Cardio Patient Cases

Question 1

Georgia is a 44 YO woman who presents for her first physical in 10 years. She recently got remarried and she and her husband have decided they want to “get healthy” together, so she wants to see what her starting baseline is. On your chart you note that she is 5’4, 174 lbs and her BP is 132/88. You notice no other abnormalities during her physical - she has no irregular heart sounds, normal strength, negative breast exam, etc. and she says she feels good overall. She works as a delivery driver 60 hrs/wk and spends long days sitting in her car. You order blood draw for a BMP and a lipid panel. What 3 values in particular might be of interest to you? What diagnosis are you concerned about? What is typically the root cause of that disorder? What recommendations might you make to Georgia?

Answer 1

Georgia has a BMI around 30 and increasing blood pressure. If she also has any one of the following, you would diagnose her w/ metabolic syndrome: HDL below 40 mg/dL, blood sugar higher than 100 mg/dL, or triglycerides higher than 150 mg/dL. Metabolic syndrome is typically caused by obesity. Depending on how her BMP/lipid panel comes back, you might rx different meds to control her trigs, LDL, or blood sugar. In the meantime, you educate Georgia about metabolic syndrome and tell her that the best thing she can do regardless is lose weight. This will help her avoid developing the syndrome in the future if she doesn’t already have it now. If she is able to reduce working hours so she can be more active, or find a way to be more active at her job that will help, as will a healthy diet.

Question 2

Mary is 64 YO woman who presents w/ dyspnea, orthopnea, and edema worsening for the last month. She has a hx of CHF. You listen to her heart and notice a harsh, midsystolic murmur that increases then decreases in volume. It seems to intensify when she breathes out and is most pronounced in the 2nd ICS, right of the sternum . What do you suspect is wrong? Where will this murmur most likely radiate to? What imaging can help confirm your dx? What is the tx for this condition?

Answer 2

You believe that Mary has aortic stenosis, and you can likely hear the murmur radiate to her neck. This is a serious condition with a high 2-year fatality rate (50%). You can confirm your dx w/ an echo. It is important that Mary receives tx immediately, such as aortic valve replacement (preferred) or balloon valvuloplasty.

Question 3

Marcus is a 60 YO male who presents w/ pain in his legs, as well as lesions on his feet that aren’t getting better after 2 weeks. He says the pain is most noticeable w/ activity and resolves some with breaks. He has a hx of HTN and a family hx of hypercholesterolemia. PE shows a pulse w/ grade 1, cool feeling feet, and painful-looking ulcers on his feet. What might you hear on femoral auscultation? What is your dx? How do you confirm? How do you tx?

Answer 3

Marcus has peripheral artery disease, a complication of atherosclerosis that limits blood flow to the extremities. His age, gender, likely hyperlipidemia, and HTN are all RFs. Femoral auscultation might reveal a bruit. You use an ABI to confirm your dx - a value <0.91 is diagnostic for PAD. You discuss w/ Marcus that he needs to make lifestyle modifications to control his cholesterol and reduce his BP including diet and exercise changes. You recommend an annual influenza vaccine. You rx ASA 325 mg/day to prevent clotting. You order a lipid panel to look for signs of dyslipidemia and discuss the likelihood of starting a statin. If these modifications aren’t successful, Marcus will need to undergo surgery for tx and you refer him to surgery for that discussion as well as to a wound care clinic for his ulcers. You ask him to return in 2 weeks to discuss his progress.

Question 4

Denise is a 44 YO female who presents w/ palpitations and syncopal episodes throughout the past 2 days. She is otherwise healthy and has no significant PMHx. She was rx’d levofloxacin 4 days ago to tx an acute bacterial rhinosinusitis infection. She appears unwell but not in acute distress. PE is normal and you hear no abnormal heart or lung sounds. Vitals are WNL except that her pulse is borderline tachycardic at 96, which she says is much higher than normal. You order an EKG and you see QTc intervals that are 480 ms long but no other abnormalities. What labs do you order? How do you dx and tx?

Answer 4

Denise has long QT syndrome, a condition that can be caused by many meds, including levofloxacin. You order CMP to look for hypokalemia and hypomagnesemia and you also check her thyroid function. You discontinue the levofloxacin and tx any underlying electrolyte or thyroid imbalances. Because you think the prolongation was stimulated by her medication, you don’t rx any BB’s but you tell her that if she has sxs again she should come back in immediately and you can discuss rx’ing BBs prophylactically.

Question 5

Glenn is a 62 YO male who presents w/ lightheadedness and fatigue for the past 3 days. He has a hx of migraines and anxiety. He was recently rx’d metoprolol to tx both of his conditions simultaneously. PE shows vitals are WNL except he has a heart rate of 48 bpm. You order an EKG and see a regular rhythm, rate 48, w/ a P before every QRS and no noted abnormalities. What is your dx and tx for Glenn?

Answer 5

Glenn has sinus bradycardia, a slow heart rate most likely caused by his metoprolol. You stop his metoprolol and discuss an alternative tx for his migraines and anxiety. You ask him to f/u w/ you in 1 week and to return sooner if his sxs don’t improve or if they worsen.

Question 6

Bob is a 43 YO male who presents w/ heavy sweating and a racing heart that’s worsened over the past month. He is a nurse and said he’s had a few episodes where he feels like he can feel his heart pounding in his chest, so he takes his BP at work and gets a very high reading - typically 148-156/96-100 mmHg, but when he rechecks it later, it has returned to normal. Today his BP is 124/82. You listen to his heart and don’t feel any abnormalities. You palpate his abdomen and notice a fullness and an irregularity in the URQ. What lab should you order? What is your dx for Bob? How do you tx?

Answer 6

Bob is having paroxysmal secondary hypertension d/t a pheochromocytoma. You order a 24-hr urine metanephrine test to confirm - if it comes back positive you’ll order a CT or MRI of his abdomen. This tumor produces epinephrine and/or NE and/or dopamine that is causing his sxs. Removal of the tumor surgically will resolve his sxs and your refer him to surgery (contingent upon positive results of tests/imaging).

Question 7

Gina is a 25 YO female who presents w/ difficulty breathing and a fluttering feeling in her chest, especially when she’s at her soccer league. At her game last night, she passed out as she was walking off the field. She felt ok when she came to, but she’s scared that there’s something seriously wrong with her. She is in otherwise good health and isn’t taking any medications. PE shows no abnormal lung sounds, but you do hear an S4 when listening to her heart. What tests should you order and what are you looking for? What is the MC etiology of her condition? What is your dx and tx? What pt education is impt?

Answer 7

Gina has hypertrophic cardiomyopathy, a condition characterized by left ventricle hypertrophy, abnormal diastolic function, and intact systolic function. This is commonly genetic, typically d/t a mutation in the autosomal dominant MYH7 gene. For this reason, you recommend her family is screened for the condition as well. You order an EKG (looking for abnormal Q waves, prominent voltages, inverted T waves) and and echo (LVH, small LV lumen, can inspect for LVOT obstruction and mitral regurgitation as well). You rx a BB (e.g. metoprolol) to decrease the O2 demand, reduce contraction and slow HR. You also tell her that she can no longer play high intensity sports, but encourage her to stay active in other ways - e.g. modest hiking, bowling, golfing, walking, jogging, etc. If her condition isn’t improving, she can try surgical tx - myomectomy or percutaneous septal ablation. You tell her to come back immediately if she develops any new cardiac sxs and you want to check w/ her in 2 wks to see how her BB is working for her.

Question 8

Blake is a 64 YO male who presents w/ “bumps” on his face. He says they don’t hurt, but they can be a little tender from time to time. PE shows a cluster or yellow-orange, flat deposits under the skin on Blake’s face. What labs might you order and what might they show? What is the dx and etiology? How do you tx?

Answer 8

Blake has xanthomas, fatty deposits mediated by foam cells which are often a manifestation of hyperlipidemia. If you order a lipid panel, you might see elevated LDL and/or elevated triglycerides. Controlling the underlying condition once you’ve identified it can help eliminate the xanthomas.

Question 9

Jonas is a 49 YO male who presents w/ chest pain for the last 3 days. He says he feels like it’s “behind the bone” and it hurts worse when he’s lying down, but feels better if he leans forward. He has no significant PMH, but says he was getting over a cold last week. On PE his respirations are 22, temp 99.8, HR 108, BP 132/82. You listen to his chest and hear a grating, rubbing sound when at the apex when he leans forward. What might you see on his EKG? What is your dx and tx? What is the likely etiology?

Answer 9

Jonas has pericarditis, and inflammation of the pericardium likely caused by a recent viral infection. His EKG would classically show diffuse ST elevation w/ PR depression but may show no changes at all. Tx is an anti-inflammatory, colchicine, and activity restriction until his sxs resolve, however if he doesn’t want to take medications, the infection is typically self-limiting.

Question 10

Clifford is a 5 YO boy who comes in for a physical. His mother has no great concerns, but she’s noticed that Cliff can’t quite seem to keep up with his friends. When they play tag, kick the can, or other games like that he is always the first to sit out and he seems to get tired easily. When you listen to his heart, you hear a grade II fixed, split S2 at the LUSB. You take a CXR and see increased pulmonary vascular markings and slight RA/RV enlargement. What other imaging should you perform to confirm your dx? How do you tx?

