for confusion. She was admitted 3 days ago after having an acute MI. Her hospital course has been complicated by narrow-complex ventricular tachycardia, which has finally been stabilized on an antiarrhythmic medication. She was also started on a post-MI protocol and an antidepressant. One day after beginning these medications, she begins to develop confusion and slurred speech. Her temperature is 36.7°C (98.1°F), blood pressure is 138/60 mm Hg, pulse is 88/min, and respiratory rate is 14/min. She is alert and oriented to person, but she does not realize she is in the hospital. Additionally, she exhibits difficulty with word articulation, although she speaks fluently, and she demonstrates a mild resting tremor. The remainder of her examination is normal. Which of the following medications is most likely to cause these central nervous system effects?

A 72-year-old male with a history of poorly controlled hypertension develops a viral upper respiratory infection. On his second day of symptoms he experiences palpitations and presents to the emergency room. His blood pressure is 118/78. The following rhythm strip is obtained. What is the best next step in the management of this patient?

A 77-year-old man, complaining of abdominal pain, anorexia, and nausea and vomiting over the past 24 hours, presents to the clinic with his son. The son reveals that his father has also complained of blurred vision. The patient’s vital signs are stable and his abdomen is soft, but he appears to be somewhat confused. He is currently taking metoprolol, digoxin, and hydrochlorothiazide for ischemic congestive heart failure. His son says that sometimes his father confuses his medications. The patient also has renal insufficiency with a baseline serum creatinine of 2.6 mg/dL. The ECG reveals a widened QRS complex and a new first-degree heart block. Which of the following is the most likely cause of this patient’s symptoms?

An otherwise asymptomatic 65-year-old man with diabetes presents to the ER with a sports-related right shoulder injury. His heart rate is noted to be irregular, and this ECG is obtained. Which of the following is the best immediate therapy?

A patient has been in the coronary care unit for the past 24 hours with an acute anterior myocardial infarction. He develops the abnormal rhythm shown below, although blood pressure remains stable at 110/68. Which of the following is the best next step in therapy?

A 70-year-old male with a history of coronary artery disease presents to the emergency department with 2 hours of substernal chest pressure, diaphoresis, and nausea. He reports difficulty “catching his breath.” An electrocardiogram shows septal T-wave inversion. The patient is given 325-mg aspirin and sublingual nitroglycerin while awaiting the results of his blood work. His troponin I is 0.65 ng/mL (normal < 0.04 ng/mL). The physician in the emergency department starts the patient on low-molecular-weight heparin. His pain is 3/10. Blood pressure is currently 154/78 and heart rate is 72. You are asked to assume care of this patient. What is the best next step in management?

An 80-year-old woman was admitted to your service for dizziness. Cardiac monitoring initially revealed atrial fibrillation with rapid ventricular response. Her ventricular rate was controlled with beta-blocker. An echocardiogram revealed an enlarged left atrium and an ejection fraction of 50%. No evidence of diastolic heart dysfunction was noted. She is now asymptomatic, with blood pressure 130/80, heart rhythm irregularly irregular, and heart rate around 80/minute. Which of the following is the best management strategy of this patient’s arrhythmia?

You are seeing a 45-year-old female patient of your partner for the first time in your clinic. A quick review of the patient’s medical record shows that her systolic blood pressure was greater than 140 mm Hg at both of her last clinic appointments. Her medical history is otherwise significant only for diabetes mellitus. Her blood pressure today is 164/92. What is the best next step in her blood pressure management?

A 68-year-old male complains of pain in his calves while walking. He notes bilateral foot pain, which awakens him at night. His blood pressure is 117/68. Physical examination reveals diminished bilateral lower extremity pulses. An ankle: brachial index measures 0.6. The patient’s current medications include aspirin and hydrochlorothiazide. Which of the following is the best initial management plan for this patient’s complaint?

An 82-year-old woman is brought to the ED by her daughter for worsening fatigue, dizziness, and light-headedness. The patient denies chest pain or shortness of breath. She has not started any new medications. Her BP is 140/70 mm Hg, HR is 37 beats per minute, and RR is 15 breaths per minute. An IV is started and blood is drawn. An ECG is seen below. Which of the following is the most appropriate next step in management?

