Pance review Cardiology and Pulmonology Questions and answers. 2022, 100% rated pass rate.

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Pance review Cardiology and Pulmonology Questions and answers. 2022, 100% rated pass rate. A two-week-old female is being evaluated, and on examination she is noted to have bounding pulses with... a widened pulse pressure. There is a murmur present at the second left intercostal space, and it is described as a rough machinery murmur. Cyanosis is not present. What is the most likely diagnosis in this patient? - ✔✔his patient is exhibiting signs of a patent ductus arteriosus. Atrial septal defects may not have a murmur associated with them early in the infant's life, but may develop four to six weeks after birth and present as a nonspecific systolic murmur. The signs and symptoms of coarctation of the aorta consist of decreased or absent femoral pulses, with a murmur present in the left axilla and the left back. Tetralogy of fallot presents with cyanosis, easy fatigability, dyspnea on exertion, and variable digital clubbing. Ventricular septal defect presents with a holosystolic murmur at the lower left sternal border and a right ventricular heave, but presentation depends on the size of the defect and the pulmonary vascular resistance. The patient with a ventricular septal defect may also present with features of heart failure, failure to thrive, and diaphoresis with feedings. What is the treatment for a patient who has recurrent ventricular tachycardia with no reversible cause, and has failed oral medication therapy? - ✔✔Patients with recurrent symptoms benefit from the implantation of a defibrillator, which will reduce sudden death. Ablation therapy is usually not indicated. In rare cases of patients who do not have any other underlying disease, cardiac transplantation is an option. Pacemakers are options if the underlying rhythm is in need of pacing. An 18-year-old female presents to your office with the complaint of palpitations for the last 2 months. The episodes are frequent and accompanied with lightheadedness and shortness of breath. The patient's mother has taken her pulse when some of the episodes occur and states that the rate gets as high as 170 beats per minute. On exam, she is alert, awake, and oriented. Her resting pulse is 55 and her blood pressure is 122/65. Her lungs are clear throughout, and her cardiac exam revealed a regular rate and rhythm, without murmurs, rubs, or gallops. An ECG is obtained, as shown. Based on her history, physical exam, and ECG, what is the best pharmacologic treatment plan for this patient? - ✔✔This patient is presenting with Wolff-Parkinson-White syndrome, as evidenced by the delta waves on the ECG. These conditions will generally occur in individuals at the onset of early adulthood. Management for this condition pharmacologically includes the use of class IA drugs, such as flecanide. Other choices include procainamide, sotalol, and amiodarone. Digoxin therapy may worsen and widen the QRS complex and place the patient into a ventricular tachycardia. A 57-year-old man with a history of HTN, hyperlipidemia, and chronic tobacco use, presents to the office with complaints of chest tightness that occurs every time he begins raking leaves. If he stops and rests, it is relieved within 5 minutes. He has no associated nausea or diaphoresis, but does admit to associated dyspnea. Which of the following is the most appropriate next step in the management of this patient? - ✔✔exercise nuclear stress testing, would provide information regarding exercise tolerance and exercise-induced dysrhythmias, as well as information regarding myocardial ischemia. Choice A, cardiac catheterization, would be utilized in patients diagnosed with acute myocardial infarction or after a stress test suspicious for myocardial ischemia. Choice C, Holter monitor, is a useful diagnostic tool for the evaluation of patients with palpitations occurring on a daily basis. Choice D, tilt table testing, is utilized in evaluation of patients suffering from near-syncope or syncope. Choice E, transesophageal echocardiogram, is helpful in more direct visualization of heart valves, especially when transthoracic echocardiogram is unclear. (Fauci et al., 2008, Chapter 238) A 4-year-old male has been experiencing a significant cough for the last 12 to 14 days, and initial episodes of coughing are characterized as frequent outbursts of 5 to 10 spastic coughs in a row. The patient does not report any fever, but does note that the coughing is worse at night. On examination, the patient is alert, awake, and oriented. His temperature is 97.70F, pulse rate is 89, respiratory rate is 16, and blood pressure is 110/56. The HEENT is unremarkable, and lung sounds are clear to auscultation. You suspect that the patient may have an acute case of pertussis. Based on the history and physical exam findings, which is the test of choice for confirming a diagnosis of pertussis? - ✔✔A special medium culture plate (such as a Bordet-Gengou agar) is required for the nasopharyngeal swab for the diagnosis of pertussis. Throat culture, chest x-rays, and complete blood counts are helpful in ruling out other disease patterns. What is the peak incidence of age for a patient who presents with acute rheumatic heart disease? - ✔✔The bulk of the cases of acute rheumatic fever are within the pediatric population. It is rare in younger children, as well as in adults over the age of 40. Following emergent appendectomy, a 58-year-old obese male develops a temperature of 102.4˚F, 18 hours postoperatively. His respiratory rate is 26 and his pulse is 116bpm. A physical exam reveals scattered fine rales. What is the most likely diagnosis? - ✔✔Pulmonary alveoli collapse, also known as atelectasis, occurs during operative procedures for a variety of reasons, including decreased clearance of secretions and decreased intra-alveolar pressure. Postoperatively, often due to pain, patients may not mobilize secretions appropriately, also contributing to atelectasis. Atelectasis is the most common postoperative pulmonary complication, and is often associated with emergent and prolonged surgeries, especially those of the thorax and abdomen. Atelectasis is associated with fever, an increased respiratory rate, an increased pulse, and lung exam findings ranging from normal to rales and decreased breath sounds. Symptoms usually present within the first 48 hours postoperatively. Pulmonary aspiration pneumonitis, although possible, is less likely due to appropriate preoperative and intraoperative measures being utilized to decrease risk. Pneumonia is also a common postoperative complication, due to the same contributing factors as atelectasis. Physical exam findings may also be similar. However, postoperative pneumonia is likely to become evident between 24 and 96 hours postoperatively. A postoperative pleural effusion may form, due to free peritoneal fluid as well as a complication of atelectasis, but has a lower incidence of occurrence than atelectasis alone. Patient symptoms will be based upon the size of the effusion, associated inflammation, and whether or not the effusion is infectious. Consideration must be given to pulmonary emboli for any post-surgical patient with tachypnea, tachycardia, and dyspnea. Pulmonary emboli may occur at any point postoperatively, but atelectasis remains a more common cause of postoperative fever and respiratory changes. A 57-year-old man with a history of HTN, hyperlipidemia, and chronic tobacco use presents to the office with complaints of worsening chest tightness over the last 2 months. He initially noticed that every time he raked leaves he had a few minutes of chest tightness, which was relieved within 5 minutes if he rested. He now notices that raking will precipitate severe chest discomfort, diaphoresis, and