Answer 10

Clifford has an atrial septal defect, a congenital heart defect that MC occurs when the newborn fails to fully transition from fetal to postnatal circulation. You tell Clifford’s mother that the defect will likely not become more problematic than it is, but you refer them to cardiology for a second opinion and possibly more aggressive tx.

Question 11

Jenny is a 24 YO female who presents w/ an arrhythmia. She is in med school. She says she’s not sure when it started but she noticed when she was practicing finding her pulse that her heart rate wasn’t regular. Jenny has no significant PMH. Her physical exam is normal and you don’t note any abnormalities when listening to her heart. You order an EKG and see a slight arrhythmia - her rate increases when she breathes in and her overall rate is 64 bpm. You see no other abnormalities.What is your dx and tx for Jenny?

Answer 11

Jenny has a very common, benign, sinus arrhythmia, a slight irregularity in rate caused by inspiration and expiration. You tell Jenny that she shouldn’t worry, this arrhythmia is very common and she has nothing to worry about and requires no tx.

Question 12

Arnie is a 65 YO male who presents w/ chest pain and difficulty breathing that came on suddenly an hour ago. He says he feels like he has a “bowling ball” sitting on the middle of his chest. He has a hx of angina, HTN, and has a 40 year hx of smoking. He takes amlodipine and HCTZ. His HR is 112 and his BP is 140/90. PE shows that he is taking labored breaths. He appears pale and diaphoretic. You order an EKG and see ST elevation in leads VI-V4. What lab should you order? What is your dx and tx for Arnie? What is the etiology? How will subsequent EKGs look for this pt?

Answer 12

Arnie has an ST-elevation myocardial infarction, a condition caused by complete blockage of the coronary artery d/t a ruptured atherosclerotic plaque that causes platelet aggregation. You order cardiac enzymes to look for elevated levels of myoglobin and troponin. Tx involves aspirin, IV NTG, heparin, a beta blocker, O2 for his labored breathing, possibly morphine as well as primary angioplasty and stent placement. If this were not possible, you would administer TPA. You also discuss w/ Arnie rechecking his BP at a later time to make sure he’s taking an effective dose of his HCTZ and amlodipine. You also talk about smoking cessation and other healthy lifestyle changes. If Arnie had an EKG done following his MI, it would show new Q waves, indicating areas of cell death in his heart.

Question 13

Colleen is a 32 YO female who presents w/ a deep, cramping pain in her left leg that’s been bothering her for the past two days. She says she’s never experienced anything like it. She is currently taking Vitamin D pills and Reclipsen. She returned home 4 days ago from Japan but doesn’t have any sick contacts that she is aware of. PE confirms that her left leg is TTP and looks slightly swollen. You ask her to flex her left foot upward and she winces in pain. What is the name of her reaction to this test? What is your dx? How do you confirm? How do you tx? What preventive measures can Colleen take? How would your tx differ if she had experienced these sxs previously?

Answer 13

Colleen has a provoked deep venous thromboembolism, likely caused by a combination of her birth control pills and her long flight home from Japan. The pain caused by dorsiflexion is known as a positive Homan’s sign. You confirm your dx w/ US to look for a clot. You decide not to hospitalize her but you tell her she needs to discontinue Reclipsen immediately and you start her on Warfarin for 3 months. She needs to come in weekly to have her INR checked to make sure the warfarin is w/in a therapeutic range. She can wear compression stockings, take ASA daily, and avoid long sedentary periods to prevent future DVTs. If she develops another clot once she finishes the warfarin, she’ll need to start taking it again for life. If she had had a DVT previously, you wouldn’t recommend a trial period w/out warfarin, and would instead recommend that she begin warfarin indefinitely right now.

Question 14

Charlotte is a 63 YO female who presents w/ palpitations and fatigue for the last 36 hours. She says her heart feels like it’s racing and she was barely able to sleep last night. She has a hx of DMII and angina.. You take her pulse and find it’s very rapid. You order an EKG and see multiple, identical P waves between every QRS complex, and a ventricular rate of 150. What is the pattern you see on EKG? What is your dx and tx for Charlotte?

Answer 14

Charlotte has atrial flutter, a rapid but regularly irregular rhythm that may be in part d/t her hx of DM and angina. The pattern you view on her EKG is “sawtooth” and characteristic of her condition. Her condition can be tx’d w/ ablation.

Question 15

Josh is a 26 YO male who presents for a physical. He has no complaints, but reviewing his chart you see that his grandfather died at age 48 of a heart attack. You ask about his parents’ health and he says they are both in good health, but his dad suffers from angina. You find no abnormalities on his physical - normal heart sounds, 5/5 strength, BMI of 22, and BP of 122/82. You order a lipid panel, BMP, and CBC. When the results come back, you see values w/in normal limits except that Josh’s LDL is 180 and you note that his TC is very high, somewhere in the 90th percentile. How do you dx and tx Josh?

Answer 15

Josh has familial hypercholesterolemia, a type of dyslipidemia influenced by a gene mutation that prevents the body from removing LDL. You discuss the importance of healthy lifestyle with Josh and tell him that you’d also like to start him on a statin to help control his LDL to prevent cardiovascular complications.

Question 16

Zoe is a 62 YO female who presents w/ several syncopal episodes in the past 4 days. She has no memory of a prodrome prior to these incidents. She has a hx of poorly controlled pulmonary HTN. There are no significant findings on PE and heart sounds are normal. You order an EKG and see widened QRS complexes (0.15 ms) in V1 and V2 that have double R peaks. What is your dx and tx for this pt? What if you had seen widened QRS complexes in V5 and V6 w/ R waves w/ flattened tops?

Answer 16

Zoe has a right bundle branch block, likely secondary to her pulmonary HTN. If you’d seen the widened, flat-peaked QRS complexes in V5 and V6, you’d suspect a LBBB instead. Because your pt is symptomatic you want to make sure you address her pulmonary HTN, discuss the importance of adherence to her meds, and discuss implanting a pacemaker.

Question 17

Barry is a 58 YO male who presents w/ orthopnea and fatigue for the past two weeks. He is 5’10, 290 lbs, BP 124/82, temp 98.8, respirations 20, and HR 96. He says he feels ok when he’s relaxed and watching TV, but when he tries to do “usual things” around the house, he gets tired and short of breath. He has a hx of HTN (currently taking amlodipine and HCTZ) and has been smoking a pack/day since he was 16 YO. PE shows his jugular veins are distended, you observe general edema, and you hear rales when listening to his lungs. You notice that his PMI is displaced and you hear an S3 when listening to his heart. You order a CXR and observe cardiomegaly and pleural effusions, EKG shows nonspecific abnormalities, and echo shows an EF of 35%. What is your dx and tx for Barry? What stage

Answer 17

Barry has heart failure, stage II. Tx involves loop diuretics (e.g. furosemide), an ACEI (e.g. lisinopril), and a BB (e.g. carvedilol). You also council Barry on the importance of healthy, low Na+ diet, weight loss, and smoking cessation and discuss available programs and resources that can help him with those issues.

Question 18

Tricia is a 33 YO female who presents w/ palpitations, lightheadedness, and near-syncope. Her fiance called an ambulance when she nearly passed out. They had shared a few bottles of champagne while watching the Bachelor when he pulled out a ring and proposed to her. She said yes and started to call her parents, but then she said she felt dizzy and her heart was racing then she almost collapsed. Tricia has no significant PMH. All vitals are w/in normal limits except her heart rate, which is 160 bpm. PE shows no other significant findings. You order an EKG and see a regular rhythm w/ a rate of 160 bpm. You don’t see any P waves, but normal, slender QRS complexes. What is your dx? What is a pharm and nonpharm tx option for Tricia?

Answer 18

Tricia is suffering from paroxysmal supraventricular tachycardia, likely d/t the excess alcohol and the excitement of her recent engagement. Nonpharmacologic tx includes the Valsalva maneuver or a carotid massage. Pharm tx for her condition is adenosine. You tell Tricia that you think her condition is episodic and if she avoids triggers (excessive alcohol, excitement, caffeine, especially in combination), she likely won’t have future episodes. However if she does, you can rx a BB or Ca++ channel blocker or digoxin prophylactically.

Question 19

Joyce is a 66 YO female who presents w/ severe headache and shortness of breath. She has a hx of HTN but hasn’t taken her meds for the past several months because she hasn’t been able to afford them. You take her BP and find that is 190/124. What are your next steps? What labs might you order? How do you do you tx Joyce?

Answer 19

Joyce is having a hypertensive crisis, caused by not taking her HTN medications. You need to admit her and control her blood pressure as soon as possible. CBC and BMP can help determine if she is suffering from organ damage (i.e. distinguish between hypertensive emergency vs urgency). In the meantime, you need to reduce her BP and a drug like labetalol or nitroprusside can accomplish that.

Question 20

Kevin is a 50 YO male who presents for a follow-up after starting another HTN medication. He was dx’d w/ Stage I HTN 1 months ago and agreed to start tx and make lifestyle modifications. He cut back on his working hours, has continued to maintain a healthy weight, and has reduced his drinking. You started him on HCTZ and amlodipine but at this visit his BP is still high - 162/90. You want to add an ACEI, so you order an electrolyte panel to make sure he’s not hyperkalemic. When the labs come back you see that his K+ is 2.0 mmol/L. What imaging might you order next? What other value on the electrolyte panel is likely out of range? What additional lab would you like to order? What is your dx and tx?