A 66-year-old retired carpenter presents with chronic shortness of breath upon exertion. He has smoked one pack of cigarettes per day for the past 5 years and drinks alcohol regularly. Physical examination reveals a displaced point of maximal impulse and hepatosplenomegaly. His medications include pantoprazole for gastroesophageal reflux and sertraline for depression. Echocardiogram reveals an ejection fraction of 30% and dilated left and right ventricles. Laboratory tests show: Na+: 129 mEq/L K+: 5.2 mEq/L Cl−: 101 mEq/L Blood urea nitrogen: 45 mg/dL Creatinine: 1.3 mg/dL Glucose: 134 mg/dL Aspartate aminotransferase: 220 U/L Alanine aminotransferase: 140 U/L Alkaline phosphatase: 280 U/L Which of the following is the most likely cause of his cardiac findings?

A 52-year-old man presents to his primary care physician’s office for routine care. He has hypertension, hypercholesterolemia, and type 2 diabetes mellitus, and has smoked one pack of cigarettes per day for the past 30 years. Medications include hydrochlorothiazide, atorvastatin, and glipizide. There is a family history of myocardial infarction in the maternal grandfather at age 60. The patient has undergone screening for colon and prostate cancer. Physical examination reveals a pleasant, obese man who is 175 cm (5′9″) tall and weighs 108 kg (238 lb). His blood pressure is 155/81 mm Hg, heart rate is 78/min, respiratory rate is 14/min, and temperature is 36.8°C (98.3°F). What one action would most reduce the patient’s stroke risk?

A 29-year-old tall, thin man presents to the ED after feeling short of breath for 2 days. In the ED, he is in no acute distress. His BP is 115/70 mm Hg, HR is 81 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 98% on room air. Cardiac, lung, and abdominal examinations are normal. An ECG reveals sinus rhythm at a rate of 79. A chest radiograph shows a small right-sided (< 10% of the hemithorax) spontaneous pneumothorax. A repeat chest x-ray 6 hours later reveals a decreased pneumothorax. Which of the following is the most appropriate next step in management?

A 47-year-old man with a history of hypertension presents to the ED complaining of continuous left-sided chest pain that began while snorting cocaine 1 hour ago. The patient states he never experienced chest pain in the past when using cocaine. His BP is 170/90 mm Hg, HR is 101 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 98% on room air. The patient states that the only medication he takes is alprazolam to “calm his nerves.” Which of the following medications is contraindicated in this patient?

A 32-year-old woman presents to the ED with a persistent fever of 101°F over the last 3 days. The patient states that she used to work as a convenience store clerk but was fired 2 weeks ago. Since then, she has been using drugs intravenously daily. Cardiac examination reveals a heart murmur. Her abdomen is soft and nontender with an enlarged spleen. Chest radiograph reveals multiple patchy infiltrates in both lung fields. Laboratory results reveal white blood cells (WBC) 14,000/μL with 91% neutrophils, hematocrit 33%, and platelets 250/μL. An ECG reveals sinus rhythm with first-degree heart block. Which of the following is the most appropriate next step in management?

Two and a half weeks after coronary artery bypass grafting, a 63-year-old man returns to the emergency department acutely short of breath. The patient states that he began having chest pain and shortness of breath approximately 1 hour earlier. He has a history of hypertension, diabetes, and two myocardial infarctions. On examination he is hypoxic with an oxygen saturation of 86% on room air. Other vital signs and results of a physical examination are normal. ECG shows no interval change from his most recent ECG. CT of the chest is shown in the image. What is the most likely etiology of this patient’s shortness of breath?

A 35-year-old woman presents to the clinic because of visual problems. She states that she has always had difficulty looking up, and over the past few years her overall vision has become blurry. Review of symptoms is notable for several recent episodes of “near fainting.” She takes no medication and has no other medical history, and has not seen a physician for 7 years. Because she was adopted as a child, she does not know her family history, but her son has required special tutoring at school. The patient also remarks that her son seems to have been dropping objects lately. Physical examination reveals bilateral ptosis. Her extraocular movements are intact and the pupils are equal, round, and reactive. Her corrected visual acuity is 20/100 in the right eye and 20/120 in the left eye. The view of the fundus is obscured. On ambulation she raises her knees and makes a slapping sound on the floor as she walks. ECG indicates heart block. What is the pathogenesis of this patient’s disorder?