dyspnea, which lasts for 20 minutes even if he rests. Last night, while watching football, he again noticed chest tightness, which began suddenly and slowly dissipated over 15 minutes. His physical examination is normal. Which of the following is the most likely diagnosis? - ✔✔Choice E, unstable angina pectoris, is based on clinical presentation, and requires chest or arm discomfort or an anginal equivalent, that either occurs at rest or with minimal activity lasting for at least 10 minutes, recent onset of severe chest discomfort, or anginal equivalent, and/or chest discomfort or anginal equivalent that has progressively been increasing in either severity, frequency, or duration. Choice A, pericarditis, would present with chest discomfort that is worse while supine and improves while sitting forward, as well as a pericardial friction rub. Choice B, acute myocardial infarction, requires troponin elevation to establish the diagnosis. Choice C, stable angina pectoris, is chest or arm discomfort that is reliably precipitated by activity and/or emotional distress, and relieved with rest or sublingual nitroglycerin. Choice D, prinzmetal angina, or variant angina pectoris, is defined as a coronary artery spasm associated with ST-segment elevation, usually occurring at rest and frequently at the same time of the day. Which of the following is the most reliable clinical tool for confirming endotracheal intubation in an emergency situation? - ✔✔Clinical assessments and practices used to assess tube placement, and help with placement, such as auscultating for breath sounds and noise within the stomach, have not had a confirmation rate comparable to directly visualizing the tube passing through the vocal cords. Tube condensation may occur with esophageal intubation as well. The Sellick maneuver may help with correct positioning, but is not a confirmatory test. Once placement is suspected, confirmation with an end-tidal CO2 detector and chest x-ray is recommended. Pulse oximetry measurement should be performed throughout the intubation, with decreased saturations representing a worsening clinical condition and/or esophageal intubation. A 24-year-old man with a recent history of a viral illness comes to the emergency room complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. On physical examination, the patient's temperature is 39°C, blood pressure is 135/78, with a pulse of 85 bpm, and a pericardial friction rub is noted. Laboratory findings demonstrate elevated serum creatine kinase levels and normal serial troponin levels. Which of the following would be the most likely electrocardiographic findings? - ✔✔In a patient with these signs, symptoms, and lab findings, acute pericarditis is the most likely diagnosis. In patients with acute pericarditis, EKG changes occur secondary to inflammation of the subepicardium, leading to widespread elevation of the ST segments, often with upward concavity, which returns to normal after several days, followed by T wave inversion. No significant QRS complex changes are noted, so choice C, the development of inferior Q waves (frequently associated with an inferior myocardial infarction), is incorrect. Choice B is frequently noted with severe hyperkalemia. Loss of R-wave amplitude, choice D, is associated with myocardial infarction. Choice E, U waves, are associated with hypokalemia. A 62-year-old African-American male is seen for his yearly physical exam. He has no complaints. He denies any current medications or medical problems, but the occupational medicine nurse has taken his blood pressure several times in the past year and told him it was high. He denies any tobacco or alcohol use. His blood pressure is 156/92 today. What is the most likely cause of his elevated blood pressure? - ✔✔The most common cause of hypertension (HTN) is essential, also known as primary hypertension, making up about 95% of patients with hypertension. Secondary causes of hypertension are less common and include sleep apnea, primary aldosteronism, pheochromocytoma, and renal artery stenosis. There is no reason to suspect these other causes in this patient, who is otherwise healthy with stage 1 hypertension based on the stated history. A 4-month-old male presents for a well child check. He is healthy and the mother feels that the child is eating and growing well. On examination, there is no evidence of cyanosis. The peripheral pulses are normal and equal. There is a medium-pitched harsh pansystolic murmur that is heard best at the left sternal border at the fourth intercostal space. There is no heave or thrill present. The murmur radiates over the entire precordium and the S2 is physiologically split. What is the most likely finding on ECG? - ✔✔In this scenario the patient most likely has a small left-to-right shunt of a ventricular septal defect, given the clinical exam findings. The ECG is most frequently normal in a patient with a small ventricular septal defect. If the patient had a large left-to-right shunt left ventricular hypertrophy would be a possibility. The other choices are not commonly seen on ECG when a ventricular septal defect is present. What is the recurrence rate of an individual with a pneumothorax? - ✔✔The recurrence rate of 30% is usually either seen right after chest tube removal by observation or by obtaining serial chest radiographs. These recurrences can be observed immediately or by delay, sometimes several weeks to months after the initial event. Once corrected by surgery the recurrence is dramatically reduced. A 24-year-old HIV-positive man comes to the emergency department complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. On physical examination, the patient's blood pressure is 135/78, with a pulse of 85 bpm, and a pericardial friction rub is noted. Laboratory findings demonstrate elevated serum creatine kinase levels and normal serial troponin levels. His EKG demonstrates peaked T waves. His CXR demonstrates no acute process. Which of the following is the most likely diagnosis in this patient? - ✔✔this patient is exhibiting signs, symptoms, and EKG findings pathognomonic for acute pericarditis, which is likely infectious in the setting of a patient with HIV. A pericardial friction rub is heard best with the patient in a seated position, during expiration, and is frequently found in patients with pericarditis. Choice B, an acute myocardial infarction, is less likely in a patient of this age, especially with normal serial troponins. Acute pericarditis can sometimes present with elevated serum creatine kinase levels when the epicardium is also involved. Choice C, acute bacterial endocarditis, is less likely in a patient with these EKG changes. Choice D, aortic dissection, would present with chest pain; however, the patient would be markedly hypotensive, less stable on presentation, and a CXR would demonstrate widening of the superior mediastinum. A 62-year-old man with a history of hypertension, diabetes mellitus type 2, hyperlipidemia, and chronic tobacco use presents to the office with complaints of a retrosternal chest pressure, associated with diaphoresis, nausea, and dyspnea, radiating down his left arm for the last 45 minutes after mowing his lawn. The patient's vital signs are stable, and on physical examination a new systolic murmur is appreciated. His EKG demonstrates evidence of acute anterolateral myocardial infarction on EKG, with ST segment elevation across the precordial leads, indicative of left anterior descending coronary artery stenosis. Which of the following cardiac markers would be expected to remain elevated one week later? - ✔✔Troponin elevation in acute myocardial infarction may be noted within two hours after myocardial infarction. It is usually elevated within 6 to 10 hours, peaks at 12 hours, and may remain elevated for 7 to 10 