A 55-year-old male is brought to the ED, by ambulance, because of crushing chest pain radiating to his left shoulder and arm that started 1 hour ago. He has a history of hypertension, high cholesterol, and has smoked a pack of cigarettes a day for 30 years. He has never had symptoms like this before.
Which of the following would be most likely to be seen on an ECG?
A. Q waves
B. P-R interval depression diffusely
C. S-T segment elevation in anterior and inferior leads
D. S-T segment elevation in anterior leads with reciprocal S-T segment depression in inferior leads
E. normal ECG
Correct Answer: D Section: (none)
Explanation: The clinical scenario described is classic for an acute MI. The patient has multiple risk factors, including smoking, hypertension, and elevated cholesterol. His symptoms of crushing chest pain radiating to the left arm is commonly seen in this setting. Often the first electrocardiographic sign of acute ischemia is the development of hyperacute T waves. The ECG will usually show S-T segment elevations in the area of the involved occluded vessel, with reciprocal S-T segment depressions in uninvolved areas. This can be followed by the eventual resolution of S-T segment abnormalities and the development of T wave inversions and Q waves. Diffuse P-R depressions are often the initial manifestation of pericarditis, a less common cause of acute chest pain. This often progresses to diffuse S-T segment elevations, the presence of which helps to distinguish pericarditis from the focal S-T elevations more classically associated with a thrombosed coronary artery. Q waves would be unlikely to occur within 1 hour of the onset of symptoms. In this clinical setting, a normal ECG, while possible, would be less likely to occur.
Ventricular arrhythmias, both tachycardia and fibrillation, are recognized complications of acute MI. The presence of ventricular fibrillation or pulseless ventricular tachycardia should lead to the primary "ABCD" survey, as outlined in the American Heart Association's ACLS protocols. The mnemonic stands for airway, breathing, circulation, and defibrillation. Epinephrine, lidocaine, or amiodarone are reserved for the setting where defibrillation is ineffective. Synchronized cardioversion would be used in efforts to convert a patient's rhythm in the setting of a stable tachycardia.
Question 662:
A67-year-old female with past medical history of rheumatoid arthritis on chronic steroid treatment and past surgical history (PSH) of complete hysterectomy secondary to fibroids presents for routine visit. Patient states that she has had multiple arthralgias worsening over the last 2 years. She had a DEXA scan done that showed a T score of -1.5. She has been taking calcium + vitamin D, and even started an exercise program at her local gym. She was started on bisphosphonates, which she has tolerated well. Prior to discharging the patient, how soon would you counsel her to repeat the DEXA scan?
A. never: although she has risk for osteoporosis, she has already made all the lifestyle changes and is on pharmacotherapy B. repeat in 5 years, since she only has osteopenia
B. 6 months
C. repeat in 1 year
D. repeat in 2 years
Correct Answer: D Section: (none)
Explanation:
Osteoporosis is generally defined as a T score of -2.5 SD or greater on assessment of BMD. Osteopenia is generally defined as a T score between 1 and 2.5 SD below the peak BMD for a healthy young person of the same gender. Osteoporosis screening with an assessment of BMD should be offered to the following groups: · All women 65 years old or older · All adult women with a history of a fracture (or fractures) not caused by severe trauma (such as a motor vehicle accident) · Younger postmenopausal women who have clinical risk factors for fractures · Modifiable risk factors: current cigarette smoking, low body weight (<127 lbs), estrogen deficiency, premature menopause, excessive thyroid hormone replacement, chronic corticosteroid therapy, low calcium intake (life-long), alcoholism, uncorrected visual impairment, inadequate physical activity, recurrent falls · Nonmodifiable risk factors: personal or family history of fragility, family history of osteoporosis, White or Asian race, age, gender, poor health/frailty, dementia, hypogonadism in males, fracture without substantial trauma Serial assessments for BMD may be useful but one must remember the precision error among the tests. Using DEXA, a BMD must have a 35% difference to be clinically significant. Patients who are on pharmacologic treatment with bisphosphonates may only show this much change in 1 year. Therefore, static BMD or slight reduction should not be regarded as treatment failure. At present, there are no hard evidencebased guidelines for the most efficient use for BMD monitoring. However, the following guidelines are generally accepted: · For patients with "normal" baseline BMD (T score more than -1.0), consider a followup measurement every 35 years. Patients whose bone density is well above the minimal acceptable level may not need further bone density testing. · For patients in an osteoporosis prevention program, perform a follow-up measurement every 12 years until bone mass stability is documented. After BMD has stabilized, perform follow-up measurements every 23 years. · For patients on a therapeutic program, perform a follow-up measurement yearly for 2 years. If bone mass has stabilized after 2 years, perform a follow-up measurement every 2 years. Otherwise, continue with annual follow-up measurements until stability of bone mass is achieved.
