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

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

175. A 65-year-old man comes to your office for a follow-up after his previous visits revealed inadequately controlled hypertension. He has no present complaints except difficulty walking uphill or climbing stairs, because of the pain in the right thigh, which makes him stop and rest. His past medical history includes stable angina, requiring coronary angioplasty and stenting 2 years ago; hypercholesterolemia; a 20-year history of hypertension; and a 10-year history of diabetes mellitus, type 2. His current medications are aspirin, metoprolol, hydrochlorothiazide, enalapril, amlodipine, pravastatin and glyburide. He smokes 1½packs of cigarettes per day and does not consume alcohol. His blood pressure is 160/100 mm Hg in his right arm and 180/110 mmHg in his left arm. Which of the following findings will point to the potential cause of the resistant hypertension in this patient?

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

179. 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?

181. A 48-year-old Caucasian male presents to your office complaining of progressive exertional dyspnea. It has become especially bothersome over the past two months. Presently, he becomes short of breath after climbing one flight of stairs. He denies any significant problems in the past. He is not taking any medications and he denies smoking or drinking alcohol. His temperature is 37.2°C (98.9F), pulse is 78/min, blood pressure is 130/75 mm of Hg and respirations are 14/min. Chest examination reveals a harsh systolic murmur that is best heard at the right second intercostal space with radiation along the carotid arteries. An S4 is heard at the apex. Based on these findings, what is the most likely cause of this patient's symptoms?

182. 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?

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

184. 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?

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

186. A 45-year-old white male presents to the ER after an episode of syncope. His medical history is unremarkable except for an upper respiratory infection one week ago. On physical examination, his temperature is 37.2°C (99.F), pulse is 90/min, blood pressure is 100/60 mmHg and respirations are 13/min. His neck veins are distended and his heart sounds are distant. His lungs are clear to auscultation bilaterally. Chest x-ray reveals small bilateral pleural effusions and an enlarged cardiac silhouette. Which of the following EKG findings is fairly specific for his condition?

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

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

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

193. 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?

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

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

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

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

198. A 41-year-old intravenous drug abuser presents with shortness of breath and pleuritic chest pain. He is febrile with a temperature of 103.5°F. He has no skin lesions and funduscopic exam is negative. He has jugular venous distension that increases with compression of the liver. The liver is pulsatile. The jugular venous pulse shows a prominent v wave. The patient has splenomegaly. Heart auscultation reveals a holosystolic murmur heard best at the left lower sternal border. The murmur increases with inspiration (Müller maneuver). Which of the following is the most likely diagnosis?

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

202. A 55-year-old man presents to the ED with chest pain and shortness of breath. His BP is 170/80 mm Hg, HR is 89 beats per minute, and oxygen saturation is 90% on room air. Physical examination reveals crackles midway up both lung fields and a new holosystolic murmur that is loudest at the apex and radiates to the left axilla. ECG reveals ST elevations in the inferior leads. Chest radiograph shows pulmonary edema with a normalsized cardiac silhouette. Which of the following is the most likely cause of the cardiac murmur?

203. A 22-year-old man presents to the ED with a history consistent with an acute MI. His ECG reveals ST elevations and his cardiac biomarkers are positive. He has been smoking half a pack of cigarettes per day for the last 3 months. He drinks alcohol when hanging out with his friends. His grandfather died of a heart attack at 80 years of age. The patient does not have hypertension or diabetes mellitus and takes no prescription medications. A recent cholesterol check revealed normal levels of total cholesterol, lowdensity lipoprotein (LDL), and high-density lipoprotein (HDL). Which of the following is the most likely explanation for his presentation?

205. 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?

207. 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?

208. 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?

209. 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?

211. 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?

212. 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?

214. 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?

215. 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?

216. A 42-year-old man develops shortness of breath (SOB) and chest pain 7 days after an open cholecystectomy. His blood pressure is 145/86 mm Hg, pulse is 120/min, respirations 24/min, and oxygen saturation of 97%. Pulmonary embolism is clinically suspected. Which of the following is the most common ECG finding of pulmonary embolism?

217. A 42-year-old man with known valvular heart disease develops a fever for 1 week. He appears unwell; findings include a pansystolic murmur at the apex that radiates to the axilla and a soft S1 sound. He has petechiae on his conjunctival sac, linear hemorrhages under a few fingernails, and painful, tender, and erythematous nodules on some of the distal fingertips. Which of the following is the most responsible mechanism for these physical findings?

