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Quiz for Practitioners
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1

A 48-year-old man is admitted to the coronary care unit with an acute inferior myocardial infarction. Two hours after admission, his blood pressure is 86/52 mmHg; his heart rate is 40 beats per minute with sinus rhythm. Which of the following would be the most appropriate initial therapy?
A)Immediate insertion of a temporary transvenous pacemaker
B)Intravenous administration of atropine sulfate, 0.6 mg
C)Administration of normal saline, 300 mL over 15 min
D)Intravenous administration of dobutamine, 0.35 mg/min
E)Intravenous administration of isoproterenol, 5.0 g/min
2

A 68-year-old man with a history of hypertension, diabetes, and urinary retention awoke feeling nauseated and light-headed. He did not respond to questions from his wife. When the emergency medical technicians arrived, his blood pressure was 60 by palpation. IV fluids and oxygen were administered. Vital signs obtained in the ER were blood pressure 60, heart rate 120 and regular, temperature 38.9°C (102°F), and respiratory rate 30. A brief physical examination revealed coarse rales approximately halfway up in the chest bilaterally and inaudible heart sounds. An indwelling urinary catheter was placed with drainage of 10 to 20 mL of dark urine. Chest x-ray revealed bilateral interstitial infiltrates; ECG was unremarkable except for sinus tachycardia. Antibiotics were administered, and the patient was transferred to the ICU, where a right heart catheterization was performed. Pulmonary capillary wedge pressure was 28 mmHg. Cardiac output was 1.9 L/min. Right atrial mean pressure was 10 mmHg. The most likely cause of this man's hypotension was
A)left ventricular dysfunction
B)right ventricular infarction
C)gram-negative sepsis
D)gastrointestinal bleeding
E)pulmonary emboli
3

A 55-year-old man with known coronary heart disease develops recurrent anginal symptoms 2 months after undergoing an apparently successful percutaneous transluminal coronary angioplasty (PTCA) procedure. The original PTCA procedure was performed because of angina unresponsive to medical therapy in the setting of two proximal 90% occlusions (one in the right coronary artery and the other in the left circumflex). Cardiac catheterization reveals that the left circumflex lesion has reoccluded. Which of the following statements concerning the patient's current condition is correct?
A)The patient probably will require coronary artery bypass surgery
B)If the patient had been treated with aspirin daily from the time of his initial PTCA, this problem would have been less likely
C)A cholesterol-lowering agent would have been useful in preventing this problem
D)The administration of warfarin therapy for 6 months after PTCA is indicated to prevent this problem
E)Coronary artery smooth-muscle hyperplasia probably played a role in the current problem
4

A 67-year-old man who has experienced recurrent episodes of dizziness over the last several months is admitted to the hospital because of a fainting episode. No evidence of acute myocardial infarction is documented. On the evening of admission, the patient tells his nurse that approximately 10 min earlier he experienced several minutes of dizziness. His current rhythm appears to be normal sinus; however, a monitoring strip obtained at the time of this episode reveals absent QRS complexes every third beat. The PR interval, while slightly prolonged, is constant from beat to beat. P waves are present at regular intervals. Which of the following is the most appropriate therapeutic action?
A)Insertion of permanent cardiac pacemaker
B)Insertion of temporary cardiac pacemaker followed by insertion of permanent cardiac pacemaker
C)Administration of atropine, 2 mg IV
D)Administration of isoproterenol, 2 mg/min IV
E)No specific therapy is required for this benign arrhythmia
5

A 53-year-old man presents to the emergency room after the acute onset of chest pain. The episode occurred 8 h prior to his arrival and lasted for a total of 20 to 30 min. The chest pain is now resolved. The patient has a long history of diabetes mellitus and hypocholesteremia and has smoked approximately 1 to 1 1/2 packs per day of cigarettes for the past 30 years. On physical exam he has a blood pressure of 84/52, and his pulse is 54. He has jugular venous distention to the angle of the mandible and clear lung fields. His rhythm strip reveals a Wenkebach pattern. Given his hypotension, a Swan-Ganz catheter is placed. Right atrial pressure is estimated at 16 mmHg (normal 0-5), pulmonary artery pressure at 20/10 mmHg (normal 12-28/3-13), and the pulmonary capillary wedge pressure is 8 mmHg (normal range 3-10). Which of the following is most consistent with this clinical picture?
A)An anterior wall myocardial infarction
B)A right ventricular infarction
C)A ruptured mitral valve leaflet
D)A constrictive pericarditis following a myocardial infarction
E)A lateral wall myocardial infarction
6

