ICM Test 3 148-161

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ICM Test 3 148-161
2012-12-09 03:50:46

This is question 148-161 from pretest with answer summaries
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  1. 148. A 71 year old man complains of occasional lower back pain. His blood pressure is 150/85 Hg and his pulse is 80 beats per minute. Cardiac examination reveals an S4 gallop. Abdominal examination reveals a pulsatile mass approximately 5.0 cm in diameter palpable in the epigastric area. Peripheral pulses are normal. Which of the following is the most appropriate test to order to evaluate this problem?
    a. CT scan w/o contrast
    b. Transthoracic echocardiography
    c. Abdominal ultrasound
    d. Abdominal radiograph
    e. Contras aortography
    • Answer: C.
    • Abdominal aortic aneurysms are best detected by ultrasound initially or with CT scan with contrast or MRI to follow size. Abd. Radiography will mis ? of cases. Contrast aortography is NOT first line due to complications. Transthoracic echo is best for thoracic aneurysms.
  2. 149. A 47-year-old man has been at home recovering from an anterior myocardial infarction that occurred 10 days ago. He presents to your office complaining of persistent chest pain is worse on inspiration and is different from his heart attack pain. The pain radiates to both clavicles. The pain is worse when the patient is lying down and improves with sitting up and leaning forward. The patient has a temperature of 38.4oC in a normal blood pressure. A heart auscultation reveals a pericardial rub. Lung examination is positive for dullness and diminished breath sounds at the right base. Chest radiograph reveals a small right-sided pleural effusion. Laboratory data reveal that the patient has mild leukocytosis and increased erythrocyte sedimentation rate (ESR).Which of the following is the most likely diagnosis?
    a. Extension of the myocardial infarcation
    b. Unstable angina
    c. Prinzmetal angina
    d. Pulmonary embolus
    e. Dressler syndrome
    • Answer: E.
    • Post-MI syndrome, or Dressler syndrome. None of the other choices explain pain from position change or pericardial rub.
  3. 150. A 22-year-old asymptomatic woman has a split second heart sound is one examination of the upper left sternal border. Be split S2 is audible with deep inspiration and disappears w/ expiration. Which of the following can you tell her about this physical examination findings?
    a. she needs an echocardiogram
    b. she needs an ECG
    c. reassure her that she inherited it from her parents
    d. reassure her that this is perfectly normal
    e. she needs a stress test
    • Answer: D.
    • Patient has a physiologically split S2 that is perfectly normal. Best heard at base of heart upon inspiration.
  4. 151. An 82-year-old woman presents for annual physical examination. She has a history of hypertension, for which she takes a calcium channel blocker. She does not smoke cigarettes. Physical examination reveals a blood pressure of 135/85 mmHg. Heart examination is remarkable for a short systolic murmur peaks early in systole and does not radiate. The second heart sound is normal in intensity. Which of the following is the most likely diagnosis?
    a. Aortic sclerosis
    b. Aortic stenosis
    c. Mitral regurgitation
    d. Tricuspid regurgitation
    e. Mitral valve prolapse
    • Answer: A.
    • Aortic sclerosis, 65% in >65 y.o. Murmur is short, and doesn't radiate to the carotids. The intensity of the second heart sound is normal w/ aortic sclerosis. Mitral and tricuspid cause holosystolic murmurs that radiate to axilla. MVP has a mid-systolic click and a mid to late systolic diamond murmur at apex
  5. 152. A 10-year-old boy is brought to the emergency room because of chest pain. He has had a fever for the last five days. Physical examination is remarkable for conjunctival injection, strawberry tongue, cervical lymphodanopathy, a diffuse polymorphous rash, and edema of the hands and feet. Electrocardiogram is consistent for myocardial infarction. Which the following the most appropriate next step in management?
    a. Intravenous fibrinolytics
    b. Percutaneous angioplasty
    c. Intravenous steroids
    d. Intravenous gamma globulin
    e. Coronary artery bypass surgery
    • Answer: D.
    • Kawasaki disease. Strawberry tongue. Treatment is gamma globulin.
  6. 153. You're asked to provide a consult on a 13-year-old boy who wishes to join his high school track team. The patient is asymptomatic. Heart examination reveals a grade 2 non-radiating systolic ejection murmur heard best at the left sternal border. He also has a physiological split of S2. The murmur does not increase with the Valsava maneuver, handgrip, or inspiration. What is the following is most appropriate next step in management?
    a. No further management is necessary
    b. Transthoracic echo
    c. Transesophageal echo
    d. ECG
    e. Holter monitor
    f. Stress test
    • Answer: A.
    • Pt. has a functional or innocent heart murmur.
  7. 154. A 73-year-old man with a history of hypertension presents for your blood pressure check. He is compliant with his four antihypertensive medications, but thinks that sometimes they are making him dizzy. He does not drink alcohol or smoke cigarettes. He walks several miles each day and follows a low-salt diet. His blood pressure in your office is 170/90 mmHg. The brachial artery is palpable when the sphygmomanometer cuff is inflated above systolic blood pressure. Which the following is the most appropriate next step in management?
    a. Add a fifth antihypertensive med
    b. Maximaze present medications
    c. Measure intra-arterial pressure directly
    d. Stress the importance of compliance
    e. No further management indicated
    • Answer: C.
    • Positive Osler sign. Measuring intra-arterial pressure can be indicated.
  8. 155. A 24-year-old man presents the emergency room after a syncopal episode. He states that before he blacked out he experienced palpitations, and the feeling that his heart was racing. He has no known medical problems and does not smoke, drink, or take any medications or illicit drugs. His ECG is shown in the following figure. Which of the following is the most likely etiology of his symptoms?

