Part 27 (106)

A 40-year-old female presents to the emergency room with palpitations and lightheadedness of acute onset. Also, she has experienced insomnia, fatigability, and weight loss lately. She does not smoke or consume alcohol. She is not taking any medication. Her blood pressure is 110/80 mmHg and heat rate is 120/min, irregular. Physical examination reveals lid lag and fine tremor of the outstretched hands. ECG shows atrial fibrillation with rapid ventricular response. What is the next best step in the management of this patient?

A 43-year-old Caucasian man with a two-year history of diabetes mellitus presents to your office for a routine. He has no complaint His medications are metformin and aspirin. He works as a computer programmer and has a sedentary lifestyle. He drinks one to two cans of beer on weekends and smokes one pack of cigarettes per day. On physical examination, his blood pressure is 153/94 mmHg and his heat rate is 82/min. His BMI is 32.5 kg/m2. The remainder of the physical examination is unremarkable. Laboratory studies reveal an HbA1c of 7.6%. At his check-up one month ago, his blood pressure was 149/92 mmHg. Which of the following interventions would be most effective for controlling his blood pressure?

A 60-year-old male is 2 days status post primary percutaneous coronary intervention (PCI) with stent placement. He had previously suffered from an antero-lateral myocardial infarction. His cardiac enzymes have been trending down since admission. He has recovered well and is ready for discharge. He is currently asymptomatic. His temperature is 37.5°C (99.5°F), blood pressure is 130/70 mmHg, pulse is 66/min, and respirations are 14/min He is discharged with instructions to take the following medications aspirin simvastatin, lisinopril metoprolol and sublingual nitroglycerine. In addition to the medications listed above, which of the following medications should this patient also be taking after discharge?

A 22-year-old Caucasian male is evaluated for an episode of syncope that occurred while playing soccer. It lasted only 2 minutes without any post-syncopal confusion, sleepiness or weakness. He had prior episodes of dizziness while playing active sports as well as vague chest discomfort. His uncle died suddenly at a young age. Auscultation of his precordium reveals a III/IV systolic murmur along the left sternal border. The patient is most likely to benefit from which of the following medications?

A 40-year-old male presents with six months of worsening dyspnea. His symptoms have progressed to the point that walking even one block causes him to become shot of breath. He has a history of cigarette smoking, but quit 10 years ago. He drinks approximately one alcoholic drink daily. His medical history is significant for peptic ulcer disease for which he takes antacids. On physical examination, he is afebrile. His pulse is 86/min, blood pressure is 140/56 mmHg, and respiratory rate is 14/min. While examining his heat you note a high-pitched blowing, early diastolic, decrescendo murmur, which is heard best in the left third intercostal space and is intensified by handgrip. There is prominent cardiomegaly on chest x-ray. Which of the following medications would improve both this patient’s symptoms and cardiomegaly

A 43-year-old white male is found to have premature atrial complexes (PACs) on routine EKG. He denies chest pain, shortness of breath or lightheadedness. He has smoked 1-2 packs of cigarettes daily for the past 20 years. He also has a 20-year history of alcoholism, though recently he has limited his use to 1-2 beers/day. The patient's family history is significant for a myocardial infarction in his mother at age 65 and a stroke in his father at age 72. He has no personal history of hypertension or diabetes. Physical examination including vital signs, is entirely within normal limits. What is the best next step in the management of this patient?

A 60-year-old man is brought to the emergency department due to syncope. He has had similar episodes a few times during the past few weeks. These episodes usually occur after he exerts himself. He does not feel confused or tired after these episodes. He denies any chest pain or palpitation. His wife reports that when he collapses, he seems to lose consciousness for a few seconds, but then is back to being alert right away. She denies any jerking movement. His past medical history is significant diverticulosis, for which he takes fiber supplements. He is not on any other medication. His temperature is 37.1°C (98.8°F), blood pressure is 110/98 mm Hg, pulse is 88/min, and respirations are 14/min. On examination, he has a fourth heart sound and harsh 3/6 systolic murmur, best heard over the right sternal border. The murmur is accentuated on expiration. The lung fields are clear to auscultation. After performing an echocardiograph to confirm the diagnosis, which of the following management options is most appropriate?