Question 663:
A64-year-old female with no significant medical history presents with vague complaints of progressive generalized muscle weakness and fatigue. She denies any history of trauma or drug use and does not take any prescription, OTC or herbal medications. This is a new complaint and she has not had any prior workup. There is no evidence of trauma and a recent TSH was normal. On examination, you find mild muscle tenderness and atrophy. She has difficulty standing from a chair unless she pushes up with her arms at the same time. Her neurologic examination is normal. Which of the following tests would be most helpful in confirming your clinical diagnosis?
Your patient's test result confirms your clinical suspicion. The patient's symptoms have become more severe. Which of the following treatment options would be most appropriate?
A. vitamin B12 injections
B. electromyography (EMG)
C. trigger point injections
D. prednisone
E. cyclobenzaprine
Correct Answer: D Section: (none)
Explanation:
Polymyositis usually presents with patients complaining of gradual muscle weakness and myalgias. The peak incidence occurs in the fifth and sixth decades, with women being affected more commonly than men. Aside from the history and physical examination, laboratory analysis such as elevated muscle enzymes such as CPK and aldolase usually confirm the diagnosis. ESR levels may not be significantly elevated in over 50% of the patients. ANAmay be positive in many patients, however this does not distinguish the condition. EMG may be helpful in making the diagnosis as certain features such as polyphasic potentials, fibrillations, and high-frequency action potentials are more consistent with polymyositis. Muscle biopsy is the most specific test, however the patchy distribution may lead to false negative tests on occasion. Muscle biopsy may reveal endomysial infiltration of the inflammatory infiltrate. Usually, the initial treatment of choice is high-dose steroids, that is, prednisone 60 mg with tapering down after clinical response to the lowest effective dose. If steroids fail, immunosuppressant such as methotrexate or azathioprine may be tried.
Question 664:
A64-year-old female with no significant medical history presents with vague complaints of progressive generalized muscle weakness and fatigue. She denies any history of trauma or drug use and does not take any prescription, OTC or herbal medications. This is a new complaint and she has not had any prior workup. There is no evidence of trauma and a recent TSH was normal. On examination, you find mild muscle tenderness and atrophy. She has difficulty standing from a chair unless she pushes up with her arms at the same time. Her neurologic examination is normal. Which of the following tests would be most helpful in confirming your clinical diagnosis?
A. complete blood count (CBC)
B. antinuclear antibody (ANA)
C. ESR
D. MRI of spine
E. aldolase
Correct Answer: E Section: (none)
Explanation:
Polymyositis usually presents with patients complaining of gradual muscle weakness and myalgias. The peak incidence occurs in the fifth and sixth decades, with women being affected more commonly than men. Aside from the history and physical examination, laboratory analysis such as elevated muscle enzymes such as CPK and aldolase usually confirm the diagnosis. ESR levels may not be significantly elevated in over 50% of the patients. ANAmay be positive in many patients, however this does not distinguish the condition. EMG may be helpful in making the diagnosis as certain features such as polyphasic potentials, fibrillations, and high-frequency action potentials are more consistent with polymyositis. Muscle biopsy is the most specific test, however the patchy distribution may lead to false negative tests on occasion. Muscle biopsy may reveal endomysial infiltration of the inflammatory infiltrate. Usually, the initial treatment of choice is high-dose steroids, that is, prednisone 60 mg with tapering down after clinical response to the lowest effective dose. If steroids fail, immunosuppressant such as methotrexate or azathioprine may be tried.
Question 665:
A 60-year-old male with a history of hypertension and hyperlipidemia undergoes an evaluation for angina. He states that he routinely experiences dyspnea, fatigue, and retrosternal chest discomfort when performing activities such as walking around the block on which his house is located or climbing the flight of stairs within his home. Besides taking medications for his blood pressure and cholesterol, he uses nitroglycerin which successfully alleviates his symptoms.