A college sophomore is found by his roommate emergency department. After resuscitation, the man complains of a severe headache and photophobia that is accompanied by dizziness, nausea, vomiting, and neck pain. Physical examination is noteworthy for positive Kernig’s and Brudzinski’s signs as well as petechiae on the trunk and mucocutaneous bleeding. Laboratory studies show: WBC count: 17,000/mm3 Hemoglobin: 11 g/dL Platelet count: 70,000/mm3 Bleeding time: 10 min Prothrombin time: 17 sec Activated partial thromboplastin time: 47 sec Thrombin time: 18 sec A peripheral blood smear is shown in the image. Which of the following is the most likely diagnosis?

A 43-year-old woman presents to the emergency department because of chest pain, shortness of breath, and worsening fatigue for the past day. The chest pain initially worsened with lying down and improved with leaning forward, but now it seems equal in intensity over all positions. On physical examination she has labored, fast breathing and appears to be in pain. She has jugular venous distention. She is tachycardic, has a regular rhythm, and has distant heart sounds with a friction rub. Her lungs are clear to auscultation bilaterally, her abdominal examination is benign, and she has no peripheral edema. Her temperature is 39.0°C (102.2°F), pulse is 126/min, blood pressure is 89/66 mm Hg, respiratory rate is 32/min, and oxygen saturation is 98% on room air. X-ray of the chest is shown in the image. Which of the following is the most likely diagnosis?

A 47-year-old woman who is 2 weeks post triple bypass surgery presents to the emergency department with a chief complaint of sudden onset, sharp chest pain for several hours. She is fatigued and short of breath. On physical examination she has distended neck veins that grow more distended on inspiration. Muffled heart sounds are heard. Her temperature is 37.0°C (98.6°F), pulse is 133/min, blood pressure is 70/50 mm Hg, respiratory rate is 30/ min, and oxygen saturation is 100% on room air. An echocardiogram shows a large pericardial effusion and chamber collapse; therefore, pericardiocentesis is performed. Although a large amount of blood is aspirated, the patient’s clinical picture acutely worsens. Her pain level increases substantially; pulse is 150/min, blood pressure is 60/41 mm Hg, respiratory rate is 30/ min, and oxygen saturation is 100%. Repeat echocardiography shows an even larger pericardial effusion with chamber collapse. Which complication of pericardiocentesis is most likely in this patient?

A 57-year-old man presents to the emergency department with worsening substernal chest pain occurring over the past 20 minutes. He has a medical history significant for a 2-packper- day smoking history, gout, obesity, hypercholesterolemia, hypertension, osteoarthritis of both knees, inflammatory bowel disease, and recently diagnosed type 2 diabetes mellitus that is well controlled on oral antiglycemics (haemoglobin A1c of 7.8%). On physical examination he is in moderate distress, diaphoretic, and nauseous. His temperature is 37.5°C (99.5°F), pulse is 112/min, blood pressure is 142/85 mm Hg, and respiratory rate is 22/min. He tests positive for MI by serial cardiac enzymes. He is started on the appropriate therapy and is ready for discharge the following evening. What is the number one preventive measure this patient can take to decrease his immediate risk for a second MI?

A 31-year-old kindergarten teacher presents to the ED complaining of acute-onset substernal chest pain that is sharp in nature and radiates to her back. The pain is worse when she is lying down on the stretcher and improves when she sits up. She smokes cigarettes occasionally and was told she has borderline diabetes. She denies any recent surgeries or long travel. Her BP is 145/85 mm Hg, HR is 99 beats per minute, RR is 18 breaths per minute, and temperature is 100.6°F. Examination of her chest reveals clear lungs and a friction rub. Her abdomen is soft and nontender to palpation. Her legs are not swollen. Chest radiography and echocardiography are unremarkable. Her ECG is shown below. Which of the following is the most appropriate next step in management?

A 51-year-old woman presents to the ED after 5 consecutive days of crushing substernal chest pressure that woke her up from sleep in the morning. The pain resolves spontaneously after 20 to 30 minutes. She is an avid rock climber and jogs 5 miles daily. She has never smoked cigarettes and has no family history of coronary disease. In the ED, she experiences another episode of chest pain. An ECG reveals ST-segment elevations and cardiac biomarkers are negative. The pain is relieved with sublingual nitroglycerin. She is admitted to the hospital and diagnostic testing reveals minimal coronary atherosclerotic disease. Which of the following is the most appropriate medication to treat this patient’s condition?

