Cardiology Q's..!!! (15)

). A 67-year-old veteran with a history of calf claudi-
cation and an abdominal aortic aneurysm repair
presents to your office for a routine visit. He has
no known coronary artery disease (CAD), diabetes,
or family history of premature CAD. He stopped
smoking 3 years ago. His blood pressure is 128/70
mmHg on an angiotensin-converting enzyme (ACE)
inhibitor. His other medications include aspirin and
multivitamins. His physical examination is notable
for a well-healed abdominal surgical scar, and dimin-
ished bilateral dorsalis pedis and posterior tibial
pulses. His wife mentions that his diet is "terrible;'
and she is concerned that his cholesterol level might
be high. A fasting lipid profile is as follows:
Plasma total cholesterol
I 96mg/dL
140mg/dL
35 mg/dL
105 mg/dL
Plasma LDL cholesterol
Plasma HDL cholesterol
Serum triglycerides
In addition to initiating therapeutic lifestyle changes,
what is the most appropriate management?
a. Repeat lipid profile in 3 months; target
LDL < 130 mg/dL
b. Repeat lipid profile in 3 months; target
LDL < 100 mg/dL
c. Initiate HMG-CoA reductase inhibitor; target
LDL < 100 mg/dL
d. Repeat lipid profile in 3-5 years
e. Initiate a fibric-acid derivative agent..


2) A 25-year-old woman presents to your clinic after
"passing out" while standing in line at a bank. Imme-
diately prior to the event, she recalls feeling nause-
ated and had a "warm sensation all over." She
subsequently felt lightheaded and lost conscious-
ness for approximately 30-40 seconds, following
which she awoke and was aware of her surround-
ings. Witnesses told her that she attempted to hold
onto a counter prior to collapsing. She denies
previous syncopal episodes. Examination reveals
normal BP and heart rate. Her pulmonary, cardiac,
and neurological examination are all normal. Hema-
tocrit, BUN, creatinine, and electrolytes are all
normal. An echocardiogram and ECG performed in
your office are unremarkable.
What is the most appropriate next test to perform
in this patient's evaluation.
a. Holter monitoring
b. electrophysiological study
c. head CT scan
d. tilt table testing
e. carotid sinus massage


3) A 35-year-old nonsmoking male without significant
past medical history presents with chest pain and
exertional dyspnea. Review of symptoms is notable
for a one-week history of antecedent flu-like symp-
toms. Physical examination reveals a jugular venous
pressure (JVP) of I 5 em H 2 0, and rales halfway up
the lung fields bilaterally. An S3 and a IIIIYI holosys-
tolic murmur at the apex are noted, as is pitting
edema of bilateral lower extremities. Electrocardio-
gram reveals diffuse ST- T wave abnormalities. The
initial creatine kinase (CK) is 586 with an index of
7%. The most likely diagnosis is:
a. pulmonary embolism
b. acute myocardial infarction
c. viral pericarditis
d. viral myocarditis
e. hypertrophic cardiomyopathy


4). You are asked to evaluate a 56-year-old man who
has recently developed intermittent chest pain. He
has a history of hypertension, smoking, and gas-
troesophageal reflux disease. Over the past three
weeks he has noted several episodes of right-sided
chest pain that occur at rest, are associated with
mild diaphoresis, last 5-10 minutes, and sponta-
neously resolve. He has not noted exertional symp-
toms. His blood pressure is 140/80mmHg, and his
heart rate is 70 bpm. He has a prominent S4 but an
otherwise normal examination. An ECG reveals
normal sinus rhythm and left ventricular hyper-
trophy with a "strain" pattern (anterolateral ST-T
abnormalities). You make the diagnosis of atypical
chest pain and schedule him for a stress test. Which
of the following is the most appropriate type of
stress test for this patient?
a. exercise ECG
b. dobutamine echocardiogram
c. adenosine stress with nuclear imaging
d. 24-hour ambulatory ECG monitoring
e. exercise stress with nuclear imaging


