P 427 p 444 *No 1 to 50 *

.9) A 38-year-old female comes to your office complaining of occasional palpitations. She describes feeling a fast and irregular heartbeat. Over the past two months, she has had three such episodes, each lasting about two hours. She denies any associated chest pain, shortness of breath cough or ankle swelling. She drinks alcohol on social occasions and does not smoke cigarettes. She has no other medical problems and is not taking any medications. On physical examination, her temperature is 37.1°C (98.9°F), pulse is 80/min, blood pressure is 130/70mmHg, and respirations are 14/min. On auscultation of her heat the apical impulse is displaced and there is an S3. You also hear a pansystolic murmur, which is loudest at the apex and radiates to the axilla. Which of the following is the most likely cause of her symptoms?

.13) A 54 year-old male comes to the physician because of abdominal distention. He thinks his big belly is making it hard for him to breathe. He received radiation therapy for Hodgkin lymphoma several years ago and was told that he is cured. He drinks alcohol on a regular basis. His temperature is 36.7°C (98°F), blood pressure is 120/76 mm Hg, pulse is 80/min and respirations are 20/min. Examination shows a jugular venous pressure 7 cm above the sternal angle. Dullness to percussion and decreased breath sounds are noted in the right lung base. The abdomen is quite distended with an obvious fluid wave. Mild hepatomegaly is present. Extremities have 2+ lower extremity edema. Initial laboratory studies are shown below: Serum creatinine 08 mg/dL, Alburnin 4.0 mg/dL, Total bihrubin 1.0 mg/dl, Prothrombin time 11 sec. Urinalysis is within normal limits. Which of the following is the most likely cause of his condition?

.14) A 32-year-old woman presents with progressively worsening dyspnea on exertion one month after returning from a vacation in Texas. She says that her symptoms have progressed to the point that she now wakes during the night with a choking sensation that improves only with sitting up. Recently her shortness of breath has required her to significantly limit her physical activity. She denies having associated chest pain, skin rash or joint pain. She has no significant past medical history. Family history is significant for thyroid cancer in her aunt and lung cancer in her father, a heavy smoker. On physical examination, her temperature is 37.2°C (99°F), pulse is 96/min, blood pressure is 110/70 mmHg, and respirations are 14/min. Bilateral pitting ankle edema is present. Her liver is enlarged 2 cm below the right costal marginal. Lung auscultation reveals decreased breath sounds at the bilateral bases. Cardiac exam reveals the presence of a third heat sound. Chest x ray shows an enlarged cardiac silhouette and small bilateral pleural effusion. EKG is unremarkable. Which of the following is the most likely cause of her symptoms?

.15) An 88-year-old female nursing home resident is brought to the hospital with a one-week history of moaning, decreased oral intake and decreased ambulation. Physical examination reveals a very thin female who is moaning and appears to be in pain. She opens her eyes spontaneously but does not respond to questions. Her blood pressure is 75/43 mmHg, pulse is 105/min, temperature is 35.5°C (96°F), and respirations are 22/min. Oxygen saturation (pulse oximetry) is 97% on room air. Her skin and oral mucosa are dry and her neck veins are flat. There is no lymphadenopathy. On chest auscultation, there are crackles in the right upper lung lobe. Abdomen is soft and non-distended. There is 2+ pitting presacral and lower extremity edema, and a deep pressure ulcer in the sacral area. Laboratory analysis reveals the following: Sodium 155mEq/L, Potassium 5.3 mEq/L, Glucose 88mg/dL, Bicarbonate 14mEq/L, BUN 151mg/dL, Creatinine 3.1mg/dl. Which of the following is the most likely cause of her lower extremity edema?

.20) A 22-year-old college student went to the health clinic complaining of a fever over the last 5 days, fatigue, myalgias, and a bout of vomiting and diarrhea. The clinic doctor diagnosed him with acute gastroenteritis and told him to drink more fluids. Three days later, the student presents to the ED complaining of substernal chest pain that is constant. He also feels short of breath. His temperature is 100.9°F, HR is 119 beats per minute, BP is 120/75 mmHg, and RR is 18 breaths per minute. An ECG is performed revealing sinus tachycardia. A chest radiograph is unremarkable. Laboratory tests are normal except for slightly elevated WBCs. Which of the following is the most common cause of this patient’s diagnosis?

.25) A 35-year-old woman who has recently emigrated from Asia presents to the emergency room with acute onset of dyspnea. She denies any cough, chest pain, or fever. She has a history of rheumatic heart disease as a teen. On examination, she has an irregular pulse of 97/min, blood pressure of 125/75 mmHg and temperature of 37.2°C (98.9°F). The first heart sound is loud and a mid-diastolic rumble is heard at the apex. Crackles are present in both lung fields. ECG shows an irregularly, irregular heart rhythm and the absence of 'P' waves. Which of the following is the most likely cause of this patient's abnormal heart rhythm?

.27) A 70-year-old Caucasian man comes to the emergency department because of the sudden onset of nausea, vomiting, diaphoresis, and chest pain. His other medical problems include hypertension, diabetes mellitus-type 2, and aortic stenosis. He has smoked one-and-a-half packs of cigarettes daily for 30 years and drinks 4 ounces of alcohol daily. His temperature is 37.2°C (99°F), blood pressure is 100/60 mmHg, pulse is 60/min, and respirations are 18/min. The patient's pulse oximetry showed 98% at room air. Examination shows normal first and second he sounds. Lungs are clear to auscultation. His EKG is shown below. Which of the following is the most likely mechanism of this patient's condition?

.28) A 24-year-old male experiences syncope while shovelling 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 mmHg, 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?

.44) A 63-year-old male is admitted for sudden onset severe chest pain. His ECG reveals ST elevation in leads V2-V6. He is treated with thrombolytic therapy, heparin, aspirin, metoprolol, morphine, and nitrates. A coronary angiogram performed after thrombolytic therapy reveals 50% obstruction of the left anterior descending artery. On the third day of hospitalization, the patient suddenly develops severe shortness of breath at rest and hypotension. Examination reveals a soft S1, an apical pansystolic murmur radiating to the axilla, and bibasilar crackles. His temperature is 37.8°C (100°F), blood pressure is 92/58 mmHg, heart rate is 102/min, and respirations are 31/min. An echocardiogram performed on the second hospital day reveals an akinetic region of the anterior wall. What is the most likely explanation for this patient's deterioration?