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50 Cards in this Set
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You see a 23-year-old gravida 1 para 0 for her prenatal checkup at 38 weeks gestation. She complains of severe headaches and epigastric pain. She has had an uneventful pregnancy to date and had a normal prenatal examination 2 weeks ago. Her blood pressure is 140/100 mm Hg. A urinalysis shows 2+ protein; she has gained 5 lb in the last week, and has 2+ pitting edema of her legs. The most appropriate management at this point would be: (check one) A. Strict bed rest at home and reexamination within 48 hours |
preeclampsia at term --> tx: Mg sulfate, prompt delivery
This patient manifests a rapid onset of preeclampsia at term. The symptoms of epigastric pain and headache categorize her preeclampsia as severe. These symptoms indicate that the process is well advanced and that convulsions are imminent. Treatment should focus on rapid control of symptoms and delivery of the infant. |
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Which one of the following is the most common cause of hypertension in children under 6 years of age? (check one) A. Essential hypertension |
ans. renal parenchymal dz Although essential hypertension is most common in adolescents and adults, it is rarely found in children less than 10 years old and should be a diagnosis of exclusion. The most common cause of hypertension is renal parenchymal disease, and a urinalysis, urine culture, and renal ultrasonography should be ordered for all children presenting with hypertension. Other secondary causes, such as pheochromocytoma, hyperthyroidism, and excessive caffeine use, are less common, and further testing and/or investigation should be ordered as clinically indicated. |
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A 70-year-old male with a history of hypertension and type 2 diabetes mellitus presents with a 2-month history of increasing paroxysmal nocturnal dyspnea and shortness of breath with minimal exertion. An echocardiogram shows an ejection fraction of 25%. Which one of the patients current medications should be discontinued? (check one) A. Lisinopril (Zestril) |
ans. glitazone. thiazolidinediones (TZDs) are associated with fluid retention, and their use can be complicated by the development of heart failure. Caution is necessary when prescribing TZDs in patients with known heart failure or other heart diseases, those with preexisting edema, and those on concurrent insulin therapy (SOR C). Older patients can be treated with the same drug regimens as younger patients, but special care is required when prescribing and monitoring drug therapy. Metformin is often contraindicated because of renal insufficiency or heart failure. Sulfonylureas and other insulin secretagogues can cause hypoglycemia. Insulin can also cause hypoglycemia, and injecting it requires good visual and motor skills and cognitive ability on the part of the patient or a caregiver. TZDs should not be used in patients with New York Heart Association class III or IV heart failure. |
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A 72-year-old African-American male with New York Heart Association Class III heart failure sees you for follow-up. He has shortness of breath with minimal exertion. The patient is adherent to his medication regimen. His current medications include lisinopril (Prinivil, Zestril), 40 mg twice daily; carvedilol (Coreg), 25 mg twice daily; and furosemide (Lasix), 80 mg daily. His blood pressure is 100/60 mm Hg, and his pulse rate is 68 beats/min and regular. Findings include a few scattered bibasilar rales on examination of the lungs, an S3 gallop on examination of the heart, and no edema on examination of the legs. An EKG reveals a left bundle branch block, and echocardiography reveals an ejection fraction of 25%, but no other abnormalities. Which one of the following would be most appropriate at this time? (check one) A. Increase the lisinopril dosage to 80 mg twice daily |
Guidelines: optimal candidates for CRT (cardiac resynch therapy) have - a dilated cardiomyopathy on an ischemic or nonischemic basis, - an LVEF ≤0.35, - a QRS complex ≥120 msec, and - sinus rhythm, - NYHA functional class III or IV despite maximal medical therapy for heart failure.
rationale: Using a pacemaker-like device, CRT aims to get both ventricles contracting simultaneously, overcoming the delayed contraction of the left ventricle caused by the left bundle-branch block.
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Of the following dietary factors recommended for the prevention and treatment of cardiovascular disease, which one has been shown to decrease the rate of sudden death? (check one) A. Increased intake of plant protein |
Omega-3 fats contribute to the production of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which inhibit the inflammatory immune response and platelet aggregation, are mild vasodilators, and may have antiarrhythmic properties. mega-3 supplements may be recommended to patients with preexisting disease, a high risk of disease, or high triglyceride levels, as well as to patients who do not like or are allergic to fish. |
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A 75-year-old male presents to the emergency department with a several-hour history of back pain in the interscapular region. His medical history includes a previous myocardial infarction (MI) several years ago, a history of cigarette smoking until the time of the MI, and hypertension that is well controlled with hydrochlorothiazide and lisinopril (Prinivil, Zestril). The patient appears anxious, but all pulses are intact. His blood pressure is 170/110 mm Hg and his pulse rate is 110 beats/min. An EKG shows evidence of an old inferior wall MI but no acute changes. A chest radiograph shows a widened mediastinum and a normal aortic arch, and CT of the chest shows a dissecting aneurysm of the descending aorta that is distal to the proximal abdominal aorta but does not involve the renal arteries. Which one of the following would be the most appropriate next step in the management of this patient? (check one) A. Immediate surgical intervention |
ans. iv labetalol Patients with thoracic aneurysms often present without symptoms. With dissecting aneurysms, however, the presenting symptom depends on the location of the aneurysm. Aneurysms can compress or distort nearby structures, resulting in branch vessel compression or embolization of peripheral arteries from a thrombus within the aneurysm. Leakage of the aneurysm will cause pain, and rupture can occur with catastrophic results, including severe pain, hypotension, shock, and death. Aneurysms in the ascending aorta may present with acute heart failure brought about by aortic regurgitation from aortic root dilatation and distortion of the annulus. Other presenting findings may include hoarseness, myocardial ischemia, paralysis of a hemidiaphragm, wheezing, coughing, hemoptysis, dyspnea, dysphagia, or superior vena cava syndrome.