days; thus, choice B is the answer. Troponin elevation is rapidly replacing CK-MB as the diagnostic cardiac marker of choice for AMI. Choice A, CK-MB, peaks earlier than creatine kinase, and is cleared within two days. Choice C, BNP, is a cardiac marker followed in patients with congestive heart failure, and unless the patient develops heart failure in the next 7 days, is unlikely to be elevated. Creatine kinase becomes elevated within 4 to 8 hours, peaks within 12 to 24 hours, and returns to normal within 3 to 4 days. Serum myoglobin levels rise within 3 hours of symptoms and are elevated at 6 to 8 hours. Myoglobin peaks at 4 to 9 hours, and, with normal kidney function, returns to baseline within 24 hours. A 63-year-old woman presents with shortness of breath, cough, and proximal muscle weakness of 1-month duration. On clinical exam, she is noted to have a blood pressure of 156/102 mm Hg, facial flushing, mild hirsutism, truncal obesity, marked proximal muscle weakness of both the upper and lower extremity, and hyperpigmentation over the palms and back of the neck. Laboratory exam reveals hypercortisolism and increased ACTH. Which of the following would be the most likely primary diagnosis in this patient? - ✔✔Tumor cells may secrete hormones that have the same biologic actions as the normal hormone. This patient's symptoms are consistent with adrenocorticoid hyperfunction. The most common cause of ectopic ACTH syndrome is small cell lung carcinoma. This should be suspected in any patient with risk factors for lung cancer. A 66-year-old man with a history of a cardiac murmur since childhood presents with complaints of increasing dyspnea while walking up one flight of stairs and increased lower extremity edema. On physical examination, a late-peaking crescendo-decrescendo murmur, preceded by a systolic ejection click, is noted. An S4 gallop is appreciated. Hepatomegaly and splenomegaly are appreciated. An EKG demonstrates right ventricular hypertrophy, and no acute ST or T wave changes. Which of the following is the most appropriate next diagnostic study? - ✔✔transthoracic echocardiogram, is a simple, sensitive and non-invasive diagnostic tool, which can evaluate for the presence of valvulopathy. However, in patients with pulmonic stenosis, it offers limited direct visualization of the pulmonic valve, and although it is the most appropriate next diagnostic study it is usually followed by other diagnostic procedures, such as transesophageal echocardiogram, which offer better visualization of the pulmonic valve directly. Choice A might be able to give evidence of cardiomegaly, or calcification of heart valves, but would not be sensitive enough to detect the degree of valvulopathy if present. Choice C is a useful diagnostic tool for the evaluation of patients complaining of palpitations, but is incorrect for this patient who has no symptoms of palpitations. Choice D, although a useful diagnostic tool for the evaluation of exercise tolerance and in patients complaining of chest pain, does not allow direct visualization of the heart valves to evaluate the degree of pulmonic stenosis. Choice E, cardiac catheterization in patients demonstrating severe pulmonic stenosis, is not only diagnostic, but also therapeutic, as percutaneous balloon valvuloplasty is the preferred method of treatment for critical pulmonic stenosis. A 78-year-old Caucasian female has a 3-year history of stiffness and achiness of bilateral shoulders and hips. She has been tested for rheumatoid arthritis in the past and has been found negative. Multiple radiographs of her hips and shoulders are unremarkable. She admits that she was placed on prednisone for an allergic reaction and noted a temporary resolution of her symptoms. For the past two weeks she complains of increasing symptoms now involving her neck and pain in her jaw with chewing. Today she noticed that her scalp is sore when she brushed her hair on the right side. What test is the gold standard for diagnosis of this patient's current symptoms? - ✔✔This patient has long standing symptoms of polymyalgia rheumatica (PMR) with current symptoms suggestive of giant cell (temporal) arteritis. Temporal artery biopsy is considered the gold standard for diagnosis of giant cell (temporal) arteritis. Patients with temporal arteritis may have an elevated erythrocyte sedimentation rate (ESR) or CRP, but this is not required for diagnosis. A color ultrasound of the temporal artery will sometimes show edema or stenosis of the affected artery but is not very sensitive for giant cell arteritis. MRA is used for diagnosis of larger arteries with vasculitis and not routinely used in the diagnosis of temporal arteritis. A 44-year-old female complains of nonproductive cough for the past 6 months. She denies rhinorrhea, wheezing, dyspnea, chest pain, or hemoptysis. Her medical problems include hypertension. Medications include benazepril 10 QD, Amlodipine 5 mg QD, and HCTZ 25 mg QD. She is a nonsmoker and denies any foreign travel. - ✔✔ACE inhibitors such as benazepril have a potential adverse reaction of a chronic cough. Discontinuing the ACE inhibitor is appropriate in this case while substituting this for another antihypertensive. The CXR is normal and there are no findings suggestive of pneumonia, bronchiectasis, or asthmatic bronchitis. A chronic cough is not a significant side effect of amlodipine. A 55-year-old woman with a history of emphysema, who is undergoing chemotherapy for lung cancer, is sent to see you by her oncologist regarding a sudden increase in dyspnea, with exertion and fatigue. On physical exam, a drop in systolic blood pressure of 20 mm Hg is noted upon inspiration. What is this physical exam finding known as? - ✔✔Pulsus paradoxus is defined as a decrease in systolic arterial pressure of greater than 10 mmHg. It is an accentuation of the normal decrease in systolic arterial pressure of less then 10mm Hg that normally accompanies inspiration. It is frequently noted in patients with pericardial tamponade. Pulsus parvus means a small weak pulse. Pulsus alternans is noted in patients who despite a regular rhythm, demonstrate a regular alteration of the pressure pulse amplitude. This is frequently found in patients with severe left ventricular systolic dysfunction. A bisferiens pulse is a pulse with two systolic peaks, commonly seen in patients with aortic regurgitation or hypertrophic cardiomyopathy. Two days following an uneventful 4-vessel CABG, a 57-year-old man develops a sudden onset of lightheadedness and palpitations. His vital signs are stable, and physical examination demonstrates no abnormalities. Given the results of his EKG, as shown (Figure 2), which of the following is the most appropriate next step in management? A. Direct-current cardioversion B. Nitroglycerin patch C. Digoxin 0.125 mg PO daily D. Neurology consult E. Meclizine 25 mg PO Q6H - ✔✔Among the choices offered here, choice A is the most appropriate next step in management of a patient with new onset atrial flutter, as determined by EKG; it most effectively converts most patients to normal sinus rhythm. Choice B is inappropriate, as the patient is not demonstrating angina pectoris, and the EKG does not demonstrate evidence of ischemia or infarction. Choice C is inappropriate, as it is the least effective agent for slowing the ventricular response when compared to beta blockade or calcium channel blockers, all of which act by blocking the AV node (digixon may occasionally convert atrial flutter to atrial fibrillation). Choice D is inappropriate, as the patient's symptoms of lightheadedness do not stem from neurologic changes. Choice E is inappropriate, as the patient's symptoms do not stem from vertigo. A 65-year-old recent alcoholic comes to the emergency department with recent onset of dyspnea with exertion, 3 pillow