1-100

Question 1

what is the most appropriate management for a patient with infective endocarditis and acute HF?

Answer 1

urgent cardiac surgery +diuretica +AB

Question 2

The next step in management for a patient who is not responsive to escalating
doses of oral diuretics is to

Answer 2

administer intravenous diuretics.

Question 3

Current guidelines recommend thrombolytic therapy for patients with STsegment elevation myocardial infarction (STEMI) who present within

Answer 3

12 hours after symptom onset when primary percutaneous coronary intervention (PCI)
cannot be performed within 2 hours after first medical contact.

Question 4

Criteria for
successful thrombolysis include

Answer 4

improvement or relief of pain, >50% resolution in the magnitude of ST-segment elevation, and reperfusion arrhythmias (e.g., accelerated idioventricular rhythm).

Question 5

Patients with new-onset heart failure and a high likelihood of coronary artery disease who are candidates for coronary revascularization should undergo

Answer 5

HC

Question 6

The most appropriate class of medications for a patient who is hospitalized with acute decompensated heart failure, severely depressed left
cardiac output, and evidence of poor renal perfusion and who is not responding to intravenous loop diuretics is

Answer 6

an inotropic agent (Dobu)

Question 7

The most likely diagnosis in a patient with dyspnea on exertion and deep,
symmetric T-wave inversions in leads V2 and V3 accompanied by a flat ST
segment is

Answer 7

unstable angina.

Question 8

In a person with symptoms consistent with myocardial ischemia,
electrocardiographic (ECG) evidence of deep, symmetric T-wave inversions in
leads V2 and V3, accompanied by a flat ST segment, is suggestive of

Answer 8

a critical stenosis of the proximal left anterior descending coronary artery. (This ECG
pattern and associated coronary stenosis is often called Wellens syndrome.)

Question 9

Most patients with
aortic dissection present with

Answer 9

h chest pain, and some have syncope.

Question 10

The most likely diagnosis in a patient with pleuritic chest pain, fever, new scratchy
systolic and diastolic auscultatory findings, and new ST-segment elevations
within a few days after an acute myocardial infarction is

Answer 10

pericarditis

Question 11

In-stent restenosis does not occur within days after stent placement. TRUE or FALSE?

Answer 11

true

Question 12

When a patient with a history of stroke requires dual antiplatelet therapy, the most
appropriate medications are aspirin plus either

Answer 12

clopidogrel or ticagrelor. NOT prasugrel (increased bleeding risk)

Question 13

Patients with pericarditis may have ST-segment elevation, but

Answer 13

the changes are not localized to a single coronary artery distribution.

Question 14

The most likely cause of acute ST-segment elevation in a patient who recently had a stent inserted is

Answer 14

stent thrombosis

Question 15

The most appropriate anticoagulant treatment for a patient with a non–ST-segment elevation acute coronary syndrome who is being managed noninvasively is

Answer 15

subcutaneous
low-molecular-weight heparin (Subcutaneous enoxaparin)

Question 16

……… has technical advantages for patients undergoing early invasive management, but once a noninvasive management strategy is chosen, ………..provides a
more practical option and is associated with lower rates of recurrent myocardial infarction.

Answer 16

Intravenous UFH …..LMWH

Question 17

……………… is usually restricted to patients undergoing early intervention and is given in the catheterization laboratory

Answer 17

Intravenous LMWH or fondaparinux

Question 18

In addition to clopidogrel and aspirin, the recommended treatment for a patient with advanced kidney disease and evidence of a non–ST-segment elevation myocardial
infarction who does not presently have chest pain is

Answer 18

intravenous unfractionated heparin.

Question 19

Management of new-onset atrial fibrillation that is characterized by a rapid
ventricular response despite multiple rate-control medications and a depressed
left ventricular ejection fraction should include

Answer 19

a trial of electrical cardioversion, if
no intracardiac thrombus is present on transesophageal echocardiography

Question 20

Cardioversion in AF is indicated when

Answer 20

rate control is not achieved promptly with pharmacologic measures or when the
patient experiences ongoing hypotension, angina, or heart failure.