A 37-year-old woman with sarcoidosis presents to her primary care physician complaining of progressive fatigue and shortness of breath over the past 3 months. She also reports that her socks and shoes do not fi t the way they used to and that she fainted a few weeks ago for the first time in many years. She denies any recent illness and only takes medications to control her sarcoid. She states that she is more comfortable sitting than lying down. She has jugular venous distension, which increases with inspiration. Her blood pressure is 134/87 mm Hg, respiratory rate is 17/min, pulse is 96/min, and temperature is 37.2°C (98.9°F). She also has decreased breath sounds bilaterally at the bases. ECG shows decreased QRS voltage. An echocardiogram shows a thick left ventricle. Which of the following is the most likely diagnosis?

A 64-year-old man in the surgical intensive care unit goes into rapid atrial fibrillation on postoperative day one after a decortication for a loculated pulmonary empyema. He is given an appropriate loading dose of digoxin, but 4 hours after his second dose, the patient complains of increased palpitations and dizziness. The patient is conscious and hemodynamically stable. STAT serum blood tests show a potassium level of 5.0 mEq/L; all other electrolytes, including divalents, are in the normal range. The digitalis level is above the therapeutic range at 4 ng/mL (therapeutic range 0.5-2 ng/mL). Results of cardiac telemetry are shown in the image. Which of the following should be administered immediately?

A 1-week-old infant presents to her general pediatrician’s office for a well-child visit. She was born at 37 weeks’ gestation without complications. Her temperature is 37.0°C (98.6°F), pulse is 130/min, blood pressure is 72/54 mm Hg, and respiratory rate is 28/min. She is currently at the 50th percentile for weight and 75th percentile for height. She is acyanotic and has a wide, fixed split S2, with a 2/6 systolic ejection murmur at the left upper sternal border. The remainder of the examination is unremarkable. Which of the following is the most likely diagnosis?

A 63-year-old woman on digitalis for chronic atrial fibrillation experiences fatigue, nausea, and anorexia. Her pulse is regular at 50 beats/min, and the heart sounds, chest, and abdominal examinations are normal. On the ECG, no P waves are visible and the QRS complexes are narrow and regular. Which of the following is the most appropriate management step?

A 49-year-old man presents to the clinic for a health maintenance visit. He has no complaints, but he requests a prescription for his “pressure pills,” as he lost his original prescription. On physical examination his blood pressure is 220/130 mm Hg. Physical examination is otherwise within normal limits. Laboratory tests show: Na+: 142 mEq/L K+: 3.8 mEq/L Cl−: 105 mEq/L Carbon dioxide: 25 mEq/L Blood urea nitrogen: 20 mg/dL Creatinine: 1.0 mg/dL Glucose: 133 mg/dL Urinalysis is within normal limits, and his ECG is normal. Which of the following is the most effective management?

A 62-year-old man with a history of benign prostatic hyperplasia and hypertension presents to his primary care provider for a routine health maintenance visit. He reports that he feels “better than ever” and explains that his daughter made him come in for his annual visit. He takes prazosin daily and occasionally some acetaminophen. He has no drug allergies and denies smoking, drinking, or the use of illicit drugs. His physical examination is within normal range except for his rectal examination, which revealed an enlarged prostate. His temperature is 36.8°C (98.2°F), respiratory rate is 13/min, pulse is 82/min, and blood pressure is 138/86 mm Hg. Which of the following is the most likely adverse effect of α1-adrenergic blockade in this patient?

A 2-year-old girl is referred to the hospital for evaluation of her inability to gain weight. She is well fed by her parents, but appears to tire during feedings and has been losing weight despite frequent high-calorie meals. There is no family history of developmental delay or short stature. She is well dressed, her hair is brushed, and she is playful but tires quickly. Her temperature is 36.5°C (97.7°F), pulse is 110/min, blood pressure is 90/50 mm Hg, and respiratory rate is 24/min. She has a harsh 2/6 holosystolic murmur that is best heard at the left sternal border, which is unchanged and has been present since birth. Which of the following is the most appropriate next step in management?