This diagnosis should be suspected in individuals in their sixties and seventies with the same risk factors as those for coronary artery disease, particularly smokers. A chest radiograph may show widening of the mediastinum, enlargement of the aortic knob, or tracheal displacement. Transesophageal echocardiography can be very useful when dissection is suspected. CT with iv contrast is very accurate for showing the size, extent of disease, pressure of leakage, and nearby pathology. Angiography is the preferred method for evaluation and is best for evaluation of branch vessel pathology. MR angiography provides noninvasive multiplanar image reconstruction, but does have limited availability and lower resolution than traditional contrast angiography. Acute dissection of the ascending aorta is a surgical emergency, but dissections confined to the descending aorta are managed medically unless the patient demonstrates progression or continued hemorrhage into the retroperitoneal space or pleura. Initial management should reduce the systolic blood pressure to 100-120 mm Hg or to the lowest level tolerated. The use of a 1. β-blocker such as propranolol or labetalol to get the heart rate below 60 beats/min should be first-line therapy. If the systolic blood pressure remains over 100 mm Hg, 2. iv nitroprusside should be added. Without prior beta-blocade, vasodilation from the nitroprusside will induce reflex activation of the sympathetic nervous system, causing increased ventricular contraction and increased shear stress on the aorta. For descending dissections, surgery is indicated only for complications such as occlusion of a major aortic branch, continued extension or expansion of the dissection, or rupture (which may be manifested by persistent or recurrent pain). |
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According to the U.S. Preventive Services Task Force, which one of the following patients should be screened for an abdominal aortic aneurysm? (check one) A. A 52-year-old male with type 2 diabetes mellitus |
guideline recommends one-time screening with ultrasonography for AAA in men 65-75 years of age who have ever smoked. No recommendation was made for or against screening women. Men with a strong family history of AAA should be counseled about the risks and benefits of screening as they approach 65 years of age. |
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A 36-year-old white female presents to the emergency department with palpitations. Her pulse rate is 180 beats/min. An EKG reveals a regular tachycardia with a narrow complex QRS and no apparent P waves. The patient fails to respond to carotid massage or to two doses of intravenous adenosine (Adenocard), 6 mg and 12 mg. The most appropriate next step would be to administer intravenous (check one) A. amiodarone (Cordarone) |
ans. beta blocker
If supraventricular tachycardia is refractory to adenosine or rapidly recurs, the tachycardia can usually be terminated by the administration of intravenous verapamil or a β-blocker. If that fails, intravenous propafenone or flecainide may be necessary. It is also important to look for and treat possible contributing causes such as hypovolemia, hypoxia, or electrolyte disturbances. Electrical cardioversion may be necessary if these measures fail to terminate the tachyarrhythmia. |
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A 60-year-old African-American female has a history of hypertension that has been well controlled with hydrochlorothiazide. However, she has developed an allergy to the medication. Successful monotherapy for her hypertension would be most likely with which one of the following? (check one) A. Lisinopril (Prinivil, Zestril) |
Monotherapy for hypertension in African-American patients is more likely to consist of DIURETICS or CALCLIUM CHANNEL BLOCKERS than β-blockers or ACE inhibitors. It has been suggested that hypertension in African-Americans is not as angiotensin II-dependent as it appears to be in Caucasians. CCB: verapamil, diltiazem |
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A 60-year-old African-American male was recently diagnosed with an abdominal aortic aneurysm. A lipid profile performed a few months ago revealed an LDL level of 125 mg/dL. You would now advise him that his goal LDL level is: (check one) A. <100 mg/dL |
ans. <100 mg/dL
Most physicians realize that the goal LDL level for patients with diabetes mellitus or coronary artery disease is <100 mg/dL. Many may not realize that this goal extends to people with CAD-equivalent diseases, including peripheral artery disease, symptomatic carotid artery disease, and abdominal aortic aneurysm. |
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An asymptomatic 3-year-old male presents for a routine check-up. On examination you notice a systolic heart murmur. It is heard best in the lower precordium and has a low, short tone similar to a plucked string or kazoo. It does not radiate to the axillae or the back and seems to decrease with inspiration. The remainder of the examination is normal. Which one of the following is the most likely diagnosis? (check one) A. Eisenmenger’s syndrome |
