2007-04-23

Front 1

Delirium tremens (DTs) is a serious, potentially fatal consequence of alcohol withdrawal. The patient’s history of previous DTs and his ongoing pattern of drinking make the occurrence of DTs likely. most appropriate management of the patient’s withdrawal?

Back 1

Given this high-risk situation, one should choose the method of withdrawal that is medically safest, which is to use a cross-tolerant agent. Benzodiazepines, such as chlordiazepoxide, are commonly used for this purpose.

Front 2

The clinical scenario of lightheadedness in the appropriate context—standing in line, no exertion, and normal ECG—suggests

Back 2

vasovagal syncope.

Front 3

often presents with substernal pain relieved with leaning forward;

Back 3

Pericarditis

Front 4

finding on ECG to suggest pericarditis.

Back 4

ST elevation

Front 5

a known adverse effect of clozapine and could present with seizures or mental status disturbances.

Back 5

Hyponatremia

Front 6

a known adverse effect of clozapine and should be suspected in individuals who develop fever with tachycardia

Back 6

Myocarditis

Front 7

should be suspected in patients presenting with high fever, decreasing mental status and muscular rigidity.

Back 7

Neuroleptic malignant syndrome

Front 8

Sialorrhea is excessive drooling and occurs in 30% to 50% of individuals taking clozapine. Most neuroleptics result in a dry mouth through their cholinergic effects, but sialorrhea casued by

Back 8

clozapine

Front 9

Regular-rate monomorphic wide QRS complex tachyarrhythmias should be assumed due to a

Back 9

pre-excitation syndrome such as Wolff-Parkinson-White (WPW) until proven otherwise.

Front 10

the drug most frequently associated with fatal outcomes in the treatment of patients with Wolff-Parkinson-White (WPW).

Back 10

Digitalis

Front 11

is considered first-line treatment in patients with wide complex tachycardia, particularly if ventricular tachycardia cannot be excluded from the diagnosis.
A. Adenosine
B. Amiodarone
C. Digoxin
D. Metoprolol
E. Verapamil

Back 11

Amiodarone

Front 12

is classically described in young women as a cause of secondary hypertension. It is an arterial disease of unknown etiology commonly affecting the renal arteries and presenting as renovascular hypertension. The internal carotid artery is the second most common location often effected bilaterally and may cause cerebral ischemia, transient ischemic attack, or thromboembolic stroke.

Back 12

Fibromuscular dysplasia

Front 13

Fibromuscular dysplasia is an arterial disease of unknown etiology most commonly affecting the

Back 13

renal arteries and presenting as renovascular hypertension

Front 14

is the second most common location in Fibromuscular dysplasia

Back 14

The internal carotid artery, often effected bilaterally and may cause cerebral ischemia, transient ischemic attack, or thromboembolic stroke.

Front 15

likely to lower the blood pressure and treat benign prostatic hypertrophy.

Back 15

α-blocker

Front 16

patient presents with temporal headache and jaw claudication suggestive of

Back 16

giant cell (temporal) arteritis

Front 17

He has experienced this headache for approximately 6 months. Upon questioning he also describes tongue pain and fatigue of the chewing muscles while eating. The physical examination is unremarkable. His erythrocyte sedimentation rate (ESR) is elevated.

Back 17

Giant cell arteritis

Front 18

arteriogram shows several small aneurysms in the branches of the superior mesenteric artery, suggestive of

Back 18

polyarteritis nodosa

Front 19

the Parkland formula

Back 19

intravenous fluid resuscitation of a burn victim involves 4 mL/kg/% burn

Half of this is given over 8 hours then the latter half over the next 16.

Front 20

intravenous fluid resuscitation of a burn victim formula

Back 20

4 mL/kg/% burn

Half of this is given over 8 hours then the latter half over the next 16.

Front 21

Skin and mucous membranes are dry. Pupils are dilated and fixed to accommodation. Chest is clear to auscultation and percussion. Cardiac examination shows a regular rhythm tachycardia only. Abdomen is soft and nontender with decreased bowel sounds. The patient is unable to provide a urine sample.