11) A 57-year-old female with a past medical history of bronchial asthma presents to the physician's office for evaluation of high blood pressure. On her previous two visits, her blood pressure has been 154/88 mmHg and 150/90 mmHg. Her blood pressure during this visit is 150/90 mmHg. She denies headaches and has no complaints. She uses fluticasone and albuterol inhalers for her chronic persistent asthma. She denies smoking or alcohol intake, and has no known drug allergies. Her family history is significant for myocardial infarction in both her mother and father. Exercise and a low salt diet have not improved her hypertension. Which of the following is the most appropriate next step in managing this patient's hypertension?

12) A 27-year-old female presents to your office for a follow-up. The previous two visits revealed an elevated blood pressure in the range of 150- 155/90-95 mmHg. She has no present complaints. Her past medical history is insignificant. She smokes 1/2 pack of cigarettes per day and does not consume alcohol. Her current medications include a combination oral contraceptive for the last 2 years, and an occasional acetaminophen for tension headache relief. There is no family history of hypertension or heart attacks. This visit, her blood pressure is 155/95 and her heart rate is 80/min. The physical examination is unremarkable. The ECG is normal. Her total cholesterol level, measured 6 months ago, was 170 mg/dL. Which of the following is the most appropriate next step in the management of this patient?

13) A 65-year-old male presents to the emergency department with substernal chest pain, severe shortness of breath, and diaphoresis that began suddenly 40 minutes ago. Since the pain started, the patient has vomited twice. The pain radiates to his left arm and does not remit with sublingual nitroglycerine. EKG shows 2 mm ST elevations in the anterior leads. On physical examination, the patient's temperature is 36.9°C (98.4°F), blood pressure is 110/70 mmHg, pulse is 60/min, respirations are 32/min, and oxygen saturation is 90% on 4L oxygen by nasal canula. Cardiac exam reveals a muffled S1 and S2 and the presence of an S3. Lung exam reveals basilar crackles that extend halfway up the lung fields bilaterally. Which of the following is the best next step in managing this patient?

14) A 55-year-old male with a history of rheumatoid arthritis and rheumatoid lung disease is admitted to the hospital with palpitations. His restrictive lung disease is of moderate severity, requiring use of 2 liters of oxygen by nasal cannula at all times. He has no known history of coronary artery disease, hypertension or diabetes. On physical examination, his blood pressure is 110/70 mmHg and heart rate is 120 and irregular. EKG shows atrial fibrillation with a rapid ventricular rate. Which of the following medications should be avoided in this patient?

15) A 32-year-old anxious-appearing male is wheeled into the emergency room with the sudden onset of excruciating left-sided chest pain. His temperature is 37.2°C (99°F), blood pressure is 160/88 mmHg, pulse is 125/min, regular and respirations are 20/min. Physical examination is normal, except for multiple venous track marks on his extremities and atrophic nasal mucosa. An EKG is done which shows ST depression and T wave inversion in leads V1-V6. Cardiac enzymes including CK-MB and Troponin Tare not elevated. Which of the following is the most appropriate next step in the management of this patient?

16) A 66-year-old white male presents for evaluation of progressively worsening dyspnea that affects him at rest and wakes him from sleep. He also notes bilateral ankle swelling. His medical history is significant for coronary artery disease for which he has undergone angioplasty and coronary artery bypass grafting. On examination today, his pulse is 86/min, blood pressure is 110/70 mmHg, and respirations are 19/min. His neck veins are distended and there is bilaterally symmetric pitting ankle edema. On chest auscultation, you hear crackles at the bilateral lung bases and a third heart sound. Chest x-ray shows an enlarged cardiac silhouette and bilateral alveolar and interstitial pulmonary edema. Of the medications listed below, which has not been shown to improve survival in patients with the above presentation?