The cause of Still’s murmur is unknown, but it may be due to vibrations in the chordae tendinae, semilunar valves, or ventricular wall. A venous hum consists of a continuous low-pitched murmur caused by the collapse of the jugular veins and their subsequent fluttering, and it worsens with inspiration or diastole. The murmur of physiologic peripheral pulmonic stenosis (PPPS) is caused by physiologic changes in the newborns pulmonary vessels. PPPS is a systolic murmur heard loudest in the axillae bilaterally that usually disappears by 9 months of age. Mitral stenosis causes a diastolic murmur, and Eisenmenger’s syndrome involves multiple abnormalities of the heart that cause significant signs and symptoms, including shortness of breath, cyanosis, and organomegaly, which should become apparent from a routine history and examination. |
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A 57-year-old male with severe renal disease presents with acute coronary syndrome. Which one of the following would most likely require a significant dosage adjustment from the standard protocol? (check one) A. Enoxaparin (Lovenox) |
Enoxaparin is eliminated mostly by the kidneys. When it is used in patients with severe renal impairment the dosage must be significantly reduced. For some indications the dose normally given every 12 hours is given only every 24 hours. Although some β-blockers require a dosage adjustment, metoprolol and carvedilol are metabolized by the liver and do not require dosage adjustment in patients with renal failure. Clopidogrel is currently recommended at the standard dosage for patients with renal failure and acute coronary syndrome. Thrombolytics like tPA are given at the standard dosage in renal failure, although hemorrhagic complications are increased. |
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A 55-year-old male who has a long history of marginally-controlled hypertension presents with gradually increasing shortness of breath and reduced exercise tolerance. His physical examination is normal except for a blood pressure of 140/90 mm Hg, bilateral basilar rales, and trace pitting edema. Which one of the following ancillary studies would be the preferred diagnostic tool for evaluating this patient? (check one) A. 12-lead electrocardiography |
Use two-dimensional echocardiography with Doppler for heart failure to assess left ventricular ejection fraction (LVEF), left ventricular size, ventricular compliance, wall thickness, and valve function. The test should be performed during the initial evaluation. Radionuclide ventriculography can be used to assess LVEF and volumes, and MRI or CT also may provide information in selected patients. Chest radiography (posteroanterior and lateral) and 12-lead electrocardiography should be performed in all patients presenting with heart failure, but should not be used as the primary basis for determining which abnormalities are responsible for the heart failure. |
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A 23-year-old female sees you with a complaint of intermittent irregular heartbeats that occur once every week or two, but do not cause her to feel lightheaded or fatigued. They last only a few seconds and resolve spontaneously. She has never passed out, had chest pain, or had difficulty with exertion. She is otherwise healthy, and a physical examination is normal. Which one of the following cardiac studies should be ordered initially? (check one) A. 24-hour ambulatory EKG monitoring (Holter monitor) |
Palpitation (increased or abnormal sensation of one’s heartbeat) is common to primary care but is often benign. Commonly, these sensations have their basis in anxiety or panic. However, about 50% of those who complain of palpitations will be found to have a diagnosable cardiac condition. It is recommended to start the evaluation for cardiac causes with an EKG, which will assess the baseline rhythm and screen for signs of chamber enlargement, previous myocardial infarction, conduction disturbances, and a prolonged QT interval. |
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Which one of the following is most appropriate for the initial treatment of claudication? (check one) A. Regular exercise |
ans. regular exercise. Claudication is exercise-induced lower-extremity pain that is caused by ischemia and relieved by rest. It affects 10% of persons over 70 years of age. However, up to 90% of patients with peripheral vascular disease are asymptomatic. Initial treatment should consist of vigorous risk factor modification and exercise. Patients who follow an exercise regimen can increase their walking time by 150%. A supervised program may produce better results. Risk factors include diabetes mellitus, hypertension, smoking, and hyperlipidemia. Unconventional treatments such as chelation have not been shown to be effective. Vasodilating agents are of no benefit. There is no evidence that anticoagulants such as aspirin have a role in the treatment of claudication. |
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In a patient who presents with symptoms of acute myocardial infarction, which one of the following would be an indication for thrombolytic therapy? (check one) A. New-onset ST-segment depression |
ans. new onset LBBB.
In patients with ischemic chest pain, the EKG is important for determining the need for fibrinolytic therapy. Myocardial infarction is diagnosed by ST elevation ≥1 mm in two or more limb leads and ≥2 mm in two or more contiguous precordial leads.