218. A 67-year-old man presents with an anterior myocardial infarction (MI) and receives thrombolytic therapy. Three days later, he develops chest pain that is exacerbated by lying down, and his physical findings are normal except for a friction rub. His ECG shows evolving changes from the anterior infarction but new PR-segment depression and 1-mm ST-segment elevation in all the limb leads. Which of the following is the most likely diagnosis?

219. 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?

220. 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 checkup 3 months earlier. Optimal management at discharge includes a review of antihypertensive therapy, a ventricular rate control agent, and which of the following?

222. A 48-year-old man presents to the emergency department complaining of crushing substernal chest pain. He is diaphoretic, anxious, and dyspneic. His pulse is 110/min, blood pressure is 175/112 mm Hg, respiratory rate is 30/min, and oxygen saturation is 94%. Aspirin, oxygen, sublingual nitroglycerin, and morphine are given, but they do not relieve his pain. ECG shows ST-segment elevation in leads V2 to V4. The duration of symptoms is now approximately 30 minutes. What is the most appropriate treatment for this patient at this time?

223. A 70-year-old woman presents to the emergency department complaining of dizziness. She is disoriented to the date and her location and it is difficult to gather an accurate history. Her pulse is 48/min, blood pressure is 84/60 mm Hg, and respiratory rate is 12/min. On examination her extremities are cool and clammy. Her capillary refill time is 5 seconds. What is the most appropriate therapy?

224. 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?

227. 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?

228. 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?

229. 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?

230. 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?

231. 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?

234. 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?

235. 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?

236. 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?

237. 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?

239. 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?

241. 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 mm Hg 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?

243. An elderly man presents to the emergency department with chest pain. He has a history of stable angina and recent onset diabetes mellitus, but now the chest pain comes on with less exertion and takes longer to go away. An ECG and cardiac enzymes are ordered. If this man has unstable angina, what are the expected findings on ECG and cardiac enzyme testing?

244. 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?

245. 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?

246. 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?

248. 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?

249. 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?

250. 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?

252. 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?

253. 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?

254. 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?

256. 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 mm Hg. 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 mm Hg in her left arm and 181/95 mm Hg 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?

258. 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 mm Hg. 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?

259. 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?

260. 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?

261. Which of the following patients has the lowest clinical probability for the diagnosis of pulmonary embolism (PE)?

262. A 29-year-old man is brought to the ED by EMS for a syncopal episode that occurred during a basketball game. A friend states that the patient just dropped to the ground shortly after scoring a basket on a fast break. On examination, you note a prominent systolic ejection murmur along the left sternal border and at the apex. An ECG reveals left ventricular hypertrophy, left atrial enlargement, and septal Q waves. You suspect the diagnosis and ask the patient to perform the Valsalva maneuver while you auscultate his heart. Which of the following is most likely to occur to the intensity of the murmur with this maneuver?

263. A 72-year-old man presents with shortness of breath and increased home oxygen requirement. The patient has coronary artery disease, he has had two previous myocardial infarctions, and he has a history of chronic obstructive pulmonary disease requiring 2 L of continuous home oxygen. The patient has a 45-pack-year history of smoking. He is unable to walk more than a block and the swelling in his legs has worsened. The physician suggests measuring a brain natriuretic peptide (BNP) level to distinguish a cardiac from a pulmonary cause of his symptoms. Which of the following statements regarding BNP is true?

264. 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?

265. 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?

266. 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?

267. 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?

269. A 70-year-old man comes to his primary care physician for his annual check-up. He has a history of hypertension, hyperlipidemia, and coronary artery disease, and had coronary artery bypass grafting 6 years ago. On examination the physician notes a right carotid bruit. Which of the following is the most appropriate next step?

270. 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?

271. 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?

272. A 60-year-old woman is transferred to a physician from an outside hospital following a motor vehicle collision. Her medical history is notable for Osler-Weber-Rendu syndrome. She is otherwise healthy. Which of the following triads is most likely to characterize her medical history prior to the collision?

273. A 65-year-old man presents to the emergency department following the acute onset of palpitations. His wife states that he was eating dinner when he noticed the palpitations, lightheadedness, and shortness of breath. The patient has a history of treated hypertension, but no other medical history. The patient is not able to relate any meaningful history. Blood pressure is 80/40 mm Hg, heart rate is 126/ min, respiratory rate is 20/min, and oxygen saturation is 99% on room air; he is afebrile. His heart rate is irregularly irregular with no murmurs, clicks, or rubs. Respiratory examination is unremarkable. X-ray of the chest shows no acute disease. ECG shows no discernible P waves and an irregularly spaced QRS response. Which of the following is the best first step in management?

