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124. A 47 yr old woman presents with chest pain that worsens with inspiration and improves when she bends forward . Pain is relieved when the patient holds her breath. Blood pressure is 140/90 mmHg. Heart exam reveals coarse, scratchy signs head throughout the cardiac cycle. ECG reveals ST elevations. Which of the following is the most appropriate next step in management?
A. IV heparin
B. Oral prednisone
E. Primary angioplasty
F. chest radiograph
Ibuprofen (patient has pericarditis
125. A 47 yo perimenopausal woman presents for annual checkup. She denies chest pain, SOB, and palpitations. She has no family hx or heart disease and does not smoke. She has no meds, and she excercises @ a fitness center 3 times a week. BP is 110/75 mm Hg and HR is 66 beats/min and regular. PE reveals no jugular venous distention. Lung exam is normal. A split S1 best heard over the tricuspid area is audible, but was not present 1 year ago. No peripheral edema. Which is best next step in DIAGNOSIS?
A. Transthroacic echocardiogram
B. Cardiac stress test
C. cardiac isoenzymes
D. cardiac catheterization
Electrocardiogram (patient has RBBB)
126. 16 yo is found to have an unexpected sound audible in right side of neck. The sound is loudest in diastole when patient is in sitting position. Sound disappears when patient is lying down or with valsalva maneuver. Patient has no complaints and is very athletic. No clubbing/cyanosis. BP and HR normal. PE is normal. What is diagnosis?
A. thyroid bruit
B. venous hum
C. carotid bruit
D. AV malformation
E. transmitted murmur
Venous hum (innocent murmur)
127. 23 year odl woman presents with a 2 year history of palpitations. She denies chest pain and dizziness. Past medical history is significant for pectus excavatum. BP and HR are normal. Physical exam reveals an apical late systolic crescendo-decrescendo murmur preceded by a midsystolic click that occurs earlier with standing. Which do you expect to find on transthoracic echocardiogram?
A. aortic stenosis
B. mitral valve prolapse
C. mitral stenosis
D. tricuspid regurg
E. aortic regurg
Mitral valve prolapse
128. you evaluate a 57 yo man in the ER with diabetes and high cholesterol who complains of a pressure like chest pain that started while he was shoveling snow 45 minutes ago. Pain radiates to jaw and left arm. Patient has no dizziness, nausea, vomiting, or palpitations. Past medical history of hypertension, and he smokes two packs per day. Brother had an MI that required balloon angioplasty when in forties. On PE, patient appears pale and diaphoretic. BP is 160/100 and pulse is 108. Extremities are cool. Heart exam reveals S4 gallop. Lungs normal. Peripheral pulses are palbable and bilaterally equal. No peripheral edema. What should be accomplished within first 10 minutes of management in ER?
A. Administration of 160 to 325 chewable aspirin
B. initiation of IV nitroglycerin
C. percutaneous coronary intervention
D. exercise stress test
Administration of aspirin
129. 41 year old IV drug abuser presents with SOB and pleuritic chest pain. He is febrile with temp of 103.5 F. He has no skin leisions, fundoscopic exam is negative. He has jugular venous distention that increases with the compression of the liver. Liver is pulsatile. Jugular venous pulse shows a prominent v wave. Patient has splenomegaly. Heart auscultation reveals a holosystolic murmur heard best at the left lower sterna that increases with inspiration. Which of the following is the most likely diagnosis?
A. bacterial endocarditis of the tricuspid valve
B. bacterial endocarditis of the mitral valve
C. rheumatic fever
e. acute hepatitis
Bacterial endocarditis of the tricuspid valve
130. A 58 yo man with a Hx of poorly controlled hypertension presents to the ER with SOB for 2 days. He admits to drinking heavily over the weekend. He has three pillow orthopnea and paroxysmal nocturnal dyspnea as well as lower extremity edema. He does not have chest pain, palpitations, dizziness, or coudh. His BP is 180/100 and his HR averages 130 beats per minute. His electrocardiogram is shown in the following figure. Which of the following will never be found in a person with this rhythm?
A. a pulse deficit compared with the central rate
B. jugular venous distention
C. a third heart sound (S3)
D. a fourth heart sound (S4)
E. lower extremity edema
A fourth heart sound (pt has atrial fibrillation)
131. An 18 yo woman presents 2 weeks after an exudative pharygitis with fever and arthritis that is asymmetrical and involves more than 3 joints. The arthritis is migratory, affecting one joint for several days and improving, then affecting another joint. On physical exam, patient has a macular rash consisting of ring shaped lesions with clear centers and her cardiac exam, reveals an S3 gallop. Which of the following is the most likely diagnosis?