The patient undergoes a cardiac catheterization and is found to have 70% narrowing of the left anterior descending and proximal left circumflex arteries. Which of the following would be the most appropriate management of this condition?
A. percutaneous transluminal coronary angioplasty (PTCA)
B. medical management with a beta-blocker, statin, and aspirin
C. medical management with an ACE inhibitor, statin, and aspirin
D. referral for coronary artery bypass grafting (CABG)
E. placement of a cardiac defibrillator
Correct Answer: D Section: (none)
Explanation:
Two generally accepted conventions for grading the severity of angina pectoris are those of the Canadian Cardiovascular Society (CCS) and the NYHA. The NYHA classification attempts to quantify the functional limitations imposed on an individual by their symptoms. Class I angina is defined as angina which does not appear as a patient undertakes ordinary physical activity. Symptoms caused by ordinary physical activity characterize class II angina. In class III angina, there is a moderate limitation of activity such that a patient remains comfortable at rest but symptoms appear during less-than-ordinary activities. In class IV angina, symptoms are present at rest so a patient is unable to perform any physical activity without feeling discomfort. Prinzmetal angina describes a syndrome of ischemic pain occurring at rest but not necessarily with exertion; it is diagnosed with detection of transient ST-T elevation with rest pain.
The goal of treatment of angina is to relieve symptoms and prolong exercise capacity by improving the relationship of oxygen demand and supply. Nitroglycerin is a smooth muscle relaxant that produces both venodilation (reduced preload) and arteriolar dilation (reduced afterload). Although the combined effect is to reduce myocardial oxygen demands, the potential exists for reflex tachycardia and increased contractility. To avoid the potential for increased oxygen demand and decreased coronary blood flow, a beta-blocker such as propranolol may be used concurrently with nitroglycerin. Another option is the careful titration of the nitroglycerin dose used. Discontinuation of nitroglycerin without further intervention would inappropriately leave the patient's angina pain untreated. Replacing nitroglycerin with the calcium channel blocker nifedipine may not address the problem of reflex tachycardia as nifedipine can also lead to a rapid vasodilation and subsequent drop in blood pressure (which, in turn, leads to increased sympathetic outflow and an increase in heart rate). Addition of isoproterenol would be inappropriate since it increases myocardial oxygen demand.
Question 666:
A 60-year-old male with a history of hypertension and hyperlipidemia undergoes an evaluation for angina. He states that he routinely experiences dyspnea, fatigue, and retrosternal chest discomfort when performing activities such as walking around the block on which his house is located or climbing the flight of stairs within his home. Besides taking medications for his blood pressure and cholesterol, he uses nitroglycerin which successfully alleviates his symptoms.
The patient states that shortly after selfadministering nitroglycerin, his heart feels like it races. He does not notice this sensation at any other times. Which of the following interventions would be most appropriate for counteracting this phenomenon?
A. discontinue nitroglycerin
B. increase the dose of nitroglycerin used
C. use nifedipine instead of nitroglycerin
D. continue nitroglycerin and start isoproterenol
E. continue nitroglycerin and start propranolol
Correct Answer: E Section: (none)
Explanation:
Two generally accepted conventions for grading the severity of angina pectoris are those of the Canadian Cardiovascular Society (CCS) and the NYHA. The NYHA classification attempts to quantify the functional limitations imposed on an individual by their symptoms. Class I angina is defined as angina which does not appear as a patient undertakes ordinary physical activity. Symptoms caused by ordinary physical activity characterize class II angina. In class III angina, there is a moderate limitation of activity such that a patient remains comfortable at rest but symptoms appear during less-than-ordinary activities. In class IV angina, symptoms are present at rest so a patient is unable to perform any physical activity without feeling discomfort. Prinzmetal angina describes a syndrome of ischemic pain occurring at rest but not necessarily with exertion; it is diagnosed with detection of transient ST-T elevation with rest pain.
The goal of treatment of angina is to relieve symptoms and prolong exercise capacity by improving the relationship of oxygen demand and supply. Nitroglycerin is a smooth muscle relaxant that produces both venodilation (reduced preload) and arteriolar dilation (reduced afterload). Although the combined effect is to reduce myocardial oxygen demands, the potential exists for reflex tachycardia and increased contractility. To avoid the potential for increased oxygen demand and decreased coronary blood flow, a beta-blocker such as propranolol may be used concurrently with nitroglycerin. Another option is the careful titration of the nitroglycerin dose used. Discontinuation of nitroglycerin without further intervention would inappropriately leave the patient's angina pain untreated. Replacing nitroglycerin with the calcium channel blocker nifedipine may not address the problem of reflex tachycardia as nifedipine can also lead to a rapid vasodilation and subsequent drop in blood pressure (which, in turn, leads to increased sympathetic outflow and an increase in heart rate). Addition of isoproterenol would be inappropriate since it increases myocardial oxygen demand.