orthopnea, lower extremity edema, and palpitations, in which he describes his heart as racing. Which of the following is the most appropriate treatment for his high-output congestive heart failure? A. IV dextrose alone B. IV thiamine C. IV enalapril D. IV dopamine E. IV diltiazem - ✔✔Choice B is the most appropriate treatment, as the patient is demonstrating high output congestive heart failure secondary to beriberi, or thiamine deficiency. In 50% of patients, IV thiamine administration, along with other vitamins and glucose, will resolve the patient's symptoms. Choice A, IV dextrose alone in patients with very low thiamine stores, can worsen signs and symptoms of heart failure. Choice C, IV enalapril, is appropriate therapy for patients in need of better blood pressure control, and as an ACE inhibitor, in patients with left ventricular systolic dysfunction, which is not the cause of this patient's heart failure. Choice D, IV dopamine, is useful in patients in need of pressor support, but will not help treat high-output heart failure secondary to thiamine deficiency. Choice E, IV diltiazem, is useful for heart rate control in patients with atrial fibrillation with a rapid ventricular rate. Which of the following is the most prevalent cause of chronic respiratory acidosis? A. Anemia B. Cerebrovascular accident C. Chronic obstructive pulmonary disease D. High altitude E. Pneumonia - ✔✔Respiratory acidosis is associated with elevated PaCO2 levels, due to the inability of elimination to keep pace with production. This may be due to a decreased rate of ventilation due to control alteration, decreased ventilatory muscle strength, underlying lung disease, or a systemic insult such as infection or medication. Chronic respiratory acidosis is generally due to underlying lung disease, with the most prevalent cause being chronic obstructive pulmonary disease (COPD). High altitude, pneumonia, and severe anemia are associated with respiratory alkalosis. Cerebrovascular accidents may be associated with either respiratory acidosis or alkalosis, depending on the location, extent, and impact. A 28-year-old patient who is a fire department paramedic presents for a routine physical examination to your family practice office. They are asymptomatic but their PPD is positive. Suddenly, they relate that they have tested positive "about five years ago" and that they were treated at that time with nine months of INH. What should your next step be in treating them? - ✔✔Health care workers (HCWs) with positive PPD test results should have a chest radiograph as part of the initial evaluation of their PPD test; if negative, repeat chest radiographs are not needed unless symptoms develop that could be attributed to TB. However, more frequent monitoring for symptoms of TB may be considered for recent converters and other PPD-positive HCWs who are at increased risk for developing active TB (e.g., HIV-infected or otherwise severely immunocompromised HCWs). Regardless of whether the patient completes treatment for latent TB infection, serial or repeat chest radiographs are not indicated unless the patient develops signs or symptoms suggestive of TB disease. A 45-year-old male with asthma and diabetes is diagnosed with influenza B by nasal swab. He has been ill for one and a half days. Which of the following is indicated for treating this patient? A. Acyclovir B. Amantadine C. Nevirapine D. Oseltamivir E. Zanamivir - ✔✔The neuraminidase inhibitors, including oseltamivir and zanamivir, are associated with a reduction in duration of illness, and secondary complications for both influenza A and B viral strains. However, zanamivir, due to the oral inhalation delivery route, is relatively contraindicated in this patient, due to his history of asthma and an associated increased risk of bronchospasm. Amantadine is inactive against influenza B, as well as certain influenza A strains. Nevirapine is an antiretroviral agent used in the treatment regimen for HIV. Acyclovir is an antiviral agent, but is not indicated for influenza. A 29-year-old female has a long history of supraventricular tachycardia, for which she has been treated with long-term flecanide, as well as prior therapy with verapamil. She continues to have repeated episodes, sometimes two to three times a week, along with shortness of breath and at times hypotension that has been recorded. What is the next best therapy for this patient? - ✔✔After exhaustion of non-invasive therapies, ablation therapy can be used to try to negate the aberrant pathway for SVT. Pacemakers will not allow for an override of the pathway, and cardioversion is only a temporary solution to an acute event. Implantable telemetry monitoring is only diagnostic and not therapeutic to treat. A 68-year-old woman with a history of hypertension and diabetes mellitus type 2 comes to the emergency department with her son, who noticed that while decorating for Christmas she seemed more dyspneic than normal, and had to sit down frequently. In addition, he noticed that she was pale and diaphoretic, and insisted on driving her to the emergency department. On questioning, she denies chest pain, but admits to being more fatigued than usual, with frequent jaw discomfort during activity. Activities such as vacuuming her house cause dyspnea, and she now has to stop several times while carrying laundry up from the basement. On physical examination, the patient's blood pressure is 90/50, pulse 99 bpm, respirations 22, and she is afebrile. Auscultation of the chest demonstrates a new systolic murmur. An EKG demonstrates normal sinus rhythm with nonspecific ST and T wave changes. Which of the following would be the most appropriate next step in the management of this patient? - ✔✔checking serial serum troponin levels, is the most appropriate next step in the management of this patient. Women and diabetics may present with atypical symptoms with acute non-ST-segment myocardial infarction, including dyspnea, jaw discomfort, and epigastric discomfort. Frequently, women present much later than men with these symptoms. Therefore, a high level of suspicion should be maintained when women present with symptoms of dyspnea, even in the setting of nonspecific EKG changes, and drawing serum troponin levels before any other testing is recommended. Once non-ST-segment myocardial infarction has been ruled out, choices E and B, and also transthoracic echocardiogram, would likely be evaluated. Transesophageal echocardiogram may be required if better visualization of the heart valves is required, but not as the next step. Choice C, cardiac catheterization, would likely occur if an abnormal stress test demonstrating symptoms of myocardial ischemia is found. Which of the following is a major contraindication for surgical resection of a lung carcinoma? A. Chest wall invasion B. Pleural effusion C. Superior vena cava syndrome D. Unilateral endobronchial tumor E. Vagus nerve involvement - ✔✔Surgical resection of lung carcinoma is contraindicated in cases of superior vena cava syndrome, extrathoracic metastases, heart, pericardial or great vessel involvement, recurrent laryngeal or phrenic nerve involvement, esophageal or carina involvement, malignant effusion, or contralateral mediastinal lymph nodes. Other contraindications are patient and staging dependent. A 76-year-old man with a history of HTN and diabetes mellitus, type 2, presents to the emergency department with complaints of palpitations, tachypnea, and chest pain. He denies history of CAD, stroke, TIA, or congestive heart failure. He is afebrile, with vital signs as follows: BP 145/98, HR 138, and RR 22. His EKG is shown (Figure 1). Troponins are negative X 1. His echocardiogram demonstrates normal LV systolic function and normal valvular function. Which of the following would be considered the most appropriate long-term