Answer 20

Kevin has secondary HTN, likely d/t hyperaldosteronism which was indicated by his refractory HTN and hypokalemia. You likely also see elevated bicarbonate, indicating metabolic alkalosis, on the panel. You could order a CT of his abdomen to look for an adrenal adenoma or adrenal hyperplasia and you might directly test for high plasma aldosterone. Tx depends on the exact cause - an adenoma can be surgically removed, while hyperplasia will be tx’d w/ an aldosterone antagonist, e.g. spironolactone.

Question 21

Herman is a 65 YO male who presents w/ sharp pain when he takes a deep breath as well as difficulty breathing. He is a lifelong smoker and recently had a right hip replacement. He says he had some pain and swelling in his right leg a few weeks ago but it went away, and he thinks it was related to his post-op recovery. PE shows that he is tachycardic. You don’t find any abnormal heart sounds and his lungs sound normal. What is your dx for Herman? How do you confirm? What is your tx? What preventive measures can he take?

Answer 21

Herman has an unprovoked pulmonary embolism. His age, smoking history, and surgery are all risk factors, and his leg pain following surgery was likely due to a DVT. You confirm your dx w/ a helical CT w/ contrast to locate the clot. You admit Herman to the hospital and begin tx w/ SQ heparin to be followed by lifelong rx for warfarin to prevent future clotting. You also discuss the importance of quitting smoking to prevent future clots, as well as many other health issues, and you discuss cessation options. He can also wear compression stockings, take ASA daily, and avoid long sedentary periods to prevent future DVTs.You schedule follow up for 2 weeks after hospital discharge.

Question 22

Mona is a 44 YO female who presents w/ chest pain that worsens when she is lying down and a fever for the past 4 days. She has a hx of pericarditis and says this felt similar when it started so she rested all weekend (she tries to avoid taking meds) but her sxs aren’t improving so she came in. Pt has a BP of 118/80, temp 99.0, HR 110, respirations 24. On EKG you see depressed PR intervals and diffuse ST elevation. Your order a CXR and see clear lung fields but cardiomegaly. What imaging do you order next? How do you dx and tx? ]

Answer 22

Mona has pericardial effusion secondary to pericarditis. You order an echo to confirm your dx and quantify the size of the effusion/evaluate for tamponade. Tx depends on the size of her effusion - since this is a new dx, she will probably need inpt management to assess the etiology, unless the effusion is very small. You rx aspirin and colchicine to tx the pericarditis, and depending on the size of the effusion, you may choose to drain it.

Question 23

Doris is a 75 YO female who presents w/ bradycardia, fatigue, and confusion for the past several hours. Her daughter brought her in when she stopped by and noticed her mother was acting strange and said she felt dizzy. She has a hx of heart disease and had heart surgery (coronary bypass) 4 months ago. PE confirmed her pulse is 48 and seems irregular. Her PE is otherwise unremarkable. You order an EKG and see widened QRS complexes with irregular P waves and an irregular rhythm. What is your dx and tx for this pt?

Answer 23

Doris has sick sinus syndrome, a condition associated w/ elderly pts w/ a hx of heart disease. Tx involves a pacemaker to control Doris’ rhythms and relieve her sxs a well as making sure you address her heart disease and how she’s managing it.

Question 24

Mike is a 35 YO male who presents w/ “skipped heartbeats” that he notices from time to time. He says it’s always worse in the morning and whenever he has presentations at work. He says he’s been growing more and more anxious about it, and he’s been noticing more and more “skipped beats.” He has no significant PMH and isn’t on any medications. He drinks coffee w/ breakfast every morning and whenever he has to get “psyched up” at work - he hates public speaking and being in front of an audience. He says he needs to leave the appointment soon because he has one of his presentations this afternoon. His vitals are all WNL and there are no significant findings on PE. All heart sounds are normal. You order an EKG and watch it for about 10 minutes. You notice that Mike is getting agitated and keeps checking his watch. Then you see an irregular, early wide QRS complex w/out a P wave in front of it. The rest of the cycles are normal. You see one more bizarre QRS complex 3 minutes later. What is your dx and tx for Mike? What is the likely etiology? If you saw three of these bizarre QRS complexes in a row, what would be your concern?

Answer 24

Mike is having very common premature ventricular contractions (PVCs), likely caused by the combination of caffeine and stress. His anxiety about a bad dx has probably been making them more frequent. You tell Mike that he doesn’t need to worry and that if he avoids the triggers - caffeine and stress - the PVCs will likely lessen/stop. You ask him to f/u w/ you in 2 wks to see if he is less bothered by the PVCs. If he is not, you can rx a BB, which will help prevent the PVCs and may address his anxiety as well.

Question 25

Bess is a 50 YO female who presents w/ complaints of worsening chest pain. She says her angina is worse than it used to be in the last few weeks. She is getting chest pain almost every day now, when she used to have it once or twice a week. She notices that it also bothers her more during her morning walks then it used to and her nitroglycerin doesn’t help as much as normal. She is wondering if you can increase the dosage. She is also taking aspirin, metoprolol, and verapamil. PE shows that she is in no acute distress, despite experiencing the chest pain currently. You notice no color or temperature changes and lung and heart sounds are normal, all vitals are WNL. What test and labs do you order and what do you expect to see? What is your dx and tx? What is the etiology?

Answer 25

Bess is having sxs of unstable angina, a progression in IHD that occurs when an atherosclerotic plaque in the coronary artery ruptures and causes platelet aggregation, narrowing the lumen further. It is important to tx this condition aggressively. You order an EKG, expecting to see ST depression and possible T-wave flattening/inversion. You also order cardiac enzymes, which may be slightly elevated. Tx involves admitting Bess and txing w/ IV BBs, heparin, and possibly clopidogrel, in addition to her NTG and aspirin.

Question 26

April is a female who was born prematurely 2 days ago. Her HR is 210 bpm and she is breathing very quickly. She seems to require more O2 than the other premies and she is not consistently stable. When you listen to her heart you hear a grade III machinery murmur at the LUSB. What do you suspect is wrong w/ April’s heart? What imaging do you use to dx? How do you tx?

Answer 26

April has patent ductus arteriosus, a failure of the ductal smooth muscle constriction after birth. You order an echo to confirm your dx. You refer her to cardiology, rx indomethacin and a diuretic, and discuss surgery w/ her parents - ligation to close the duct. She should have a normal life expectancy and she won’t require long-term cardiology care or f/u.

Question 27

Kyle is a 20 YO male who comes in for a physical. He says he currently has no concerns, and has no complaints secondary to his Marfan syndrome. When listening to his heart, you notice a high-pitched, blowing murmur that starts loud, then gets softer. It is most pronounced in the 3rd ICS, left of the sternum. After listening again, you notice there is a 3rd heart sound, too. If you want to hear the murmur better, what might you ask Kyle to do? What is your dx? What imaging can help confirm? How do you tx?

Answer 27

Kyle has aortic regurgitation, secondary to his Marfan’s syndrome, which causes aortic root dilation. If you want to hear his murmur more clearly, you could ask him to lean forward and exhale while you listen. You can confirm your dx w/ an echo. Kyle is having no symptoms, but since he also has Marfan’s, you choose to refer him to cardiology. They may choose to observe/monitor or they may decide to replace his aortic valve.

Question 28

Michelle is a 38 YO male who presents w/ swollen legs and arrhythmias worsening over the past week. She says she has been really tired at work and doesn’t feel like herself. PE confirms that Michelle has bilateral edema of her calves and ankles. EKG shows a conduction abnormalities - you observe a first-degree AV block. You order a cardiac MRI and you observe myocardial scarring. You also decide to order a tissue biopsy of the heart. What are you looking for? How do you dx and tx?

Answer 28

Michelle has dilated cardiomyopathy secondary to sarcoidosis. These pts rarely reach HF. On tissue biopsy, you’re looking for granulomas that are often present in the basal septum and posterior LV wall. Tx involves symptomatic care (e.g. diuretics), steroids, and cyclophosphamides and you also refer Michelle to cardiology.

Question 29

Ann is a 60 YO male who presents w/ muscle pain and swelling. She said it started a couple weeks ago and has gotten worse. She’s also noticed that her urine is darker than usual. She has a hx of hypercholesterolemia and recently started taking simvastatin. What labs/tests do you order? How do you dx and tx?

Answer 29

Ann may be one of the rare cases who develops rhabdomyolysis d/t statin use. You order a CPK to look for extreme elevation (>1100) and a urine dipstick will be positive for blood. If these tests indicate rhabdomyolysis, your main concern is protecting Ann’s kidneys. You’ll admit her and hydrate her via IV as well as discontinuing her statin in favor of a different medication, e.g. ezetimibe.

Question 30

Matt is a 28 YO male who presents w/ painful, reddened fingertips that have been worsening over the past month. He says the pain worsens when he’s using his hands - typing, playing tennis, etc. He has been a smoker since age 15. PE shows the fingers on both of his hands are dusky and purplish and are tender to TTP. What is your dx and tx for Matt? What possible complications could occur if the condition isn’t resolved?

