Cardiology Question Set 2

A 54-year-old female presents to the emergency ward with a chief complaint of chest pain. Pain is sharp and is present in the anterior part of the chest. There is no radiation of pain; however, intensity is decreased while sitting and leaning forward. There is no associated shortness of breath. Her blood pressure is 132/84 mmHg; pulse is 82/ min rhythmic and regular. Lungs are clear on auscultation and cardiovascular examination shows scratchy and squeaking sound at the left sternal border. Kussmaul sign is positive and EKG shows new widespread ST segment elevation and PR depression in leads II, III and aVF. The most likely cause for these findings in this patient is?

An 11 year old child complains of pain in leg while playing. Blood pressure in the upper limb is 140/90 mmHg and lower limbs are 110/70 mmHg. There is a brachiofemoral delay in the pulse. Auscultation shows a loud S1, loud S2 and S4. There is presence of ejection systolic murmur in the interscapular area. CXR reveals notching of the ribs. What is the most likely diagnosis in this patient?

A 56 year old female presents to the emergency room with pain in the chest for the past 4 hours. EKG shows ST segment elevation in leads V2, V3 and V4. The most likely pathological changes which would be observed after 48 hours are?

74-year old male had sudden severe crushing retrosternal pain that radiated to his left arm. He was rushed to the emergency department. His Troponins and CK MB were elevated. Unfortunately, patient died within next 2 hours and an autopsy was performed immediately. The gross examination of the heart will show:

A 35-year-old man with a smoking habit presents with feet pain during exercise and at rest. He says that his fingers and toes become pale on exposure to cold. He used to exercise a lot but has stopped because of the symptoms. On inspection, a tiny ulcer was found on his toe. On laboratory analysis, his blood sugar, blood pressure, and lipids are all within normal range. Which is the most probable diagnosis?

A 64-year-old male presents with severe respiratory distress. Past history involves congestive heart failure. Sputum examination shows heart failure cells. Which of the following subcellular organelles is significant in the formation of these cells?

A 49-year-old male is diagnosed with hypertension. He has asthma. His creatinine and potassium are both slightly elevated. Which of the following anti-hypertensive drugs would be appropriate in his case?

A 60-year-old female has been taking medications for hypertension and congestive cardiac failure. She suddenly develops skin rashes along with swelling of the tongue and lips, as well as the eyes. This is causing her difficulty in breathing. Which of the following medications is most likely responsible for her symptoms?

A 56-year-old male presents to the emergency room with severe substernal distress diaphoresis. He was diagnosed with acute myocardial infarction. While in ICU after 56 hours, he experiences chest pain. Which of the following enzymes helps in the diagnosis of his condition during his stay in ICU?

An autopsy of a 75-year-old male shows obliterating endarteritis of the vasa vasorum of the aorta. Which of the following investigations will likely be positive in this patient?

A 26-year-old male presented with a headache and fatigue for the past few months. On presentation to the clinic, blood pressure is found to be elevated to 190/110 mmHg; the femoral pulse is reduced compared to radial pulse; and an ejection click is heard. There was no murmur. Which of the following is associated with his condition?

A 43-year-old patient with fever and chills, anorexia, weight loss, malaise, night sweats, shortness of breath, and cough was diagnosed with infective endocarditis. The microbiology revealed Strep. bovis infection. Which of the following condition should be considered in this patient irrespective of the presence or absence of associated symptoms?

A 35-year-old alcoholic patient presented with high-output cardiac failure, tachycardia, bounding pulse, and warm extremities. Blood work revealed that he had a vitamin deficiency. Deficiency of which of the following vitamins could cause such a clinical picture?

A 68-year-old female presents with headaches. Clinical examination shows a tender and prominent left temporal artery. Biopsy of the temporal artery shows granulomatous inflammation. Which of the following complications can this patient develop if left untreated?

A 49-year-old female is brought to the emergency room at 4 am by her husband, complaining of crushing pain on the chest, behind the sternum, radiating to the left arm. She is overweight and has a history of diabetes. Myocardial infarction is suspected. An ECG is performed which reveals ST elevation and T-wave inversion in leads II, III, and aVF. Which of the following is the most probable diagnosis?

An 18-year-old male presents with sudden loss of consciousness while playing college football. There was no history of any concussion. Echocardiography shows left ventricular hypertrophy and increased the thickness of interventricular septum. The most likely pathology behind the present condition is?

A patient presents to the clinic with symptoms of dizziness on standing up. He says it started soon after he was diagnosed with hypertension and started taking treatment for it. He has no other medical history. The physician decides to switch to another antihypertensive that does not cause orthostatic hypotension. Which of the following should be the drug of choice for this patient?

