#Cardiovascular_System#Internal_Medicine#Clinical_USMLE_Step2#Lecturio

A 63-year-old woman with end-stage renal disease complains of feeling lightheaded for the past month after hemodialysis. She worries she might lose her balance and fall. She has had diabetes mellitus for 22 years. Her medications include folic acid, vitamin B12, amlodipine, and erythropoietin. At the clinic, her blood pressure is 135/80 mm Hg when lying down before dialysis and 110/55 mm Hg when seated after hemodialysis. Cardiopulmonary examination shows no abnormal findings. Laboratory studies after hemodialysis show a Hb of 10.5 mg/dL, blood glucose of 189 mg/dL, and a hemoglobin A1C of 7.1%. To reduce the likelihood of falls, what is the most appropriate management?

A 42-year-old woman presents to the emergency department with recurrent chest pressure and pain radiating to her jaw. An ECG shows ST-segment elevation, but her cardiac enzymes are normal on initial testing and repeat testing several hours later. Her heart rate is 82/min, and her blood pressure is 128/76 mm Hg. Physical examination reveals regular heart sounds with no friction rub. Which of the following is an acceptable treatment regimen for this patient’s suspected condition?

A 53-year-old woman presents to the clinic with a 1-month history of a “pounding in her head and neck” and swelling of her feet. She has frequent episodes of flushing and wheezing that occur sporadically and last 1–2 hours. She used to walk 2 miles a day for exercise but now complains of dizziness, fatigue, and trouble breathing after walking only 1 block. On review of systems, she has recently had watery, non-bloody diarrhea, and abdominal cramps. She eats a well-balanced diet and has never used alcohol, tobacco, or other recreational drugs. Her temperature is 37.0°C (98.6°F), heart rate is 88/min, respiratory rate is 20/min, and blood pressure is 146/88 mm Hg. On physical examination, she has mild, diffuse abdominal tenderness without guarding or rebound, jugular venous distention, and bilateral pedal edema. There are a few telangiectasias over her chest and abdomen. The lungs are clear to auscultation. Cardiac auscultation along the left sternal border in the 3rd–4th intercostal space reveals the sound in the audio recording. What is the most likely side effect of the first-line medication used to manage her condition?

A healthy 20-year-old African American man presents to the clinic for a pre-participation sports physical for college football. He has no health complaints at this time and no chronic medical problems. He denies chest pain, palpitations, or history of syncope. He had surgery 2 years ago for appendicitis. His family history is significant for his father, who had a myocardial infarction at the age of 53, and a paternal uncle who died suddenly at the age of 35 of unknown causes. His temperature is 37.1°C (98.8°F), heart rate is 78/min, respiratory rate is 16/min, and blood pressure is 110/66 mm Hg. He has a tall, normally-proportioned body. There are no chest wall abnormalities, and the lungs are clear to auscultation. His pulses are normal in both the upper and lower extremities. The point of maximal impulse is nondisplaced. Auscultation of the heart in the 5th intercostal space at the left midclavicular line reveals the following sound. Which of the following will be the most likely outcome of this patient’s cardiac findings?

A 71-year-old man develops chest pressure while shoveling snow in the morning. He tells his wife that he has a squeezing pain radiating to his jaw and left arm, and she calls for an ambulance. On the way to the hospital, he receives chewable aspirin and 3 doses of sublingual nitroglycerin, with little relief from the pain. His chronic medical problems include pre-diabetes and hypertension. He has smoked 15–20 cigarettes daily for the past 37 years. His blood pressure is 172/91 mm Hg, heart rate is 111/min, and temperature is 36.7°C (98.0°F). On physical examination in the emergency department, he looks pale, very anxious, and diaphoretic. His ECG is shown in the image. The patient’s troponin levels are elevated. Percutaneous coronary intervention is not available at this hospital. What is the most appropriate next step in this patient’s management?