Answer 30

Matt has Buerger’s disease, a lesion of the arteries, veins, and nerves that MC affects the hands and feet. The main RF is tobacco use and Matt needs to stop smoking for the sxs to resolve. If he doesn’t, the lesions could cause gangrene and nonhealing ulcers in the affected tissues.

Question 31

Ruth is a 48 YO female who presents w/ shortness of breath, fatigue, lower extremity swelling, and weight gain over the past month. She says she no longer feels like she has the energy for her morning walk, but she doesn’t think that accounts for her sudden weight gain. PE confirms pitting LE edema and +JVD. She has normal heart sounds, but you notice that she has labored breathing and you hear crackling in the base of her lungs. CXR shows pulmonary congestion and pleural effusions, and EKG shows atrial enlargement and RBBB. You order an echo and observe thickened, speckled walls w/ reduced ventricular lumens. What else might you see on the echo? What is your dx and tx? What is Ruth’s prognosis?

Answer 31

Ruth has restrictive cardiomyopathy secondary to amyloidosis, an impairment of ventricular filling. On Ruth’s echo, you might see a “cherry on top” appearance as well as the speckled, thick walls. Tx involves making positive lifestyle changes - low sodium diet and continued exercise. You also rx HCTZ and warfarin to tx the sxs as well as a beta blocker to control her arrhythmia. Unfortunately, the prognosis is typically not good - 5 year mortality is 70%.

Question 32

Harold is a 68 YO male who presents w/ dizziness, chest pain, and SOB for the past 30 minutes. He says it came on really suddenly and he’s worried he’s having a heart attack. He has a hx of heart disease and is taking lisinopril, but not regularly. He looks very unwell and you urgently order an EKG and cardiac enzymes. The enzymes show normal troponin. On EKG you see a very rapid (180 bpm), regular rhythm of wide QRS complexes w/ no visible P waves. What is your dx and tx for Harold? What is the likely etiology? What could this condition progress to? How would your tx differ?

Answer 32

Harold has ventricular tachycardia, likely caused by his heart disease. This condition can progress to the even more dangerous ventricular fibrillation. Because he still has a pulse, you tx w/ cardioversion. If he were pulseless and/or the condition progress to Vfib, you could tx w/ defibrillation and epinephrine/amiodarone. You also discuss w/ Harold the importance of managing his heart disease carefully and discuss his medication habits w/ him.

Question 33

Janice is a 67 YO female who presents w/ a cold, “tingly,” painful lower left arm that feels weak. She says the sxs started a few days ago and have worsened. She rates the pain a 7. She has a 50 pack year hx of smoking, a hx of HTN, and a BMI of 30. PE confirms that her lower left arm feels cooler than her right arm, appears pale, and she has a diminished radial pulse. What possible diagnostics could you order? What is your dx and tx for this condition?

Answer 33

Janice has an arterial embolism, likely d/t her smoking and HTN. To dx you could use an angiogram, doppler US, and/or MRI to locate a clot. Tx involves anticoagulants (e.g. Heparin and/or warfarin) and pain meds. You consult cardiology regarding the need of thrombolytics and/or angioplasty.

Question 34

Blake is a 34 YO male who presents w/ dyspnea and exercise intolerance for the past 3 days. He says he is normally very active and healthy and he’s never felt like this before. He recently returned from a trip in Arizona - he was camping in the desert w/ friends and they left a bit early because he was stung by a scorpion. He said they sting wasn’t terrible so he ended up not going to urgent care - he says the sting site seems to be healing. His PE is unremarkable except for the sting site, which looks uninfected. He doesn’t appear to be in acute distress. His heart and lungs sound normal. You order a CXR and observe an enlarged heart and troponin is elevated. You see T wave inversion on his EKG but nothing diagnostically abnormal. What is your dx and tx for this pt?

Answer 34

Blake has myocarditis, likely caused by the scorpion sting he endured while camping. Because he is relatively stable, you don’t admit but you advise a low Na+ diet and you refer him to cardiology and ID to coordinate care based on the etiology of his heart condition.

Question 35

Bianca is a 17 YO female who presents w/ fever, aching joints, and a rash for the past 3 days. She ran away from home 1 month ago and has been living at a crowded homeless encampment ever since. She said it started w/ a sore throat shortly after she arrived at the encampment, but that went away. Then a few days ago she started to feel worse and the new sxs began. You confirm that she has a temperature of 101 F, and you note an ring-shaped, slightly raised erythematous rash on her trunk. You listen to her heart and hear no murmurs. What is the rash called? What test and imaging might you perform to confirm your dx? What is the name of the criteria used to make the dx? What is your dx and tx for Bianca? How might this disease progress if left untreated, and if it progressed, what organ is most likely affected and what part? What pt education is important for Bianca?

Answer 35

Bianca has acute rheumatic fever, secondary to untreated strep infection. The rash on her trunk is an erythema marginatum rash. You can help confirm your dx w/ a throat culture growing GABHS (Jones Criteria). You may also order an echo to examine her heart to confirm no valvular abnormalities. Treatment includes an initial course of penicillin followed by a 10 year prophylactic course of penicillin to prevent further attacks of ARF and subsequent damage to the heart valves, which would then qualify as rheumatic heart disease. RHD MC affects the mitral valve. You tell her it is important to continue dental care to prevent infections being transmitted to her heart. You also refer Bianca to a community resource officer to help her find better housing, mental health resources, and other services she may need following leaving home.

Question 36

Chase is a 48 YO male who presents w/ dyspnea at rest and chest pain for the past 14 hours. He has been a patient in the ICU since he had surgery to replace a stenotic valve 3 days ago. He says he feels pressure in his chest that’s getting worse. His vitals are BP 100/70, temp 98.8, pulse 90, respirations 20. You notice his jugular vein is distended and he appears unwell. On listening to his heart, it sounds muffled. On his monitor you notice that his systolic BP is decreasing 11 mmHg during inspiration. What is this phenomenon called? What triad of sxs is Chase displaying? What might you see on his EKG? How do you dx and tx Chase?

Answer 36

Chase has cardiac tamponade, a compression of the heard secondary to pericardial effusion, very possibly caused iatrogenically during his heart surgery. He displayed Beck’s triad for cardiac tamponade - hypotension, muffled heart sounds, and JVD, as well as pulsus paradoxus. On EKG you might see electrical alternans - alternating QRS morphology from beat to beat. Tx involves either percutaneous catheter drainage or a pericardial window, following which he will need frequent vitals, continued cardiac monitoring, volume repletion and f/u echos.

Question 37

Molly is a 65 YO female who presents w/ a “fluttery” heart and fatigue for the past two months. She has a hx of poorly-controlled HTN. When you listen to her heart you notice a holosystolic, high-pitched blowing murmur when you listen in the 4th ICS on the left sternal border, where it radiates to. It intensifies when she takes a breath. If you ordered a CXR what might you expect to see? What is your dx for Molly? How can you confirm w/ imaging? What is your tx?

Answer 37

Molly has tricuspid regurgitation, a condition that is most commonly caused by RVH, which would be possible, given her HTN; therefore if you ordered a CXR, you might see an enlarged ventricle. You can confirm your dx w/ an echo. You tell Molly that it is important that she adhere to HTN meds to reduce the strain on her CV system, especially her right ventricle. You rx antiarrhythmics and also refer Molly to cardiology.

Question 38

Leah is a 57 YO female who presents w/ dizziness, racing heart, and orthopnea for the past 3 months. She said she thought it was d/t stress and she cut back on caffeine and work hours, but it hasn’t improved. When you listen to her heart, you hear a late systolic murmur over the apex and a late systolic click. What is your dx for Leah and what is the MC cause? What causes the click? How do you confirm your dx? What is your tx?

Answer 38

Leah has sxs of mitral valve prolapse, and the late systolic click you hear is the sound of her weak mitral valve reopening when it shouldn’t be. The most common cause of this defect is myxomatous degeneration. You can confirm your dx w/ an echo. Tx options include pharmacological management - e.g. beta blockers - or even surgery for valve repair or replacement if her condition is refractory.

Question 39

John is a 30 YO male who presents w/ chest pain that’s been bothering him for the past few weeks. He says he hasn’t changed anything about his routine, he’s not sure what’s causing it. It seems to happen around the same time every day - 3 PM, regardless of what he’s doing (and normally he’s sitting at his desk working). He’s getting worried about it, so he decided to make an appointment before work today. John is 6’3, 180 lbs, respirations 14, HR 70, BP 118/78. He is not taking any medications and currently has not other health complaints or significant family hx or PMH. You order an EKG and see no abnormalities, and labs show no cardiac enzyme elevations. What is your dx and tx for John? What is the etiology?

Answer 39

John has Prinzmetal angina, a rare condition caused by coronary artery spasm. It’s possible that his coronary arteries are entirely healthy. You educate John about his condition, and rx nitroglycerin to be taken PRN for the pain, as well as verapamil to take prophylactically to prevent the artery from spasming. You tell John you’d like to f/u in 2 weeks to see how the meds are working, but that he should return immediately to clinic if he has new or worsening sxs.