Question 667:
A 60-year-old male with a history of hypertension and hyperlipidemia undergoes an evaluation for angina. He states that he routinely experiences dyspnea, fatigue, and retrosternal chest discomfort when performing activities such as walking around the block on which his house is located or climbing the flight of stairs within his home. Besides taking medications for his blood pressure and cholesterol, he uses nitroglycerin which successfully alleviates his symptoms.
Which of the following best describes the severity of this patient's angina?
A. class I
B. class II
C. class III
D. class IV
E. Prinzmetal angina
Correct Answer: C Section: (none)
Explanation: Two generally accepted conventions for grading the severity of angina pectoris are those of the Canadian Cardiovascular Society (CCS) and the NYHA. The NYHA classification attempts to quantify the functional limitations imposed on an individual by their symptoms. Class I angina is defined as angina which does not appear as a patient undertakes ordinary physical activity. Symptoms caused by ordinary physical activity characterize class II angina. In class III angina, there is a moderate limitation of activity such that a patient remains comfortable at rest but symptoms appear during less-than-ordinary activities. In class IV angina, symptoms are present at rest so a patient is unable to perform any physical activity without feeling discomfort. Prinzmetal angina describes a syndrome of ischemic pain occurring at rest but not necessarily with exertion; it is diagnosed with detection of transient ST-T elevation with rest pain.
The goal of treatment of angina is to relieve symptoms and prolong exercise capacity by improving the relationship of oxygen demand and supply. Nitroglycerin is a smooth muscle relaxant that produces both venodilation (reduced preload) and arteriolar dilation (reduced afterload). Although the combined effect is to reduce myocardial oxygen demands, the potential exists for reflex tachycardia and increased contractility. To avoid the potential for increased oxygen demand and decreased coronary blood flow, a beta-blocker such as propranolol may be used concurrently with nitroglycerin. Another option is the careful titration of the nitroglycerin dose used. Discontinuation of nitroglycerin without further intervention would inappropriately leave the patient's angina pain untreated. Replacing nitroglycerin with the calcium channel blocker nifedipine may not address the problem of reflex tachycardia as nifedipine can also lead to a rapid vasodilation and subsequent drop in blood pressure (which, in turn, leads to increased sympathetic outflow and an increase in heart rate). Addition of isoproterenol would be inappropriate since it increases myocardial oxygen demand.
Question 668:
A 74-year-old male with gout, osteoporosis, and type II diabetes presents for routine followup. As you review his medication list you note that he is on insulin, vitamin D, glypizide, quinidine, and allopurinol. You now diagnose him with hypertension that requires pharmacologic management. Which of the following medications would be contraindicated in this patient?
A. enalapril
B. hydrochlorothiazide
C. diltiazem
D. losartan
E. atenolol
Correct Answer: B Section: (none)
Explanation:
Quinidine can prolong the Q-T interval resulting in the development of polymorphic ventricular tachycardia (torsade de pointes). Hypokalemia, a side effect of thiazide diuretics, increases the risk of torsade de pointes, which can then degenerate into fatal ventricular fibrillation. Thiazide diuretics may decrease the effectiveness of uricosuric agents, insulin, and sulfonylureas and may increase the effects of vitamin D. However, these effects tend not to be life threatening
Question 669:
A 63-year-old male presents to your office with palpitations for the past 3 weeks. He has had no chest pains or dyspnea. He has no significant medical history and takes no medications. He does not smoke cigarettes and a recent lipid panel was normal. On examination, he is in no apparent distress. His pulse is 115 bpm and irregular. His BP is 125/77. His lungs are clear and his cardiac examination reveals an irregularly irregular rhythm with no murmurs, rubs, or gallops. Which of the following studies would be most appropriate to order at this time?