A 24-year-old G4P4031 woman presents to the emergency department approximately 10–12 hours after delivering a 2.8 kg (6.3 lb) boy at home. Her last menstrual period was estimated to be around 8 months ago. She had no prenatal care but is known to the obstetrics department because of multiple miscarriages over the previous 6 years. All her pregnancies resulted from a consanguineous relationship with her 33-year-old first cousin. She states that the delivery was uneventful, and she only had a small amount of vaginal bleeding after birth. The infant seemed healthy until an hour ago, when he became unresponsive. His body and arms are blue. He is hypotonic in all 4 extremities. On ECG, there is evidence of left axis deviation. Cardiac auscultation at the left sternal border 4th intercostal space reveals the findings in the audio file. Despite resuscitation efforts, the infant passes away soon after presentation. What will most likely be seen on autopsy?

A 24-year-old woman presents to the emergency department with palpitations for the last hour. This is her third emergency department visit in the last 8 weeks with the same complaint. She denies fever, shortness of breath, nasal discharge, bowel changes, weight loss, and heat intolerance. She has asthma that is poorly controlled despite regular inhaler use. She drinks a cup of coffee each morning, is physically active, and jogs for at least 30 minutes daily. Her last menses was 1 week ago. Her vital signs are blood pressure 104/70 mm Hg, pulse 194/min and regular, and respiratory rate 18/min. Her ECG is shown (click on image to enlarge). A gentle massage over the carotid artery for 5 to 10 seconds does not terminate her palpitations. What is the most appropriate next step in the management of this patient?

A 39-year-old man presents to the emergency department because of progressively worsening chest pain and nausea that started at a local bar 30 minutes prior. The pain radiates to the epigastric area. He was diagnosed with hypertension 5 years ago but did not take the prescribed medication and was lost to follow-up. He has smoked 1 pack of cigarettes daily for the past 15 years and has been using cocaine for the past 2 weeks. The patient is diaphoretic and in marked distress. What is the best first step in this patient's management?

A 40-year-old woman with a past medical history of high cholesterol, high blood pressure, hyperthyroidism, and asthma presents to the primary care clinic for a medication follow-up visit. She has tried several different statins that resulted in bothersome side effects. Her current medications include hydrochlorothiazide, levothyroxine, albuterol, oral contraceptives, and a multivitamin. Her physical examination is unremarkable. Her blood pressure is 116/82 mm Hg, and her heart rate is 82/min. Colesevelam is prescribed. What is a concern with starting this medication?

A 54-year-old man comes to the emergency department because of worsening shortness of breath, bilateral leg swelling, and constant chest pain not related to exertion for the last two weeks. He underwent aortic valve replacement surgery for chronic aortic regurgitation one year ago, and his postoperative course was uncomplicated. He denies smoking or alcohol use. His blood pressure is 80/60 mm Hg, his temperature is 36.6℃ (97.9℉), and his pulse is regular at 110/min. On physical examination, his jugular veins are distended, the heart sounds are distant, and there is 1+ bilateral pitting edema on both ankles. A chest X-ray is shown. A transthoracic echocardiogram shows a large pericardial effusion, chamber collapse, and respiratory variation of ventricular filling. What does the ECG most likely show?

A 45-year-old man presents to the emergency department with upper abdominal pain. He vomited blood twice at home. He is otherwise well, takes no medications, and does not drink alcohol. He has smoked 30–40 cigarettes daily for 15 years. In the emergency department, he vomits bright red blood and becomes lightheaded. His blood pressure is 86/40 mm Hg, pulse is 120/min, and respiratory rate is 24/min. His skin is cool to touch, pale, and mottled. Which physiologic variable matches this patient’s condition?

A 69-year-old man presents to his primary care provider after 2 episodes of dizziness while watching television over the past 2 days. He reports progressive fatigue and shortness of breath on exertion for the past few weeks. His medical history is significant for hypertension and congestive heart failure, for which he takes multiple medications. His blood pressure is 100/50 mm Hg, his heart rate is 50/min, and his temperature is 36.6℃ (97.8℉). The physical examination is within normal limits. An ECG is obtained (click on image to enlarge). What is the best initial step for managing this patient?