Question 21

Transesophageal echocardiography to exclude intracardiac thrombus (especially
left atrial appendage thrombus) and anticoagulation are recommended when?

Answer 21

before cardioversion in a patient with atrial fibrillation of unknown or more than 48 hours’
duration. Anticoagulation is recommended for one month after cardioversion.

Question 22

Although flecainide can be used to terminate atrial fibrillation, it should be avoided
in patients with

Answer 22

coronary artery disease, significant structural heart disease, or
left ventricular dysfunction.

Question 23

Postcardiac injury syndrome (Dressler syndrome) should be treated with

Answer 23

high-dose aspirin, analgesics, and colchicine

Question 24

Use of simvastatin has been associated with an increased risk for myopathy, and
several common medications increase plasma levels of this drug. Medications
that are contraindicated in simvastatin users include

Answer 24

ketoconazole, erythromycin,
protease inhibitors, gemfibrozil, cyclosporine, and danazol. Verapamil, diltiazem,
amiodarone, and dronedarone can be used safely only when a patient’s
simvastatin dose is kept at or below 10 mg daily. Amlodipine can be added when
the simvastatin dose is no more than 20 mg. Ramipril can be added to a
medication regimen that includes daily simvastatin at 40 mg

Question 25

The most appropriate long-term treatment for a patient with chest pain and a
diagnosis of Prinzmetal variant angina is

Answer 25

a calcium-channel blocker.

Question 26

As-needed sublingual nitroglycerin would not prevent recurrent episodes of
variant angina. TRUE OR FALSE?

Answer 26

true

Question 27

Beta-blockers are recommended for patients with angina and conventional
obstructive coronary disease but not for patients with vasospasm and otherwise
normal coronary arteries. Propranolol (a nonselective beta-blocker) has been
shown to exacerbate

Answer 27

vasospasm

Question 28

The medication that is most appropriate for a patient with refractory, low-level,
chronic stable angina whose heart rate and blood pressure are low-normal while
taking appropriate doses of a beta-blocker and a nitrate is

Answer 28

ranolazine. Ranolazine, an inhibitor of myocyte sodium channels, prevents cellular calcium
overload, reduces diastolic wall tension, and improves oxygen supply–demand
mismatch — thereby improving angina. Ranolazine has minimal effects on blood
pressure and heart rate. In a patient with chronic stable angina who is receiving
maximal doses of routine antianginal medications or whose low blood pressure
and heart rate prevent the safe uptitration of other antianginal agents, ranolazine
is the therapy of choice

Question 29

……….is an absolute contraindication to
thrombolytic therapy because of concern for hemorrhagic conversion and
intracranial hemorrhage in this setting. Hence, this patient should not receive
reteplase, tenecteplase, or alteplase.

Answer 29

An ischemic stroke within the past 3 months
Other absolute contraindications to
thrombolytic therapy include previous intracranial hemorrhage, cerebrovascular
lesion or intracranial neoplasm, suspected aortic dissection, active bleeding or
diatheses, closed-head or facial trauma within the past 3 months, intracranial or
intraspinal surgery within the past 2 months, and severe uncontrolled
hypertension that is unresponsive to emergency treatment.

Question 30

The goal is to perform primary PCI within ………. after the first
medical contact.

Answer 30

90 minutes

Question 31

The lipid-lowering therapy that is most appropriate for a patient with an acute coronary syndrome is

Answer 31

high-dose statin therapy, such as atorvastatin 80 mg daily

Question 32

Patients ……………..who are experiencing a myocardial infarction are
more likely than other patients to present without chest pain. Health care
providers should be alert for atypical symptoms such as jaw, neck, ear, arm, or
epigastric discomfort, which can be “anginal equivalents.” New-onset exertional
dyspnea is the most common anginal equivalent.

Answer 32

with diabetes mellitus

Question 33

Cardiogenic shock, which occurs in about ………….f patients with acute
myocardial infarction (AMI), is associated with high rates of morbidity and
mortality.