A. lyme disease
C. rheumatoid arthritis
E. rheumatic fever
132. A 53 yo man presents complaining of leg pains. HE notices the discomfort primarily in his calf when he walks. It seems to feel better after he stops and rests for a few minutes. He has smoked since high school. On PE, he has diminished popliteal and dorsalis pedis pulses with loss of hair and skin mottling of the anterior tibial surface bilaterally. What is the most appropriate next step in diagnosing his condition?
A. lower extremity Doppler ultrasound
B. angiography of the lower extremities
C. ankle-brachial index
D. Magnetic resonance angiography
E. CT angiography
Ankle-brachial index (pt has intermittent claudication)
133. A 23 old student presents to your office for health clearance to play collegiate sports. He is asymptomatic and excercises daily. On physical exam, his blood pressure is 160/50 mm Hg, and his pulse rate is 60 beats/minute with a rapid rise and fall. Heart examination reveals with a hyperdynamic apical impulse with an early diastolic murmur at the left sternal border. Nail beds reveal capillary pulsations. Which of the following is the most likely diagnosis?
A. cardiac tamponade
B. aortic insufficiency
C. mitral stenosis
D. atrial septal defect
E. tetralogy of fallot
Aortic insufficiency (ex. Marfan’s. note water hammer pulse=rise and fall)
134. While palpating the pulse of a patient, you note that the pulse wave has two equal peaks during systole. You auscultate the heart and are certain that there is only one heartbeat for each two pulse waves. Which of the following best describes this finding?
A. pulsus alternans
B. dicrotic pulse
C. pulsus parvus et tardus
D. pulsus bigeminus
E. pulsus bisferiens
135 A 69 year old women with a history of hypertension and diabetes mellitus presents with shortness of breath. She denies chest pain and palpitations. Physical exam reveals a blood pressure of 130/60 and a HR of 72 beats/minute. Patient’s lungs are normal . Heart auscultation reveals an S4 gallop. She has no jugular venous distention and no peripheral edema. Chest radiograph shows a normal size heart , and ECG shows left ventricular hypertrophy. Echocardiogram reveals concentric left ventricular hypertrophy with a hyperdynamic ventricle. Which of the following is the most likely diagnosis?
A. systolic dysfunction
B. diastolic dysfunction
C. left heart failure
D. right heart failure
E. normal heart
136. A 50 yo woman presents with malaise and weight loss. She denies chest pain, SOB, dizziness, and palpitations. Her temp is 100.9F, and her heart rate is 80 beats/minute. There is a diastolic sound that is variable from cycle to cycle. Splinter hemorrhages are visible in the finernails of both hands. Which of the following is the most likely diagnosis?
A. mitral stenosis
C. aortic insufficiency
D. atrial myxoma
E. tricuspid stenosis
Atrial myxoma (benign tumor of the heart)
137. A 30 yo woman presents for a routine checkup. She has no complaints and denies previous medical problems. On heart exam, the patient has a loud S1. She has a grade 2 low-pitches mid to late diastolic murmur that is heart best at the apex. Immediately preceding the murmur is a loud extra sound. Which of the following is the most likely diagnosis?
A. mitral valve prolapsed
B. mitral stenosis
C. ventricular septal defect
D. aortic insufficiency
E. atrial septal defect
138. A 16 year old adolescent comes to your practice for a physical exam to enroll in a sports program. Upon taking his vital signs, you note that his right arm BP s 150/110. On auscultation, a systolic murmur best heard over the middle of the upper back is detected. The report from a chest x ray done a few months ago, when he had a productive cough and fever, comments on notching of the ribs. Which of the following would most likely confirm your suspicion of the etiology of your findings today?
A. elevated blood pressure in the legs
B. unequal arm blood pressures
C. delayed femoral pulse when compared to the brachial pulse
D. earlier femoral pulse when compared to the brachial pulse
E. normal ECG findings
Delayed femoral pulse when compared to the brachial pulse (coarctation of the aorta)
139. A 66 yo man with a history of lung cancer treated 5 years ago presents with worsening shortness of breath and fatigue. His blood pressure and heart rate are normal. Physical exam is positive for jugular venous distention which does not fall with inspiration, ascities, and peripheral edema. A loud and high pitched extra sound is heard in early diastole corresponding to early ventricular filling. Which of the following is the most likely diagnosis?