17) A 26-year-old primigravida at 20th week gestation presents to the emergency room with a sudden onset of tearing chest pain radiating to her back and left arm. The patient is pale and diaphoretic. Her PR: 116/min; BP: 192/ 104 mmHg in left arm, and 123/65 mmHg in right arm; RR: 36/min. Her cardiac examination reveals a diastolic murmur along the left sternal border. Her previous prenatal care is not known. She is a smoker with a 10 pack/year history and drinks alcohol. Her ECG reveals mild left axis deviation and ST segment depression in lead II, III, and AVF. What is the most appropriate next step in the management of this patient?

18) A 53-year-old woman presents to the physician's office with a 3-week history of burning, substernal chest pain that usually comes on with exertion and is relieved with rest. The pain does not radiate to the arms or jaw. Her past medical history is significant for bronchial asthma, type 2 diabetes, hypercholesterolemia, and hypertension. A diagnosis of stable angina is suspected, and the patient is scheduled for an exercise EKG stress test. Which of her medications should be withheld 24 hours before the test?

19) A 50-year-old Caucasian male returns to the clinic for the evaluation of his blood pressure control. He was diagnosed with essential hypertension one year ago. He claims compliance with his reduced salt intake diet. He is currently on a thiazide diuretic and a beta-blocker. His past medical history is significant for angina, which is always relieved with sublingual nitroglycerine, but he has not had an attack of angina in over a month. He has never had a myocardial infarction. He lives with his wife and two children. He quit smoking two years ago, but previously had a 25-pack year history. He drinks 4 bottles of wine per week. His blood pressure is 150/90 mm Hg. What is the best next step in management?

20) A 34-year-old woman is referred by an OB-GYN colleague for the onset of fatigue and dyspnea on exertion 1 month after her second vaginal delivery. Physical examination reveals a laterally displaced PMI, elevated jugular venous pressure and 2+ pitting lower extremity edema. Echocardiogram shows systolic dysfunction with an ejection fraction of 30%. Which statement most accurately describes her condition?

21) A 72-year-old Caucasian male presents with shortness of breath that awakens him at night. At baseline he is able to walk less than a block before stopping to catch his breath. Physical examination findings include bilateral basilar rales and neck vein distention. The patient has a known history of congestive heart failure, and his last echocardiogram revealed an ejection fraction of 25%. The patient is compliant with a medication regimen including an ACE inhibitor, beta-blocker, and loop diuretic. Blood pressure is well controlled. What additional treatment should you begin next?

22) A 30-year-old female presents with a chief complaint of palpitations. A 24-hour Holter monitor shows occasional unifocal premature ventricular contractions and premature atrial contractions. Which of the following is the best management for this patient?

23) A 52-year-old man complains of frequent chest pain. The pain typically occurs at night and is described as retrosternal and burning in quality. He leads a sedentary lifestyle but does not smoke or drink alcohol. His past medical history includes a chronic cough and occasional hoarseness. He does not take any medications. His BMI is 28.5 kg/m2 ECG stress testing reveals 1 mm ST segment depression in the inferior leads at 90% of predicted maximal heart rate. He did not experience chest pain during the stress test. Which of the following is most likely to relieve this patient's chest pain?

24) 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?

25) 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?

26) A 63-year-old woman complains of leg swelling that is especially bothersome in the evening. She also complains of chronic cough and exertional dyspnea. She has been smoking one pack of cigarettes per day for the past 30 years. She also drinks one or two cans of beer on weekends. Her medical history is significant for a hospitalization for a "chest infection" two years ago, for which she was treated with antibiotics, steroids, and inhalers. She also reports having been diagnosed with hypertension, but says that she has never taken medications for it. On physical examination, her blood pressure is 160/90 mmHg and her heart rate is 80/min. Chest examination reveals bilateral scattered wheezes and prolonged expirations. Her jugular venous pulsation is seen 2 cm above the sternal angle with the head of the bed elevated 30°. Her abdomen is soft and non-distended. On examination of her lower extremities, you note bilateral pitting edema and dilated, tortuous, superficial veins. Which of the following is most likely to relieve this patient's edema?