Examination of the carotid pulse reveals two impulses or peaks during ventricular systole. Which of the following physical findings probably would be associated with this finding?
A)Diastolic murmur beginning after an opening snap
B)Decrease in systolic arterial pressure during inspiration
C)Systolic murmur increasing during the Valsalva maneuver
D)Right-sided third heart sound
E)Left-sided third heart sound
7

Digitalis glycosides enhance myocardial contractility primarily by which of the following mechanisms?
A)Opening of calcium channels
B)Release of calcium from the sarcoplasmic reticulum
C)Stimulation of myosin ATPase
D)Stimulation of membrane phospholipase C
E)Inhibition of membrane Na+, K+-ATPase
8

A 65-year-old man with a long history of untreated hypertension complains of recurrent shortness of breath on minimal exertion. Examination of the cardiovascular system is normal except for a prominent precordial impulse. Chest x-ray is normal except for a prominent left ventricular shadow. An exercise tolerance test with thallium scanning reveals no evidence of myocardial ischemia. Two-dimensional echocardiography reveals left ventricular hypertrophy. Radionuclide ventriculography reveals normal right and left ventricular ejection fractions. What is the most likely explanation for the patient's symptoms?
A)Chronic obstructive pulmonary disease
B)Reactive airways disease
C)Systolic congestive heart failure
D)Diastolic congestive heart failure
E)Myocardial ischemia
9

Clues to the presence of atrioventricular nodal block (as opposed to trifascicular block) include which of the following?
A)Clinical evidence of inferior myocardial infarction
B)No change in the escape rhythm with exercise
C)An escape-focus rate slower than 40 beats per minute
D)A widened QRS complex at the escape focus
E)Unresponsiveness of the escape focus to atropine
10

Which of the following agents has been shown to reduce mortality in patients with congestive heart failure?
A)Digitalis
B)Furosemide
C)Enalapril
D)Procainamide
E)Aspirin
11

A 68-year-old Haitian man presents with a chronic nonproductive cough, dyspnea on exertion, and chronic nonexertional chest pain. The patient notes a loss of 10 pounds over the past 6 months, decreased appetite, and swelling of the ankles. Physical findings reveal an ill-appearing man with decreased skeletal mass. Blood pressure is 100/70 without a significant inspiratory decrease in systolic pressure. Heart rate is 110; respiratory rate is 25; temperature is 37.2°C (99.0°F) orally. Significant physical findings include the absence of rales on chest examination and the presence of jugular venous distention with a decline during inspiration. The apical cardiac pulse is reduced. The heart sounds are distant; an early third heart sound occurs very shortly after aortic valve closure; there are no murmurs. Both the liver and the spleen are enlarged, and there is a fluid wave on abdominal examination. Electrocardiography displays low QRS voltage but is otherwise unremarkable. Chest x-ray reveals clear lungs and an enlarged cardiac silhoutte. Which of the following findings is most likely to appear on echocardiographic examination?
A)Enlarged right ventricular size
B)Pericardial effusion
C)Thickened myocardium
D)Thickened pericardium
E)Right ventricular diastolic collapse
12