Back 21

anticholinergic syndrome.

Front 22

QRS widening in patients with anticholinergic syndrome
A. Diphenhydramine
B. Neostigmine
C. Physostigmine
D. Sodium bicarbonate
E. Syrup of Ipecac

Back 22

Option D (Sodium bicarbonate) is correct. The patient shows classic signs and symptoms of anticholinergic syndrome. QRS widening in patients with anticholinergic syndrome is one of the few remaining indications for bicarbonate administration.

Option A (Diphenhydramine) is incorrect. Diphenhydramine overdose is a common cause of this syndrome. Obviously, this medication should not be administered.

Option B (Neostigmine) is incorrect. Physostigmine is the only reversible inhibitor capable of directly antagonizing the CNS effects of anticholinergic toxicity. Additionally, QRS widening occurring in the presence of anticholinergic syndrome is a contraindication for acetylcholinesterase inhibitor therapy.

Option C (Physostigmine) is incorrect. Although physostigmine is the antidote for the patient's likely overdose of a substance with anticholinergic properties, the presence of QRS widening is a strong contraindication for this pharmacotherapy.

Option E (Syrup of Ipecac) is incorrect. Ipecac should not be used in patients with anticholinergic syndrome because of the increased risk for aspiration in patients with altered mental status and at increased risk for seizures

Front 23

high serum sodium, low serum potassium, and low renin levels.

Back 23

Primary hyperaldosteronism

Front 24

high serum sodium, low serum potassium, and high renin levels.

Back 24

secondary hyperaldosteronism

Front 25

This patient has unexplained syncope following a normal history, physical examination, and ECG. In the absence of any guiding information, the most appropriate next diagnostic step is
A. Electroencephalogram (EEG)
B. Head computed tomography (CT)
C. Holter monitor
D. Psychiatric evaluation
E. Tilt-table test

Back 25

Option E (Tilt-table test) is correct. This patient has unexplained syncope following a normal history, physical examination, and ECG. In the absence of any guiding information, the most appropriate next diagnostic step is the use of tilt-table testing. The test is performed by altering the angle of the table.

Option A (Electroencephalogram [EEG]) is incorrect. EEG can be useful if epilepsy were suspected, but there is nothing in the history to suspect seizure activity.

Option B (Head computed tomography [CT]) is incorrect. There is nothing suggestive in the history or on physical examination of a specific intracranial pathology detectable on head CT.

Option C (Holter monitor) is incorrect. A Holter monitor is indicated in patients who have underlying heart disease, but no suggestive reason for syncope on history or physical examination.

Option D (Psychiatric evaluation) is incorrect. Psychiatric evaluation is indicated in young patients who do not have a demonstrable pathophysiologic reason for recurrent syncope. The tilt-table test should generally be performed prior to referring a patient for psychiatric evaluation.

Front 26

patient is in atrial fibrillation. What is the first line of therapy?
A. Heparin
B. Methimazole
C. Propranolol
D. Propylthiouracil
E. Radioactive iodine

Back 26

Option C (Propranolol) is correct. It is important to reduce cardiac stress.

Option A (Heparin) is incorrect. There is no role for this medication.

Option B (Methimazole) is incorrect. This may be part of the overall therapy, but cardiac protection comes first.

Option D (Propylthiouracil) is incorrect. This may be part of the overall therapy, but cardiac protection comes first.

Option E (Radioactive iodine) is incorrect. This may be part of the overall therapy, but cardiac protection comes first.

Front 27

Nonconducted P waves are seen in the absence of progressive PR prolongation. AV block type

Back 27

Second-degree AV block, type II.

Front 28

atrial tachycardia with a 2:1 AV block. AV block type

Back 28

Digoxin-induced second-degree atrioventricular (AV) block

Front 29

prolongation of the P-R interval without dropped beat. AV block type

Back 29

First-degree AV block

Front 30

progressive PR prolongation preceding a nonconducted P wave. AV block type

Back 30

Second-degree AV block, type I (Wenckebach)

Front 31

wide, fixed split S2 with a systolic ejection murmur over the pulmonic region.