5) A 63-year-old male smoker presents to your clinic
for a regularly scheduled appointment. On exami-
nation, his blood pressure is 140/90. His pulse is 70
and regular. His respiratory rate is 20. There is no
jugular venous distension. His carotid pulses are 1+
bilaterally without bruits. Examination of his chest
reveals diffusely decreased breath sounds with scat-
tered rhonchi. Precordial examination is unremark-
able. Abdominal examination reveals a pulsatile
mass with an associated bruit. Peripheral pulses are
diminished but symmetric. You obtain an abdomi-
nal ultrasound that reveals an abdominal aortic
aneurysm. Which of the following factors would
prompt you to recommend elective surgical repair?
a. coexistent coronary artery disease
b. family history of abdominal aneurysm
c. absence of symptoms
d. concomitant peripheral vascular disease
e. aneurysm diameter of 6 em


The following options apply to questions 6-8:

a. acute myocardial infarction
b. unstable angina
c. stable angina
d. pulmonary embolism
e. spontaneous pneumothorax
f. pericarditis
g. costochondritis
h. aortic dissection
I. coronary artery spasm

6. A 60-year-old male with a history of hypercholes-
terolemia and smoking reports a 2-year history of
substernal chest discomfort precipitated by exer-
tion and relieved by rest. In the past several weeks,
the pain has become more frequent and is precipi-
tated by less exertion.

7. A 45-year-old man presents with sudden, severe,
sharp chest pain that radiates to his back. On exam-
ination, his weight is 160 pounds; his height is 72
inches. His heart rate is 110 bpm. His blood pres-
sure is 124/70 in the left arm and barely palpable in
the right arm.

8. A 36-year-old man presents with intermittent,
sharp, mid-sternal chest pain. The pain is somewhat
worse with inspiration and is associated with mild
dyspnea. Several weeks prior, he and his children had
"cold" symptoms.

9. A 73-year-old man with a history of hypertension
and peripheral vascular disease presents with acute
onset of chest pain. The pain was initially epigastric,
but then settled between his shoulder blades. On
physical exam, he appears quite anxious. His blood
pressure is 190/90 mmHg in both arms. Pulse is 98
bpm and regular. Respiratory rate is 20/min. His
jugular veins are not distended, and his lungs are
clear. Precordial exam reveals an S4' No murmur is
noted. Abdominal exam is notable for moderate
tenderness with deep palpation and a peri-umbilical
bruit. His right dorsalis pedis and posterior tibial
pulses are 1+.
laboratory studies include:
BUN: 40
Creatinine: 1.5
Hematocrit: 34%
ECG: Sinus tachycardia, left ventricular hypertrophy,
no acute ischemic changes.
The most likely diagnosis is:
a. aortic dissection
b. acute myocardial infarction
c. acute arterial embolus
d. pulmonary embolism
e. pancreatitis


10. The patient in the preceding question undergoes
a computed tomography (CT) scan that demon-
strates a descending aortic dissection originating
just distal to the aortic arch and extending to the
aortic bifurcation. There is no significant vascular
obstruction seen. The most appropriate initial
therapy for this patient should include:
a. labetalol and nitroprusside
b. heparin
c. emergent surgical intervention
d. thrombolytic therapy
e. intravenous fluids and narcotic analgesics


II. A 41-year-old male smoker is referred to your
clinic for the evaluation of claudication. This began
several months ago and has steadily progressed
since that time. Additional questioning reveals
symptoms of cold-induced vasospasm. He has no
history of diabetes or hypertension. On physical
examination, the patient is a thin man in no acute
distress. His blood pressure is 140/80 mmHg, and
his pulse is 68 bpm. His chest is clear and cardiac
examination is unremarkable. His abdomen is soft
and nontender without masses or bruits. His extre-
mities are warm but with diminished radial, dorsalis
pedis, and posterior tibial pulses. Which of the fol-
lowing should you recommend?
a. atenolol SO mg daily
b. diltiazem 30 mg four times daily
c. assessment of ankle-brachial indices
d. smoking cessation
e. surgical revascularization