274. 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?

275. A 72-year-old woman had a pacemaker inserted 4 years ago for symptomatic bradycardia because of AV nodal disease. She is clinically feeling well and her ECG shows normal sinus rhythm at a rate of 68/min but no pacemaker spikes. Her pacemaker only functions when the ventricular rate falls below a preset interval. Which of the following best describes her pacemaker function?

276. A 47-year-old man is found to have edema, ascites, and hepatosplenomegaly. The examination of his neck veins reveals elevated venous pressure with a deep y descent. Heart size on x-ray is normal. Which of the following etiologies is not a possible explanation for this syndrome?

278. 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 mm Hg, 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?

280. 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 mm Hg, HR 86 beats per minute, and RR 15 breaths per minute. ECG reveals 2-mm ST-segment elevation in leads I, aVL, and V3 to V6. Which of the following is an absolute contraindication to receiving thrombolytic therapy?

282. 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?

283. A 62-year-old man has progressive symptoms of dyspnea, and more recently noticed difficulty lying supine. Examination shows an elevated JVP at 8 cm, with a third heart sound, pedal edema, and bibasilar crackles on auscultation. Which one of the following may be implicated in fluid retention for this condition?

287. 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?

289. 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?

290. 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?

291. A 36-year-old man is seen because of palpitations. He admits to precordial discomfort, weakness, and anxiety. His pulse is 150/min, and his blood pressure is 124/70 mm Hg. Heart sounds are normal. Carotid sinus pressure gradually changes the rate to 75/min, but when released, the pulse rate returns to 150/min. Which of the following is the most likely diagnosis?

292. 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?

297. 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?

298. 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?

299. 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 mm Hg, 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?

300. A 57-year-old man complains of chest palpitations and light-headedness for the past hour. Five years ago he underwent a cardiac catheterization with coronary artery stent placement. He smokes half a pack of cigarettes daily and drinks a glass of wine at dinner. His HR is 140 beats per minute, BP is 115/70 mm Hg, and oxygen saturation is 99% on room air. An ECG reveals a wide complex tachycardia at a rate of 140 that is regular in rhythm. An ECG from 6 months ago shows a sinus rhythm at a rate of 80. Which of the following is the most appropriate medication to treat this dysrhythmia?

302. A 19-year-old woman was attacked while coming home from a party and is brought to the emergency department. She recalls being punched in the side of the head and stabbed in the left flank. Her speech is slow and she complains of a bad headache. Her pulse is 110/min, blood pressure is 90/50 mm Hg, and respiratory rate is 25/min. On examination she has a stab wound at the left costal margin in the midaxillary line. Two large-bore intravenous lines are inserted, and after infusion of 2 L of lactated Ringer’s solution her blood pressure rises to 95/55 mm Hg. What is the most appropriate next step in management?

303. 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?

304. 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?

305. While palpating the pulse of a patient, you note that the pulse wave has two peaks. You auscultate the heart and are certain that there is only one heartbeat for each two pulse waves. Which of the following best describes this finding?

306. A 42-year-old female with acute pericarditis develops jugular venous distention and hypotension. The ECG shows electrical alternans. Which of the following is the most likely additional physical finding?

307. Yesterday you admitted a 55-year-old white male to the hospital for an episode of chest pain, and you are seeking to rule out MI plus assess for any underlying coronary artery disease. The patient tends to be anxious about his health. On admission, his lungs were clear, but his heart revealed a grade 1/6 early systolic murmur at the upper left sternal border without radiation. Blood pressure readings have consistently been in the 140/90 to 150/100 range. Cardiac enzymes are normal. A resting ECG shows only left ventricular hypertrophy with secondary ST-T changes (“LVH with strain”). Why would a treadmill ECG stress test not be an appropriate test in this patient?

308. A 67-year-old male presents to your office after community ultrasound screening revealed an aortic aneurysm measuring 3.0 x 3.5 cm. Physical examination confirms a palpable, pulsatile, nontender abdominal mass just above the umbilicus. The patient’s medical conditions include hypertension, hyperlipidemia, and tobacco use. What is the best recommendation for the patient to consider?

309. A 67-year-old male presents to your clinic to establish primary care; he is asymptomatic. He has a history of hypertension for which he takes hydrochlorothiazide. His father had a myocardial infarction at age 62. The patient smoked until 5 years ago, but has been abstinent from tobacco since then. His blood pressure in the office today is 132/78. Aside from being overweight, the remainder of the physical examination is unremarkable. Which of the following preventive health interventions would be most appropriately offered to him today?