anti-coagulation therapy for him? - ✔✔warfarin 5 mg dosed to INRs between 2.0 and 3.0, is correct because the patient demonstrates non-valvular atrial fibrillation, and has a CHADS2 score of 3 (1 pt each for age > 75 years old, HTN, and diabetes), placing him at a higher risk for thromboembolism. Choices A, B and E are incorrect because there is no research data to suggest that Plavix, Aspirin, or Aggrenox is of value in the prevention of thromboembolism in atrial fibrillation. Choice C is appropriate therapy following PTCA and placement of a drug-eluting cardiac stent. A 67-year-old female with a history of hypertension and non-insulin dependent diabetes mellitus (NIDDM) returns to the internal medicine office for a review of her labs. Her total cholesterol = 250 mg/dl, HDL = 35mg/dl, LDL = 200mg/dl. What is this patient's optimal treatment goal?A. TC < 200 B. HDL < 30 C. LDL < 130 D. TC < 160 E. LDL < 70 - ✔✔The correct answer is (E). This patient has a significantly elevated LDL and risk factors for coronary artery disease (CAD) including NIDDM and hypertension. Her cholesterol should ideally be treated to reduce the LDL below 70 mg/dl due to her risk of CAD. Reduction of total cholesterol is not significant for reducing her CV risk if the LDL is still elevated. HDL has a protective effect and should be increased. What is the hallmark finding on an EKG that is consistent with Wolff-Parkinson-White syndrome? A. Prolonged PR interval B. Long QT interval C. Widened QRS complex D. Sinus arrhythmia E. Delta wave formation - ✔✔The delta wave appears as an up sloping curvature that begins the QRS complex (as seen on the ECG shown). A 27-year-old African American female presents to the emergency department with low blood pressure of 100/40, palpitations, and shortness of breath. She is currently under treatment for Wolff-Parkinson-White syndrome and has been taking procainamide for the last two years. An electrocardiogram is obtained on the monitor and reveals the rhythm strip shown. What is the treatment of choice for this patient? A. Intravenous calcium B. Intravenous magnesium C. Oral potassium D. Subcutaneous epinephrine E. Metoprolol - ✔✔The rhythm strip reveals ventricular tachycardia in the form of torsades de pointes. In this case, the primary medical intervention is to administer magnesium sulfate to counter the irregular activity. Antiarrhythmics, antidepressants, and some antibiotics can be responsible for this arrhythmia. In addition to the magnesium, administration of beta-blockers can also be helpful. A 17-year-old female presents to your family practice office for the annual physical examination required by her cheerleading coach. Upon examination you note that her joints are more flexible than anticipated. You also note her long thin fingers. You listen to her heart and hear no murmurs. Her blood pressure is 105/65 mmHg, pulse 60 beats/min and regular, respirations of 15 breaths/min, and temperature 98.7˚F. As you are examining her she tells you that her "joints sprain and strain easily." Furthermore, you obtain family history and she tells you that some connective tissue disorder runs in her family. Before you can medically clear her you should do which of the following? A. This patient does not require any further evaluation. B. Obtain an echocardiogram. C. Perform and EKG. D. Perform a chest radiograph. E. Refer her to a rheumatologist. - ✔✔This patient has clear signs and symptoms that are suspicious for Marfan syndrome. The complications of Marfan syndrome include cardiovascular issues, especially valvular and aortic disease. An electrocardiogram is an appropriate noninvasive initial first-step to begin your investigation to rule out significant valvular and/or aortic root abnormalities. A 44-year-old female is involved in a motor vehicle accident, during which she suffered blunt trauma to the left chest and abdomen from the car door. She presents via rescue with marked dyspnea, tachypnea, and an oxygen saturation of 87% on room air. You obtain the chest x-ray shown. Based on the following x-ray, what is the diagnosis? - ✔✔Diaphragmatic rupture is often the result of direct injury to the diaphragm or increased intra-abdominal or intrathoracic pressure. Patient symptoms are often the result of impaired lung expansion and decreased oxygenation. Additional symptoms may include bowel obstruction or other nonspecific bowel complaints. The chest x-ray shows elevation and irregularity of the left diaphragmatic border, with decreased left lung volume. Also of note is a widened mediastinum, which may suggest additional injury, including to the aorta. Lung markings extend through the lung space, which is not consistent with a hemothorax or pneumothorax. Evaluation for a pericardial effusion and/or pericarditis should be performed on this patient, based on the history, with evaluation including echocardiography and EKG. The typical x-ray result for pericardial effusion is termed a "water bottle" heart. However, this would be difficult to assess in the setting of a diaphragmatic rupture. Cor pulmonale is not associated with trauma, and is due to lung disease or pulmonary vascular disease. What is the treatment of choice for rheumatic fever? A. Macrolides B. Cephalosporin C. Fluoroquinolone D. Aminoglycosides E. Penicillin - ✔✔The goal is to eradicate the Streptococcus bacteria. Penicillins are the drug of choice, with the dose being benzathine penicillin G, 1.2 million units intramuscularly every four weeks as the ideal regimen. Oral penicillin does not absorb as well and has a weaker effect. The alternative to those with penicillin allergies is erythromycin 250 mg BID. Other alternatives are azithromycin or sulfadiazine. During a hospitalization for acute exacerbation of COPD, troponin levels are drawn on a 62-year-old man with a history of hypertension, hyperlipidemia, and chronic tobacco use, and found to be elevated above the 99th percentile of normal. Which of the following choices would qualify this patient for the most recent ACC/AHA consensus guideline's definition of myocardial infarction? A. Ischemic symptoms B. New right bundle branch-block on EKG C. J wave on EKG D. Pulmonary vascular congestion on CXR E. Elevated WBC count - ✔✔Choice A is the most appropriate choice, as troponin elevation may occur in the setting of patients who do not suffer from acute coronary syndrome. Therefore, the 2007 consensus guidelines recommended that the definition of myocardial infarction be applied to those patients who not only had troponin elevation above the 99th percentile, but also met one of the following criteria: "ischemic symptoms, new left bundle branch block (not right bundle branch-block as in choice B), new ST and T-wave changes, new Q waves, or imaging evidence of a new loss of viable myocardium or new regional wall-motion abnormality." Choice C, J wave, is characteristic of patients with hypothermia. Choice D, pulmonary vascular congestion, is frequently noted on CXR of patients with congestive heart failure. Choice E, an elevated WBC count, is indicative of an infectious process. What is the most common cause of restrictive cardiomyopathy? A. Amyloidosis B. Pericarditis C. Marfans syndrome D. Fatty infiltrative disease E. Sarcoidosis - ✔✔While restrictive cardiomyopathy is seen in such cases as hemochromatosis, glycogen deposition, endomyocardial fibrosis, sarcoidosis, hypereosinophilic disease, and scleroderma, amyloidosis is the most common cause among the choices provided. amyloidosis refers to a variety of conditions wherein amyloid proteins are abnormally deposited in organs or tissues and cause harm. A protein is described as being amyloid if, due to an alteration in its secondary structure, it takes on a particular aggregated insoluble form, similar to the beta-pleated sheet.