Cardiology Scenarios Flashcards
A pt with a long hx of innocent palpitations comes to the clinic complaining now of pre syncopal symptoms. She is admitted for evaluation and definitive therapy. Which condition is likely an indication for implantation of a permanent cardiac pacemaker?
a) first degree AV block
b) Mobitz type I heart block with HR of 72 bp
c) third degree heart block
d) fascicular block without AV block
c: The American college of Cardiology recommendations for permanent pacing include symptomatic third degree heart block. First degree AV block is not an indication for a pacemaker unless the PR interval is longer than 300ms. Moritz type I heart block generally does not progress to complete heart block, so it is unlikely to require permanent pacing. Asymptomatic fascicular block without AV block is considered a rare indication for pacemaker insertion
A 62yo woman comes into the office complaining of substernal CP and diaphoresis. Her ECG indicates ST elevation in leads II, III, and aVF. What is the next step of care for this pt?
a) Obtain a stat CXR
b) Start a verapamil drip
c) Have the pt chew an aspirin
d) Repeat the ECG
c: Evidence suggests that aspirin in a pt with acute ischemia is beneficial. There is no need to get further tests to confirm the pts condition until the pt gets to the hospital . Verapamil is c/i in acute ischemia
Indications for abdominal aortic aneurysm repair include
a) asymptomatic aneurysm greater than 5.5 cm
b) 5 cm aneurysm in a pt with coronary artery disease
c) asymptomatic aneurysm of 3.4 cm in diameter
c) 4 cm aneurysm in a pt with a recent CVA
a: An aneurysm that is 5.5 cm is size requires surgical intervention. Pts who have an aneurysm between 4-5 cm require surgical intervention only if their co-morbidities are low.
A 33yo healthy woman during a routine physical exam 3 months ago was found to be hypertensive with a BP of 150/98. She has no family hx of hypertension but her provider was concerned so she was started on an ACE inhibitor. Her BP improved slightly but on a routine blood draw her creatinine was noted to be 2.3. She is asymptomatic but is noted to have an abdominal bruit. Based on her history and lab evaluation, which of the following is her likely dx?
a) essential (primary) hypertension
b) isolated systolic hypertension
c) secondary hypertension
d) pheochromocytoma
c: This pt likely has renovascular disease, which is responsible for her secondary HTN. Pts with renovascular stenosis have decreased blood flow to one kidney. This ischemic state initiates renin release, which increases the vascular tone in the remaining normal renal artery. Essential HTN usually responds to meds and is more likely to be dx in a pt who is older. Secondary HTN is also associated with pheochromocytoma, but these pts generally have HA, palpitations, anxiety attacks, and hyperglycemia. Isolated systolic HTN is defined as a systolic BP of greater than 140 but a diastolic pressure less than 90.
A 73yo man with a hx of rheumatic fever and coronary atherosclerosis presents to the ED with dyspnea on exertion and orthopnea. He called 911 because he could not catch his breath. On exam, he was found to have jugular venous distention (JVD), hepatic congestion, and peripheral edema. A blowing holosystolic murmur along the left sternal border that is intensified during a Valsalva maneuver and inspiration is noted. A fib is noted on his ECG. What is his most likely dx?
a) aortic stenosis
b) mitral regurgitation
c) mitral stenosis
d) tricuspid regurgitation
d: Tricuspid regurgitation is associated with HOLOSYSTOLIC soft murmur heard best at the left sternal border and the intensity may increase with inspiration. Aortic stenosis is associated with a paradoxical split of S2, a murmur that is loudest at mid systole and is heard best at the base of the heart. Severe disease also is associated with a murmur, which can be heard near the carotid arteries. The murmur of mitral regurgitation is heard best at apex and radiates to the axilla. The Valsalva maneuver reduces it. Mitral stenosis is associated with an opening snap, which is followed by a low pitched rumbling murmur in diastole.
A retired operating room nurse comes to the clinic complaining of a dull ache in her legs after prolonged standing. She notes her legs feel heavy and she has mild ankle edema when she spends the day shopping. The aching pain and the edema resolve spontaneously if the pt elevates her legs. She denies calf tenderness or dyspnea. Physical exam reveals +1 ankle edema bilaterally. What is her most likely dx?
a) DVT
b) lymphedema
c) varicose veins
d) intermittent claudication
c: Varicose veins develop when individuals spend a prolonged amount of time on their feet. Lymphedema is a condition also associated with calf heaviness and edema but the symptoms do not resolve spontaneously. DVT edema is usually unilateral, may be associated with calf tenderness or a palpable cord, and does not resolve on its own. Intermittent claudication is not associated with peripheral edema generally and while the pain is resolved with rest, walker exacerbates the pain.
A 55yo man presents to the ED with CP that started 30 min ago, diaphoresis, and nausea. An ECG shows ST elevation in I, aVL, and V2-V6. What is the dx?
a) inferior infarction
b) lateral infarction
c) anterior infarction
d) posterior infarction
c: Anterior infarctions are characterized by ST elevation in I, aVL, and chest leads. Inferior wall MI is consistent with elevations in II, III, and aVF. Lateral wall and posterior infarctions have a loss of depolarization, which my be noted simply by increases in R wave amp in V1 and V2.