A. pericardial effusion
B. pericardial tamponade
C. dilated cardiomyopathy
D. constrictive pericarditis
E. infectious myocarditis
Constrictive pericarditis (presents with right sided heart failure)
140. A 57 year old man presents with midsternal pressure-like chest pain that radiates to the left arm accompanied by diaphoresis and nausea. He has a blood pressure of 80/50 mm Hg and neck vein distention with inspiration. The rest of the physical exam is normal. Electrocardiogram reveals ST elevations in leads II, II, and aVf. Which of the following is the most likely diagnosis?
A. congestive heart failure
B. pericardial tamponade
C. right ventricular infarction
D. anterior wall ST segment elevation MI
E. rupture of the papillary muscle
Right ventricular infarction (kussmaul’s sign is neck vein distention on inspiration)
141. A mother brings her 11 yo son to your office because he easily becomes short of breath while running. She states that he dose not seem to be able to play for as long of a period of time as his friends. The patients’ blood pressure is 140/60, and he has bounding peripheral pulses. On auscultation of the heart, you detect a harsh, loud continous mumur heard best below the left clavicle. Which of the following is the most likely diagnosis?
A. cervical venous hum
B. hepatic venous hum
C. coartation of the aorta
D. patent ductus arteriosus
E. mammary soufflé
Patent ductus arteriosus (continuous machinery murmur)
142. A 54 yo man with a 20 year history of COPD has a heave that is palpable at the left lower sternal border at the 3rd, 4th, and 5th intercostal spaces. He has no palpable thrill. Which of the following best explains etiology of the heave?
A. it is a displaced point of maximum impulse
B. it means the patient has congestive heart failure
C. it means the patient has aortic stenosis
D. it means the patient has right ventricular hypertrophy
E. it means the patient has a pericardial effusion.
It means the patient has right ventricular hypertrophy
143. A 64 year old man with a history of poorly controlled hypertension presents with a sharp midsternal chest pain that occurred suddenly and radiates to his back between his shoulder blades. Blood pressure in 170/110 with a normal pulse in his right arm and 90/60 with a diminished pulse in his left arm. Heart auscultation reveals a diastolic murmur. Je has a tracheal tug sign. ECG is normal. Chest radiograph reveals a widened mediastinum. Which of the following is the most likely diagnosis?
A. myocardial infarction
B. pulmonary embolus
C. aortic dissection
D. coarctation of the aorta
E. aortic stenosis
Aortic dissection (sudden pain b/t shoulder blades)
144. An 81 year old woman presents with syncope. Blood pressure is 120/80 mm Hg and heart rate is 30 beats/minute. There is no jugular venous distension, but cannon a waves are visible. Lung and heart exams are otherwise normal. Her ECG is hsown in the following figure. Which of the following is the most likely cause of her syncope?
A. ventricular tachycardia
B. complete heart block
C. atrial flutter
D. atrial fibrillation
E. cardiac tamponade
F. myocardial infarction
Complete heart block
145. A 16 year old adolescent is referred to your office for a blood pressure of 140/55 mm Hg. He has a well healed surgical scar about 12 cm long over the medial aspect of his left thigh.On questioning, he states he acquired the scar 4 years ago by impaling his thigh on a large nail after falling. Auscultation of the scar reveals a bruit, and there is a palpable thrill. Which of the following is the most likely diagnosis?
A. premature atheroscleoris
B. ateriovenous fistula
C. scar tissue compressing the femoral artery
D. congenital femoral artery bruit
E. patent ductus arteriosus
146. A 55 year old woman with diabetes and hypertension comes to your office for a routine checkup. She has no other medical problems and does not smoke. Her father dies of an MI at her age. Her blood pressure is 150/90 mm Hg and her physical exam is normal. Upon obtaining a screening fasting lipid profile, what is the goal for her low density lipoprotein (LDL) cholesterol?
A. LDL< 160
B. LDL <130
C. LDL <100
D. LDL <190
E. LDL <40
LDL <100 mg/dL
147. A 51 year old man is involved in a motor vehicle accident. He was not wearing a seatbelt and remembers striking the steering wheel during the collision. On arrival at the ER, the patient is complaining of chest pain and SOB. His blood pressure is 120/80 but decreases to 90/50 at the end of inspiration. He has JVD with distant heart sounds. Lung exam reveals normal breathing sounds bilaterally. Which of the following is the most likely diagnosis?
A. aortic dissection
B. dialated cardiomyopathy
D. congestive heart failure
E. cardiac tamponade