27) 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 mmHg 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?

28) 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 36.7°C (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?

29) 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?

30) 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?

31) 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?

32) 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?

33) A 45-year-old male presents to your clinic with complaints of pleuritic chest pain. He says he is a heavy smoker and has been having intermittent cough for the past 2 weeks. His blood work is normal and his chest x ray is clear. EKG reveals a normal sinus rhythm with a heart rate of 68. He does have a PR interval > 0.2 seconds. The next step in the management of his arrhythmia is:

34) 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?

35) 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?

36) 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?

37) 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?

38) 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:

39) 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 113/76mmHg; Temperature 37.1°C (98.9°F); 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?

40) 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?

41) 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?

43) 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 mmHg, 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?

46) 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?

47) 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?

48) 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?

49) 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 mmHg). 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 mmHg 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?

50) 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?

51) 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 light-headedness, 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 mmHg 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?

52) A 59-year-old man presents to the emergency department (ED) complaining of new-onset chest pain that radiates to his left arm. He has a history of hypertension, hypercholesterolemia, and a 20-pack-year smoking history. His electrocardiogram (ECG) is remarkable for T-wave inversions in the lateral leads. Which of the following is the most appropriate next step in management?

53) 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 mmHg, 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?

54) You have been asked to evaluate a 42-year-old white male smoker who presented to the emergency department with sudden onset of crushing substernal chest pain, nausea, diaphoresis and shortness of breath. His initial ECG revealed ST segment elevation in the anterior-septal leads. Cardiac enzymes were normal. The patient underwent emergent cardiac catheterization, which revealed only a 25% stenosis of the left anterior descending (LAD) artery. No percutaneous intervention was performed. Which of the following interventions would most likely reduce his risk of similar episodes in the future?

55) Two weeks after hospital discharge for documented myocardial infarction, a 65-year-old returns to your office concerned about low-grade fever and pleuritic chest pain. There is no associated shortness of breath. Lungs are clear to auscultation and the heart is free of murmur, gallop, or rub. ECG is unchanged from the last one in the hospital. Which therapy is most likely to be effective?

56) A 55-year-old patient presents to you after a 3-day hospital stay for gradually increasing shortness of breath and leg swelling while away on a business trip. He was told that he had congestive heart failure, but is asymptomatic now, with normal vital signs and physical examination. An echocardiogram shows an estimated ejection fraction of 38%. The patient likes to keep medications to a minimum. He is currently on aspirin and simvastatin. Which would be the most appropriate additional treatment?

57) An active 78-year-old female with history of hypertension presents with the new onset of left hemiparesis. Cardiac monitoring reveals atrial fibrillation. She had been in sinus rhythm on check-up 3 months earlier. Optimal management at discharge includes a review of antihypertensive therapy, a ventricular rate control agent, and which of the following?

61) 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 mmHg and heart rate is 72. You are asked to assume care of this patient. What is the best next step in management?

62) You are volunteering with a dental colleague in a community indigent clinic. A nurse has prepared a list of patients who are scheduled for a dental procedure and may need antibiotic prophylaxis beforehand. Of the patients listed below, who would be most likely to benefit from antibiotic prophylaxis to prevent infective endocarditis?

63) 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 mmHg, heart rhythm irregularly irregular, and heart rate around 80/minute. Which of the following is the best management strategy of this patient’s arrhythmia?

64) 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 mmHg at both of her last clinic appointments. Her medical history is otherwise significant only for diabetes mellitus. Her blood pressure today is 164/92 mmHg. What is the best next step in her blood pressure management?

65) 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 mmHg. 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?

67) 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 mmHg, 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?

68) 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 mmHg, 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?

69) 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 mmHg, 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?

70) A 60-year-old man with coronary artery disease, peptic ulcer disease, and gout presents to the emergency department with a 24-hour history of abdominal pain. The pain, which is most intense in the upper abdomen, was sudden in onset and has become progressively more severe. Free air in the abdomen is detected on x-ray films. The patient is in an agitated state. His extremities are cool and capillary refill time is 3 seconds. His blood pressure is 80/40 mmHg and heart rate is 130/min. The neck veins are flat and the lungs are clear to auscultation. His hemoglobin is 13.8 g/dL. A urinary catheter is inserted and 10 mL of urine is drained. What is the most appropriate treatment for this patient at this time?