Answer 33

5% to 8% o

Question 34

Mechanical causes of post-AMI cardiogenic shock are

Answer 34

pump failure,
acute mitral regurgitation (MR) caused by papillary muscle rupture, ventricular
septal rupture, and free wall rupture. A papillary muscle rupture is the mechanical
complication most likely to cause cardiogenic shock in a patient who has had an
inferior myocardial infarction and has no evidence of intracardiac shunting.

Question 35

A 72-year-old woman presents with an 8-month history of chest pressure and left-arm pain that occur only during substantial physical activity. Nuclear imaging during an
exercise test identifies a reversible area of hypoperfusion in the distribution of the right coronary artery. Other than optimizing medical therapy, what is the most appropriate
management approach?

Answer 35

Patients with low-risk stable angina are best managed with optimal medical therapy and do not require further investigation.

Question 36

Dobutamine echocardiography, a form of pharmacologic stress testing with echocardiographic imaging during rest and stress, is indicated in a patient

Answer 36

who cannot exercise.

Question 37

Echocardiography is preferred over nuclear imaging when

Answer 37

dyspnea prompts the stress testing, because the patient’s diastolic left ventricular function, valvular abnormalities, and right ventricular function and pressures can be assessed.

Question 38

Coronary CT angiography is reasonable for symptomatic patients who

Answer 38

are at intermediate risk for CAD, including patients with equivocal stress-test results and those with
known or suspected coronary anomalies.

Question 39

Cardiac catheterization with coronary angiography is recommended for stable CAD if

Answer 39

symptoms interfere with lifestyle despite optimal medical therapy or if a stress test
identifies high-risk findings (e.g., low exercise tolerance, electrocardiographic or imaging findings suggesting left-main or 3-vessel CAD).

Question 40

Coronary calcium scoring is generally performed to estimate the risk for CAD in

Answer 40

asymptomatic person. It adds no useful information in a symptomatic patient with imaging abnormalities on stress testing.

Question 41

The recommended duration of dual antiplatelet therapy after implantation of a
drug-eluting stent depends on

Answer 41

the original indication for the stent but should not
exceed one year.

Question 42

Pseudoaneurysm,

Answer 42

the most common peripheral vascular complication after cardiac catheterization, occurs when the wall of an artery is disrupted by the puncture and does
not adequately seal after the procedure. Pseudoaneurysms are rare after diagnostic cardiac catheterization, but the incidence increases to 2% to 6% after coronary intervention
because of the intensity of required anticoagulation. Pseudoaneurysms manifest as a pulsatile mass at the catheter insertion site and have a systolic bruit. Ultrasound can
confirm the diagnosis of pseudoaneurysm

Question 43

Femoral artery dissection should not result in

Answer 43

a pulsatile mass or a systolic bruit

Question 44

The most appropriate management approach for a patient with type 2 diabetes who has severe three-vessel coronary disease and left ventricular systolic dysfunction is

Answer 44

coronary artery bypass grafting

Question 45

Thrombolytic therapy can reduce the mortality risk associated with an STsegment-elevation myocardial infarction. It should be administered to patients
who present

Answer 45

within 12 hours after symptom onset when primary percutaneous
coronary intervention (PCI) cannot be performed within 2 hours.

Question 46

Clinical markers of successful reperfusion include
.

Answer 46

resolution of chest pain, >70%
ST-segment resolution on electrocardiogram (ECG), and reperfusion arrhythmias,
such as accelerated idioventricular rhythm.

Question 47

Urgent transfer to a PCI-capable hospital is recommended for patients who are in

Answer 47

cardiogenic shock, have severe heart failure, or have failed reperfusion.

Question 48

Early
cardiac catheterization with coronary angiography — within 24 hours (but not
within the first 2 to 3 hours after thrombolysis) — is recommended for

Answer 48

patients
with ST-segment-elevation myocardial infarction who have received thrombolytic
therapy, even when they are hemodynamically stable and have clinical evidence of
successful reperfusion.