A 77yo woman with a hx of hypertension presents to the office with an ulcer on the anterior aspect of the right leg. She presents to the office because she shopped all day yesterday and has developed significant edema. The skin in the pretibial region appears thin and has excessive brown pigment. What is the most likely dx?
a) venous insufficiency
b) arterial insufficiency
c) expected complication of DM
d) peripheral neuropathy
a: Pts with chronic venous insufficiency note occasional pain with prolonged standing, edema, hyper pigmentation, dermatitis, and erythema. Pts with arterial insufficiency complain of claudication and they are found to have decreased pulses, distal hair loss, thick nails, and pallor. Pts with diabetes that is well controlled may have no symptoms in the lower extremities. Peripheral neuropathies are not associated with pigmentation changes or edema, although ulcers may develop if the pt have lost their proprioception
A 34yo woman with a hx of tobacco use comes to the ED complaining of severe substernal anginal symptoms. She has never had these symptoms before. She states that she had been watching TV this afternoon and the pain was not related to physical exertion. ECG demonstrates ST elevation. What is the pts most likely dx?
a) acute coronary syndrome
b) stable angina
c) unstable angina
d) Prinzmetal angina
d: Prinzmetal angina occurs in younger pts AT REST, with no preceding angina. It is associated with ECG changes and is thought to be related to transient coronary vasospasm rather than atherosclerosis. A squeezing chest pressure that is crescendo-decrescendo in nature, which lasts 2-5 min, characterizes stable angina. It is often exacerbated by exertion. Unstable angina is noted in an individual with coronary artery disease who notes severe, new-onset pain at rest lasting greater than 10 min that is crescendo in character. It may be associated with ECG changes as well. Acute coronary syndrome is usually seen in older pts who have a hx of anginal symptoms.
(not sure if we learned this) Pts with SLE have a predilection to which cardiovascular abnormality? a) congestive heart failure b) acute myocardial infarction c) abdominal aortic dissection d) pericarditis
d: Pericarditis occurs in about ⅔ of pts with lupus. It generally follows a benign course. Pts with lupus may also develop valvular endocardial lesions. It is less common for pts to develop acute coronary syndrome, dissection, or CHF although these complications are seen in pts with antiphospholipid syndromes
A 45yo pts with a hx of hypertension, DM, and cocaine abuse presents to the ED with acute 10/10, non radiating, substernal CP. She denies recent cocaine use but appears very anxious. ECG reveals sinus tachycardia with no other significant changes. Which test(s) should be ordered to determine this pts disease?
a) arterial blood gases
b) CPK enzymes
c) troponin levels
d) AST and ALT
c: We must determine whether there is a life threatening etiology of her CP. Troponin levels are useful in the dx of acute coronary syndrome because this amino acid does not exist in skeletal muscle. Troponins have a high sensitivity and specificity for acute coronary syndromes. The enzyme levels rise after 6hrs and peak at 12hrs. Abnormalities in arterial blood gases exist for many reasons but are not sensitive or specific to acute coronary syndromes. CPK enzymes vary in their specificity because of the distribution of these enzymes in other parts of the body. CPK release can occur from the myocardium as well as skeletal muscle. AST and ALT levels may be elevated but these are not specific markers for acute coronary syndrome
A 48yo pt with a hx of ionizing radiation to the chest wall presents to the ED with dyspnea and fatigue. Physical exam reveals tachycardia, 4cm JVD, and slight peripheral edema of the extremities. ECG shows low voltage GRS complexes and CXR demonstrates normal lung fields and cardiac silhouette. What test should be ordered next in this pt?
a) Holter monitor
b) echocardiogram
c) cardiac catheterization
d) stress test
b: This pt is suffering form pericarditis. Pericarditis is dx using the Doppler echocardiography. Holter monitor should be used to aid in the dx of arrhythmias and to work up syncope. Cardiac catheterization is generally used to evaluate individual coronary arteries and cardiac function. Electrocardiographic stress tests are used to screen for coronary artery disease in an ambulatory pt who is complaining of chest discomfort.
A febrile pt with petechiae and a new onset murmur or aortic regurgitation should have which of the following diagnostic tests to determine if surgical intervention is required ?
a) Holter monitor
b) transthoracic echocardiogram
c) Cardiac catheterization
d) transesophageal echocardiogram
d: The most likely dx in this pt is infective endocarditis. Evaluation of the blood flow and the functional status of the myocardium can be evaluated with either transthoracic or transesophageal echocardiogram. However, vegetations can be detected with more sensitivity and specificity using the transesophageal (TEE) echocardiogram. Hotter monitors and cardiac catheterization do not detect valvular lesions or vegetations.
A late systolic murmur that may be preceded by a systolic click describes this valvular abnormality..
a) aortic stenosis
b) mitral valve prolapse
c) aortic regurgitation
d) mitral valve stenosis
b: Mitral valve prolapse is characterized by a mid systolic click and a late systolic murmur. The murmur associated with aortic stenosis is a mid systolic murmur, also known as systolic ejection murmur. Aortic regurgitation is characterized by a high pitched decrescendo murmur in early diastole. Mitral valve stenosis is associated with a low-pitched, mid-diastolic murmur.
Remember:
Systolic murmurs= AS, MR
Diastolic murmurs= AR, MS
Which pt population is most predisposed to developing varicose veins?
a) men
b) women
c) those with a hx of DVT
d) those with a hx of lymphedema
b: Women are 2-3x more likely then men to develop varicosity’s of their lower extremities. Pts who develop secondary varicosities may have a hx of deep venous insufficiency. Pts with lymphedema generally have a different physical presentation, which is inconsistent with varicose veins. Lymphedema does not increase ones risk of developing varicosities.
A pt found to have a split of the second heart sound that persists unchanged with expiration may have which of the following conditions?
a) pulmonary embolus
b) increased pulmonary vascular resistance
c) pulmonary valve stenosis
d) atrial septal defect
d: Physiologic splitting of the second heart sounds occur in inspiration as the aortic and pulmonic valves close at different times. Fixed splitting of the S2 heart sound is heard in patients with atrial septal defects. Pts with pulmonary embolus and pulmonary valve stenosis have a split that is prolonged and is noted in expiration. Pts with increased pulmonary vascular resistance have a narrowing of the second heard sound split.