Question 40

Tom is a 67 YO male who presents w/ sudden worsening pain in his lower left leg. He says it got rapidly worse this morning when he was on his daily walk this morning. He took ibuprofen but it didn’t help the pain at all. He tried resting in his recliner when he got back but that made the pain worse. He describes the pain as throbbing and shooting. He denies any chest pain and reports no bowel or bladder changes. He has a hx of PAD. PE shows his left leg is mottled and pale relative to his right and he his pedal pulse is diminished in that leg. What is the medical term for the mottling you observe? What test do you perform? Who do you consult emergently? What is your dx and tx?

Answer 40

Tom has critical limb ischemia, a complication of his PAD. The mottling you observe on his leg is called livedo reticularis. You perform an ABI (value < 0.90) and possibly perform arteriography. You get an immediate vascular surgery consult and rx heparin and strong pain medications. Further tx will be determined by vascular surgery.

Question 41

Mona is a 74 YO female who presents w/ severe headache. She says the pain is in her temples and has been bothering her for the past 2 days. She has a hx of polymyalgia rheumatica. PE confirms her scalp is tender and she winces when you palpate her temples. She says the pain worsens when she yawns. What labs do you order? How can you definitely dx Mona? What is your dx and tx? What is a possible complication of this condition?

Answer 41

Mona has giant cell arteritis, an inflammation of the temporal artery that is associated w/ polymyalgia rheumatica but isn’t fully understood. You order labs to look for elevated ESR and CRP, but an arterial biopsy is definitive. You start Mona on prednisone immediately and empirically to prevent blindness, a complication of GCA as it progresses.

Question 42

Laney is a 27 YO female who presents w/ cold fingers in both of her hands for the past two months. She says that her fingertips seem to blanch when her hands get cold and that they feel prickly when she runs them under warm water or puts mittens on to warm them up. What is your dx and tx for Laney? How might you confirm your dx? What lifestyle changes should she make?

Answer 42

Laney has Raynaud’s disease, a condition caused by vasospasm that is worsened w/ cold weather or temperature exposure. You could confirm your dx w/ a cold water test as well as order labs to look for +ANA or elevated ESR (These would indicate an underlying condition causing the Raynaud’s syndrome, as opposed to Raynaud’s disease, which has no underlying disease process). You also recommend avoiding extreme temperature changes, exercise, bundling up outdoors (and indoors as needed). You can also rx a vasodilator like amlodipine to see if it alleviates her sxs at all.

Question 43

Tristan is a 2 wk old male who presents w/ bluish skin, shortness of breath when feeding, prolonged crying, and irritability since he arrived home from the hospital. His parents say he turned even bluer when he’s crying hard and after eating. You listen to his heart and hear a systolic ejection murmur over the LUSB. What other imaging should you order? What is his postprandial cyanosis called? What is your dx and tx?

Answer 43

Tristan has tetralogy of Fallot, a combination of 4 congenital heart defects - ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and overriding aorta - caused by fetal heart malformation. The cyanotic Tet spell is very characteristic, but you order an echo to confirm the dx. Tx involves referral to cardiology, O2, sedation, BB, and phenylephrine for the Tet spells, and surgery at 3-9 months old to close the ventral septum and relieve the right ventricular outflow tract obstruction. Tristan will require lifelong cardiology f/u.

Question 44

Clarice is a 34 YO female who presents w/ heart palpitations, dyspnea, and lightheadedness for the past 12 hours. She says her heart feels “jumpy” and she’s exhausted, but that might be d/t the holidays - she’s been to four Christmas parties in the past 2 days. You inquire about her alcohol intake, and she says she was never “more than tipsy” but she drank throughout the day at each party, which is “way more than normal.” She has no other significant medical hx and isn’t taking any medications. You take her pulse and find it to be incredibly fast - 180 bpm, as well as irregular. EKG confirms the rapid rate and you see an irregularly irregular rhythm with no well-defined P waves. What imaging might you order and why? What is your dx and tx?

Answer 44

Clarice has atrial fibrillation, an erratic arrhythmia that, given her medical hx, is likely d/t overconsumption of alcohol. You might order a TEE to examine her heart for any clots that may have developed. You rx metoprolol to control her rate. If you find a clot on TEE you would rx warfarin, and you may consider rx’ing aspirin or warfarin regardless, simply because she is a woman and scores 1 on the CHADSVASc chart. If you don’t find a clot you can also consider rx’ing amiodarone to return her rhythm to normal, but it may also resolve as her body recovers from the alcohol use. You ask her to f/u with you in 2 days to talk about her progress, but you advise her to return to clinic w/ new or worsening sxs.

Question 45

Derek is a 14 YO male who presents for a physical. He has no complaints and you find nothing significant on his physical. You ask if he would mind having an EKG done so the student with you can see what a “normal” EKG looks like. He says yes. When you look at his EKG, you actually do see an abnormality - you notice consistently prolonged PR intervals. This is the only abnormality. There are no extra P waves or dropped QRS complexes. What is going on Derek? What is your tx plan?

Answer 45

Derek has a congenital 1st degree AV block. This is a relatively benign condition and since he has no sxs, you are not very concerned about it. You tell him to let you know if he develops any new sxs but that he doesn’t require any tx currently (and probably never will).

Question 46

Chris is a 43 YO male who presents w/ difficulty breathing and a dry cough worsening for the past 3 weeks. He says he’s passed out twice from coughing hard since the difficulty started. He denies orthopnea and PND. He works in a brick manufacturing plant. On PE you observe that his breathing is very labored and you hear crackles in his lungs. He seem very fatigued. EKG indicated RVH and slight right axis deviation, and CXR shows enlargement of the pulmonary artery and hilar vessels. CT shows lung fibrosis. What is your dx and tx for this pt? What is the etiology?

Answer 46

Chris has cor pulmonale secondary to interstitial lung disease, a condition that can be caused by repetitive exposure to silica dust, likely found in the brick manufacturing plant. You tx Chris w/ a diuretic for his cor pulmonale sxs and you also rx prednisone and esbriet to slow the fibrosis. You discuss w/ him precautions he can take at work to reduce further exposure. You also recommend healthy diet and exercise, and O2 PRN.

Question 47

Marina is a 38 YO female who presents w/ fatigue, dyspnea, and edema for the past wk. She had her first baby 3 wks ago when doctors induced labor d/t preeclampsia and she’s been up late with her newborn a lot, so she’s wondering if that’s what’s causing her sxs. PE shows she has bilateral LE edema, +JVD, and crackles in the bases of her lungs. You notice her breathing is labored. EKG reveals nothing specific, but on echo you see LV dilation and CXR shows pleural effusions and enlarged cardiac silhouette. What is your dx and tx for Marina?

Answer 47

Marina has peripartum cardiomyopathy, a subtype of dilated cardiomyopathy, a condition characterized by ventricular dilation w/ decreased systolic function. Her maternal age and pre-eclampsia were both RFs for this condition. You rx a BB, ACEI, and HCTZ to tx her sxs and reassure her that she should have improvement w/in a few months. You ask her to f/u w/ you in 2 wks.

Question 48

Connor is a 82 YO male who presents w/ dizziness, loss of coordination, and drooping on the right side of his face for at least the past hour. His daughter found him dazed at the kitchen table when she came to join him for breakfast and brought him in immediately. He has a hx of Afib and CAD. PE shows that he is able to raise his right eyebrow and he is having difficulty speaking. He doesn’t seem fully cognizant of his surroundings. You also find that strength is diminished in his right arm. What is your dx and tx for this pt?

Answer 48

Connor is having an ischemic stroke, a possible complication of his Afib. Once you’ve confirmed the ischemia as the cause, you rx tPA to break up the clot and refer him to neurology for immediate care and f/u.

Question 49

Mona is a 60 YO female who presents with swelling, dyspnea, and orthopnea worsening for the past week. She was a previously healthy patient who took no medications. PE confirms bilateral swelling of her calves and ankles, and you observe labored breathing. You notice that her stomach is distended and swollen too. Echo shows thick ventricular walls and you observe both systolic and diastolic dysfunction. You order a liver biopsy contingent upon what elevated lab? What is the etiology of this condition? How do you dx and tx?

Answer 49

Mona has restrictive cardiomyopathy secondary to hematochromatosis, a condition caused by an overload of iron in the body. You would order the liver biopsy to confirm iron elevation if it is indicated by elevated plasma iron, serum ferritin, and transferrin. Tx involves iron chelation therapy and tx of Mona’s accompanying sxs. You advise that Mona should avoid excess iron in her diet moving forward.

Question 50

Darlene is a 65 YO female who presents w/ tachycardia and altered mental status. She was admitted to the hospital earlier this morning w/ unstable myocarditis. She appears to be in acute distress and her breathing is severely labored. Pulse is faint and 140 and BP is 85/50. You notice that her skin is cold to the touch and she is slipping in and out of consciousness as you speak to her. What is your dx and tx for Darlene? What must you avoid w/ this pt?

Answer 50

Darlene is in cardiogenic shock, a complication of her myocarditis. You intubate her and provide mechanical ventilation PRN. It is important to avoid giving too many fluids to this pt as it could lead to pulmonary congestion and further hypoxia. You give her dobutamine or epinephrine to increase her contractility and CO and you work w/ the crash team to dx and tx the underlying cause of her crash. It is likely that her myocarditis has led to an MI, stroke, or heart failure.