A 35-year-old female presents with a complaint of oral ulcers. It is the third recurrence of the ulcers in the last 8 months. She is sexually active and complains of dysparunia. Examination shows the presence of uveitis. Which of the following antibodies are positive in this person?

A 62-year-old man is brought to the emergency room because of accidental overdoses on his antiarrhythmic medication. He is diabetic and hypertensive. To counteract the effects of the overdose, he is administered a drug in the ER. Which of the following combinations of an antiarrhythmic with its treatment is correct?

A 42-year-old female arrives at the emergency room with complaints of sharp pain in her chest upon coughing and inhalation. She has had a butterfly rash on her face, joint pains, fatigue, and increased photosensitivity for a few weeks now. Which of the following is most likely to be observed in this patient?

A woman presents with fever and a sudden onset sharp, pleuritic retrosternal chest pain worsening while breathing and coughing. She has been recently diagnosed with systemic lupus erythematosus. A friction rub is present upon physical exam. Which of the following is most likely consistent with this clinical picture?

A 63-year-old patient presents to the emergency room because of worsening breathlessness that started overnight.He was diagnosed with asthma 3 years ago and has been using albuterol and steroid inhalers. He does not have any prior history of cardiac or other respiratory diseases. He is a retired insurance agent and has lived all his life in the United States of America. His vital signs include a respiratory rate of 40/minute, blood pressure of 130/90 mmHg and pulse rate of 110 beats /minute and temperature of 37 °C. Physical examination shows severe respiratory distress with the patient unable to lie down on the examination table. Auscultation of the chest reveals widespread wheezes all over the lungs and presence of S3 gallop rhythm. He is admitted and laboratory investigations and imaging studies are ordered. The results are given below: White blood cell count: 18.6 × 109/L with eosinophil cell count 7.6 × 109/L (40 % eosinophils) Troponin T: 0.5 ng/mL Anti-MPO Antibodies: negative Anti-PR3-C-ANCA: positive Immunoglobulin E: 1000 IU/mL Serological tests for HIV, echovirus, adenovirus, Epstein barr and parvovirus B19 are negative. EKG shows regular sinus tachycardia with absence of strain pattern or any evidence of ischemia. Transthoracic echocardiography reveals an ejection fraction of 30 % in the left ventricles (normal 55 % or greater) and dilated left ventricles. Which of the following diagnosis best explains the clinical presentation and lab findings in this patient?

A 46-year-old man presents with a 2-week history of fever, fatigue, and coughing of blood. On questioning, he admitted to having noticed some weight loss over the past 4 months. He has also noticed a change in the urine color ,with intermittent passage of dark colored urine dating back to about 4 months. The patient does not have a prior history of a cough or hemoptysis and has not been in contact with person with a chronic cough. 2 weeks ago, he noticed production of rust-colored sputum which has now progressed to coughing of blood mixed sputum which takes place on an average of 2 times daily. Sputum production is about 2-spoonful per episode. Vital signs include a temperature of 98 °F, respiratory rate of 42/minute, pulse of 88 beats per minute and temperature of 37°C. Physical examination reveals an anxious but tired looking man with mild respiratory distress and mild pallor. Laboratory tests were ordered and findings include: Hematocrit: 34 % Hepatitis antibody test: negative Hepatitis C antibody test: negative 24-hour urinary protein: 2 grams Urine microscopy: More than 5 RBC under high power microscopy. Antibody tests: C-ANCA: negative Anti MPO/P-ANCA: positive Serum urea: 140 mg/dl Serum creatinine: 28 mg/dl Renal biopsy is done which shows glomerulonephritis with crescent formation. Which of the following is the most likely diagnosis?

A 46-year-old African American female presents to your clinic with a 5-month history of worsening dry cough, occasional shortness of breath, and fatigue. She is now having trouble walking a full block. Additional complaints include fatigue, bilateral swelling of the lower legs and occasional shortness of breath. She denies chest pain, syncope or bloody sputum. Current vitals are a temperature of 37 °C, (98.6 °F), pulse: 63/min, blood pressure: 128/91 mmHg, and a respiratory rate of 15/min. Upon further examination, you notice elevated jugular venous pressure, decreased breath sounds bilaterally at the lung bases and +1 non-pitting edema bilaterally in the lower extremities. Chest x-ray demonstrates a slightly enlarged heart. What is the most appropriate next step of diagnosis?