A 77-year-old man with a history of hypertension, hypercholesterolemia, chronic obstructive pulmonary disease, and a 90-pack-year smoking history presents to the emergency department with lethargy and abdominal pain. His temperature is 36.9°C (98.5°F), blood pressure is 82/54 mm Hg, pulse is 125/min, and respiratory rate is 16/min. A pulsatile abdominal mass is palpable just superior to the umbilicus. There is diffuse abdominal tenderness, although rebound tenderness and guarding are absent. There is also slight skin discoloration noted in the left lower back. Which of the following is the most likely diagnosis?

A 52-year-old African-American man with a history of smoking and asthma presents to the emergency department complaining of shortness of breath. He has alcohol on his breath and admits to drinking 3–4 beers each night plus an occasional “mixed drink.” He denies drug use and states that he has been feeling well until recently, when he began to sleep with more pillows and to become out of breath when walking. His blood pressure is 143/89 mm Hg, respiratory rate is 21/min, pulse is 112/min, and he is afebrile. On physical examination he has a laterally displaced point of maximal impulse and an S3 gallop, as well as rales over his right lung base. X-ray of the chest shows cardiomegaly and a pleural effusion. Echocardiogram reveals an ejection fraction of 25%. Which of the following is the most likely diagnosis?

A cardiologist is called to consult on the care of a 2-day-old girl delivered at 33 weeks’ gestation. The infant is lying supine in her isolette. She is acyanotic, but has a heart rate of 192/ min and a respiratory rate of 60/min. She has a nonradiating continuous machinery murmur at the left upper sternal border that remains the same with compression of the ipsilateral, then contralateral jugular veins. S1 and S2 are normal. Her peripheral pulses are bounding. Which of the following is the most likely diagnosis?

A 64-year-old white man with type 2 diabetes mellitus presents to the emergency department after “passing out.” While climbing the stairs, he felt dyspneic and lost consciousness as he reached the top. Before the event he experienced no palpitations or change in vision. When he awoke he felt alert and called for help immediately. He reports dyspnea on exertion for the past year. He has no history of chest pain, seizures, or recent illnesses. Medications include calcium and vitamin D supplements, glyburide, and synthroid. He is allergic to penicillin. Family history is noncontributory. He drinks wine socially and does not smoke or use illicit substances. His blood pressure is 136/92 mm Hg, heart rate is 88/min, respiratory rate is 14/min, and temperature is 36.5°C (97.7°F). Physical examination reveals a systolic crescendodecrescendo murmur best heard in the second right intercostal space with a soft S2. ECG shows nonspecific ST-segment changes and left ventricular hypertrophy with a normal heart rate and rhythm. Which of the following interventions will most likely reveal the cause of this syncopal event?

A 56-year-old woman with a history of chronic renal disease presents to the emergency department because of severe, sharp, retrosternal chest pain that radiates to her jaw. The pain worsens when the patient lies down, and she is most comfortable leaning forward and hugging her knees. She takes erythropoietin, furosemide, calcitriol, and sodium polystyrene sulfonate. She is scheduled for dialysis three times per week, but she admits to sometimes missing sessions. She stopped drinking and smoking 20 years ago, and she has no family history of heart or renal problems. Auscultation of the heart reveals a friction rub. Laboratory tests show: WBC count: 12,000/mm3 Hemoglobin: 10.0 g/dL Hematocrit: 30.0% Platelet count: 150,000/mm3 Na+: 141 mEq/L K+: 4.8 mEq/L Cl: 101 mEq/L HCO3 : 22 mEq/L Blood urea nitrogen: 63 mg/dL Creatinine: 3.2 mg/dL Glucose: 111 mg/dL The emergency medicine physician urges the patient to be more compliant with her dialysis, but the patient complains that she is too tired to go to dialysis all of the time and that it is ruining her life. Which of the following is the most likely complication if the patient’s condition remains untreated?

A 32-year-old man is brought to the emergency department by paramedics after being found wandering downtown, apparently delirious and agitated. During transport to the hospital the patient becomes diaphoretic and tremulous and has a blood pressure to 163/100 mm Hg, pulse of 102/min, and temperature of 39°C (102.2°F). On examination the patient has dilated pupils and ulcerations of his nasal septum mucosa with the residue of a white powder along the nasal alae in addition to his tachycardia, hypertension, hyperthermia, and agitation. Which of the following is the reason why nonselective β-blockers should be avoided in this patient?