Question 49

The most appropriate management for a patient with a non–ST-segment elevation myocardial infarction who is determined to be at risk for recurrent ischemia or death is an
invasive strategy, with cardiac catheterization with coronary angiography performed within

Answer 49

12 to 24 hours after presentation

Question 50

guidelines mbt NSTEMI?

Answer 50

Question 51

TIMI Risk Score for UA/NSTEMI

Answer 51

Question 52

GRACE

Answer 52

Question 53

complications after HC?

Answer 53

all correct, but occlusion and fistula are rare, dissection no mass, hematoma not plusatile

Question 54

For a STEMI patient who presents to a facility that is unable to perform PCI, the
goal is to transfer him or her to a PCI-capable facility and perform the procedure
within

Answer 54

120 minutes after the first medical contact (although <90 minutes is
optimal). If primary PCI cannot be performed within 120 minutes, thrombolytic
therapy (e.g., tenecteplase) should be administered, barring any contraindications.
After successful thrombolysis, expeditious transfer to a PCI-capable facility
should be part of a pharmacoinvasive strategy because of the potential for
coronary reocclusion. Transfer is also warranted for rescue PCI when reperfusion
is not successful

Question 55

An implantable cardioverter–defibrillator is appropriate as primary prevention for
patients with heart failure whose left ventricular ejection fraction is

Answer 55

≤35%. Few
data support placement of an implantable cardioverter–defibrillator in
asymptomatic patients with sustained (≥30 sec) VT and a left ventricular ejection
fraction >35%.

Question 56

…………………………………..are more likely than
other patients to lack typical, ischemic chest pain when they experience a
myocardial infarction (MI). Providers should remain vigilant for atypical
symptoms of MI, such as diaphoresis, unexplained fatigue, nausea, vomiting,
upper abdominal discomfort, and exertional symptoms. An MI should be
excluded as a matter of urgency in this older woman with unexplained, worsening
abdominal discomfort.

Answer 56

Women, older adults, and patients with diabetes mellitus

Question 57

If the presentation represents unstable angina, an
electrocardiogram may show abnormalities only during

Answer 57

an episode of pain.

Question 58

calculate senstivity, specificity, PPV, NPV

Answer 58

Question 59

describe the hemodynamiks in patient with inferior MI and right ventricular MI?

Answer 59

In a patient with RV infarction, the central venous pressure (a measure of right
atrial pressure) is elevated, whereas the systolic pressures in the more central
chambers (i.e., right ventricle and pulmonary artery) are normal.
The pulmonary capillary wedge pressure (a measure of left atrial pressure) is low
or normal.
Cardiac output is normal or reduced, not increased, in the setting of MI. Despite
the elevation in central venous pressure, patients with RV infarction are quite
preload-dependent; thus, in the setting of hypotension, they often require
substantial expansion of intravascular volume (with intravenous fluid
administration).

Question 60

when does the right ventricular infarction occur? what are the consequences? how to detect it?

Answer 60

The electrocardiogram shows an inferior myocardial infarction (MI), which is
most often the result of right coronary artery occlusion. If the occlusion occurs in
the proximal portion of the vessel, right ventricular (RV) MI may occur. In a patient
with an inferior MI, one indicator of concomitant RV involvement is hypotension
that is precipitated or exacerbated by administration of nitroglycerin. A right-sided
electrocardiogram can help in reaching this diagnosis; ST-segment elevation in
lead V4R is the single most powerful predictor of right ventricular involvement.

Question 61

what do you expect in early acute pericarditis in the ECG?

Answer 61

In the absence of treatment, the ECG changes may progress through four stages:
● Stage 1: diffuse ST-segment elevation and PR-segment depression
● Stage 2: normalization of the ST and PR segments, often with T-wave flattening
● Stage 3: widespread T-wave inversions
● Stage 4: normalization of T waves
Stage 1 typically occurs in the first hours to days, stage 2 within several days, and
stages 3 and 4 within days to weeks. This patient has had chest pain for 7 days,
and his ECG changes are in stage 3.

Question 62

how to define acute pericarditis?