Each of the following patients was noted to have an abnormally high serum cholesterol and was placed on a reduced calorie, cholesterol, and fat diet for the past 3 months. None has any history of ischemic heart disease. In which of the following patients would it be most appropriate to recommend lipid-lowering drug therapy at this time?
A)A 52-year-old smoker and diabetic with an LDL cholesterol value of 3.2 mmol/L (120 mg/dL)
B)A 60-year-old hypertensive woman with an LDL cholesterol value of 3.5 mmol/L (140 mg/dL)
C)A 50-year-old man with cholesterol of 6 mmol/L (230 mg/dL)
D)A 45-year-old man with LDL cholesterol of 5 mmol/L (200 mg/dL)
E)A 58-year-old male smoker with cholesterol of 5.5 mmol/L (220 mg/dL) and LDL cholesterol of 4 mmol/L (150 mg/dL)
13

Which of the following statements regarding secundum atrial septal defect is true?
A)Surgical correction is advisable when the pulmonary-to-systemic flow ratio has reached 2.0
B)Affected persons are usually symptomatic in childhood
C)Electrocardiography shows a leftward axis
D)Echocardiography shows a normal ventricular septal motion
E)Atrial arrhythmias are uncommon
14

A 75-year-old man presents with recurrent episodes of shortness of breath on minimal exertion. He has no prior significant past medical history. Physical examination reveals blood pressure of 110/70 without pulsus paradoxus, heart rate of 110, respiratory rate of 25, and temperature of 37°C (98.6°F) orally. Jugular veins are distended and the heart sounds are distant, but there are third and fourth extra heart sounds. The liver is enlarged, and pedal edema is present. The electrocardiogram shows nonspecific ST-T wave changes and occasional premature ventricular contractions. The chest x-ray reveals clear lung fields and a mildly dilated cardiac silhouette. Echocardiography reveals normal systolic function and thickened ventricular walls with a "speckled" appearance. Which of the following conditions is most consistent with the patient's clinical presentation?
A)Alcoholic cardiomyopathy
B)Hemochromatosis
C)Amyloidosis
D)Viral myocarditis
E)Tuberculosis
15

A 20-year-old woman has mild pulmonic stenosis (transvalvular gradient is 20 mmHg). Which of the following statements regarding this situation is true?
A)Heart size on chest x-ray is likely to be enlarged
B)Electrocardiogram is likely to be abnormal
C)There is loss of the jugular a wave
D)(D) Compared to other valvular defects, the risk of endocarditis is relatively low
E)Frequent monitoring for progression of the stenosis is indicated
16

Which of the following findings would be expected in a person with coarctation of the aorta?
A)Both a systolic murmur and a diastolic murmur would be heard best along the left sternal border
B)A higher blood pressure in the left arm than in the right
C)Inability to augment cardiac output with exercise
D)Often associated with a bicuspid aortic valve
E)Hypertension typically resolves after complete surgical repair
17

A 15-year-old boy residing with his parents on a military base presents with a fever of 38.6°C (101.5°F) and complains of lower back, knee, and wrist pain. The arthritis is not localized to any one joint. He gives a history of a severe sore throat several weeks earlier. Physical examination of the skin reveals pea-sized swellings over the elbows and wrists. He also has two serpiginous, erythematous pink areas on the anterior trunk, each about 5 cm in diameter. Laboratory investigation includes negative blood cultures, negative throat culture, normal CBC, and an erythrocyte sedimentation rate (ESR) of 100. An antistreptolysin-O (ASO) titer is elevated. At this point, appropriate therapy would consist of
A)supportive care alone
B)parenteral penicillin
C)parenteral penicillin and glucocorticoids
D)parenteral penicillin and aspirin
E)parenteral penicillin, aspirin, and diazepam
18

Each patient below is alert and oriented and has a blood pressure of 110/60. In which patient would adenosine constitute appropriate initial therapy?
A)A 65-year-old man with no ischemic heart disease and wide complex tachycardia
B)A 65-year-old woman with known ischemic disease and narrow complex tachycardia
C)A 25-year-old woman with known preexcitation syndrome and narrow complex tachycardia
D)A 28-year-old man with known preexcitation syndrome and wide complex tachycardia
E)A 44-year-old man with atrial fibrillation without a prior history of heart disease
19