12. A 70-year-old woman is admitted for progressive
dyspnea. Physical examination reveals moderate res-
piratory distress. Her heart rate is 110 bpm and her
blood pressure is 105/60 mmHg, but the systolic
pressure falls to 90 mmHg with inspiration. Her
radial pulse is 100 bpm, and the pulse volume varies
significantly with the respiratory cycle. Her jugular
venous pressure is elevated, and there is moderate
lower extremity edema. Chest examination reveals
distant heart sounds and faint crackles at the base
of the left lung. This patient is most likely to benefit
from:
a. intravenous diuretics and oral ACE inhibitors
b. nebulized albuterol and intravenous steroids
c. pericardiocentesis
d. aspirin, nitroglycerin, and beta-blockers
e. intravenous antibiotics


13. A 60-year-old male smoker presents with inter-
mittent fevers over a several-week period. He has
no significant past medical history, but was told that
he had a murmur at some point in the past. His tem-
perature is 100°F (37.7°C), heart rate 85 bpm, and
blood pressure 135/70 mmHg. Physical examination
reveals digital clubbing and splenomegaly. Small, ery-
thematous, nontender spots are noted over the
palmar aspect of his hands. His lungs are clear to
auscultation. Cardiac examination reveals a mid-
systolic click and a faint, apical, holosystolic mur-
mur. What is the most likely diagnosis?
a. pneumonia
b. viral syndrome
c. infectious endocarditis
d. pericarditis
e. congenital cardiac shunt

14. A 44-year-old woman presents to the emergency
room with complaint of increased pedal edema. She
has a history of smoking, borderline hypertension,
and class II heart failure resulting from a non is-
chemic cardiomyopathy. Her medications include a
diuretic, a beta-blocker, and birth control pills. She
lives in Mexico and recently came to the US to visit
family. Shortly after her arrival she noted increased
pedal edema. She denies any change in her baseline
dyspnea, has been compliant with her medications,
and denies any recent chest pain.
On examination, she is mildly uncomfortable but in
no respiratory distress. Her blood pressure is
130/70 mmHg. Her pulse is 88 bpm and regular. Her
JVP is elevated at 8 em H 2 0 without hepatojugular
reflux (HJR). Chest exam reveals moderate aeration
but no evidence of consolidation. Precordial exam-
ination demonstrates distant heart sounds and a
soft S3' Her abdominal examination is benign. There
is I + edema of the right lower extremity. The left
lower extremity demonstrates 2-3+ edema with
mild erythema and warmth. What is the most ap-
propriate next step in her management?
a. administer intravenous diuretics
b. obtain blood cultures and start intravenous
antibiotics
c. obtain bilateral lower extremity ultrasound
studies
d. check 24-hour urine protein excretion
e. start an ACE inhibitor and arrange follow-up
with a local physician

15. A 69-year-old man is referred to you for a recent
episode of syncope. While walking on the beach in
Florida, he had sudden loss of consfiousness and
awoke to find his family looking over him. He does
not recall the event, but his daughter states that he
"fell over" without warning. He has never had
syncope in the past, but does admit to occasional
chest pain and exertional dyspnea.A physical exam-
ination reveals a blood pressure of 132/76 mmHg
and a heart rate of 72 bpm. His lungs are clear.There
are delayed and subdued carotid upstrokes with a
loud, late-peaking, systolic crescendo-decrescendo
murmur over the sternal border near the 2 nd inter-
costal space. The second heart sound is faintly
audible. Pulses are I + in all four extremities, there
is no edema.
The most likely cause of this patient's syncope is:
a. acute myocardial infarction
b. vasovagal syncope
c. orthostatic hypotension
d. aortic stenosis
e. mitral stenosis

16. A 75-year-old woman with chronic atrial fibrillation
presents to the ambulatory care clinic complaining
of one week of fatigue and intermittent dizziness.
She had previously been very active and normally
walks around a small park every day. She denies any
dyspnea or angina and reports no episodes of
syncope. Her only other medical history is hyper-
tension for which she takes hydrochlorothiazide.
She also takes warfarin for her atrial fibrillation. An
ECG in the clinic reveals atrial fibrillation with an
average heart rate of 38-45 beats per minute.
The next appropriate step in the management of
this patient would be:
a. Holter monitoring
b. echocardiogram
c. implantation of a pacemaker
d. implantation of an implantable cardioverter-
fibrillator (ICD)
e. no therapy other than reassurance