- A 75 year old woman with a long history of mitral valve stenosis secondary to rheumatic heart disease presents with increasing dyspnea on exertion, fatigue, lower extremity edema, and orthostasis. She recently noted the onset of palpitations. On exam, she has an irregular pulse at 120 bpm, a blood pressure of 105/70, respirations 20 per minute, afebrile. The lungs have bilateral wet crackles (rales) 1/3 up. The cardiac apex is displaced laterally, there is a diastolic rumble in the mitral area, and there is a III/VI crescendo-decrescendo systolic murmer in the right 2nd intercostal space with transmission to the carotids. The carotid upstrokes are delayed relative to the apical beat. The patient most likely has [1]:
A. Mitral Stenosis and Atrial Fibrillation
B. Mitral Stenosis, Aortic Regurgitation, and Atrial Fibrillation
C. Mitral Stenosis, Aortic Stenosis, and Atrial Fibrillation
D. Mitral Stenosis, Systolic Flow Murmer, and Atrial Fibrillation
E. Mitral Stenosis and Multifocal Atrial Tachycardia - A chest radiograph shows enlargement of the left atrium, the left ventricle, and the pulmonary vessels, with mild pulmonary edema. An ECG shows no evidence of acute ischemia; there is mild LVH by voltage criteria. The patient is gradually becoming more tachypnic; her oxygen saturation on room air is 85%, on 2 liters oxygen delivered by nasal canula it is 92%. Her blood pressure is 90/60. Appropriate treatment could consist of [2]:
- For patients undergoing stress echocardiography for evaluation of coronary artery disease (CAD), which of the following drug(s) is suitable to increase "cardiac work" [3] ?
- Anti-coagulation with warfarin (coumadin) is NOT appropriate in which situation [4]:
A. Idiopathic dilated cardiomyopathy and a left ventricular ejection fraction of 20%
B. For 3-6 months following insertion of a porcine aortic valve
C. For the third episode of deep vein thrombosis in patient with Protein S deficiency
D. For a hypertensive 50 year old patient with atrial fibrillation
E. For 6 months following the diagnosis of pulmonary embolism - Which medication below is strongly contraindicated in hypertrophic cardiomyopathy [5]:
A. Diltiazem (Cardizem®, others)
B. Propranolol (Inderal®)
C. Verapamil (Calan®, others)
D. Nifedipine (Procardia®, others)
E. Digoxin (Lanoxin®, others) - A 50 year old patient presents with an anterior myocardial infarction. He receive thrombolytic therapy is doing well. On day 3 he suddenly becomes acutely tachycardic, drops his blood pressure to 75/30, and has distended neck veins. Administration of 2 liters normal saline increases the blood pressure to 95/50. The most likely diagnosis is [6]:
A. Cardiac Tamponade due to myocardial wall rupture
B. Cardiac Tamponade due to Post-Myocardial Pericarditis
C. Septal Perforation
D. Acute papilary muscle rupture
E. Acute pulmonary edema due to ventricular failure - Which of the following is NOT a risk factor for myocardial infarction (MI) [7] ?
- A 55 year old patient presents to the emergency room with headaches, a blood pressure of 220/115mm Hg equal in both arms, a pulse of 110 bpm, mildly diaphroetic, and mild abdominal pain. The patient has a history of hypertension, mild renal insufficiency (baseline creatinine 1.9mg/dL) and mild chronic obstructive pulmonary disease. The most appropriate initial tests are [8]:
A. Urinalysis, Renal Function Tests, and Chest Radiograph
B. Urinalysis, Renal Function Tests, and Electrocardiogram
C. Electrocardiogram, Renal Function Tests, and Chest Radiograph
D. Electrocardiogram and Abdominal Computerized Tomographic Scan
E. Urinalysis, Renal Function Tests, and Blood Gas - Intravenous nitroglycerin is administered in the emergency room in order to reduce the blood pressure. The patient is then move to the intensive care unit. The creatinine is found to be 3.1mg/dL. An electrocardiogram shows 0.5mm diffuse ST segment depression and non-specific T wave changes. The blood pressure is 190/105 in both arms. The most appropropriate medication is [9]:
A. Nifedipine, sublingual
B. Nitroprusside intravenously
C. Continue the intravenous nitroglycerin
D. Enalapril 0.125mg intravenously followed by 2.5mg orally
E. Fenoldopam (Corlopam®) - The blood pressure is controlled in the intensive care unit; myocardial infarction is ruled out. The patient is switched over to oral medications, including a thiazide diuretic, a low dose of angiotensin converting enzyme (ACE) inhibitor and a ß-adrenergic blocker. All three medications are required to adequately control the blood pressure to <150/85. The pulse is 75 bpm and regular. The serum creatinine falls to 2.3mg/dL and is stable. The serum electrolytes are notable for a slightly low potassium (3.4mM) with normal sodium (139mM). Urine electrolytes show a sodium of 11mM, potassium 95mM, creatinine 1.07mg/dL. The most likely diagnosis is [10]: A. Cushing's Syndrome
I. Immediate (emergent) cardioversion and FurosemideII. Digoxin iv and Furosemide (Lasix®)III. Diltiazem iv and FurosemideIV. Digoxin iv and Furosemide and Nitrates
V. Diltiazem iv and Furosemide and Nitrates
A. I, II or III are appropriate treatments
B. I or III are appropriate treatments
C. II or IV are appropriate treatment
D. V alone is the appropriate treatment
E. Any of the treatments listed is appropriate
I. DobutamineII. Dobutamine + AtropineIII. ArbutamineIV. Norepinephrine
V. Dopamine
A. I, II or III are suitable for stress echocardiography
B. I or III are suitable for stress echocardiography
C. II or IV are suitable for stress echocardiography
D. V alone is suitable for stress echocardiography
E. Any of the agents are suitable for stress echocardiography
I. Left Ventricular HypertrophyII. End Stage Renal DiseaseIII. Cocaine AbuseIV. Diabetes mellitus
V. Moderate Ingestion of Alcoholic Beverages (2-3 standard drinks per day)
A. I, II, and III are NOT risk factors for MI
B. I and III are NOT risk factors for MI
C. II and IV are NOT risk factors for MI
D. V alone is NOT a risk factor for MI
E. All are risk factors for MI
B. Renal Artery Stenosis
C. Hyperaldosteronism (Conn Syndrome)
D. Hyperthyroidism
E. Pheochromocytoma
