- A 55 year old man with a 40 pack-year smoking history presents with pain in his legs. The pain is present when he walks for about a block, and progressively worsens until he is in severe pain after a block and one-half. He sits down, and the pain subsides after about 30 minutes. He has also noted decreased sensation in his feet, right worse than left. On examination, the blood pressure is 150/92mm, pulse 84, respirations 16, temperature 98.2°, there is a II/VI systolic ejection murmer at the left upper sternal border. The radial, carotid, and femoral pulses are 2+ bilaterally. The right dorsalis pedis and tibialis anterior pulses are absent, and the left dorsalis pedis pulse is 1+ with an absent tibialis anterior. The right foot is ashen colored, cool to touch, and there is decreased sensation but normal strength. There is no cord or Homan's sign bilaterally. The most appropriate therapy is [1]:
A. Risk factor modification; begin aspirin 325mg orally each day
B. Risk factor modification; begin pentoxyphylline (Trental®) 400mg orally four times per day
C. Prescribe an exercise program and begin aspirin; nicotine patch for smoking cessation
D. Referral for immediate vascular surgery consultation and possible intervention
E. Referral for vascular surgery consultation within 1 month; begin aspirin 325mg each day - The recommended therapy for treatment of first episode of uncomplicated proximal (thigh) deep vein thrombosis with no obvious underlying medical condition is [2]:
A. Warfarin therapy with a target INR (International Normalization Ratio) of 3-4 for 3 months
B. Warfarin therapy with a target INR (International Normalization Ratio) of 2-3 for 3 months
C. Aspirin therapy, 325mg orally once per day for 3 months
D. Aspirin therapy, 650mg orally once per day for 3 months
E. Combination of aspirin; 325 orally each day and warfarin (INR 2-3) for 3 months - A 69 year old man is brought to the emergency room with severe pain in the chest radiating to the back. The pulse is 120 bpm and regular, blood pressure is 180/100 in the right arm and 210/120 in the left arm, respirations 36 per minute. The patient is diaphoretic and terrified. The remainder of the exam is notable only for decreased lower extremity pulses including the femoral pulses. An anterior-posterior chest radiograph done in the emergency room shows aortic calcification but is considered otherwise normal. An electrocardiogram shows ischemia in the inferior leads. The next diagnostic step is [3]:
A. Immediate coronary angiography
B. Magnetic Resonance Angiography of the chest
C. Repeat chest radiography with lateral views
D. Exploratory Thoracotomy
E. Transesophageal Echocardiography - The most appropriate therapy for the above patient is [4]:
A. ß-adrenergic blockade
B. ACE Inhibition
C. Reserpine
D. Nitroglycerin paste
E. Clonodine - A 54 year old man with a history of smoking and hypertension undergoes aorto-bifemoral bypass surgery for severe peripheral vascular disease. Thirty six hours after the proceedure he is recovering well but develops acute pain in his right 1st and 3rd toes. There are purpuric spots in the painful areas. His blood pressure is 100/60mm, pulse 110 per minute, temperature 100.2°F (tympanic), respirations 22 per minute. The surgical scars appear to be healing well, and the physical examination is unremarkable except for the distal lesions. The white blood cell count is 14K/µl with 78% mature neutrophils, 2% immature (band) neutrophils, 10% lymphocytes, 4% monocytes, 5% eosinophils and 1% basophils. The most likely diagnosis is [5]:
A. Addisonian Crisis
B. Cholesterol Emboli
C. Bacterial Endocarditis
D. Atrial Myxoma
E. Septic Shock - Migratory Thrombophlebitis (Trousseau's Syndrome) is NOT commonly associated with which of the following [6]:
A. Pancreatic Carcinoma
B. Behcet's Disease
C. Thromboangiitis Obliterans
D. Acute Myelomonocytic (M4) Leukemia
E. Ovarian Cancer - Which of the following has NOT been shown to be beneficial in treating peripheral vascular disease (PVD) [7] ?
A. Angioplasty of femoral stenosis or occlusion
B. Pentoxyphilline (Trental®) Therapy
C. Persantine Therapy
D. Vascular Bypass Surgery
E. Discontinuing Tobacco Abuse (Smoking) - A 45 year old woman with a 20 pack-year smoking history recently returned from Europe with her husband. She developed pain and swelling in her right calf about 10 hours into the return flight. She took three ibuprofen tablets yesterday with little relief and would like your opinion regarding her condition. She has never had a similar problem. There was no fever, chest pain, shortness of breath, abdominal pain, nausea or vomiting. She has no bleeding conditions. She has a history of nasal polyps and allergic rhinitis for which she takes a glucocorticoid inhaler and a cromylin compound. She takes no other medications. She has no drug allergies but is allergic to seafood and certain types of nuts. The most appropriate next step is [8]:
A. Administration of warfarin with a target INR of 2.0-3.0
B. Lower extremity doppler ultrasound study
C. Administration of aspirin
D. Obtain an arterial blood gas and a ventillation-perfusion scan
E. Administration of heparin with a target APTT of 2 times normal - What is the approximate overall likelihood that the patient described above (Question 8) has a pulmonary embolism (without symptoms) [9] ?
A. 80-90%
B. 60-70%
C. 50%
D. 30-40%
E. 20-30% - Of the conditions below, which is LEAST likely to be associated with the development of aneurysms [10] ? A. Polycystic Kidney Disease
B. Marfan's Syndrome
C. Ehlers-Danlos Syndrome
D. Ventricular Septal Defect
E. Takayasu Arteritis
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