A 59-year-old man presents to his internist for a routine visit. He has no complaints, and review of symptoms is negative. His past medical history is significant for poorly controlled hypertension for 15 years due to noncompliance with antihypertensive medications. He takes hydrochlorothiazide 25 mg orally four times a day. His family history is significant for hypertension, heart failure, and stroke. He has a 30-pack-year smoking history and drinks two beers a day. On physical examination he is a mildly obese man in no acute distress. He has a normal jugular venous pressure. He has a prominent point of maximum impulse, regular rate and rhythm, normal S1, loud S2, and audible S4 with no murmurs. His lungs are clear to auscultation bilaterally, and he has no signs of edema. His abdominal and neurologic examinations are within normal limits. His temperature is 37.0°C (98.6°F), pulse is 81/min, respiratory rate is 12/min, blood pressure is 165/96 mm Hg, and oxygen saturation is 100% on room air. His ECG shows normal sinus rhythm with large amplitude of the S wave in V1 and V2 and of the R wave in V5 and V6. Also present are diffuse ST segment/T wave changes, widened bifid P waves, and prolonged QRS waveforms. Which of the following is the most likely diagnosis?

A 62-year-old man with coronary artery disease (CAD) presents with presyncope. His physical examination is normal except for bradycardia (pulse 56 beats/min) and an irregular pulse. The electrocardiogram (ECG) shows Wenckebach’s type atrioventricular (AV) block. Which of the following are you most likely to see on the ECG?

A 65-year-old man develops palpitations and dizziness. His blood pressure is 80/50 mm Hg and his pulse is regular at 150/min. His ECG shows a “saw-toothed” pattern of P waves. Which of the following procedures is most appropriate in converting him back to sinus rhythm?

A 55-year-old man presents to the ED with worsening weakness, muscle cramps, and paresthesias. His past medical history is significant for hypertension and diabetes. He smokes one pack of cigarettes per day. On examination, the patient is alert and oriented and diffusely weak. An ECG is seen below. Which of the following is the most important next step in management?

A 27-year-old man who is otherwise healthy presents to the ED with a laceration on his thumb that he sustained while cutting a bagel. You irrigate and repair the wound and are about to discharge the patient when he asks you if he can receive an ECG. It is not busy in the ED so you perform the ECG, as seen below. Which of the following is the most appropriate next step in management?

A 55-year-old man presents to the ED at 2:00 AM with left-sided chest pain that radiates down his left arm. He takes a β-blocker for hypertension, a proton pump inhibitor for gastroesophageal reflux disease, and an antilipid agent for high cholesterol. He also took sildenafil the previous night for erectile dysfunction. His BP is 130/70 mm Hg and HR is 77 beats per minute. Which of the following medications is contraindicated in this patient?

Three months after an anterior MI, a 73-yearold man has a follow-up ECG. He is clinically feeling well with no further angina symptoms. His ECG shows Q waves in the anterior leads with persistant ST-segment elevation. The current ECG is most compatible with which of the following diagnosis?

A 47-year-old woman develops accelerated hypertension (blood pressure 210/105 mm Hg) but no clinical symptoms except frequent headaches. Which of the following findings are most likely on examination of the fundii?

A 32-year-old man presents for rountine evaluation. He has no symptoms but has noticed some new “nodules” on his legs. Physical examination reveals lumps on his Achillis tendon, yellow lesions around his eyes, and pigmentation of his iris. Which of the following is the most likely diagnosis?

A 36-year-old woman presents to the ED with sudden onset of left-sided chest pain and mild shortness of breath that began the night before. She was able to fall asleep without difficulty but woke up in the morning with persistent pain that is worsened upon taking a deep breath. She walked up the stairs at home and became very short of breath, which made her come to the ED. Two weeks ago, she took a 7-hour flight from Europe and since then has left-sided calf pain and swelling. What is the most common ECG finding for this patient’s presentation?