Question 51

Lynne is a 30 YO female who presents w/ side pain and discolored urine. Her BMI is 22 and she has good dietary habits and works out regularly. She says she’s been having intermittent side pain for the past month and lately her urine has been darker, maybe bloody. BP confirms that Lynne has flank pain and she winces as you palpate. You also see on her chart that her BP is 150/92 and ask her about it. She says that’s a bit higher than usual but it’s always been on the high side, even when she was a teenager, her mom and her two brothers are the same way. What imaging do you order? How do you dx and tx Lynne?

Answer 51

Lynne has secondary hypertension d/t polycystic kidney disease. You can order CT, US, or MRI to image the cysts. You rx a thiazide to control her HTN and also talk to her about a low-fat, low-sodium diet to help bring her BP down. You also rx an abx for possibly kidney infection d/t her flank pain and you tell her she should drink plenty of fluids to help w/ the hematuria. You tell her that this is a chronic condition and you’ll want to continue monitoring her from now on. You also tell her that her siblings and her mother should be examined for the condition and you refer her to a nephrologist.

Question 52

Caleb is a 45 YO male who presents for an overdue physical. He got laid off and was without health insurance for the past 5 years and has been avoiding doctor’s visits until now - he finally found a new position and has benefits again. You ask him if he has any concerns from the past several years. He said he was lucky, he only got sick once. He’s pretty sure it was strep - he always gets “white spots” on the back of his throat. He figured it would go away so he just slept a lot until he felt better. He has no current complaints. During his physical, you notice that he has a low-pitched, diastolic, rumbling murmur that increases in volume toward the end. You hear it clearly listening over his lower left sternal border, but it doesn’t radiate elsewhere. It gets a little louder when he inhales. With tangential lighting, you notice he has slight jugular distention. What do you
think you’ve found? How can you confirm this dx w/ imaging? What is your tx for Caleb?

Answer 52

Caleb has tricuspid stenosis, likely d/t his previous Strep infection progressing to ARF to RHD. You can confirm the abnormality w/ an echo. You rx abx to prevent further future infections. Because Caleb is otherwise asymptomatic, you decide to observe him and ask him to follow up with you in 1 month or sooner if he notices any other new or worsening sxs.

Question 53

Molly is a 43 YO female who presents w/ dark blue, bulging veins and aching in both of her legs that has developed over the past 3 months. She works as a cashier at her local grocery store. She is otherwise healthy and has no complaints. PE shows tortured, dilated veins in both of her legs that are deep purple in color. What is your dx and tx for Molly? What vein is involved? What lifestyle changes may help her condition?

Answer 53

Molly has varicose veins, a condition caused by incompetent valves that allow blood pooling in the lower extremities and involves the great saphenous vein. Tx is typically nonsurgical to begin with - you recommend compression stockings, exercise (which encourages venous return), and taking regular breaks at work to walk or sit for a brief period of time. If the stockings don’t help w/ the pain, Molly can have surgery to remove her entire saphenous vein or cluster of the varicose veins. Alternately she can have compression sclerotherapy to shrivel the veins w/out surgery.

Question 54

Wilhelmina is a 65 YO female who presents w/ palpitations and shortness of breath for the past 4 days. She has no other complaints and no significant medical hx except that she recently started taking diltiazem to manage Stage I HTN. Her PE is unremarkable and you notice no abnormal heart sounds on exam. You run an EKG and see progressively prolonged PR intervals w/ dropped QRS complexes. What is your dx and tx for Wilhelmina?

Answer 54

Wilhelmina has a second degree Mobitz Type 1 (Wenckebach) AV block, likely d/t her new diltiazem medication. You tell her you want to switch her to stop the diltiazem and start HCTZ instead. You tell her to f/u w/ you in 1 week but to return sooner if her sxs worsen or don’t improve.

Question 55

Brian is a 28 YO male who presents w/ fever and chills and joint pain that’s worsened for over the last week. He says he’s been sweating a lot at night too. He has a hx of IVDU and no known chronic health problems or recent surgeries or illnesses. On PE you hear a holosystolic murmur in the 4th ICS and you note macular, erythematous lesions on his palms and soles. Labs confirm elevated ESR, CRP, and WBCs. What other test do you order? Imaging? What are the lesions you observed called? What is your dx and tx for Brian? What valve is affected? What is the most likely etiology? What pt education do you offer?

Answer 55

Brian has infective endocarditis, a condition involving heart inflammation and bacteremia, likely caused by his IVDU. Typically, the bacterial cause is S. aureus. The heart murmur you hear indicates damage to the tricuspid valve, and the lesions you observed were Janeway lesions. You order blood cultures to definitively identify the bacterial cause and an echo to confirm and characterize the heart damage. You rx empiric abx (to be adjusted when blood cultures are back) and refer to ID. You also administer ibuprofen for fever and refer to cardiology to evaluate for valve replacement. You discuss w/ Brian the dangers of IVDU, offer to put him in touch with addiction counseling and also offer to have him tested for HIV and hepatitis.

Question 56

Marcus is a 51 YO male who presents for a physical. He is 5’10 and 240 lbs. His temp is 98.8, HR 80 bpm, BP is 150/94, and respirations are 16/min. He has no complaints, says he feels happy with work and his relationships. You see on his chart that during his last visit a year ago, his weight was 220 and his BP was 130/88. There are no significant findings on exam but you order a CBC, BMP, and lipid panel. Assuming the results are WNL, what is your concern for Marcus. How do you tx?

Answer 56

Marcus has stage II primary/essential HTN. You rx HCTZ and lisinopril to lower his BP and you also talk to him about the importance of losing weight, eating a healthy diet, and exercising to reduce his risk and help control his BP. You ask him to follow up w/ you in 2 weeks to see how the medication is working for him.

Question 57

Tanya is a 53 YO female who presents for a yearly physical. She says she feels well and has no concerns currently, although she says she feels like she can’t go on longer runs like she used to, but she attributes that to her age. When you listen to her heart, you notice a blowing, high-pitched, holosystolic murmur. It is strongest at the apex and seems to intensify when she exhales. You notice it radiates to her left axilla. What is your dx for Tanya and what is the most likely cause? What imaging can confirm your dx? How do you tx Tanya?

Answer 57

Tanya has mitral regurgitation, and the MC cause is mitral valve prolapse. This is possibly the cause of her recent exercise intolerance. You can confirm your dx w/ an echo. Because Tanya isn’t having major sxs, she can go w/out tx if she prefers, or you can offer her a vasodilator if she would like and/or a cardiology referral. If the damage were more severe, she might require surgical repair or replacement of the valve.

Question 58

Molly is a 48 YO female who presents w/ dizziness and syncope for the past week. She was recently tx’d for myocarditis but has no other significant medical hx. Her PE and neuro exam are unremarkable and you hear no abnormal heart sounds. EKG shows punctual, equally prolonged PR intervals and only every third P wave is followed by a QRS complex. What is your dx and tx for Molly?

Answer 58

Molly has a second degree Mobitz type II AV block, likely d/t permanent damage caused to her heart by myocarditis. Because the myocarditis itself has been tx’d, the next step is surgery to implant a pacemaker that will prevent the arrhythmia from progressing further and resolve Molly’s sxs.

Question 59

Charity is a 6 week old who presents w/ poor feeding and irritability for the past several days. Her mother says she also has noticed that she seems to be very sweaty frequently and the crib sheets are always damp w/ sweat. On PE you hear a harsh, holosystolic murmur at the LLSB and you palpate a thrill. Her EKG is normal but on CXR you observe cardiomegaly. What additional imaging do you order? How do you dx and tx?

Answer 59

Charity has ventricular septal defect, a congenital heart condition caused by failure of septation of the ventricular component of the cardiac tube in the embryo. You order an echo to confirm your dx. Tx involves referral to cardiology, monitoring for spontaneous closure (as well as pulmonary HTN). She needs to have surgery (her sxs indicate a larger defect), but in the meantime you rx lasix, enalapril, spironolactone, and high calorie formula (plus possibly a feeding tube). She’ll have surgical closure before she is 6 mo old and should have a normal life expectancy w/ no activity restrictions or long-term meds. She’ll need cardiology f/u through childhood at least.

Question 60

Millie is a 28 YO female who presents w/ a painful, red patch on her left leg that came on suddenly yesterday. She has no idea what might have caused it - she doesn’t remember being ill or injuring herself recently (although she was in the hospital 2 weeks ago for the birth of her first child). PE shows a warm, swollen, erythematous patch on her left leg but no sign of a nidus of infection. What is your dx and tx for Millie? Are you concerned about any complications?

Answer 60

Because there is no known nidus of infection, you believe Millie has superficial thrombophlebitis, a superficial blood clot that can create sxs that resemble those of cellulitis. You tell Millie she doesn’t need to worry, this type of clot won’t develop into a pulmonary embolism. Tx is NSAIDs for the swelling and pain, heat, elevation and an ACE wrap, if she wants. She can still walk on that leg if she is comfortable doing so.