In a patient with an MI, new left bundle branch block suggests occlusion of the left anterior descending artery, placing a significant portion of the left ventricle in jeopardy. Thrombolytic therapy could be harmful in patients with ischemia but not infarction – they will show ST-segment depression only. Frequent unifocal ventricular ectopy may warrant antiarrhythmic therapy, but not thrombolytic therapy. |
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A 68-year-old female has an average blood pressure of 150/70 mm Hg despite appropriate lifestyle modification efforts. Her only other medical problems are osteoporosis and mild depression. The most appropriate treatment at this time would be (check one) A. lisinopril (Prinivil, Zestril) |
ans. HCTZ Isolated systolic hypertension in the elderly responds best to diuretics and to a lesser extent, β-blockers. Diuretics are preferred, although long-acting dihydropyridine calcium channel blockers may also be used. In the case described, β-blockers or clonidine may worsen the depression. In this case, thiazide diuretics may also improve osteoporosis, and would be the most cost-effective and useful agent in this instance. |
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A 31-year-old healthy female is admitted to the hospital from the emergency department after presenting with aching in her right shoulder and swelling in the ipsilateral forearm and hand. The only precipitating event that she can recall is digging strenuously in the back yard to put in a new garden. Ultrasonography is remarkable for a thrombus in the axillosubclavian vein. She has no prior history of clotting, takes no medications, and has no previous history of medical or surgical procedures involving this extremity. The most likely etiology for this patient's condition is (check one) A. a hypercoagulable state |
Thrombosis of the upper extremity accounts for about 10% of all venous thromboembolism (VTE) cases. However, axillosubclavian vein thrombosis (ASVT) is becoming more frequent with the increased use of indwelling subclavian vein catheters. Spontaneous ASVT (not catheter related) is seen most commonly in young, healthy individuals. The most common associated etiologic factor is the presence of a compressive anomaly in the thoracic outlet. These anomalies are often bilateral, and the other upper extremity at similar risk for thrombosis. While a hypercoagulable state also may contribute to the thrombosis, it is much less common. Budd-Chiari syndrome refers to thrombosis in the intrahepatic, suprahepatic, or hepatic veins. It is not commonly associated with spontaneous upper-extremity thrombosis. |
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A 56-year-old white male presents with a 2-week history of intermittent pain in his left leg. The pain usually occurs while he is walking and is primarily in the calf muscle or Achilles region. Sometimes he will awaken at night with cramps in the affected leg. He has no known risk factors for atherosclerosis. Which one of the following would be the best initial test for peripheral vascular occlusive disease? (check one) A. Ankle-brachial index |
The ankle-brachial index (ABI) is an inexpensive, sensitive screening tool and is the most appropriate first test for peripheral vascular occlusive disease (PVOD) in this patient. The ABI is the ratio of systolic blood pressure measured in the ankle to systolic pressure using the standard brachial measurement. A ratio of 0.9-1.2 is considered normal. Severe disease is defined as a ratio <0.50. More invasive and expensive testing using Doppler ultrasonography, arteriography, or magnetic resonance angiography may be useful if the ABI suggests an abnormality. Venous ultrasonography would not detect PVOD, but it could rule out deep venous thrombosis, which is another common etiology for calf pain. |
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A 69-year-old male has a 4-day history of swelling in his left leg. He has no history of trauma, recent surgery, prolonged immobilization, weight loss, or malaise. His examination is unremarkable except for a diffusely swollen left leg. A CBC, chemistry profile, prostate-specific antigen level, chest radiograph, and EKG are all normal; however, compression ultrasonography of the extremity reveals a clot in the proximal femoral vein. He has no past history of venous thromboembolic disease. In addition to initiating therapy with low molecular weight heparin, the American College of Chest Physicians recommends that warfarin (Coumadin) be instituted now and continued for at least (check one) A. 1 month |
ans. warfarin for 3 mths.
For patients with a first episode of unprovoked deep venous thrombosis, evidence supports treatment with a vitamin K antagonist for at least 3 months (SOR A). The American College of Chest Physicians recommends that patients be evaluated at that point for the potential risks and benefits of long-term therapy (SOR C). |
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A 35-year-old African-American female has just returned home from a vacation in Hawaii. She presents to your office with a swollen left lower extremity. She has no previous history of similar problems. Homan’s sign is positive, and ultrasonography reveals a noncompressible vein in the left popliteal fossa extending distally. Which one of the following is true in this situation? (check one) A. Monotherapy with an initial 10-mg loading dose of warfarin (Coumadin) would be appropriate |
The use of low-molecular-weight heparin allows patients with acute deep vein thrombosis (DVT) to be managed as outpatients. The dosage is 1 mg/kg subcutaneously twice daily. Patients chosen for outpatient care should have good cardiopulmonary reserve, normal renal function, and no risk for excessive bleeding. Oral anticoagulation with warfarin can be initiated on the first day of treatment after heparin loading is completed. Monotherapy with warfarin is inappropriate. The incidence of thrombocytopenia with low–molecular-weight heparin is lower than with conventional heparin. The INR should be maintained at 2.0–3.0 in this patient. The 2.5–3.5 range is used for patients with mechanical heart valves. The therapeutic INR should be maintained for 3–6 months in a patient with a first DVT related to travel. |
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Which one of the following historical features is most suggestive of congestive heart failure in a 6-month-old white male presenting with tachypnea? (check one) A. Diaphoresis with feeding |
Symptoms of congestive heart failure in infants are often related to feedings. Only small feedings may be tolerated, and dyspnea may develop with feedings. Profuse perspiration with feedings, is characteristic, and related to adrenergic drive. Older children may have symptoms more similar to adults, but the infant’s greatest exertion is related to feeding. Fever and nasal congestion are more suggestive of infectious problems. Noisy respiration or wheezing does not distinguish between congestive heart failure, asthma, and infectious processes. A staccato cough is more suggestive of an infectious process, including pertussis. |
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Which one of the following procedures carries the highest risk for postoperative deep venous thrombosis? (check one) A. Abdominal hysterectomy |
ans. total knee replacement.