A. radionuclide ventriculography
B. exercise stress test
C. echocardiogram
D. cardiac catheterization
E. electrophysiologic studies
Correct Answer: C Section: (none)
Explanation:
Atrial fibrillation is the most common sustained clinical arrhythmia. It occurs in approximately 4% of the population over the age of 60. It is diagnosed by the presence of irregularly irregular QRS complexes on an ECG with an absence of P waves. The QRS complex is most commonly narrow, as this is a supraventricular arrhythmia. Wide QRS complexes can occur if there is an underlying conduction abnormality, such as Wolff-Parkinson-White syndrome or a bundle branch block. Saw-tooth Pwaves occur in atrial flutter, another atrial arrhythmia that may present similarly to atrial fibrillation but which is less common. The saw-tooth P waves, or flutter waves, are representative of an atrial rate typically in the range of 300350/minute.
Not infrequently, atrial flutter will lead to atrial fibrillation. Q waves in II, III, and aVF would be seen if there had been a previous inferior MI. Peaked T waves are seen in certain conditions, such as hyperkalemia, but are not routinely associated with atrial fibrillation. Atrial fibrillation may be precipitated by both cardiac and noncardiac conditions. Among the noncardiac conditions are metabolic abnormalities, which include hyperthyroidism. Of the tests listed, a suppressed TSH level, consistent with hyperthyroidism, would be most likely to be causative of atrial fibrillation. Troponin may be elevated in acute myocardial ischemia. Atrial fibrillation can occur following a MI, particularly when complicated by CHF. This is not consistent with the clinical scenario presented. Renal disease and diabetes may contribute to some of the conditions that can predispose to the development of atrial fibrillation, such as metabolic derangements or CAD. Acute and chronic pulmonary disease may also precipitate atrial fibrillation. In the setting of a man who is otherwise healthy and without significant medical history, new-onset atrial fibrillation would be less likely to be the initial presentation of diabetes, renal failure, or pulmonary disease than hyperthyroidism. For this reason, choice A is the single best answer of those provided.
Question 670:
A 63-year-old male presents to your office with palpitations for the past 3 weeks. He has had no chest pains or dyspnea. He has no significant medical history and takes no medications. He does not smoke cigarettes and a recent lipid panel was normal. On examination, he is in no apparent distress. His pulse is 115 bpm and irregular. His BP is 125/77. His lungs are clear and his cardiac examination reveals an irregularly irregular rhythm with no murmurs, rubs, or gallops.
An abnormal result of which of the following laboratory tests would be most likely to explain the cause of this condition?
A. TSH
B. troponin T
C. BUN and creatinine
D. serum glucose
E. arterial blood gas
Correct Answer: A Section: (none)
Explanation:
Atrial fibrillation is the most common sustained clinical arrhythmia. It occurs in approximately 4% of the population over the age of 60. It is diagnosed by the presence of irregularly irregular QRS complexes on an ECG with an absence of P waves. The QRS complex is most commonly narrow, as this is a supraventricular arrhythmia. Wide QRS complexes can occur if there is an underlying conduction abnormality, such as Wolff-Parkinson-White syndrome or a bundle branch block. Saw-tooth Pwaves occur in atrial flutter, another atrial arrhythmia that may present similarly to atrial fibrillation but which is less common. The saw-tooth P waves, or flutter waves, are representative of an atrial rate typically in the range of 300350/minute.
Not infrequently, atrial flutter will lead to atrial fibrillation. Q waves in II, III, and aVF would be seen if there had been a previous inferior MI. Peaked T waves are seen in certain conditions, such as hyperkalemia, but are not routinely associated with atrial fibrillation. Atrial fibrillation may be precipitated by both cardiac and noncardiac conditions. Among the noncardiac conditions are metabolic abnormalities, which include hyperthyroidism. Of the tests listed, a suppressed TSH level, consistent with hyperthyroidism, would be most likely to be causative of atrial fibrillation. Troponin may be elevated in acute myocardial ischemia. Atrial fibrillation can occur following a MI, particularly when complicated by CHF. This is not consistent with the clinical scenario presented. Renal disease and diabetes may contribute to some of the conditions that can predispose to the development of atrial fibrillation, such as metabolic derangements or CAD. Acute and chronic pulmonary disease may also precipitate atrial fibrillation. In the setting of a man who is otherwise healthy and without significant medical history, new-onset atrial fibrillation would be less likely to be the initial presentation of diabetes, renal failure, or pulmonary disease than hyperthyroidism. For this reason, choice A is the single best answer of those provided.
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