311. A 36-year-old man presents to the clinic with complaints of a genital sore. The patient is a sexually active heterosexual involved with three partners and practices unprotected intercourse. Four days ago he noted a painless sore on his penis. He is afebrile, with a heart rate of 80/min and blood pressure of 120/77 mm Hg. Physical examination reveals a solitary ulcerated lesion located on the lateral aspect of his penis. The lesion is nontender and associated with bilateral inguinal lymphadenopathy. Physical examination is otherwise normal. If left untreated, this man is at increased risk for which of the following?

312. An 81-year-old man is hospitalized for acute onset of shortness of breath and lower extremity edema. Although he lives by himself, it is very difficult for him to move around his apartment without experiencing fatigue. He has not seen his physician in years but was told in the past that he had high blood pressure. On physical examination his jugular venous pulse is palpated 9 cm above his sternal notch, inspiratory crackles are heard at his lung bases, and there is 3+ lower extremity edema. Which of the following will confirm the most likely diagnosis?

314. A 62-year-old man with a prosthetic aortic valve develops fevers and malaise. His valve was replaced 5 years ago because of aortic stenosis from a bicuspid valve. He has a systolic ejection murmur but no other abnormalities on examination. Blood cultures are most likely to grow which of the following?

315. A 58-year-old man with no prior cardiac history presents with retrosternal chest pain starting at rest and lasting 30 minutes. The pain radiates to the left arm and is associated with diaphoresis and dyspnea. His blood pressure is 150/90 mm Hg, pulse 100/min, the heart sounds are normal, and the lungs are clear to auscultation. Which of the following is the next most appropriate investigation?

318. 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 mm Hg, 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?

319. 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?

320. A 20-year-old woman arrives at the emergency department actively seizing with QRS prolongation on ECG per paramedics. The patient’s roommate called emergency medical services after the patient collapsed, was not responsive to questioning, and began having clonic jerks bilaterally in her upper extremities. The patient’s roommate denies any knowledge of the patient consuming alcohol or illicit drugs. She does not believe the patient had any plan of harming herself, but does acknowledge that the patient has seemed “down” lately and was recently prescribed medication for generalized anhedonia. Which of the following is the most appropriate first-line treatment?

322. A 67-year-old woman is brought to the ED by paramedics complaining of dyspnea, fatigue, and palpitations. Her BP is 80/50 mm Hg, HR is 139 beats per minute, and RR is 20 breaths per minute. Her skin is cool and she is diaphoretic. Her lung examination reveals bilateral crackles and she is beginning to have chest pain. Her ECG shows a narrow complex irregular rhythm with a rate in the 140s. Which of the following is the most appropriate immediate treatment for this patient?

323. A 61-year-old woman with a history of congestive heart failure (CHF) is at a family picnic when she starts complaining of shortness of breath. Her daughter brings her to the ED where she is found to have an oxygen saturation of 85% on room air with rales halfway up both of her lung fields. Her BP is 185/90 mm Hg and pulse rate is 101 beats per minute. On examination, her jugular venous pressure (JVP) is 6 cm above the sternal angle. There is lower extremity pitting edema. Which of the following is the most appropriate first-line medication to lower cardiac preload?

324. A 27-year-old man complains of chest palpitations and lightheadedness 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 mm Hg, 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?

326. A 28-year-old man with a history of intravenous drug abuse presents to the emergency department with a 2-day history of fever, chills, and shortness of breath. On physical examination the patient has a new heart murmur, small retinal hemorrhages, and subungual petechiae. Which of the following is the most likely causative organism?

327. A boy is delivered at 37 weeks’ gestation via spontaneous vaginal delivery. He is the product of a normal pregnancy and was delivered without complications. Prenatally the mother was blood type B and was rubella immune and negative for Rh antibody, group B streptococci, rapid plasma reagin, hepatitis B surface antigen, gonorrhea, and chlamydia. The patient appears cyanotic. He is breathing at a rate of 60/min and his heart rate is 130/min. He has a normal S1 and S2. There is a harsh holosystolic murmur that is loudest at the left lower sternal border. His examination reveals palpable nonbounding peripheral pulses bilaterally. Which of the following is the most likely diagnosis?