Question 61

Liz a 52 YO female who presents w/ intermittent chest pain and difficulty breathing. She said she hasn’t been feeling well for the past 2 months - her husband and oldest son were killed in a car accident 8 and ½ wks ago. Her psychiatrist rx’d anxiety medications but they didn’t help and she stopped taking them 2 wks ago. The sxs have remained unchanged the whole time. She is in good health and has no hx chronic diseases. PE shows her vitals are normal and confirms labored breathing. You order an EKG and see signs of ischemia. Echo shows apical ballooning, hyperdynamic base, and hypodynamic apex of the heart. You order a coronary angiogram but find no blocked vessels. All other studies come back w/ insignificant results. What is your dx and tx for Liz?

Answer 61

You believe that Liz has Takotsubo cardiomyopathy, aka broken heart syndrome, a type of dilated cardiomyopathy. You rx HCTZ and lisinopril to tx her sxs and reassure her that they should improve w/in 1 month. Once her EF has normalized, she can stop the meds. You also talk to her about grief counseling, and encourage her to continue seeing her psychiatrist.

Question 62

Daisy is a 36 YO female who presents w/ weight gain and stretch marks. She is 5’8, 165 lbs, temp 98.6, BP 138/84, respirations 12, heart rate 84. She isn’t currently taking any meds. She says over the past year she’s put on 20 lbs and she’s not sure why - she eats the same foods, has the same workout routine, and has been happily dating her girlfriend for 4 years now. PE shows striae on her abdomen and breasts, you see darker hair on her face, and you notice fat concentrated around her midsection and rounding out her face. What lab test do you order? What imaging? What is your dx for Daisy? How do you tx?

Answer 62

Daisy has secondary hypertension caused by Cushing’s Syndrome, a condition caused by excess cortisol in the body. Because Daisy isn’t taking any corticosteroid medications, it’s possible that a pituitary adenoma or an ectopic tumor is secreting the the excess hormone. You order a urinalysis to look for excess cortisol and also order a CT to look for a tumor. If a tumor is found, tx involves surgical removal.

Question 63

Herbert is a 52 YO male who presents w/ intermittent chest pain for the past 2 weeks. He didn’t want to come in, but his wife is worried about his heart and made him. He says the pain is like a squeezing around his chest, and it only bothers him when he plays pick-up basketball a couple times a week w/ his old college buddies. It lasts about 10 minutes at most, and gets better when he rests and gets water. He has smoked half a pack/day since he was 15 and has a hx of hyperlipidemia. He is currently taking Lovastatin. PE shows a WNWD male in no acute distress. His vitals are all w/in normal limits. You order an EKG and see no abnormalities and cardiac enzymes show no elevation. What is your dx and tx for this pt? What is the etiology?

Answer 63

Herman has (stable) angina pectoris, a condition caused by athersclerotic narrowing of the coronary arteries that lead to inadequate oxygen supply during higher-oxygen demand activities (e.g. playing basketball). You rx sublingual NTG, aspirin, metoprolol, and diltiazem. You tell Herman to take the NTG PRN for the pain, and you tell him you’d like to see him back in two weeks to discuss how the medications are working. You also talk to him about smoking cessation and encourage him to keep exercising.

Question 64

Peter is a 42 YO male who presents w/ palpitations and fatigue for the past 6 weeks. He says he feels like his heart is fluttering and he doesn’t have energy like he did even a few months ago. He said he had a “really bad cold” a couple months ago and thought maybe these sxs were the tail end of that. You listen to his heart and hear a rumbling diastolic murmur that increases in volume toward the end. It is noticeable over the apex of his heart, but doesn’t seem to radiate anywhere else. You also notice a kind of “snap” after S2. What is your dx for Peter? How do you confirm w/ imaging? What side of the stethoscope did you use to listen to the murmur? What is the “snapping” noise you noticed? How do you tx Peter?

Answer 64

Peter has mitral stenosis, and you think his really bad cold was probably strep throat that ultimately led to ARF. You listen to his murmur using the bell side of the stethoscope to hear the low-pitched rumbling. Because the valve is stenotic, it is noisy upon opening AND closing, so the snapping you hear after S2 was the valve opening to allow ventricular filling. You can confirm your dx w/ an echo. You tx Peter w/ abx to prevent a recurrence of rheumatic fever, and you rx anti-arrhythmics for his sxs. You tell him you’d like to follow up w/ him in 2 wks, and you’ll refer him to cardiology as well.

Question 65

Steph is a 58 YO female who presents w/ itching, swollen, red legs worsening over the past month. She is 5’4, 177 lbs, BP of 124/82, HR 84, respirations 14, temp 98.8. She has a hx of DVT and is currently taking warfarin, amiodarone, and HCTZ. PE shows bilaterally dusky, rust-colored, edematous ankles and calves. How do you dx and tx Steph?

Answer 65

Steph has chronic venous insufficiency, a prolonged inadequacy of venous valves that promotes pooling of blood in the lower extremities. Steph’s age, weight, and hx of DVT are all RFs for this CVI. It is important to tx the conditions to prevent formation of ulcers. You discuss making lifestyle changes - you encourage Steph to lose weight, exercise more, avoiding sitting or standing for extended periods of time, and you advise her to get compression stockings to encourage blood flow. You also encourage her to continue taking her warfarin. Possible procedures include sclerotherapy, endovenous thermal ablation, or surgical repair, bypass, or transplant.

Question 66

Damien is a 44 YO male who presents w/ chest pain and palpitations for the past 4 hours. He was running this morning when he got lightheaded and the other sxs began shortly after that. He has no significant PMHx and denies radiating pain and SOB. PE shows that his vitals are WNL and there are no significant exam findings - heart and lung sounds are normal. Damien doesn’t appear to be in acute distress. Cardiac enzymes come back w/ no elevation but on EKG you do see shortened PR intervals with the end of the P wave swooping up into the R wave. QRS complexes appear normal. What is this characteristic sign called? What is your dx and tx for Damien?

Answer 66

Damien has Wolff-Parkinson-White Syndrome, a conduction disorder caused by an accessory pathway called the Bundle of Kent. The characteristic sign of WPW is the delta wave you observed on EKG. Nonpharmacologic tx options include Valsalva maneuver or carotid massage. If these aren’t helpful, you cant tx w/ Adenosine. Long-term tx involves catheter-based radiofrequency ablation.

Question 67

Herman is an 84 YO male who presents w/ light-headedness and fatigue that have worsened over the past 3 days. He has a hx of CAD and has a 60 pack year hx of smoking. He doesn’t take his medications for this condition regularly. PE is unremarkable except that you notice your pt looks unwell and when you listen to his heart the beats sound abnormal and the rate is somewhat slow - approx 50 bpm. EKG shows regular waves and regular QRS complexes but they are not synchronized. What is your dx and tx for Herman?

Answer 67

Herman has 3rd degree or complete AV block, a condition likely caused by his chronic ischemic heart disease. You talk to Herman about the importance of faithfully taking his CAD meds and you also discuss with him that he will need a pacemaker to address the conduction disorder.

Question 68

Carey is a 30 YO female who presents w/ a racing heart and weight loss for the past 3 months. Carey is 5’6, 118 lbs, respirations 16, heart rate 102, BP 142/86. She says she noticed that her clothes were starting to feel baggy a couple of weeks ago and she couldn’t figure out why - she’s had the same exercise and diet routine since classes started 8 months ago. She says she also notices her heart feels like it’s racing, even when she’s been sitting in class for the past half hour. PE confirms tachycardia, but no abnormal heart sounds. You see a slight tremor when Carey holds her hands out and you note that Carey seems anxious and is slightly diaphoretic. Halfway through the appointment she takes off her jacket and her sweatshirt and complains that it’s too hot in the office. What panel do you order? What is your dx and tx?

Answer 68

Carey has secondary hypertension caused by hyperthyroidism. You order a thyroid panel to confirm elevated thyroxine and low TSH. Possible tx includes radioactive iodine or anti-thyroid medications. You also rx a beta blocker like metoprolol to help control her tachycardia, tremor, and anxiousness.

Question 69

Connor is a 57 YO male who presents w/ worsening fatigue over the past year. He is 6’3, 242 lbs, HR 90, respirations 14, BP 132/88, temp 98.8 F. He said he feels like no matter how much sleep he gets, he feels exhausted throughout the day. He’s tried going to bed earlier, but that hasn’t helped, although his wife has noticed that he’s snoring loudly when she comes in to go to bed later, and the snoring has started making her lose sleep and feel fatigued as well. You find no abnormalities during PE and the labs you run all come back WNL. What is your dx and tx for Connor? What referral do you make?

Answer 69

Connor probably has obstructive sleep apnea. Both his obesity and his prehypertension may be contributing factors. You refer Connor for a sleep study and you discuss the importance of making lifestyle changes to lose weight that can help improve his sleep and his BP. You also recommend using a CPAP or a mouthpiece that will help him get better sleep in the meantime and you ask to follow up w/ him in one month.

Question 70

Braden is a 58 YO male who presents w/ difficulty breathing and swelling for the past month. He says it’s gotten worse and he has started taking days off from work (he’s in construction) and has to sleep in his recliner. He has a hx of alcoholism for the past 30 years and has been unsuccessful in multiple attempts to reduce his intake. PE confirms bilateral LE edema, +JVD, and you hear crackles in his lungs and a holosystolic heart murmur. His EKG doesn’t show anything significant, but echo shows LV dilation and CXR shows cardiac enlargement and pleural effusion. What is your dx and tx for Braden? What are other possible etiologies?