A 50-year-old man presents to the emergency department with complaints of headache, chest discomfort and blurry vision. The headache has been persisting over the past two days. He describes it as a throbbing pain at the back of his head, 8/10 in intensity that worsens further throughout the day. He feels nauseated but has not vomited so far. His past medical history is significant for hypertension diagnosed 15 years ago, for which he had been on beta blockers until he stopped taking them a month ago. He believes yoga and meditation have helped keep his blood pressure under control, and does not want to take pills until they are necessary. He has not seen a physician in the past 2 years. His family history is positive for hypertension and MI in his father and diabetes mellitus in his mother. His blood pressure at present is 200/110 mmHg in all four limbs in the supine position and his pulse rate is 100/minute. Ophthalmoscopy reveals the presence of arteriolar nicking and papilledema. The EKG is normal. He is started on intravenous nitroprusside. Laboratory studies show: Serum Creatinine: 1.4 mg/ dL; Blood urea nitrogen: 25 mg/dL; Urine protein: ++. Which of the following explains the pathophysiology responsible for the neovascular effects seen in this condition?

A 58-year-old male comes to the emergency department with complaints of severe chest pain and uneasiness for half an hour. He describes it as being a sharp pain at the center of the chest, 8/10 in intensity and radiating to the back and shoulders, but not showing any change with breathing or change of position. It started suddenly while he was watching television. He feels nauseated but has not vomited. There is no fever, chills or cough. His past medical history is significant for hypertension, hyperlipidemia and diabetes mellitus for which he takes lisinopril, hydrochlorothiazide, simvastatin and metformin. He has smoked a pack of cigarettes every day for the past 30 years and has 1-2 drinks during the weekend. His family history is positive for hypertension, hyperlipidemia and MI in his father and paternal uncle. His blood pressure is 220/110 mmHg on the right arm and 180/100 mmHg on the left arm. The patient is diaphoretic. On examination, the physician hears a grade 2/6 diastolic decrescendo murmur over the left sternal border. The rest of the examination is normal. The chest X-ray shows widening of the mediastinum. The EKG shows non-specific ST-T changes. Intravenous morphine and beta blockers are started. Which of the following is the most likely diagnosis of this patient based on the presentation and findings?

A 70-year-old man comes into the clinic for his annual check-up. He feels well except for occasional abdominal pain 4-5/10 in intensity and radiating to the groin that occurs 1-2 times a month and subsides on its own. He denies any fever, chills, nausea, vomiting, change in body weight or change in bowel/bladder habits. He has been smoking a pack of cigarettes and has 1-2 drinks daily for the past 40 years. His past medical history is significant for hypertension, hyperlipidemia and peripheral vascular disease, for which he takes lisinopril and simvastatin. His blood pressure is 150/100 mmHg, and his pulse rate is 80/minute. The peripheral pulsations are equally palpable over all limbs. His EKG is normal. On examination, a bruit is appreciated at the epigastrium along with mild tenderness to palpation. A pulsating abdominal mass is also found on physical examination. The rest of the examination is normal. Laboratory studies show: Serum total cholesterol: 175 mg/dL; Serum total bilirubin: 1 mg/dL; Serum amylase: 25 U/L; Serum alanine aminotransferase: 20 U/L; Serum aspartate aminotransferase: 16 U/L. Which of the following is the most likely diagnosis in this patient based on his history and examination findings?

A 52-year-old woman is accompanied by her husband to the emergency department with a severe occipital headache that started suddenly an hour ago. She is drowsy but able to answer the physician’s questions. She describes it as the worst headache she has ever had, 9/10 in intensity. The husband says it was localized to the occiput initially but has now spread all over her head and she also complained of a generalized heaviness. She took an ibuprofen without experiencing any relief. She also complained of blurring of vision and nausea, and had one episode of vomiting. He denies a recent history of fever, chills, numbness or seizures. Her past medical history is significant for hypertension controlled with lisinopril and metoprolol. On examination, she is drowsy but oriented. Papilledema is seen on ophthalmoscopy. Neck flexion is difficult and painful. The rest of the exam is unremarkable. Her blood pressure is 160/100 mm Hg, the pulse rate is 100/min, and temperature is 37 ºC. The EKG, cardiac enzymes and laboratory studies are normal. Lumbar puncture results are as follows: Opening pressure: 210 mm H20; RBC: 50/mm^3; numbers steady over 4 test tubes; Cell count: 5/mm^3; Glucose: 40 mg/dL; Proteins: 100 mg/dL. The patient is admitted to the ICU for further management. Which of the following is the most likely pathophysiology based on her history and CSF findings?

A 50-year-old female teacher presents to the clinic with complaints of discoloration of the skin around the right ankle accompanied by itching. She began noticing it a month ago and the pruritus worsened over time. She also has some pain and swelling of the region every night, especially on days when she teaches late into the evening. Her past medical history is significant for diabetes mellitus type 2, for which she takes metformin. She lives with her husband and takes oral contraceptive pills. On examination, the physician observes hyperpigmentation of the medial aspect of her right ankle. The skin is dry, scaly and edematous along with some superficial varicosities. Dorsiflexion of the foot is extremely painful. Peripheral pulses are equally palpable on both lower limbs. There is a small 2 cm ulcer noted near the medial malleolus with thickened neighboring skin and indurated edges. Laboratory studies show: D-dimer: 1000 mcg/L; HbA1c: 9 %. Doppler ultrasound of the lower extremity reveals an intramural thrombus in the popliteal vein. Which of the following is the most likely diagnosis in this patient?