Answer 62

Acute pericarditis is defined by the presence of two of the following three
features: pleuritic anterior chest pain, a pericardial friction rub (which is often
scratchy in character), and characteristic electrocardiographic (ECG) changes
consisting of widespread ST-segment elevation and PR-segment depression. On
physical examination, patients will often have improvement or relief of their pain
when leaning forward.

Question 63

PE findings in short?

Answer 63

Although pulmonary embolism can cause pleuritic chest pain, the patient has no
tachycardia or hypoxemia. Furthermore, the pleural friction rub associated with
pulmonary embolism is audible only during active breathing (i.e., it is absent as
the breath is held), in contrast with a pericardial friction rub, which is audible
throughout the respiratory cycl

Question 64

when should you consider ICD in patients with MI? and WHEN?

Answer 64

Left ventricular (LV) dysfunction after a myocardial infarction (MI) predisposes the
patient to ventricular arrhythmias and increased risk for sudden cardiac death. An
implantable cardioverter–defibrillator (ICD) should be considered if the patient
meets one of these two criteria:
● Persistent LV dysfunction (LV ejection fraction <35%) despite optimal medical
therapy (a beta-blocker, an angiotensin-converting–enzyme inhibitor, and a
statin, with or without spironolactone)
● A malignant ventricular arrhythmia (ventricular tachycardia or fibrillation) more
than 24 hours after the MI

Current guidelines recommend echocardiographic evaluation of LV systolic
function for an ICD a minimum of 40 days (about 6 weeks) after an MI or 3
months after primary percutaneous coronary intervention or coronary artery
bypass surgery. By then, stunned myocardium may have recovered its function
and/or ventricular remodeling may have occurred, resulting in an improvement in
LV function and obviating the need for an ICD.

Question 65

The most appropriate treatment for Helicobacter pylori infection is

Answer 65

standard
quadruple therapy (a proton pump inhibitor, bismuth subsalicylate, metronidazole,
and tetracycline).

Question 66

The most appropriate initial treatment for a patient whose stomach biopsy
findings show Helicobacter pylori infection and dense infiltrates of B-cells of the
mucosal lymphoid tissue

Answer 66

(representing MALT lymphoma) includes antibiotics for
the Helicobacter pylori infection. This treatment results in a remission in 50% to
80% of patients with H. pylori–associated gastric mucosal–associated lymphoid
tissue lymphoma

Question 67

Schatzki rings are

Answer 67

benign, mucosal structures at the gastroesophageal junction
that classically cause intermittent solid food dysphagia, most commonly with
meat and bread. Schatzki rings appear as a narrowing in the distal esophagus on
upper gastrointestinal series; additional imaging with a barium-covered tablet can
help identify the site of the functional obstruction.

Question 68

First-line therapy for Schatzki rings is

Answer 68

balloon or Savary dilation, which is
associated with prompt symptom resolution and a low rate of recurrence. After
dilation, acid suppression is recommended, particularly in patients with recurrent
strictures and symptomatic gastroesophageal reflux disease.

Question 69

Esophageal stenting is used to treat

Answer 69

malignant obstructions and refractory peptic
strictures, which usually cause progressive solid food dysphagia.

Question 70

Botulinum toxin injection into the lower esophageal sphincter can be used to treat

Answer 70

achalasia, particularly in patients who are not candidates for surgery. Achalasia
typically causes dysphagia to both solid foods and liquids, as well as regurgitation
of undigested food. A barium esophagram classically demonstrates a dilated
esophagus with a narrowed esophgogastric junction; this results in a bird-beak
appearance caused by the loss of peristalsis in the distal esophagus and a
persistently contracted lower esophageal sphincter.

Question 71

An upper esophageal sphincter myotomy is the treatment for

Answer 71

Zenker diverticulum,
which typically occurs in older patients and causes regurgitation and aspiration.

Question 72

Swallowed budesonide is used to treat

Answer 72

eosinophilic esophagitis, which tends to
occur in younger patients and causes dysphagia (predominantly to solids) and
food impaction.