Neurosurgical procedures, particularly those with penetration of the brain or meninges, and orthopedic surgeries, especially those of the hip, have been linked with the highest incidence of venous thromboembolic events. The risk is due to immobilization, venous injury and stasis, and impairment of natural anticoagulants. For total knee replacement, hip fracture surgery, and total hip replacement, the prevalence of DVT is 40%-80%, and the prevalence of pulmonary embolism is 2%-30%. Other orthopedic procedures, such as elective spine procedures, have a much lower rate, approximately 5%. The prevalence of DVT after a coronary artery bypass graft is approximately 5%, after transurethral prostatectomy <5%, and after abdominal hysterectomy approximately 16%. |
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A 13-year-old male is found to have hypertrophic cardiomyopathy. His father also had hypertrophic cardiomyopathy, and died suddenly at age 38 following a game of tennis. The boy’s mother asks you for advice regarding his condition. What advice should you give her? (check one) A. He may participate in noncontact sports |
Hypertrophic cardiomyopathy is an autosomal dominant condition and close relatives of affected individuals should be screened. The hypertrophy usually stays the same or worsens with age. This patient should not participate in strenuous sports, even those considered noncontact. Beta-blockers have not been shown to alter the progress of the disease. The mortality rate is believed to be about 1%, with some series estimating 5%. Thus, in most cases lifespan is normal. |
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A 70-year-old white male has a slowly enlarging, asymptomatic abdominal aortic aneurysm. You should usually recommend surgical intervention when the diameter of the aneurysm approaches: (check one) A. 3.5 cm |
ans. 5.5cm --> surgery Based on recent clinical trials, the most common recommendation for surgical repair is when the aneurysm approaches 5.5 cm in diameter. Two large studies, the Aneurysm Detection and Management (ADAM) Veteran Affairs Cooperative Study, and the United Kingdom Small Aneurysm Trial, failed to show any benefit from early surgery for men with aneurysms less than 5.5 cm in diameter. The risks of aneurysm rupture were 1% or less in both studies, with 6-year cumulative survivals of 74% and 64%, respectively. Interestingly, the risk for aneurysm rupture was four times greater in women, indicating that 5.5 cm may be too high, but a new evidence-based threshold has not yet been defined. |
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Which one of the following drug classes is preferred for treating hypertension in patients who also have diabetes mellitus? (check one) A. Centrally-acting sympatholytics |
ACE inhibitors have proven beneficial in patients who have either early or established diabetic renal disease. |
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A 75-year-old Hispanic male presents with dyspnea on exertion which has worsened over the last several months. He denies chest pain and syncope, and was fairly active until the shortness of breath slowed him down recently. You hear a grade 3/6 systolic ejection murmur at the right upper sternal border which radiates into the neck. Echocardiography reveals aortic stenosis, with a mean transvalvular gradient of 55 mm Hg and a calculated valve area of 0.6 cm2. Left ventricular function is normal. Which one of the following is appropriate management for this patient? (check one) A. Aortic valve replacement |
ans. aortic valve replacement
Since this patient’s mean aortic-valve gradient exceeds 50 mm Hg and the aortic-valve area is not larger than 1 cm2, it is likely that his symptoms are due to aortic stenosis. As patients with symptomatic aortic stenosis have a dismal prognosis without treatment, prompt correction of his mechanical obstruction with aortic valve replacement is indicated. Medical management is not effective, and balloon valvotomy only temporarily relieves the symptoms and does not prolong survival. Patients who present with dyspnea have only a 50% chance of being alive in 2 years unless the valve is promptly replaced. Exercise testing is unwarranted and dangerous in patients with symptomatic aortic stenosis |
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Which one of the following is considered a contraindication to the use of beta-blockers for congestive heart failure? (check one) A. Mild asthma |
ans. symptomatic heart block
According to several randomized, controlled trials, mortality rates are improved in patients with heart failure who receive beta-blockers in addition to diuretics, ACE inhibitors, and occasionally, digoxin.
Contraindications to beta-blocker use include hemodynamic instability, heart block, bradycardia, and severe asthma. Beta-blockers may be tried in patients with mild asthma or COPD as long as they are monitored for potential exacerbations. Beta-blocker use has been shown to be effective in patients with NYHA Class II or III heart failure. There is no absolute threshold ejection fraction. Beta-blockers have also been shown to decrease mortality in patients with a previous history of myocardial infarction, regardless of their NYHA classification. |
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Which one of the following is the leading cause of death in women? (check one) A. Breast cancer |
Cardiovascular disease is the leading cause of death among women. According to the CDC, 29.3% of deaths in females in the U.S. in 2001 were due to cardiovascular disease and 21.6% were due to cancer, with most resulting from lung cancer. Breast cancer is the third most common cause of cancer death in women, and ovarian cancer is the fifth most common. |
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A 72-year-old African-American male comes to your office for surgical clearance to undergo elective hemicolectomy for recurrent diverticulitis. The patient suffered an uncomplicated acute anterior-wall myocardial infarction approximately 18 months ago. A stress test was normal 2 months after he was discharged from the hospital. Currently, the patient feels well, walks while playing nine holes of golf three times per week, and is able to walk up a flight of stairs without chest pain or significant dyspnea. Findings are normal on a physical examination. Which one of the following would be most appropriate for this patient prior to surgery? (check one) A. A 12-lead resting EKG |
ans. 12-lead resting EKG.