[1] Symptoms vary widely depending upon where in the body amyloid deposits accumulate. Amyloidosis may be inherited or acquired.[2] A 48-year-old African American male presents with dyspnea, 2-pillow orthopnea, and swelling to his lower legs that has developed over the last month. He also complains of fatigue and decreased exercise tolerance, stating that he has trouble climbing one flight of steps. On physical examination, his blood pressure is 178/98, pulse rate is 102, and respiratory rate is 20. There is 5 cm JVD, crackles at the bilateral lung fields, and tachycardia and an S3 is heard on cardiac auscultation. There is 2+ pitting edema to the lower extremities. His electrocardiogram reveals a sinus tachycardia at a rate of 105 and left ventricular hypertrophy. The chest x-ray reveals cardiomegaly with increased interstitial markings in all lung fields. There is a small right pleural effusion that blunts the costophrenic angle. Which medication is the treatment of choice for controlling this patient's heart rate? A. Amlopidine B. Minoxidil C. Isosorbide mononitrate D. Metoprolol E. Atropine - ✔✔The use of beta-blockers is indicated for heart rate control. The other choices are not indicated for rate control and have no primary action on rate, but rather on blood pressure. A 48-year-old male has a positive PPD and a negative chest x-ray. Which of the following laboratory studies must be conducted before initiating standard isoniazid therapy? A. Complete blood count B. Hepatic function panel C. Lipid profile D. PT/PTT E. Thyroid-stimulating hormone - ✔✔Isoniazid has been associated with hepatotoxicity, as well as severe and sometime fatal hepatitis. Monitoring should begin at initiation and continue throughout the course of therapy. Isoniazid is also associated with peripheral neuropathy development, especially in patients with an increased predisposition for developing a neuropathy. Alteration of renal function and visual changes have also been associated with tuberculosis therapies, indicating that renal function testing and routing eye examination should also be performed. Additional laboratory testing may be utilized for monitoring overall patient health and determining if any other conditions are also associated with the patient, such as the other choices provided. A 66-year-old female patient inquires about receiving the pneumococcal vaccination due to the death of a friend from pneumonia. The patient is healthy and does not have contraindications to the vaccination. Based on current clinical guidelines, which of the following is most appropriate for this patient? A. Inform the patient that she is healthy and does not need vaccination B. Emphasize the influenza vaccination prior to pneumococcal vaccination C. Administer the pneumonococcal vaccination D. Discuss the low prevention rate of the pneumococcal vaccination E. Repeat her pneumococcal vaccination if she had it three years ago - ✔✔Current recommendations include vaccination of all individuals 65 years of age and older if there are no contraindications. Patients aged 19 to 64 with comorbid chronic conditions affecting immunity should also be vaccinated. Revaccination is recommended for patients receiving the initial vaccination between the ages of 19 and 64, with continued immunocompromising conditions or asplenia. A 25-year-old asymptomatic, non-smoking male presents with a 9mm solitary pulmonary nodule, with dense central calcification on routine chest x-ray. The nodule's appearance is smooth and calcified with a well-defined edge. This same lesion was present on a work physical x-ray two years ago. Which of the following is the most appropriate management step for this patient? A. Positron emission tomograph to rule out malignancy B. Resection of the pulmonary nodule C. Thoracic magnetic resonance imaging (MRI) D. Watchful waiting with serial imaging E. Pulmonary function tests - ✔✔A 25-year-old asymptomatic, non-smoking male presents with a 9mm solitary pulmonary nodule, with dense central calcification on routine chest x-ray. The nodule's appearance is smooth and calcified with a well-defined edge. This same lesion was present on a work physical x-ray two years ago. Which of the following is the most appropriate management step for this patient? A. Positron emission tomograph to rule out malignancy B. Resection of the pulmonary nodule C. Thoracic magnetic resonance imaging (MRI) D. Watchful waiting with serial imaging E. Pulmonary function tests A 67-year-old male with a history of dilated cardiomyopathy, 3-vessel coronary artery disease, and an ejection fraction of 20% has a history of palpitations for the last two weeks. A 24-hour Holter monitor is ordered and reveals >1000 episodes of the attached rhythm strip. His blood pressure on examination is 102/62, and his resting pulse is 52. Based on these findings, what is the best therapy to treat the patient's symptoms? - ✔✔: The rhythm strip reveals episodes of non-sustained ventricular tachycardia. Due to the patient having a low ejection fraction with the dilated cardiomyopathy, primary prevention for this patient at a minimum would be to provide him with a biventricular pacer. A 29-year-old female who is only taking oral contraceptives presents to the emergency department with a 1-day history of worsening shortness of breath. On examination, the patient is afebrile, her pulse rate is 105, respiratory rate is 24, and blood pressure is 122/78. She has wheezing to all lung fields and appears to be in mild to moderate distress. There is no swelling or edema to the lower extremities. Based on these findings, what is the best test to order to determine the diagnosis in this patient? A. CT chest B. Chest x-ray C. Ventilation to perfusion scan D. Pulmonary arteriography E. MRI chest - ✔✔This patient presents with a history and physical exam that is consistent with an acute pulmonary embolus (PE). The prognosis for this type of illness can be serious, and in some cases death can result. The test that is still the gold standard for determination of a PE is the pulmonary arteriogram. CT of the chest with contrast tends to be the more utilized testing modality, but the arteriogram remains the test of choice. A soft tissue neck x-ray of a patient who complains of a progressively worsening sore throat reveals this lateral film (see image). Based on these findings, what is the initial treatment of choice for this patient? A. Endotracheal intubation B. Intravenous steroids C. Ribovirin injection D. Incision and drainage E. Cricoidotomy - ✔✔This case of acute epiglottitis is treated with immediate intravenous steroids. Provided that the patient is able to maintain the airway and also keep oxygen saturation rates above 92%, the patient can improve with steroids and supportive care. Antiviral medications have little effect on the overall illness. You are evaluating a 55-year-old female with a history of hypertension. Her blood pressures have been in the 120s to 130s systolic and 60s to 70s diastolic until recently. She notices some days her blood pressure is normal and other days her systolic readings are in the 150s to 160s and wonders if a medication she could be taking might be contributing to the elevation. Her blood pressure today is 142/66. Which of the following medications is most likely to result in her blood pressure being elevated? A. loratadine B. simvastatin C. pseudoephedrine D. acetaminophen E. lisinopril - ✔✔The correct answer is (B). Decongestants, such as pseudoephedrine, are known to increase blood pressure. Discontinuing pseudoephedrine and rechecking the blood pressure off of this medication may provide further information on the need for additional antihypertensive drug therapy. Loratadine, simvastatin, and acetaminophen are not known to cause secondary hypertension. Lisinopril is an ACE inhibitor used to