A previously healthy 31-year-old man is rushed to the emergency department after an all-night binge that included smoking, alcohol, and cocaine. He complains of chest fluttering, fatigue, and lightheadedness. His past medical and family history are noncontributory. Social history is significant for occasional smoking and social drinking. At the hospital, blood pressure is 110/70 mm Hg, and heart rate is 160/min and regular. The electrocardiogram (ECG) is shown. A physical maneuver involving carotid massage is attempted without improvement. The patient is given the appropriate medication to decrease his heart rate, and his ECG returns to normal. What is the mechanism of action of the drug?

A 63-year-old man presents to the Emergency Department with a sudden onset of excruciating chest pain, which he describes as a tearing sensation. He was diagnosed with essential hypertension 20 years ago, but he is not compliant with his medications. On physical examination, his temperature is 37.1℃ (98.8℉), his heart rate is 95/min, and his blood pressure is 195/90 mm Hg in the right arm and 160/80 mm Hg in the left arm. The pulses are absent in his right leg and diminished in his left leg. A chest X-ray shows a widened mediastinum. Which of the following is the next best step?

A 72-year-old man presents to the outpatient clinic. He has New York Heart Association (NYHA) class III heart failure and an ejection fraction of 35%. His current medications include lisinopril, furosemide, potassium chloride, rosuvastatin, and aspirin. He reports that he generally feels well and has not had any recent worsening of his symptoms. His blood pressure is 132/85 mm Hg, and his heart rate is 84/min. His physical examination is unremarkable except for trace pitting edema of both lower extremities. What other medication should be added?

A 34-year-old primigravida presents with progressive shortness of breath on exertion and while sleeping. The patient says that she uses 2 pillows while sleeping at night. These symptoms started in the 3rd week of the 2nd trimester of pregnancy. She has no chronic health problems. She denies smoking and alcohol intake. Her blood pressure is 110/50 mm Hg, her temperature is 36.9℃ (98.4℉), and she has a regular pulse of 90/min. Previous physical examination in the first trimester had disclosed no cardiac abnormalities, but she has a loud S1 and a 2/6 diastolic rumble over the cardiac apex on current physical examination. A transthoracic echocardiogram shows evidence of mitral valve stenosis. Which of the following is the best initial treatment for this patient?

A 63-year-old man presents to the Emergency Department with a sudden onset of excruciating chest pain, which he describes as a tearing sensation. He was diagnosed with essential hypertension 20 years ago, but he is not compliant with his medications. On physical examination, his temperature is 37.1℃ (98.8℉), his heart rate is 95/min, and his blood pressure is 195/90 mm Hg in the right arm and 160/80 mm Hg in the left arm. The pulses are absent in his right leg and diminished in his left leg. A chest X-ray shows a widened mediastinum. Which of the following is the next best step?

A 49-year-old woman presents to her oncologist because of progressive shortness of breath at rest, decreased exercise tolerance, and ankle swelling bilaterally for the past two weeks. She had breast cancer 4 years ago and was treated with surgery, radiation, and chemotherapy. She does not smoke or drink alcohol. Her family history is positive for breast cancer in her older sister. She looks anxious and tachypneic. Temperature is 36.7℃ (98.1℉), heart rate is 110/min, respiratory rate is 20/min, and blood pressure is 85/50 mm Hg. The physician notices that the patient's radial pulse becomes weaker during inspiration. On physical examination, the jugular venous pressure (JVP) is 14 cm, heart sounds are distant, the lungs are clear, and 1+ pedal edema is noted. Her chest X-ray is shown in the exhibit. What will an echocardiogram of this patient most likely show?

A 64-year-old man presents with progressive malaise, weakness, and confusion for one day. His wife reports he started having fever, a productive cough productive with yellow sputum, and chest tightness 3 days ago, but he did not seek medical care. He has smoked a pack of cigarettes daily for the past 30 years. He has had type 2 diabetes mellitus for 20 years, for which he takes metformin. His vital signs include temperature 38.0°C (100.4°F), blood pressure 87/64 mm Hg, heart rate 95/min, and respiratory rate 20/min. His oxygen saturation is 95% at rest. On physical examination, the patient appears severely ill, weak, obtunded, and is unable to speak. His skin is warm to the touch. Auscultation reveals distant lung sounds with crackles at the left base. Which of the following parameters is most likely to be found in this patient?