Back 31

Atrial septal defect, secundum type

Front 32

neonate demonstrates pronounced cyanosis and a loud, single S2.

Back 32

Transposition of the great vessels

Front 33

Atrial septal defect Physical Findings

Back 33

Parasternal RV impulse Widely and fixed split S2 Ejection murmur across pulmonic valve

Front 34

Atrial septal defect Chest Radiograph

Back 34

Large pulmonary artery Increased pulmonary markings

Front 35

Atrial septal defect Electrocardiogram

Back 35

Right bundle branch block Left axis deviation with ostium primum defect

Front 36

Ventricular septal defect Physical Findings

Back 36

Hyperdynamic precordium Holosystolic left parasternal murmur, ±thrill

Front 37

Ventricular septal Electrocardiogram

Back 37

LV and RV hypertrophy

Front 38

Ventricular septal defect Chest Radiograph

Back 38

Cardiomegaly Prominent pulmonary vasculature

Front 39

Patent ductus arteriosus Physical Findings

Back 39

Hyperdynamic apical impulse Continuous "machinery" murmur

Front 40

Patent ductus arteriosus Electrocardiogram

Back 40

LV hypertrophy

Front 41

Patent ductus arteriosus Chest Radiograph

Back 41

Prominent pulmonary artery Enlarged LA and LV

Front 42

the most common congenital heart defect to produce cyanosis within the first 24 hours of life

Back 42

Transposition of the great vessels

Front 43

gray baby from birth, hepatomegaly, and dyspnea while feeding. on Doppler echocardiography, there is no forward blood flow through the ascending aorta.

Back 43

Hypoplastic left heart syndrome

Front 44

Patients with slight, mild limitation of activity and are comfortable at rest are categorized as CHF class

Back 44

CHF class II. Addition of digoxin is recommended in these patients.

Front 45

idiopathic pulmonary arterial hypertension
A. Calcium channel blockers
B. Corticosteroids
C. Glycoprotein IIb/IIIa inhibitors
D. Prostacyclin agents
E. Tumor necrosis factor inhibitors

Back 45

Epoprostenol is a formulation of naturally occurring PGI2 (prostacyclin) that is used to treat pulmonary arterial hypertension (PAH).

Option D (Prostacyclin agents) is correct. Untreated, idiopathic pulmonary arterial hypertension leads to right-sided heart failure and death with an overall survival of approximately 30% at 3 years. The use of long-term prostacyclin agents resulted in a 5-year survival rate greater than 65%.

Option A (Calcium channel blockers) is incorrect. Calcium channel blockers were, until recently, the most widely used class of drugs for idiopathic pulmonary arterial hypertension. The introduction of long-term prostacyclin agents for treatment of idiopathic pulmonary arterial hypertension has resulted in a improvement in survival from 30% at 3 years to a 5-year survival rate greater than 65%.

Option B (Corticosteroids) is incorrect. Corticosteroids clearly improve survival in patients with SLE. They have no effect on the relentlessly fatal progression of idiopathic pulmonary arterial hypertension and therefore provide no improvement in this patient's prognosis of 30% 3-year survival without prostacyclin therapy.

Option C (Glycoprotein IIb/IIIa inhibitors) is incorrect. Glycoprotein IIb/IIIa inhibitors such as abciximab, eptifibatide and tirofiban are potent inhibitors of platelet aggregation. They have no effect on the progression of idiopathic pulmonary arterial hypertension.

Option E (Tumor necrosis factor inhibitors) is incorrect. Tumor necrosis factor inhibitors, such as infliximab, etanercept, and adalimumab, are promising new agents in the treatment of several autoimmune mediated diseases including juvenile arthritis. There is no evidence that they improve survival in patients with idiopathic pulmonary arterial hypertension.