The current recommendations from the American College of Cardiology and the American Heart Association on preoperative clearance for noncardiac surgery state that preoperative intervention is rarely needed to lower surgical risk. Patients who are not currently experiencing unstable coronary syndrome, severe valvular disease, uncompensated congestive heart failure, or a significant arrhythmia are not considered at high risk, and should be evaluated for most surgery primarily on the basis of their functional status. If these patients are capable of moderate activity (greater than 4 METs) without cardiac symptoms, they can be cleared with no stress testing or coronary angiography for an elective minor or intermediate-risk operation such as the one this patient is to undergo. A resting 12-lead EKG is recommended for males over 45, females over 55, and patients with diabetes, symptoms of chest pain, or a previous history of cardiac disease.
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A 73-year-old male with COPD presents to the emergency department with increasing dyspnea. Examination reveals no sign of jugular venous distention. A chest examination reveals decreased breath sounds and scattered rhonchi, and the heart sounds are very distant but no gallop or murmur is noted. There is +1 edema of the lower extremities. Chest radiographs reveal cardiomegaly but no pleural effusion. The patient’s B-type natriuretic peptide level is 850 pg/mL (N <100) and his serum creatinine level is 0.8 mg/dL (N 0.6–1.5). Which one of the following would be the most appropriate initial management? (check one) A. Intravenous heparin |
ans. furosemide
B-type natriuretic peptide (BNP) is secreted in the ventricles and is sensitive to changes in left ventricular function. Concentrations correlate with end-diastolic pressure, which in turn correlates with dyspnea and congestive heart failure. BNP levels can be useful when trying to determine whether dyspnea is due to cardiac, pulmonary, or deconditioning etiologies. A value of less than 100 pg/mL excludes congestive heart failure as the cause for dyspnea. If it is greater than 400 pg/mL, the likelihood of congestive heart failure is 95%. Patients with values of 100–400 pg/mL need further investigation. There are some pulmonary problems that may elevate BNP, such as lung cancer, cor pulmonale, and pulmonary embolus. However, these patients do not have the same extent of elevation that those with acute left ventricular dysfunction will have. If these problems can be ruled out, then individuals with levels between 100–400 pg/mL most likely have congestive heart failure. Initial therapy should be a loop diuretic. It should be noted that BNP is partially excreted by the kidneys, so levels are inversely proportional to creatinine clearance. |
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A 25-year-old female at 36 weeks gestation presents for a routine prenatal visit. Her blood pressure is 118/78 mm Hg and her urine has no signs of protein or glucose. Her fundal height shows appropriate fetal size and she says that she feels well. On palpation of her legs, you note 2+ pitting edema bilaterally. Which one of the following is true regarding this patient’s condition? (check one) A. You should order a 24-hr urine for protein |
ans. no further workup
Lower-extremity edema is common in the last trimester of normal pregnancies and can be treated symptomatically with compression stockings. Edema has been associated with preeclampsia, but the majority of women who have lower-extremity edema with no signs of elevated blood pressure will not develop preeclampsia or eclampsia. For this reason, edema has recently been removed from the diagnostic criteria for preeclampsia. Disproportionate swelling in one leg versus another, especially associated with leg pain, should prompt a workup for deep venous thrombosis but is unlikely given this patient’s presentation, as are cardiac or renal condition |
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A 72-year-old male with a history of previous inferior myocardial infarction sees you prior to surgery for symptomatic gallstones. He denies chest pain or dyspnea. His current medications include aspirin, 81 mg daily; ramipril (Altace), 10 mg daily; and pravastatin (Pravachol), 40 mg daily. He is in good health otherwise and has no other health complaints. He has been cleared for surgery by his cardiologist. Which one of the following should be considered before and after surgery, assuming no contraindications? (check one) A. Atenolol (Tenormin) |
ans. use of beta blocker perioperatively for pt with cardiac risk factors as prophylaxis for surgery-related cardiac complications |
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In prescribing an exercise program for elderly, community-dwelling patients, it is important to note that: (check one) A. Graded exercise stress testing should be done before beginning the program |
Initial exercise routines for the elderly can be as short as 6 minutes in duration. Even 30 minutes per week of exercise has been shown to be beneficial. Graded exercise testing need not be done, especially if low-level exercise is planned. A target heart rate of 60%–75% of the predicted maximum should be set as a ceiling. Patients with peripheral neuropathy should not perform treadmill walking or step aerobics because of the risk of damage to their feet. |
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A 52-year-old white male is being considered for pharmacologic treatment of hyperlipidemia because of an LDL cholesterol level of 180 mg/dL. Before beginning medication for his hyperlipidemia, he should be screened for: (check one) A. Hyperthyroidism |
ans. hypothyroidism
any person with elevated LDL cholesterol or any other form of hyperlipidemia should undergo clinical or laboratory assessment to rule out secondary dyslipidemia before initiation of lipid-lowering therapy. Causes of secondary dyslipidemia include diabetes mellitus, hypothyroidism, obstructive liver disease, chronic renal failure, and some medications. |
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A 56-year-old African-American male with longstanding hypertension and a 30-pack-year smoking history has a 2-day history of dyspnea on exertion. Physical examination is unremarkable except for rare crackles at the bases. Which one of the following serologic tests would be most helpful for detecting left ventricular dysfunction? (check one) A. Beta-natriuretic peptide (BNP) |