Answer 70

Braden has alcohol-induced cardiomyopathy, a type of dilated cardiomyopathy, caused by long-term alcohol abuse. Other substances can cause this CM as well - cocaine, meth, and doxorubicin (a chemo tx) can all produce similar sxs. The most important part of tx for Braden is alcohol cessation. You admit him and rx HCTZ and a BB. You order an electrolyte panel and put him on a low Na+ diet. You discuss w/ him the w/drawal sxs that come w/ quitting, and tell him you can help tx those as they arise. You also refer him to psych for therapy regarding his dependence and put him in touch with the hospital’s community resource center for information on resources to help him stay sober. You tell him that his heart function will improve as long as he stops drinking.

Question 71

George is a 32 YO male who presents w/ persistent dyspnea for the past 4 weeks. He has a BMI of 27 and he’s been taking appetite-suppressants for the past 6 months to try to lose weight. You take his BP and see that it’s 145/90 mmHg. You listen to his heart and notice a high-pitched, blowing, diastolic murmur that gets quieter at the end. You hear it in the 3rd ICS on the left sternal border, and it intensifies when he breathes in. What is going on with George’s heart? What is most likely causing this condition? If you heard the same heart sounds in a child, what would the likely etiology be? How can you confirm your dx? What is your tx for George?

Answer 71

George has pulmonary regurgitation, a condition that is MC caused by pulmonary HTN. His HTN, in turn, may be caused, unfortunately by both his weight and his appetite suppressant pills. If you heard the same heart sounds in a child, however, you would be more likely to suspect a congenital condition: tetralogy of Fallot. You can confirm the defect w/ an echo. You tell George that you think it’s a really great choice for him to lose weight, and you encourage him to keep trying, but you tell him he needs to stop taking the suppressants. You refer him to a dietician and also discuss healthier ways of losing the weight. You tell him you want to eliminate his HTN, and that will help his heart sxs go away. You want him to follow up in two weeks to see if eliminating the suppressant pills have helped lower his BP sufficiently. If not, you can rx a thiazide like HCTZ to help w/ his HTN.

Question 72

Gordon is a 72 YO male who presents w/ a throbbing in his abdomen and back pain that have increased over the past 2 weeks. He rates the pain an 8 and says it started at a 6. BP is currently 138/86. He is a lifelong smoker and has a hx of HTN. He is currently taking HCTZ and amlodipine. PE confirms a palpable pulsing in the Gordon’s abdomen, though you don’t hear any abnormalities when you listen with your stethoscope. What imaging might you order? How do you dx and tx?

Answer 72

Gordon has an abdominal aortic aneurysm, a weakness in the aortic wall that causes permanent local dilation and degeneration of the vessel wall layers. You order a US (CT and MRI are also options) to confirm your dx. You discuss the importance of quitting smoking w/ Gordon - it will improve his HTN and reduce the risks of his AA. You also encourage him to continue taking his HTN meds, and you tell him you’d like to increase his dosage because his BP doesn’t seem to be controlled. Surgical tx is dependent on the size of the aneurysm - if you see dilation > 5 cm you will refer him to surgery, otherwise you’ll check in with him at least annually to monitor the condition.

Question 73

Jill is a 48 YO female who presents w/ palpitations and “racing heart” that have been worsening over the past 4 days. She has a hx of alcoholism and GERD and has been taking omeprazole for the past 18 months. She has no other significant PMH. PE is unremarkable, but you notice that her pulse is racing at 120 bpm. You hear no abnormal heart sounds. EKG show rapid, widened QRS complexes that have “party streamer appearance” and oscillate in altitude. What is your dx and tx for Jill? What is the etiology?

Answer 73

Jill has Torsades de Pointes, a type of polymorphic ventricular tachycardia that is likely caused by hypomagnesemia. Both her long-term use of a PPI (omeprazole) and her alcoholism are likely factors. You start Jill on IV magnesium as tx and discuss w/ her the importance of reducing her alcohol intake and offer her resources to help her cope with her addiction. You also discuss rx’ing a magnesium supplement to prevent future hypomagnesemia d/t the omeprazole.

Question 74

Jane is a 14 YO female who presents w/ cold, cramping feet and intermittent headaches that have been more frequent over the past several months. She has a BMI of 21, temp 98.4, respiration 14, heart rate 76 bpm, BP 144/92. Her mother says she’s always had blood pressure on the high side since she was little, but she didn’t know it was this high. PE shows her feet are cooler to the touch than her hands and when you listen to her heart you hear a systolic murmur on the RSB in the second ICS. What else might you want to do during PE? What is your dx and tx? What imaging do you order to confirm?

Answer 74

Jane has secondary hypertension, caused by coarctation of the aorta, a congenital narrowing of the aorta that is producing her increased BP. You may want to take her BP in her legs to see if it is lower than in her arm. You also order an echo to better examine her heart and look for the narrowing. Tx is surgical repair and you refer Jane to surgery.

Question 75

Kailey is a 3 YO female in for a well-child exam. Her mother says she seems happy, aside from the occasional tantrum, and she doesn’t have any concerns. When listening to Kailey’s heart, you hear a harsh, midsystolic murmur that increases then decreases in volume. You can hear it on the left sternal border in the 2nd ICS, but it also radiates to Kailey’s upper left neck. What is your dx and tx? What imaging can confirm? What possible complication can occur if left untreated?

Answer 75

Kailey has pulmonary stenosis, a condition that, when dx’d in childhood, is typically a congenital anomaly. You can confirm your dx w/ an echo. Left untreated, severe stenosis can lead to RVH, which can ultimately cause the foramen ovale to reopen, creating a much more dangerous condition. Because Kelly is asymptomatic, you want to monitor her, but you also refer her cardiology as well. If her stenosis becomes symptomatic or more severe, she will need valve replacement or repair.

Question 76

Sean is a 44 YO male w/ a hx of smoking who presents for a follow up visit. He was recently started on amlodipine and HCTZ following a HTN dx 1 month ago and you want to check on his progress. He’s lost 7 lbs and has started eating better. He’s also cut back on smoking and is working out 3 times a wk. He says in some ways he feels better, but he also notices that sometimes he feels really swollen, despite the weight loss and sometimes he has sudden spurts of dyspnea. When you recheck his BP at his visit, it hasn’t really improved - 138/88 - but Sean promises he’s been taking his meds daily. You listen to his heart and it sounds normal, but when you listen to his abdomen, you notice a whooshing noise. What is going on w/ Sean? What labs might you order? What imaging? How do you tx?

Answer 76

Sean has secondary hypertension caused by renal artery stenosis. You might order ACR and GFR to determine his kidney function, and you can image the organ w/ US, CT, or MRI. You continue to tx Sean for his HTN, but your primary concern now is preserving his kidney function. You encourage him to continue making positive lifestyle changes, refer him to nephrology, and discuss the possibility of renal angioplasty and stenting or renal artery bypass surgery.

Question 77

Phil is a 66 YO male who presents to the ED w/ sudden severe, tearing pain in his chest and SOB. His daughter is accompanying him and says he almost passed out from pain in the ambulance. PE shows that his pulse is weaker in his right arm and he is visibly focusing on taking deep breaths. He rates the pain a 10 and says he can feel it “spreading to his back.” He has a hx of HTN and you ask him if he’s been taking his meds, and he responds that he doesn’t always remember to. What is your dx and tx for Phil? What imaging can confirm the dx? What is your tx plan?

Answer 77

Phil is suffering from an aortic dissection that has possibly developed into an aortic rupture. This condition is likely d/t his age and poorly controlled HTN that created an aortic aneurysm that can weaken the wall and grow over time until a dissection occurs. Ultrasound can be used to confirm the dx. This situation is an emergency and Phil requires surgery right away. If he recovers from surgery, you’ll discuss w/ him the importance of adhering to his HTN meds in maintaining his general health and preventing future visits to the hospital.

Question 78

Greta is a 66 YO female who presents w/ lightheadedness for the past 4 months. She says it’s worse in the morning when she first gets out of bed and stands up, and she notices when she gets up from her desk to leave for lunch and at the end of the day. She says she feels a little more tired than usual, and sometimes weak. She’s almost passed out a couple of times. She didn’t come in to the doctor for a while because the feeling normally cleared up a bit in w/in a couple of minutes, but now she’s worried something’s very wrong with her. She is currently not taking any meds. You listen to her heart and don’t hear any abnormalities. What do you do during your physical exam of Greta? What special test could you perform? What are you looking for? What is your dx and tx?

Answer 78

Greta has orthostatic hypotension. You’ll order a CBC to look for possible causes (like DM, anemia, etc.). You also take her BP while lying down, sitting up, and standing to look for a systolic drop > 20 mmHg or a diastolic drop > 10 mmHg. You could also perform a tilt-table test. Assuming tests are w/in normal limits, you advise that Greta makes some small changes - avoid alcohol, try to stay hydrated, stand up slowly, don’t cross your legs while sitting, get out of bed slowly, etc - to tx the conditions. You can also rx a drug to increase blood volume (e.g. erythropoietin) or constrict blood vessels (e.g. midodrine).