A 67-year-old man comes to the physician because of exertional dyspnea and lower extremity swelling for the last 4 weeks. The patient has been a smoker for the last 45 years and has been diagnosed with COPD. He has no history of diabetes mellitus or ischemic heart disease. He is nonadherent with his medications for COPD. The patient is a retired social worker and spends most of his time at home. His vital signs are temperature 37.2°C (98.9°F), blood pressure 135/115 mm Hg, heart rate 90/min, and respirations 22/min. Oxygen saturation on room air is 92%. Physical examination reveals a barrel-shaped chest, neck vein distension,3+ bilateral pitting edema of his lower extremities, and tender hepatomegaly 6 cm below the costal margin. Application of pressure on the upper abdomen causes persistent distension of the jugular veins. His lungs are clear to auscultation. A chest X-ray shows pulmonary vascular congestion; ECG shows right bundle branch block and right ventricular hypertrophy. What is the gold standard test for diagnosing this patient’s condition?

A 32-year-old man presents for an immigration physical examination. The patient has mild intermittent asthma, but he has noticed that he has been more out of breath with exertion over the past 2 years. He is otherwise healthy. He does not recall if he had any serious infections during childhood, and there is no family history of congenital diseases. Blood pressure is 132/76, and heart rate is 78/min. You hear an opening snap followed by a mild diastolic rumble at the cardiac apex. What medication could have prevented the development of this condition?

A 58-year-old woman with New York Heart Association (NYHA) Class III heart failure, atrial fibrillation, and bipolar disorder presents to the urgent care center with nausea, vomiting, abdominal pain, and double vision. She also describes seeing green-yellow outlines around objects. Her current medications include ramipril, bisoprolol, spironolactone, digoxin, amiodarone, and lithium. Which medication is most likely responsible for her symptoms?

A 73-year-old woman with atrial fibrillation presents to discuss the need for anticoagulation. Her history is significant for hypertension, type 2 diabetes mellitus, osteoporosis, and depression. She previously smoked but quit about 16 years ago. She has never had a stroke or TIA, congestive heart failure, or vascular disease. Her physical examination is remarkable for an irregular heartbeat, but otherwise, her heart, lung, and neurologic exams are normal. Her blood pressure is 136/94 mm Hg, and her heart rate is 74/min. What is her CHA2DS2-Vasc score?

A 56-year-old Caucasian male presents to the clinic to establish care. He has never seen a healthcare provider and denies any chronic medical problems. His blood pressure is 158/94 mm Hg, and his heart rate is 92/min. Physical examination is notable for central obesity, but the patient has a normal heart and lung exam. He follows up 2 weeks later, and his blood pressure is still high. At this time, he is diagnosed with essential hypertension, and antihypertensive therapy is initiated. Per the 2017 ACC/AHA guidelines for treating high blood pressure, of the following combinations of drugs, which can be considered for first-line treatment of high blood pressure in the general population?

A 68-year-old man presents to the emergency department with difficulty breathing, tightness in his chest, and productive cough with a lot of green sputum for the past 3 days. He has had chronic obstructive pulmonary disease (COPD) for 10 years, but the cough and sputum are different from his baseline. He used his home nebulizer with albuterol and ipratropium twice without much relief. He has a 50 pack-year smoking history and drinks alcohol occasionally. Vital signs are temperature 37.2℃ (98.9℉), heart rate 130–140/min with an irregular rhythm, respiratory rate 26/min, blood pressure 110/60 mm Hg, and oxygen saturation is 88% on room air. On physical examination, the patient appears drowsy, has bibasilar crackles, and has irregular heart sounds. A chest X-ray shows hyperinflation of both lungs and a flattened diaphragm. An ECG strip is shown. What is the best initial treatment for this patient’s arrhythmia?

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