Beta-natriuretic peptide (BNP) is a 32-amino acid polypeptide secreted from the cardiac ventricles in response to ventricular volume expansion and pressure overload. The major source of BNP is the cardiac ventricles, and because of its minimal presence in storage granules, its release is directly proportional to ventricular dysfunction. It is a simple and rapid test that reliably predicts the presence or absence of left ventricular dysfunction on an echocardiogram. |
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Patients with Wolff-Parkinson-White syndrome who have episodic symptomatic supraventricular tachycardia or atrial fibrillation benefit most from: (check one) A. Episodic intravenous digoxin |
Radiofrequency catheter ablation of bypass tracts is possible in over 90% of patients and is safer and more cost effective than surgery, with a similar success rate. Intravenous and oral digoxin can shorten the refractory period of the accessory pathway, and increase the ventricular rate, causing ventricular fibrillation. Beta-blockers will not control the ventricular response during atrial fibrillation when conduction proceeds over the bypass tract. |
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A 72-year-old male with class III congestive heart failure (CHF) due to systolic dysfunction asks if he can take ibuprofen for his “aches and pains.” Appropriate counseling regarding NSAID use and heart failure should include which one of the following? (check one) A. NSAIDs are a good choice for pain relief, as they decrease systemic vascular resistance |
ans. Avoid aspirin and NSAID b/c can cause fluid accumulation (except low dose aspirin). If possible, NSAIDs should be avoided in patients with heart failure. They cause sodium and water retention, as well as an increase in systemic vascular resistance which may lead to cardiac decompensation. |
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A 72-year-old male presents to your clinic in atrial fibrillation with a rate of 132 beats/min. He has hypertension, but no history of congestive heart failure or structural heart disease. He is otherwise healthy and active. The best INITIAL approach to his atrial fibrillation would be: (check one) A. Rhythm control with antiarrythmics and warfarin (Coumadin) only if he cannot be consistently maintained in sinus rhythm |
ans. Ventricular rate control with a calcium channel blocker or beta-blocker, and warfarin for anticoagulation
AFib - initial aproach of RATE CONTROL (not rythm control) is best. The most efficacious drugs for rate control are calcium channel blockers and beta-blockers. Digoxin is less effective for rate control and should be reserved as an add-on option for those not controlled with a beta-blocker or calcium channel blocker, or for patients with significant left ventricular systolic dysfunction. In patients 65 years of age or older or with one or more risk factors for stroke, the best choice for anticoagulation to prevent thromboembolic disease is WARFARIN. Of note, in patients who are successfully rhythm controlled and maintained in sinus rhythm, the thromboembolic rate is equivalent to those managed with a rate control strategy. Thus, the data suggest that patients who choose a rhythm control strategy should be maintained on anticoagulation regardless of whether they are consistently in sinus rhythm. |
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Cilostazol (Pletal) has been found to be a useful drug for the treatment of intermittent claudication. This drug is contraindicated in patients with: (check one) A. Congestive heart failure |
ans. congestive heart failure.
Cilostazol is a drug with phosphodiesterase inhibitor activity introduced for the symptomatic treatment of arterial occlusive disease and intermittent claudication. Cilostazol should be avoided in patients with congestive heart failure. There are no limitations on its use in patients with previous stroke or a history of diabetes. It has been found to have beneficial effects on HDL cholesterol levels and in the treatment of third degree heart block. |
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A 35-year-old white male with known long QT syndrome has a brief episode of syncope requiring cardiopulmonary resuscitation. Which one of the following is most likely responsible for this episode? (check one) A. Sinus tachycardia |
Patients with long QT syndrome that have sudden arrhythmia death syndrome usually have either torsades de pointes or ventricular fibrillation. Sinus tachycardia would not explain the syncope, and atrial flutter and asystole are not usual in long QT syndrome. |
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An 83-year-old female presents to your office as a new patient. She recently moved to the area to be closer to her family. A history reveals that she has been in excellent health, has no complaints, and is on no medications except occasional acetaminophen for knee pain. She has never been in the hospital and has not had any operations. She says that she feels well. The examination is normal, with expected age-related changes, except that her blood pressure on three different readings averages 175/70 mm Hg. These readings are confirmed on a subsequent follow-up visit. In addition to lifestyle changes, which one of the following would be most appropriate for the initial management of this patient’s hypertension? (check one) A. An alpha-blocker |
ans. Thiazide
Clinical trials support the treatment of systolic hypertension in the older person with a systolic blood pressure of at least 160 mm Hg. (Systolic hypertension is defined as systolic blood pressure of at least 140 mm Hg and a diastolic blood pressure of less than 90 mm Hg.) The studies most strongly support the use of thiazide diuretics and long-acting calcium channel blockers as first-line therapy. Alpha-blockers are not recommended. ACE inhibitors, beta-blockers, and angiotensin receptor blockers are used when certain compelling indications are present, e.g., in a patient with diabetes or who has a hx of myocardial infarction. |
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Of the following, the INITIAL treatment of choice in the management of severe hypertension during pregnancy is: (check one) A. Labetalol (Trandate, Normodyne) intravenously |
ans. labetolol
In pregnant women with severe hypertension, the primary objective of treatment is to prevent cerebral complications such as encephalopathy and hemorrhage. IV hydralazine, IV labetalol, or ORAL nifedipine may be used.