treat blood pressure. A 57-year-old woman with a history of rheumatic fever is seen complaining of dyspnea while vacuuming her apartment, which has been worsening over the last few months. On physical exam, a possible opening snap, loud S1, and a very soft diastolic rumbling murmur is auscultated. Which of the following maneuvers would be the most appropriate to choose to increase the intensity of the murmur for better identification? A. Isometric hand grip exercise B. Listening with the bell at the apex, with the patient in the left lateral decubitus position C. Inspiration, followed by the patient holding his/her breath D. Valsalva maneuver E. Having the patient lie flat with the knees bent - ✔✔Choice B is best used when listening to the murmur of mitral stenosis, which is the murmur auscultated in this patient. Choice A, isometric hand grip exercises, increase the intensity of the murmur of mitral regurgitation by increasing arterial and left ventricular pressure, which increases the flow across the mitral valve, thereby increasing the murmur's intensity. Choice C will increase the AP diameter, making it more difficult to hear the murmur. With the Valsalva maneuver, choice D, the murmur decreases in intensity. Choice E is the best position for the abdominal exam, especially in males. A 55-year-old woman with a history of hypertension and 2 vessel CABG presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that for the last 24 hours she has also noticed palpitations. On physical examination, her vital signs are stable. On EKG, she demonstrates atrial flutter with 2:1 AV block. Her echocardiogram demonstrates normal LV systolic function and normal valvular function. Which of the following is the most appropriate therapy for this patient? A. IV ibutilide after 4 weeks of anticoagulation with warfarin B. IV ibutilide alone C. IV quinidine after 4 weeks of anticoagulation with warfarin D. IV quinidine alone E. IV dopamine - ✔✔Choice B, IV ibutilide, is the most appropriate choice for this patient. Therapy for patients with atrial flutter and atrial fibrillation is the same in regards to anticoagulation; therefore, in a patient with a CHADS2 score of 1 and with symptoms of less than 48 hours duration, cardioversion to normal sinus rhythm, whether chemically or electrically, is recommended. Out of all the choices listed, IV ibutilide has been found to be most effective in converting atrial flutter to sinus rhythm. Choices B and C are contraindicated, regardless of the type of anticoagulation paired with it, as quinidine is a class I antiarrhythmic. The atrial conduction may decrease to the point that 1:1 atrial to ventricular conduction can occur with the administration of class I antiarrhythmics. The ventricular rate can then increase to rates greater than 200 bpm, and hemodynamic collapse may occur. Choice E is useful for pressor support, which is not indicated in this patient who is quite stable. A 24-year-old man with a recent history of a viral illness comes to the emergency department complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. On physical examination, the patient's temperature is 39°C, blood pressure is 135/78, with a pulse of 85 bpm, and a pericardial friction rub is noted. Laboratory findings demonstrate elevated serum creatine kinase levels and normal serial troponin levels. His EKG demonstrates peaked T waves. His CXR demonstrates no acute process. Which of the following is the most appropriate treatment for this patient? A. Morphine B. Enoxaparin C. Nitroglycerin D. Penicillin V E. Indomethacin - ✔✔Choice E, indomethacin 25-75 mg QID, and bed rest would be the most appropriate treatment in a patient with acute viral pericarditis, as a nonsteroidal anti-inflammatory agent will ameliorate the inflammatory process. Choices A and C are appropriate in a patient suspected of acute coronary syndrome. Choice B, enoxaparin, is contraindicated in patients with pericarditis, as anticoagulants could lead to worsening of pericardial effusion and cardiac tamponade, especially if it is secondary to bleeding into the pericardial space, such as with trauma or postoperatively. A 61-year-old man arrives at the emergency department (ED) suffering an acute myocardial infarction as a result of coronary artery thrombosis. One of the agents administered to the patient is a thrombolytic agent. From the choices below, which drug is a thrombolytic agent? A. abciximab B. alteplase C. warfarin D. heparin E. clopidogrel - ✔✔Both warfarin and heparin are anticoagulants that are indicated for the prevention of thrombi. They do not actively lyse clots, but are capable of preventing further thrombogenesis. Both abciximab and clopidogrel are considered antiplatelet agents. Abciximab inhibits the activation of glycoprotein IIb/IIIa receptors on platelets, which helps to reduce platelet aggregation. Clopidogrel blocks adenosine diphosphate (ADP) receptors on platelets. The binding of ADP to these receptors is an important cellular mechanism in stimulating platelet aggregation. Alteplase converts plasminogen to plasmin, which then actively dissolves the fibrin threads associated with a thrombus. A 16-year-old boy is seen for a sports physical prior to starting football. He denies any symptoms. His physical examination is normal, except for a grade II/IV holosystolic murmur auscultated at the cardiac apex. Utilizing isometric hand grip exercises, the murmur increases in intensity and can be heard radiating to the axilla. With the Valsalva maneuver, the murmur decreases in intensity. Given the patient's physical exam findings, which of the following is the most appropriate next diagnostic study? A. Chest x-ray B. Transesophageal echocardiogram C. Holter monitor D. Treadmill exercise stress test E. Transthoracic echocardiogram - ✔✔Choice E, transthoracic echocardiogram, is a simple, sensitive, and non-invasive diagnostic tool that can evaluate for the presence of valvulopathy or congenital heart disease in this young patient. Choice A might be able to give evidence of cardiomegaly, but would not be sensitive enough to detect valvulopathy. Choice C is a useful diagnostic tool for evaluation of patients complaining of palpitations, but incorrect for this patient who has no symptoms. Choice D, although a useful diagnostic tool for the evaluation of exercise tolerance and in patients complaining of chest pain, does not allow direct visualization of the heart valves to evaluate for valvulopathy. A 32-year-old female with history of non-insulin-dependent diabetes mellitus (NIDDM) returns to the clinic for a routine visit. She reports that she her blood sugars have been controlled. However, her vitals today show a blood pressure (BP) of 136/78 P = 72. You note the past three office visits that her blood pressures were in the mid 130s to 140 systolic. She is not currently taking anything for her blood pressure but admits that she has not been exercising as much as usual. What do you advise the patient? A. Advise lifestyle modification and continue to monitor BP next visit. B. Initiate antihypertensive therapy to target BP < 130/80. C. Initiate DASH diet and recheck blood pressure in 6 months. D. Monitor blood pressure next visit, and if > 140/90, initiate antihypertensive therapy. E. Her blood pressure indicates prehypertension, there is no need for treatment other than exercise at this time. - ✔✔The correct answer is (B). According to the JNC-7 guidelines, a patient with diabetes mellitus (DM) or chronic kidney disease (CKD) with this patient's blood pressures should be treated to achieve a goal BP of < 130/80. Although she would be classified as prehypertensive, due to her compelling indication of DM initiation of antihypertensive treatment should begin because she is at higher risk for cardiovascular disease. Lifestyle modifications such