Front 46

A postoperative patient who goes into shock and was previously on corticosteroids should be suspected of
A. Adrenal insufficiency
B. Diabetic ketoacidosis
C. Hypoglycemia
D. Postoperative bleeding
E. Small-bowel obstruction

Back 46

Option A (Adrenal insufficiency) is correct. A postoperative patient who goes into shock and was previously on corticosteroids should be suspected of having adrenal insufficiency as a result of a lack (or insufficient dose) of steroid administration. Prolonged steroid administration results in down-regulation of adrenocorticotropic hormone (ACTH), and if exogenous steroids are removed, ACTH is unable to rise quickly enough to compensate, and the patient can go into shock.

Option B (Diabetic ketoacidosis) is incorrect. Although diabetic ketoacidosis can occur in patients with type 1 diabetes, a high serum glucose is expected.

Option C (Hypoglycemia) is incorrect. The patient is hypoglycemic, but the cause of her symptoms is to the result of adrenal insufficiency. Hypoglycemia can result from lack of glucocorticoids.

Option D (Postoperative bleeding) is incorrect. This patient does have a slightly decreased hematocrit, but that is likely the result of anemia of chronic disease. Massive postoperative bleeding would be less likely following an uncomplicated surgery compared with adrenal insufficiency.

Option E (Small-bowel obstruction) is incorrect. Small-bowel obstruction can present in this manner; it would be unlikely for the patient to rapidly progress into a state of shock.

Front 47

55-year-old woman sees her internist with a complaint of difficulty breathing when she lies flat on her back. She also reports shortness of breath with exertion and swelling of her ankles. DX?

Back 47

CHF

Front 48

Which of the following findings on physical examination is most likely in CHF?
A. Absent abdominal jugular reflux
B. Jugular venous distension at rest
C. Pedal edema
D. Rales
E. Third heart sound (S3)

Back 48

Option B (Jugular venous distension at rest) is correct. This is found in patients, such as this one, presenting with congestive heart failure.

Option A (Absent abdominal jugular reflux) is incorrect. The absence of abdominal jugular reflux in a patient presenting with congestive heart failure (CHF) would be unusual.

Option C (Pedal edema) is incorrect. Pedal edema would be a likely finding in CHF, but it is often not present on examination in patients with CHF.

Option D (Rales) is incorrect. This finding is not as likely as the finding of jugular venous distention at rest in a patient presenting with CHF.

Option E (Third heart sound [S3]) is incorrect. This has a high predictive accuracy, but it is often not heard in patients presenting with CHF.

Front 49

An electrocardiogram (ECG) reveals irregularly irregular RR intervals and an absence of P waves. Echocardiography demonstrates a dilated left ventricle, left ventricular ejection fraction of 36% and mild mitral regurgitation.
What is the most appropriate intervention to improve this patient's left ventricular function?
A. Afterload reduction
B. Coronary revascularization
C. Heart rate control
D. Inotropic support
E. Mitral valve replacement

Back 49

Option C (Heart rate control) is correct. This patient has heart failure as evidenced by his poor ejection fraction (normal is between 50% and 60%). He also has developed atrial fibrillation, which is demonstrated by the irregularly irregular RR interval and absence of P waves on ECG. Normally, the atrial filling of the left ventricle is not overly significant. However, when there is dysfunction of the left ventricle (possibly an alcoholic cardiomyopathy in this case), the atrial kick becomes important. Controlling the heart rate is a method by which to improve the left ventricular ejection fraction (LVEF) by improving left ventricular filling. Importantly, heart rhythm control has been shown to be equally effective in this case.

Option A (Afterload reduction) is incorrect. Afterload reduction is a method of management for congestive heart failure (CHF). However, this patient is in atrial fibrillation and we would expect a more significant improvement if it were treated.

Option B (Coronary revascularization) is incorrect. This patient has a poor left ventricular ejection fraction (LVEF) that could be the result of alcoholic cardiomyopathy or even possibly, coronary artery disease. There is no clear indication in this question as to the specific etiology of this patient's heart failure. There is, however, clear evidence of atrial fibrillation that needs to be addressed.