DON'T USE: Sublingual nifedipine can cause severe hypotension, and reserpine is not indicated. Nitroprusside can be used for short intervals in patients with hypertensive encephalopathy, but fetal cyanide toxicity is a risk with infusions lasting more than 4 hours. ACE inhibitors are never indicated for hypertensive therapy during pregnancy. |
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Which one of the following has been shown to decrease mortality late after a myocardial infarction? (check one) A. Nitrates |
Beta-blockers and ACE inhibitors have been found to decrease mortality late after myocardial infarction. Aspirin has been shown to decrease nonfatal myocardial infarction, nonfatal stroke, and vascular events. Nitrates, digoxin, thiazide diuretics, and calcium channel antagonists have not been found to reduce mortality after myocardial infarction. |
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Which one of the following is preferred for chronic treatment of congestive heart failure due to left ventricular systolic dysfunction? (check one) A. Diuretics |
ACE inhibitors are the preferred drugs for congestive heart failure due to left ventricular systolic dysfunction, because they are associated with the lowest mortality. The combination of hydralazine/isosorbide dinitrate is a reasonable alternative, and diuretics should be used cautiously. It is not known whether digoxin affects mortality, although it can help with symptoms |
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Which one of the following is most predictive of increased perioperative cardiovascular events associated with noncardiac surgery in the elderly? (check one) A. An age of 80 years |
ans. renal insufficiency
Clinical predictors of increased perioperative cardiovascular risk for elderly patients include
MAJOR risk factors such as unstable coronary syndrome (acute or recent myocardial infarction, unstable angina), decompensated congestive heart failure, significant arrhythmia (high-grade AV block, symptomatic ventricular arrhythmia, supraventricular arrhythmias with uncontrolled ventricular rate), and severe valvular disease.
INTERMEDIATE predictors are mild angina, previous myocardial infarction, compensated congestive heart failure, diabetes mellitus, and renal insufficiency.
MINOR predictors are advanced age, an abnormal EKG, left ventricular hypertrophy, left bundle-branch block, ST and T-wave abnormalities, rhythm other than sinus, low functional capacity, history of stroke, and uncontrolled hypertension. |
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The use of automated external defibrillators by lay persons in out-of-hospital settings: (check one) A. Has been frustrated by liability concerns |
ans. The use of automated external defibrillators (AEDs) by lay persons, trained and otherwise, has been quite successful, with up to 40% of those treated recovering full neurologic and functional capacity. At present, 45 states have passed Good Samaritan laws covering the use of AEDs by well-intentioned lay persons. There are initiatives for widespread placement of AEDs, to include commercial airlines and other public facilities. Implantable cardioverter defibrillators (ICDs) are useful in known at-risk patients, but the use of AEDs is for the population at large. |
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A 74-year-old white male complains of pain in the right calf that recurs on a regular basis. He smokes 1 pack of cigarettes per day and is hypertensive. He has a history of a previous heart attack but is otherwise in fair health. Which one of the following findings would support a diagnostic impression of peripheral vascular disease? (check one) A. Pain during rest and exercise and the presence of swelling and soreness behind the knee and in the calf |
ans. drop of 20mmhg in ankle systolic blood pressure following exercise.
Peripheral vascular disease (PVD) is a clinical manifestation of atherosclerotic disease and is caused by occlusion of the arteries to the legs. Patients with significant arterial occlusive disease will have a prominent decrease in the ankle-brachial index from baseline following exercise, and usually a 20-mm Hg or greater decrease in systolic blood pressure. Doppler waveform analysis is useful in the diagnosis of PVD and will reveal attenuated waveforms at a point of decreased blood flow. Employment of the ankle-brachial index is encouraged in daily practice as a simple means to diagnose the presence of PVD. Generally, ankle-brachial indices in the range of 0.91–1.30 are thought to be normal
Pain during rest and exercise and the presence of swelling and soreness behind the knee and in the calf is found in those with Baker’s cysts.
Peripheral nerve pain commonly begins immediately upon walking and is unrelieved by rest.
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In a 34-year-old primigravida at 35 weeks' gestation, which one of the following supports a diagnosis of MILD preeclampsia rather than severe preeclampsia? (check one) A. A blood pressure of 150/100 mm Hg |
ans. BP of 150/100
The criteria for severe preeclampsia specify a blood pressure of 160/110 mm Hg or above on two occasions, 6 hours apart. Other criteria include proteinuria above 5 g/24 hr, thrombocytopenia with a platelet count <100,000/mm3, liver enzyme abnormalities, epigastric or right upper quadrant pain, and alteration of mental status. |
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A 72-year-old white female is scheduled to undergo a total knee replacement for symptomatic osteoarthritis. She is otherwise healthy, with no history of vascular disease or deep vein thrombosis. She takes no routine medications. Which one of the following is most appropriate for prophylaxis against deep vein thrombosis? (check one) A. No prophylaxis if there are no surgical complications |
Prophylaxis is indicated with total knee or hip replacements. The two regimens recommended are low–molecular-weight heparin and adjusted-dose warfarin. These may be augmented by intermittent pneumatic compression (compression device on leg). |