328. A 32-year-old man is stabbed in the left chest and presents to the emergency department in distress. His pulse is 130/min, blood pressure is 70/50 mm Hg, and respiratory rate is 39/min. The stab wound is in the left fifth intercostal space in the midaxillary line. On examination his trachea is deviated to the right, jugular veins are distended bilaterally, and he has absent breath sounds and hyperresonance to percussion on the left side. Subcutaneous emphysema is palpated on the left thoracic wall. What is the best next step in management?

329. A 75-year-old man comes into the emergency department with a 10-minute history of crushing substernal chest pain radiating to his left arm. This man is well known to the staff due to his long history of chest pain. His creatine phosphokinase level is elevated and his troponin T level is 0.4 ng/mL. Which of the following is the most likely diagnosis?

330. A 91-year-old woman presents to the emergency department with a chief complaint of shortness of breath over the past 2 days. She has a history of hypertension and coronary artery bypass surgery 25 years earlier. Her blood pressure is 178/92 mm Hg and she has jugular venous distension, hepatomegaly, and 3+ lower extremity edema. ECG is remarkable for left ventricular hypertrophy, no ST-segment elevations or depressions, no Q waves, and no T wave abnormalities. Echocardiogram reveals an ejection fraction of 60% and left atrial dilatation. There is universal left ventricular thickening. No valvular regurgitation or stenosis was noted. Which of the following underlying conditions is the most likely cause of this patient’s symptoms?

331. A 39-year-old white man with essential hypertension presents for a routine health maintenance visit. He has no complaints and reports compliance with his hydrochlorothiazide. His pulse is 70/min, blood pressure is 145/92 mm Hg, and respiratory rate is 16/min. His body mass index is 24 kg/m2. His physical examination is within normal limits. For which condition is the patient at increased risk?

332. A 69-year-old woman complains of easy fatigue and one episode of presyncope. On examination of the jugular venous pressure (JVP), there are irregular large a waves. The ECG has fixed PP and RR intervals but varying PR intervals. Which of the following conditions is this most likely caused by?

333. A 47-year-old woman has new-onset transient right arm weakness and word finding difficulty symptoms lasting 3 hours. She is also experiencing exertional dyspnea, and had a syncopal event 1 month ago. Her echocardiogram reveals a cardiac tumor in the left atrium, it is pendunculated and attached to the endocardium. Which of the following is the most likely cause of this lesion?

334. A 58-year-old man is undergoing cardiac catheterization for evaluation of chest pain symptoms. He is worried about the risks, and as part of obtaining informed consent, you advise him about the risks and benefits of the procedure. Which of the following aspects of angiography is true?

335. A 23-year-old man develops sharp left-sided chest pain, fever, and a friction rub heard at the lower left sternal border, unaffected by respiration. The pain is also aggevated by lying down and relieved by sitting up. He is otherwise well with no other symptoms and the remaining physical examination is normal. Which of the following is the most likely cause for his symptoms?

336. A 55-year-old man with hypertension and a one-pack-per-day smoking history presents to the ED complaining of three episodes of severe heavy chest pain this morning that radiated to his left shoulder. In the past, he experienced chest discomfort after walking 20 minutes that resolved with rest. The episodes of chest pain this morning occurred while he was reading the newspaper. His BP is 155/80 mm Hg, HR 76 beats per minute, and RR 15 breaths per minute. He does not have chest pain in the ED. An ECG reveals sinus rhythm with a rate of 72. A troponin I is negative. Which of the following best describes this patient’s diagnosis? b. Stable angina

338. In the ICU, a patient suddenly becomes pulseless and unresponsive, with cardiac monitor indicating ventricular tachycardia. The crash cart is immediately available. What is the best first therapy?

339. 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. 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?

340. A 55-year-old African American female presents to the ER with lethargy and blood pressure of 250/150. Her family members indicate that she was complaining of severe headache and visual disturbance earlier in the day. They report a past history of asthma but no known kidney disease. On physical examination, retinal hemorrhages are present. Which of the following is the best approach?

341. A 36-year-old male presents with the sensation of a racing heart. His blood pressure is 110/70, respiratory rate 14/minute, and O2 saturation 98%. His ECG shows a narrow QRS complex tachycardia with rate 180, which you correctly diagnose as paroxysmal atrial tachycardia. Carotid massage and Valsalva maneuver do not improve the heart rate. Which of the following is the initial therapy of choice?

345. A 17-year-old girl develops exertional dyspnea, but has no cough, sputum, or wheezing symptoms. On examination, she has a fixed splitting of her second heart sound and a 3/6 systolic ejection murmur heard best over the left sternal border. An echocardiogram confirms the condition. Which of the following is the best physiologic explanation for her condition?