Option D (Inotropic support) is incorrect. Inotropic support could improve this patient's left ventricular function, but heart rate control would allow for better left ventricular filling and would be a better solution in this case.

Option E (Mitral valve replacement) is incorrect. This patient has a dilated left ventricle, which often results in small mitral valve incompetence. Major cardiac surgery would not be the answer to this patient's problems.

Front 50

In patients younger than age 45 years with a clinical picture of distal paresthesias, digital ulcers, claudication, normal proximal pulses, and diminished distal pulses with a negative workup for possible diabetic, autoimmune, hypercoagulation, or other thromboembolic etiologies disorders, the most likely diagnosis is

Back 50

thromboangiitis obliterans (Buerger's disease).

Front 51

patients younger than age 45 years with a clinical picture of distal paresthesias, digital ulcers, claudication, normal proximal pulses, and diminished distal pulses with a negative workup for possible diabetic, autoimmune, hypercoagulation, or other thromboembolic etiologies disorders, Virtually all patients have a history of

Back 51

Virtually all patients with Buerger's disease have a heavy smoking history.

Front 52

inferior wall MI.
A. ST depression is I, AVL
B. ST flattening V4–V6
C. ST segment elevation in II, III, AVF
D. ST segment elevation in V1, V2, V3
E. T wave deflection opposite to QRS deflection

Back 52

Option C (ST segment elevation in II, III, AVF) is correct. These are the classic ECG changes associated with an inferior wall MI.

Option A (ST depression is I, AVL) is incorrect. This would be seen in an anterior wall MI.

Option B (ST flattening V4–V6) is incorrect. These are nonspecific changes.

Option D (ST segment elevation in V1, V2, V3) is incorrect. This would be seen in an anterior wall MI.

Option E (T wave deflection opposite to QRS deflection) is incorrect. These are nonspecific changes.

Front 53

anterior wall MI.
A. ST depression is I, AVL
B. ST flattening V4–V6
C. ST segment elevation in II, III, AVF
D. ST segment elevation in V1, V2, V3
E. T wave deflection opposite to QRS deflection

Back 53

A&D

Option A (ST depression is I, AVL) is incorrect. This would be seen in an anterior wall MI.


Option D (ST segment elevation in V1, V2, V3) is incorrect. This would be seen in an anterior wall MI.

Front 54

nonspecific changes
A. ST depression is I, AVL
B. ST flattening V4–V6
C. ST segment elevation in II, III, AVF
D. ST segment elevation in V1, V2, V3
E. T wave deflection opposite to QRS deflection

Back 54

B & E

Option B (ST flattening V4–V6) is incorrect. These are nonspecific changes.

Option E (T wave deflection opposite to QRS deflection) is incorrect. These are nonspecific changes.

Front 55

Virchow’s triad

Back 55

stasis, endothelial injury, and hypercoagulability.risk of pulmonary embolism is increased

Front 56

describe pulsus paradoxus, which is often seen in pulmonary embolism.

Back 56

Inspiratory increase in arterial pressure greater than 10 mm Hg

Front 57

very effective in mild to moderate hypertension. They are the agents of choice in African Americans and when there is salt and water retention.

Back 57

Diuretics, particularly thiazides

Front 58

Thiazides ineffective when creatinine > X?

Back 58

Thiazides ineffective when creatinine >2.5 mg/dL

Front 59

patient’s blood pressure is uncontrolled with amlodipine. The secondary hyperaldosteronism associated with alcoholic cirrhosis leads to salt and water retention and contributes to worsening of hypertension. Hence, addition of what helps ameliorate ascites, edema, and hypertension?

Back 59

an aldosterone antagonist such as spironolactone

Front 60

The appropriate antihypertensive agent for patients with diabetes with “micro” or overt proteinuria is

Back 60

an angiotensin-converting enzyme (ACE) inhibitor. This is based on compelling evidence that ACE inhibitors reduce proteinuria and are renal protective.