Question 73

eosinophilic esophagitis treatment? what is it?

Answer 73

Swallowed budesonide is used to treat eosinophilic esophagitis, which tends to
occur in younger patients and causes dysphagia (predominantly to solids) and
food impaction.

Question 74

Zenker diverticulum treatment

Answer 74

An upper esophageal sphincter myotomy is the treatment for

which typically occurs in older patients and causes regurgitation and aspiration.

Question 75

Before diagnosing or initiating therapy in a patient with suspected achalasia, ………….and other structural diseases must be ruled out with …………….

Answer 75

pseudoachalasia …………upper endoscopy

Question 76

The differential diagnosis possibilities for salivary swellings are as follows, in order of frequency:

Answer 76

● Benign neoplasms
● Malignancy
● Salivary stones and stenosis
● Salivary swelling (adenosis) secondary to a systemic illness such as Sjögren syndrome or HIV infection

Question 77

The most appropriate evaluation for an older adult with a new 1.5-cm submandibular mass that is not erythematous is

Answer 77

CT of the head and neck.

Question 78

Pseudoachalasia refers to diseasesthat can cause esophageal motor
abnormalities similar to primary achalasiaa such as

Answer 78

(e.g., malignancy,
eosinophilic gastroenteritis, Chagas disease)

Question 79

When primary achalasia is the likely diagnosis, it should be confirmed with highresolution esophageal manometry; therapy options include

Answer 79

nifedipine, injection of
botulinum toxin into the LES, pneumatic dilation of the LES, or Heller myotomy.

Question 80

Patients of any age with chronic obstructive pulmonary disease should receive

Answer 80

pneumococcal vaccination and an annual influenza vacci

Question 81

Annual influenza immunization is recommended for all individuals over 6 months
of age. Multiple formulations of the influenza vaccine are available:

Answer 81

● Trivalent inactivated influenza vaccine injections (high-dose or made with
adjuvant) are licensed only for individuals aged 65 or older.
● Standard-dose quadrivalent inactivated influenza vaccine injections are used in
children and adults up to 64 years of age.
● The quadrivalent nasal spray influenza vaccine containing live attenuated virus
can be used in individuals 2 to 49 years of age who are not pregnant and who
do not have immunosuppression or other high-risk medical conditions.

Question 82

A patient with a presumed chronic obstructive pulmonary disease exacerbation that is unresponsive to conventional treatment should be evaluated for

Answer 82

pulmonary embolism.

Question 83

Up to ………….. of patients hospitalized for an exacerbation of chronic obstructive pulmonary disease (COPD) may have an underlying …………..

Answer 83

25%
PE pulmonary embolism.

Question 84

The most appropriate initial management for a patient who has chronic obstructive pulmonary disease with acute on chronic hypercapnic respiratory failure and who can
adequately protect his or her airway is

Answer 84

bilevel noninvasive positive-airway pressure.
The most appropriate intervention for a patient with chronic obstructive pulmonary disease who develops acute on chronic hypercapnic respiratory failure is a trial of bilevel
noninvasive positive-pressure ventilation (NPPV). Compared with endotracheal intubation, NPPV has been shown to reduce mortality risk and shorten the duration of
hospitalization. NPPV should not be used in patients with severely impaired consciousness because they might not be able to protect their airway. However, in the presence of
very mild impairments in mentation, such as patients who have slight somnolence but can be aroused and will interact with the examiner, NPPV can still be tried with close
monitoring before proceeding to endotracheal intubation

Question 85

Increasing oxygen supplementation in a patient whose partial pressure of oxygen is close to normal i

Answer 85

increases the chance of carbon dioxide retention and can contribute to
clinical deterioration (by decreasing hypoxia-induced respiratory drive) and to worsening ventilation-perfusion matching (by releasing hypoxic vasocontriction).