71) A 19-year-old man complains of chest pain while playing basketball on his high school team. Paramedics are called and he is rushed to the hospital. Physical examination reveals moderate mitral regurgitation and a crescendodecrescendo systolic ejection murmur that gets louder with Valsalva maneuver. Echocardiography reveals thickened left ventricular walls and dynamic left ventricular outflow tract obstruction. What is the best first step in management?

72) 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 mmHg, 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?

74) 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?

75) While discussing a case presentation with a medical student, a nearby patient who just returned from getting an ankle radiograph done yells out in pain. You walk over to him and ask what is wrong. He states that since returning from the radiology suite, his automatic implantable cardioverter defibrillator (AICD) is discharging. You hook him up to the monitor and note that his rhythm is sinus. You observe a third shock while the patient is in sinus rhythm. Which of the following is the most appropriate next step in management?

76) A 22-year-old primagravida woman develops hypertension at 28 weeks. She is asymptomatic and the examination is normal except for 1+ pedal edema. Her complete blood count, liver enzymes, and electrolytes are normal. The urinalysis is positive for proteinuria. Which of the following is true for this type of hypertension?

77) A 61-year-old man has a non-ST-elevation MI and is admitted to the coronary care unit. The following day, he develops bradycardia but no symptoms. His blood pressure is 126/84 mmHg, pulse 50/min, and on examination, the heart sounds are normal, with no extra sounds or rubs. His ECG has changed. Which of the following ECG findings is the best indication for this patient to receive a pacemaker?

79) A 26-year-old white nonsmoking woman returns for a follow-up appointment with her primary care provider. At a routine health maintenance visit 8 months earlier, her blood pressure was 179/97 mmHg. Since then she has adhered to a low-fat diet and exercises regularly. On repeat measurement 1 month later, her blood pressure was still elevated, despite her compliance with the prescribed hydrochlorothiazide and lisinopril. She has no complaints and denies headaches, chest pain, or mental status changes. On physical examination she is a slender woman in no apparent distress. An abdominal bruit that lateralizes to the left is heard. Her blood pressure is 178/99 mmHg in her left arm and 181/95 mmHg in her right arm. A basic metabolic panel and complete blood count are within normal range. Which of the following is the most appropriate next step in patient care?

80) A 58-year-old man is admitted to the coronary care unit for telemetric monitoring after an episode of bradycardia. While in the unit, he suddenly loses consciousness. His pulse is undetectable and his blood pressure drops to 40 mmHg. His airway is clear and patent, and he is still breathing on his own. An ECG shows electrical activity. Chest compressions are started and he is quickly given a bolus of intravenous sodium bicarbonate and atropine. When his tracing does not improve, the boluses are repeated twice, and finally his tracing returns to normal sinus rhythm. Moments later, when he regains consciousness, he complains of a dry mouth, blurred vision, and feeling flushed. What is the most appropriate next step in the management of this patient?

81) 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 mmHg, 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?

82) A 31-year-old man who works for a moving company presents to the ED because he thinks he was having a heart attack. He does not smoke, and jogs 3 days a week. His father died of a heart attack in his sixties. He describes a gradual onset of chest pain that is worse with activity and resolves when he is at rest. His HR is 68 beats per minute, BP is 120/70 mmHg, and RR is 14 breaths per minute. On examination, his lungs are clear and there is no cardiac murmur. You palpate tenderness over the left sternal border at the third and fourth ribs. An ECG reveals sinus rhythm at a rate of 65. A chest radiograph shows no infiltrates or pneumothorax. Which of the following is the most appropriate next step in management?

84) 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 mmHg (146/82 mmHg 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?