A 72-year-old man with a long history of tobacco use presents to the emergency room with shortness of breath. He is mildly cyanotic and hypotensive. On exam he has poor air movement bilaterally and has evidence of an elevated jugular venous pressure. A Swan-Ganz is placed revealing right atrial pressures of 15 mmHg (normal range 0-5), a pulmonary artery pressure of 70/28 (normal range 12-28/3-13), and a pulmonary capillary wedge pressure of 10 (normal range 3-11). Which of the following is most consistent with this clinical picture?
A)Inferior myocardial infarction
B)Mitral stenosis
C)Cor pulmonale
D)Mitral regurgitation
E)Constrictive pericarditis
20

A 23-year-old man presents to the emergency room with palpitations; his heart rate is 180 and he has a normal systolic blood pressure. An attempt to slow his heart rate is made using verapamil. Unfortunately, the patient's condition rapidly deteriorates. He is now pulseless, and a rhythm strip reveals ventricular fibrillation. Which of the following is most consistent with the patient's initial cardiac rhythm at presentation?
A)Atrial flutter
B)Sinus tachycardia
C)Atrial fibrillation with aberrant conduction
D)Atrial fibrillation
E)Proximal supraventricular tachycardia (PSVT)
21

Which of the following statements best describes long-acting nitrate preparations?
A)Tolerance often develops
B)Their effect can be blocked by high doses of beta2 selective inhibitors
C)Transdermal patches are more likely to be associated with headaches than are sublingual nitrates
D)Oral preparations are more effective than sublingual ones
E)Oral administration of isosorbide should not exceed 15 mg every 3 to 4 h
22

A 70-year-old retired banker with no past medical history presents to the emergency department 4 h after the onset of severe substernal crushing chest pain with radiation to the left arm and neck. Electrocardiography reveals significant ST-segment elevation in leads I, L, V5, and V6. The patient has no clear-cut medical contraindications to anticoagulation. Which of the following would be the optimal management strategy at this time?
A)Intravenous tissue plasminogen activator alone
B)Intravenous tissue plasminogen activator and aspirin
C)Intravenous tissue plasminogen activator and heparin
D)Intravenous tissue plasminogen activator, heparin, and aspirin
E)Thrombolytic therapy is contraindicated because of the patient's age
23

A 14-year-old boy is brought into the emergency room pulseless and undergoing cardiopulmonary resuscitation. He collapsed while playing basketball. There is no history of trauma, and no prior history of cardiovascular disease. Which of the following conditions would most likely be identified at the time of autopsy?
A)Normal findings
B)Anomalous left coronary artery
C)Ruptured aorta
D)Hypertrophic cardiomyopathy
E)Coronary artery disease
24

A previously healthy 58-year-old man is admitted to the hospital because of an acute inferior myocardial infarction. Within several hours, he becomes oliguric and hypotensive (blood pressure is 90/60 mmHg). Insertion of a pulmonary artery (Swan-Ganz) catheter reveals the following pressures: pulmonary capillary wedge, 4 mmHg; pulmonary artery, 22/4 mmHg; and mean right atrial, 11 mmHg. This man would best be treated with
A)fluids
B)digoxin
C)norepinephrine
D)dopamine
E)intraaortic balloon counterpulsation
25

A 63-year-old black woman with a long history of hypertension and diabetes is brought to the emergency department by relatives because she has become incoherent over the past 24 h. Physical examination reveals a disoriented woman whose blood pressure is 230/160, respiratory rate is 25, and pulse is 110. The patient is afebrile. The chest reveals bibasilar rales. Cardiac examination is remarkable only for the presence of an S4. There is no organomegaly or focal neurologic findings. The patient is oriented to person only.

The family revealed that the patient has not been taking her antihypertensive medicines in the past several weeks. The patient is placed on a cardiac monitor, and both intravenous and intraarterial lines are placed. An emergent CT scan reveals no evidence of hemorrhage or mass lesion. The most appropriate next step in management would be to
A)observe the patient in a quiet room for 1 h before administering therapy
B)wait for laboratory values to return before deciding on specific therapy
C)administer sodium nitroprusside
D)administer diazoxide
E)administer intravenous nicardipine







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