as increased exercise, low salt diet, and weight loss are recommended, but in addition to drug therapy at this time due to her increased risk of cardiovascular disease. Which of the following represents a positive tuberculin skin test result? A. A college student with 4mm of superficial erythema at site B. An HIV-positive patient with 2mm induration C. A low-risk individual with a pre-employment test result of 6mm induration D. A nursing home resident with 12mm induration E. A recent immigrant from Mexico with 8mm induration - ✔✔A tuberculin purified protein derivative (also known as a TB test or PPD), is utilized to screen for latent Mycobacterium tuberculosis infection. Guidelines for interpreting test results, based upon induration, patient risk, and patient medical status, are published by the Centers for Disease Control and Prevention (summarized in Table 9-10 below). False-negative reactions may occur in immunosuppresed patients and those with extensive infection. False-positive and false-negative reactions can occur for various reasons, including previous vaccination with bacillus Calmette-Guirein (BCG), which may cause a false-positive. A 62-year-old man with a history of hypertension, diabetes mellitus type 2, hyperlipidemia, and chronic tobacco use presents to the office with complaints of a retrosternal chest pressure radiating down his left arm, associated with diaphoresis, nausea, and dyspnea, for the last 45 minutes after mowing his lawn. The patient's vital signs are stable, and on physical examination a new systolic murmur is appreciated. According to the most recent American College of Cardiology/American Heart Association Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation MI recommendations, an EKG should be performed on patients with a clinical suspicion for acute coronary syndrome within how many minutes of their arrival to the emergency department? - ✔✔the 2007 American College of Cardiology/American Heart Association Guidelines for Management of Patients with Unstable Angina/Non-ST-Elevation MI recommend that an ECG "be performed and shown to an experienced emergency physician as soon as possible after ED arrival, with a goal of within 10 minutes of ED arrival for all patients with chest discomfort or other symptoms suggestive of ACS." Although choices A and B would be optimal, the question asks for the goal time for which busy emergency departments should aim for in obtaining an EKG in at-risk patients. Choices D and E are less desirable, as times greater than 10 minutes increase both morbidity and mortality rates. (Tintinalli et al., 2011, Chapter 52) Assuming no contraindications, which of the following class of medications is considered the preferred long-term control therapy for persistent asthma? A. inhaled corticosteroids B. leukotriene antagonists C. long-acting B2 agonists D. methylxanthines E. muscarinic antagonists - ✔✔Inhaled corticosteroids (eg, beclomethasone, fluticasone, triamcinolone, etc) are the preferred long-term control therapy for persistent asthma in all patients because of their potency and consistent effectiveness. Low- to medium-dose inhaled corticosteroids offer several advantages over other medications, including the ability to reduce bronchial hyper-responsiveness, improve overall lung function, and reduce severe exacerbations that often lead to emergency department visits and hospitalizations. (Chesnutt et al., 2008, p. 209; Kelly and Sorkness, 2008, pp. 485-486;) A chest x-ray on an 81-year-old male with a four-day history of productive cough, dyspnea, fever, chills, and shortness of breath reveals a left sided pleural effusion. Pleural fluid analysis reveals a decreased glucose level, elevated lactate dehydrogenase, and 20,000 polymorphonuclear white blood cells/mcL. What is the most likely cause of this effusion? A. Bacterial pneumonia B. Congestive heart failure C. Malignancy D. Pulmonary embolus E. Tuberculosis - ✔✔A pleural effusion is a collection of fluid within the pleural space, due to an increased rate of fluid formation with decreased absorption. Pleural effusions are classified as transudative versus exudative, based on the underlying cause. This patient exhibits pleural fluid analysis results that are consistent with a parapneumonic effusion. Malignancy and tuberculosis also cause exudative effusions, with different fluid analysis results and various patient presentations (see Table 9-23). Congestive heart failure and pulmonary embolism are associated with transudative effusions. What is the most common electrolyte that can effect the initiation of ventricular tachycardia? A. Magnesium B. Sodium C. Chloride D. Phosphorus E. Calcium - ✔✔Hypomagnesia and hypokalemia are the two electrolyte disorders for ventricular tachycardia. A 47-year-old male presents to the hospital with complaints of palpitations. He has a history of hypertension, for which he takes diltiazem. On exam he is alert, awake, and oriented. His blood pressure is 144/76, his pulse rate is 52, and his respiratory rate is 18. Lung sounds are clear, and cardiac is a regularly irregular rhythm. There is no peripheral edema noted, and a neurological exam is non-focal. The rhythm strip shown is produced. Based on these findings, what is the next step in the treatment of this patient? - ✔✔This patient has a second-degree AV block, Mobitz Type I, or Wenckebach. In this case, putting the patient on a calcium channel blocker can increase the vagal tone and slow the rate down. The best intervention for this patient is to stop the diltiazem. If there is a suspicion of ischemia, then cardiac catheterization is warranted. There is no indication for a pacer or surgery. A 4-year-old female is brought in by her parents due to an increased nightly cough and low grade temperature. The x-ray shown reveals a classic finding for which of the following diagnoses? - ✔✔Croup, also known as laryngotracheobronchitis, is associated with upper tracheal narrowing and edema, which is visible on an anteroposterior soft tissue neck x-ray. This is termed the "steeple sign." Epiglottitis is associated with a thickened epiglottis on a lateral soft-tissue neck x-ray, termed the "thumb" sign. Foreign body aspiration and tracheal carcinoma may have x-ray findings based on the location, size, and components present. Peritonsillitis is best visualized on physical exam. If assessing for a potential peritonsillar abscess, a contrasted CT is recommended. A patient is being evaluated for fatigue, weight loss, a two-week cough, and erythema nodosum. Today, the patient noted eye symptoms and your exam reveals iritis. A chest xray reveals hilar and paratracheal lymphadenopathy. You suspect sarcoidosis. Which of the following is the most appropriate next step of evaluation to determine the diagnosis? - ✔✔A diagnosis of sarcoidosis must incorporate clinical findings and radiologic findings, ruling out other conditions and obtaining definitive information. A biopsy should be performed, and may be performed utilizing tissue from any affected organ, including skin or from a transbronchial biopsy, which has a high conclusive yield. Histologically, sarcoidosis is associated with noncaseating granulomas; however, other granulomatous disease must be ruled out. The additional testing listed may also be utilized for further evaluation, but is considered adjunctive A 70-year-old man with a history of hypertension, DM Type 2, and hyperlipidemia is seen for preoperative evaluation prior to left knee replacement. On auscultation, a very soft high-frequency decrescendo early diastolic murmur is heard at the upper left sternal border. Which of the following maneuvers would be the most appropriate to choose to increase the intensity of the murmur for better identification? A. [Show More]

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