85) A 34-year-old woman presents to your office complaining of several months of chest pain. She says that the pain is left-sided, does not change with deep inspiration, and typically lasts several hours. The pain has no relation to physical activity, but worsens with emotional stress. The patient has no significant family history, and does not use tobacco, alcohol or drugs. She takes no medications and has no drug allergies. On exam, her blood pressure is 110/70 mmHg and her heart rate is 78/min. ECG is normal. Which of the following is the best next step in her management?

86) A 60-year-old male patient is receiving aspirin, an angiotensin-converting enzyme inhibitor, nitrates, and a beta-blocker for chronic stable angina. He presents to the ER with an episode of more severe and long-lasting angina chest pain each day over the past 3 days. His ECG and cardiac enzymes are normal. Which of the following is the best course of action?

87) A 42-year-old man presents to the clinic for routine evaluation. His medical history is signified cant for gallstones. The patient denies smoking and drinks alcohol occasionally. His mother had a heart attack at the age of 63 years. His blood pressure is 134/77 mmHg. The patient is overweight with well-healed laparoscopic cholecystectomy scars. Fasting laboratory tests show: Aspartate aminotransferase: 37 U/L, Alanine aminotransferase: 28 U/L, Alkaline phosphatase: 88 U/L, Total cholesterol: 268 mg/dL, LDL cholesterol: 183 mg/dL, HDL cholesterol: 46 mg/dL, Triglycerides: 166 mg/dL. What is the most appropriate next step in management?

88) A 60-year-old man with a history of congestive heart failure presents to his physician. He has a 5-year history of excessive daytime sleepiness and snoring. He also admits to three drinks of alcohol per day. His temperature is 36.6°C (98.0°F), pulse is 85/min, blood pressure is 138/82 mmHg, respiratory rate is 14/min, and oxygen saturation is 99% on room air. His body mass index is 31 kg/m2. Physical examination is significant for macroglossia and a short neck. Polysomnography is performed and is significant for multiple nocturnal episodes of airflow cessation at the nose and mouth, despite evidence of continuing respiratory effort. Which of the following is the most effective management for this patient?

89) During a screening physical examination for participating in high school sports, a 14-yearold girl is found to have a late apical systolic murmur preceded by a click. The rest of the examination is unremarkable. Echocardiography shows superior displacement of the mitral leaflets of > 2 mm during systole into the left atrium, with a thickness of at least 8 mm. In addition, she states that her father also has some type of heart “murmur,” but she knows nothing else about it. Which of the following is the most appropriate management at this time?

90) A 27-year-old man complains of chest palpitations and light-headedness for the past hour. He has no past medical history and is not taking any medications. He drinks a beer occasionally on the weekend and does not smoke cigarettes. His HR is 180 beats per minute, BP is 110/65 mmHg, and oxygen saturation is 99% on room air. An ECG reveals an HR of 180 beats per minute with a QRS complex of 90 milliseconds with a regular rhythm. There are no discernable P waves. Which of the following is the most appropriate medication to treat this dysrhythmia?

91) A 70-year-old female has been healthy except for hypertension treated with a thiazide diuretic. She presents with sudden onset of a severe, tearing chest pain, which radiates to the back and is associated with dyspnea and diaphoresis. Blood pressure is 210/94 mmHg. Lung auscultation reveals bilateral basilar rales. A faint murmur of aortic insufficiency is heard. The BNP level is elevated at 550 pg/mL (Normal < 100). ECG shows nonspecific ST-T changes. Chest x-ray suggests a widened mediastinum. Which of the following choices represents the best initial management?

92) A 67-year-old homeless male presents 24 hours after the onset of substernal chest pain and is diagnosed with an anterior wall myocardial infarction. There is no history of previous chest pain, dyspnea, palpitations, syncope or leg swelling. He has no hypertension or diabetes mellitus. He does acknowledge a 40 pack-year smoking history. Upon discharge, echocardiography shows normal left ventricular size, left ventricular anterior wall hypokinesis and an ejection fraction of 50%. Two years later, the patient is found dead in the street. Autopsy reveals a dilated left ventricle with a globular shape and thinned walls along with a scar on the anterior wall. Which of the following would have most likely prevented this patient's pathologic findings?