A 60-year-old male professor presents to the clinic for his annual check-up. He is healthy and has no complaints at present. His past medical history is significant for hypertension which is controlled by metoprolol and lisinopril. He has smoked half a pack of cigarettes daily for the past 30 years. He does not drink alcohol. Family history is significant for MI in his father at the age of 55 years. His blood pressure is 130/80 mmHg and the pulse rate is 78/minute. On physical examination, there are tortuosities of the veins over his lower limb, more pronounced over the left leg. Peripheral pulses are equal over all extremities and there are no skin changes. On questioning, the patient says he has occasional leg cramps and his legs feel heavy especially after standing for long hours to take his classes. There is no complaint of weakness or numbness and no pain on dorsiflexion of the foot. The rest of the examination and the laboratory tests are normal. Which of the following best describes the pathophysiology responsible for his symptoms?

A 33-year-old Caucasian female presents to the clinic complaining of a 9 -month history of weight loss, fatigue and general sense of malaise. She additionally complains of an unusual sensation in her chest upon rapidly rising from a supine to a standing position. Current vitals include a temperature of 98.2 °F, pulse: 72 beats per minute, blood pressure: 118/63 mmHg, and a respiratory rate of 15/min. Her BMI is 21 kg/m^2. Auscultation demonstrates an early-mid diastole low-pitched sound at the left upper sternal border. A chest X-ray reveals a poorly demarcated abnormality in the heart and requires CT imaging for further analysis. What would most likely be seen on CT imaging?

A 67- year old African American female comes to the clinic complaining of progressive fatigue for the past 4 months. She noticed that she is feeling increasingly short of breath after walking the same distance from the bus stop to her home. She denies chest pain, syncope, lower extremity edema or cough. She denies difficulty breathing while sitting comfortably but increased difficulty upon walking or other mildly strenuous activity. Her past medical history includes mild osteoporosis and occasional gastric reflux disease. She takes oral omeprazole as needed and daily baby aspirin after her husband died of cardiovascular complications. The patient is a retired accountant and denies smoking history but does admit to 1 small glass of red wine daily for the past 5 years. Her diet is varied, having devoutly following a Mediterranean diet of fruits, vegetables and fish. She states with pride that she has been very healthy previously, having managed her own health without a physician for the past 20 years. On physical examination, her blood pressure is 128/72 mmHg, pulse is 87 beats/min and oxygenation of 94% on room air. HEENT examination demonstrates mild conjunctival pallor. Lung and abdominal examinations are within normal limits. Heart examination reveals a 2/6 systolic murmur at the right upper sternal border. The following laboratory values are obtained: Hematocrit: 29 % Hemoglobin: 11 mg/dL Mean red blood cell volume: 78 fl Platelets: 240,000/mm^3 White blood cells: 6,000/mm^3 What is the most likely reticulocyte range for this patient? (Normal: 0.5- 1.5 %)

A 35-year-old man presents to the physician because he is concerned that a "bad flu” he has had for the past 10 days is now getting worse and causing him sleeplessness. On presentation today, his sore throat has improved; however, fever, chest, and body ache are still present despite the use of ibuprofen. The chest pain is sharp and comes and goes and is worse with exertion. He has not traveled recently outside the United States and does not have a history of substance abuse or alcohol use. Physical examination shows a temperature of 101°F, heart rate of 110 beats per minute, blood pressure of 120 /60 mmHg and oxygen saturation is 98% on room air. Bilateral pedal edema at the level of the ankle is seen. Auscultation reveals normal S1, S2, and a third early diastolic heart sound. Also jugular vein distension is appreciated. An EKG shows sinus tachycardia and diffuse ST segment elevation throughout the precordial leads, with 1.0-mm PR-segment depression in leads I and II. Laboratory results: White Blood Cell: 14,000 /mm^3 Lymphocyte count: 70 % Hematocrit: 45 % CRP: 56 mg/dl Troponin T: 1.15 ng/mL Troponin I: 0.2 ng/mL Ck-MB: 22 ng/mL Coxsackie Type B Viral Antibody: Positive A chest X-Ray shows clear lung fields bilaterally and a mildly enlarged cardiac silhouette. Transthoracic ultrasound reveals a left ventricular ejection fraction of 30 %. Which of the following is the cause of this patients difficulty sleeping?