    a. An accessory AV pathway
    b. Rapid impulse formation from the sinoatrial node
    c. An ectopic focus in the atria
    d. Dual pathways within the AV node
    e. Increased vagal influence on the normal pacemaker
    • Answer: A.
    • Wolff-Parkinson-White syndrome. A shortened PR interval with a delta wave. Digoxin, eta blockers, and calcium channel blockers should be avoided.
  9. 156. It 35-year-old pregnant woman presents at 37 weeks of pregnancy with blood pressure measurements on successive visits around 145/95 mmHg. Protein is detected on her urine dipstick. Which of the following is the most likely diagnosis?
    a. Prehypertension
    b. Chronic hypertension
    c. Gestational hypertension
    d. Preeclampsia
    e. Eclampsia
    • Answer: D.
    • Chronic hypertension & pre- is a milder form that does not resolve post-partum. Women >35yo, diabetic, or chronic hypertension, and obesityhave higher risk for Preeclampsia. This causes a rise in BP >20 weeks and leads to proteinuria. Seizures signal transition to eclampsia. If it comes and normalizes by 12 weeks it is gestational hypertension.
  10. 157. A 23-year-old medical student presents with a chief complaint of palpitations while playing basketball. The episode lasted 15 minutes. He denies dizziness, syncope, chest pain, and shortness of breath. He admits to a sedentary lifestyle but tries to eat three healthy meals per day. He is adopted, and a family history of heart disease is unknown. Physical examination is remarkable for a triple apical precordial impulse. What's the following is most likely diagnosis?
    a. Hypertrophic cardiomyopathy
    b. Pulmonary embolism
    c. Aortic regurgitation
    d. Right ventricular infarction
    e. Atrial septal defect
    • Answer: A.
    • Hypertroophic cardiomyopathy is a harsh, diamond-shaped midsystolic murmur, bisferiens carotid pulse, loud S4, and a double or triple apical impulse.
  11. For each patient with a heart murmur select the heart lesion most likely responsible for the murmur.

    158. A 50-year-old man presents with syncope that occurred while he was dancing at his high school reunion party. His blood pressure is normal but his pulse pressure is narrow. Heart examination reveals a crescendo-decrescendo systolic murmur heard best at the second left intercostal space that radiates to the carotid artery. The patient has a soft S2 heart sound.
    Answer: Aortic Stenosis
  12. For each patient with a heart murmur select the heart lesion most likely responsible for the murmur.

    159. A 19-year-old man presents after having a syncopal episode while playing in a college intramural basketball game. His father died suddenly at the age of 30. Physical examination reveals a rapid, brisk carotid upstroke. Heart examination reveals a holosystolic murmur heard best in the left sternal border that radiates to the neck. The murmur increases with Valsalva maneuver.
    Answer: Hypertrophic Cardiomyopathy
  13. For each patient with a heart murmur select the heart lesion most likely responsible for the murmur.

    160. A 14-year-old adolescent experiences shortness of breath while in a gym class. Heart examination reveals fixed splitting of S2. There is a crescendo-decrescendo systolic murmur heard best in the left second intercostal space.
    Answer: Atrial Septal Defect
  14. For each patient with a heart murmur select the heart lesion most likely responsible for the murmur.

    161. A 56-year-old man is four days post-myocardial infarction. A thrill is palpable over the precordium. On heart auscultation, a new holosystolic murmur is heard at the left lower sternal border that radiates to the right of the sternum.
    Answer: Ventricular Septal Defect.