Question 86

what does this guy have?
a recently hospitalized 64-year-old man with morbid obesity, obstructive sleep apnea, and chronic obstructive pulmonary disease
(COPD) who develops acute on chronic respiratory acidosis secondary to a COPD exacerbation, who has mild somnolence but can be easily aroused and answer simple
questions, and who has been started on bronchodilator, glucocorticoid, and antibiotic therapy as well as supplemental oxygen at 4 liters per minute via nasal cannula with
resulting arterial blood gas values of pH 7.28 (reference range, 7.38–7.44), partial pressure of carbon dioxide 78 mm Hg (35–45), and partial pressure of oxygen 78
(80–100)?

Answer 86

acute on chronic hypercapnic respiratory failure

Question 87

Nitrofurantoin, which is often used to treat urinary tract infections, causes a wide
range of

Answer 87

pulmonary toxicities, including acute, subacute, and chronic forms of
interstitial lung disease

Question 88

Sarcoidosis can manifest as

Answer 88

hilar adenopathy (on a chest radiograph) and skin
lesions, such as erythema nodosum. Erythema nodosum is the characteristic
lesion of acute sarcoidosis; its tenderness can be mitigated by treatment with a
nonsteroidal antiinflammatory drug, such as ibuprofen.

Question 89

Pulmonary sarcoidosis has four stages:

Answer 89

● Stage 1 (as in this case): bilateral hilar adenopathy
● Stage 2: bilateral hilar adenopathy and parenchymal infiltrates
● Stage 3: parenchymal infiltrates without adenopathy
● Stage 4: signs of fibrosis

Question 90

Vocal-cord dysfunction should be suspected in a patient who

Answer 90

experiences
shortness of breath, coughing, and tightness of the chest for brief periods despite
adequate treatment for asthma. During these episodes, the patient typically has
normal oxygen saturation and appears acutely dyspneic. Auscultation of the
chest may reveal more prominent wheezing over the proximal airways and
sometimes stridor. Normally, vocal cords are open during inhalation. Vocal-cord
dysfunction or paradoxical vocal-fold motion can be diagnosed when the vocal
cords are observed to close abnormally during inhalation. Laboratory tests are
usually unrevealing between episodes, and the patient’s symptoms may be
erroneously attributed to anxiety.

Question 91

The best therapeutic strategy for treating idiopathic pulmonary fibrosis is

Answer 91

supportive therapy, including pulmonary rehabilitation and adequate oxygen supplementation.

Question 92

the differential for ground-glass opacities
includes

Answer 92

acute exacerbation of idiopathic pulmonary fibrosis (IPF), infectious pneumonia, pulmonary edema, and pulmonary hemorrhage.

Question 93

Worsening hypoxemia in a patient with idiopathic pulmonary fibrosis may represent an acute exacerbation of the IPF, but

Answer 93

other diagnoses must be ruled out

Question 94

This patient has severe, symptomatic hypokalemia with electrocardiographic changes (QT prolongation) and requires

Answer 94

urgent potassium replacement to avoid further
complications, such as arrhythmias and rhabdomyolysis.

Question 95

Refractory hypokalemia in a patient who recently received chemotherapy with
cisplatin is likely related to

Answer 95

a deficiency in magnesium.

Question 96

Magnesium depletion that is unrecognized, untreated, or both can lead to
refractory hypokalemia. Magnesium deficiency can stem from

Answer 96

gastrointestinal
causes or renal causes. Gastrointestinal losses can occur in the setting of
diarrhea or from the use of proton pump inhibitors. Renal magnesium wasting
can be induced by any number of medications, including chemotherapeutic
agents (e.g., cisplatin, carboplatin, vinblastine, bleomycin, pegylated liposomal
doxorubicin, cetuximab, panitumumab), antibiotics (e.g., amphotericin B and
aminoglycoside), and loop or thiazide diuretics. The majority of renal magnesium
reabsorption occurs in the thick ascending loop of Henle; the remainder is
absorbed in the proximal tubule and distal convoluted tubule.

Question 97

To control blood pressure and improve long-term outcomes in a patient with
scleroderma renal crisis, the initial choice of antihypertensive drug class is

Answer 97

an
angiotensin-converting–enzyme inhibitor.