A 54-year-old woman presents to the ED because of a change in behavior at home. For the past 3 years, she has end-stage renal disease requiring dialysis. Her daughter states that the patient has been increasingly tired and occasionally confused for the past 3 days and has not been eating her usual diet. On examination, the patient is alert and oriented to person only. The remainder of her examination is normal. An initial 12-lead ECG is performed as seen on the following page. Which of the following electrolyte abnormalities best explains these findings?

A 42-year-old man found vomiting in the street is brought to the ED by emergency medical services (EMS). He has a known history of alcohol abuse with multiple presentations for intoxication. Today, the patient complains of acute onset, persistent chest pain associated with dysphagia, and pain upon flexing his neck. His BP is 115/70 mm Hg, HR is 101 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 97% on room air. As you listen to his heart, you hear a crunching sound. His abdomen is soft with mild epigastric tenderness. The ECG is sinus tachycardia without ST-T–wave abnormalities. On chest radiograph, you note lateral displacement of the left mediastinal pleura. What is the most likely diagnosis?

A 65-year-old man with a history of chronic hypertension presents to the ED with sudden-onset tearing chest pain that radiates to his jaw. His BP is 205/110 mm Hg, HR is 90 beats per minute, RR is 20 breaths per minute, and oxygen saturation is 97% on room air. He appears apprehensive. On cardiac examination you hear a diastolic murmur at the right sternal border. A chest x-ray reveals a widened mediastinum. Which of the following is the preferred study of choice to diagnose this patient’s condition?

A 25-year-old man complains of left precordial chest pain that radiates to the left shoulder but not down the left arm. The pain is accentuated by inspiration and relieved by sitting up. The pain is accompanied by fever and chills. His blood pressure is 105/75 mm Hg, pulse 110/min and regular, and temperature 37.5°C. Aside from the tachycardia, there are no abnormal physical findings in the heart or lungs. The ECG shows STsegment elevation in all leads except aVR and VI. On the third hospital day, the patient’s blood pressure falls, JVP rises, and he goes into CHF. Which of the following is the most likely diagnosis?

A 80-year-old man with Type II diabetes and hypertension presents with increasing dyspnea. He appears short of breath, blood pressure is 170/95 mm Hg, pulse 100/min and regular. The JVP is at 7 cm; there is a loud second heart sound and a systolic ejection murmur at the right sternal border, which does not radiate. The lungs have bibasilar crakles up to the scapula. The CXR has bilateral infiltrates and vascular redistribution. His echocardiogram reports aortic sclerosis, concentric left ventricular hypertrophy (LVH), and normal ejection fraction. Which of the following is the most likely mechanism for this condition?

A 68-year-woman with hypertension and dyslipidemia presents with 30 minutes of retrosternal chest pain radiating to her neck. She is diaphoretic and in moderate distress. The ECG shows ST-segment elevation in the inferior leads. Which of the following mechanisms is the most likely cause of her condition?

Image below is an x-ray of an asymptomatic 64- year-old male executive coming in for his regular annual medical checkup. He had an anterior Q wave MI 4 years ago. What is your diagnosis?

A 70-year-old man has dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. He has generalized cardiomegaly and pulmonary and systemic venous hypertension. The ECG is shown in Fig. What is the cardiac rhythm?

A 72-year-old man with coronary artery disease and hypertension is hospitalized after suffering a myocardial infarction 5 days ago. He suddenly complains of severe chest pain. His blood pressure is 90/60 mm Hg and heart rate is 65/min. Auscultation reveals no murmurs or rubs. An ECG reveals sinus rhythm with an acute ST-segment elevation in the anteroseptal area. Urgent bedside echocardiography showed anteroseptal, lateral, and apical akinesis, mild left ventricular systolic dysfunction, and severe pericardial effusion. Within 20 minutes he is unconscious with undetectable pulses and blood pressure. What is the most likely cause of the patient’s sudden decompensation?

A 56-year-old woman was recently started on medication for high blood pressure. At her next office visit her hypertension is under good control, but she now complains of “feeling strange” since she started the medication. On further questioning, she reports feeling chest tightness several times over the past 2 weeks, and has also noticed pain in her elbows and knees. Her blood pressure is 124/78 mm Hg (146/82 mm Hg on last visit), heart rate is 102/min, and respiratory rate is 14/min. Her examination is notable for several erythematous plaques on the malar distribution of the face, arms, and upper torso. What medication was she most likely started on during her last visit?