93) A 55-year-old white male presents to the Emergency Room with a four-hour history of chest pain. The pain is substernal and radiates to the left arm. He has a history of hypertension, diabetes, and hypercholesterolemia. His temperature is 36.7°C (98°F), blood pressure is 110/65 mmHg, pulse is 110/min, and respirations are 18/min. ECG is recorded and reveals ST segment elevation in the anterior leads and several ventricular premature beats (VPBs). What would the administration of lidocaine to such a patient most likely result in?

94) 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?

95) 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 mmHg, 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?

96) 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 mmHg. Which of the following is the most likely adverse effect of α1-adrenergic blockade in this patient?

97) A 59-year-old man presents to the ED with left-sided chest pain and shortness of breath that began 2 hours prior to arrival. He states the pain is pressure-like and radiates down his left arm. He is diaphoretic. His BP is 160/80 mmHg, HR 86 beats per minute, and RR 15 breaths per minute. ECG reveals 2-mm ST-segment elevation in leads I, aVL, and V 3 to V 6. Which of the following is an absolute contraindication to receiving thrombolytic therapy?

100) A 62-year-old woman comes to the office for evaluation of a pigmented lesion on her left forearm. The lesion occasionally itches but is otherwise asymptomatic. She admits that she only came because her daughter had persuaded her to do so. On examination, there is a slightly elevated, brown-colored lesion measuring 7 mm in diameter with irregular borders. What is the best next step in management?

101) A 17-year-old white male presents to your office because the "spots" on his face "got so much worse recently!" He has several months history of acne. He has not visited a doctor before. Inspection reveals multiple papules with several pustules and nodules. Atrophic scars are seen. What is the best next step in the management of this patient?

102) A 47-year-old woman presents to your office complaining of two days of pain and itching over her left chest. Her medical history is significant for breast cancer for which she underwent a left-sided mastectomy six months ago. She has also been receiving chemotherapy and radiation. Physical examination reveals erythema around the mastectomy scar, with excoriations and occasional vesicles. Which of the following is the best treatment for her condition?

103) A 34-year-old Caucasian female presents to the ER with a rash and pruritis. She says that she has had a sore throat for several days, and her friend gave her amoxicillin that turned out to be out dated. The rash developed about 30 minutes after she took the drug. Her blood pressure is 110/70 mmHg and heart rate is 80/min. Physical examination reveals wide spread urticaria and excoriations. Pharyngeal mucosa and tonsils are hyperemic, and tender lymph nodes are palpated in the submandibular area. Lungs are clear on auscultation. Which of the following is the best next step in the management of this patient?

104) A 35-year-old white male presents with high-grade fever, chills, rigors, malaise, and pain in his right calf for the last 24 hours. His temperature is 39.5°C (103.1°F), pulse is 105/min, blood pressure is 130/80 mmHg, and respirations are 15/min. Physical examination shows generalized swelling of the calf with linear streaks of erythema. The lesion is warm, tender, and not very well-demarcated. No pain is felt in the calf when the ankle is dorsiflexed. Scaling is found in the toe webs on the right side, and KOH preparation of these lesions show hyphae. Blood cultures are obtained. CBC shows a WBC count of 14,000 with 6% bands. What is the most appropriate next step in management?

105) A 14-year-old white female presents with "spots" on her face that are "so embarrassing!" Physical examination reveals comedones with minimal inflammation. Her past medical history is insignificant. She does not smoke or consume alcohol. What is the best next step in the management of this patient?

98) 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 mmHg and HR is 77 beats per minute. Which of the following medications is contraindicated in this patient?

99) A 62-year-old woman presents to the ED with general weakness, shortness of breath, and substernal chest pain that radiates to her left shoulder. Her BP is 155/80 mmHg, HR is 92 beats per minute, and RR is 16 breaths per minute. You suspect that she is having an acute MI. Which of the following therapeutic agents has been shown to independently reduce mortality in the setting of an acute MI?