Extra credit questions Flashcards by Francisco Miranda

A 53 yo Caucasian male arrives at your naturopathic medicine clinic seeking alternatives to statin drugs. He has read about harmful side effects on the internet and is concerned. His cardiologist prescribed atorvastatin (Lipitor) 80 mg po QD after the patient underwent catheterization and stent placement for a coronary artery blockage. You provide health teaching about the pleiotropic effects of Statins which includes all EXCEPT:

a. Plaque stabilization
b. Lowering of cholesterol
c. Vasodilation
d. Association with decreased cardiovascular events

c. Vasodilation (correct answer)

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SB, a 60 yo Asian female, has average ambulatory home monitoring BPs in the 140’s/90’s mm Hg. PE is negative for signs of end organ damage. Her ASCVD score is 4.8%. Your diagnosis is Stage 1 HTN. An initial trial of diet and lifestyle intervention may include:

a. DASH diet + low sodium <1500 mg/d
b. Hibiscus tea 1 cup po TID
c. Weight management to decrease waist circumference and BMI
d. All of the above

d. All of the above (correct answer)

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An 80 yo African American female presents for her annual exam. She appears frail, with slow gait and appears out of breath as she reaches the exam room. Vital signs are T98.8, P110, R22, BP 160/94, O2 Sats 89%. She states she feels tired all the time and anxious but thinks it’s because her husband passed last winter. Your next step includes:

a. 02 via NC at 2L/min
b. one nitroglycerin tab sublingual
c. ECG
d. A and C

d. A and C (correct answer)

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A 46 yo Hispanic male presents with blurred vision and severe headache (pain 8/10; 10 worst) not relieved by acetaminophen (Tylenol). Vital signs are T98.4, P90, R20, BP 210/120, O2 Sats 98%. Fundoscopic exam reveals papilledema and cotton wool spots. SHx includes recreational cocaine and methamphetamine use. Abdominal exam is positive for mild TTP, negative hepatosplenomegaly. UA is positive for blood and protein. You suspect ___ and your plan includes ____.

a. HTN stage 2; increase anti-hypertensive medication dose
b. White coat HTN; prescribe ambulatory home BP monitoring
c. Hypertensive Emergency; refer to ER
d. Hypertensive Urgency; refer to cardiology

c. Hypertensive Emergency; refer to ER

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A 19 yo male was resuscitated on the field during a college soccer match. He was diagnosed with hypertrophic cardiomyopathy (aka Idiopathic Hypertrophic Subaortic Stenosis or IHSS). He comes to you after hospital discharge because he doesn’t want to take “heart drugs” for the rest of his life and would prefer diet and lifestyle management so he can play soccer professionally. He reports feelings of depression. Your recommendations include:

a. Ongoing cardiology co-management and beta-blockers
b. PHQ-9 screen and counseling referral
c. Avoiding strenuous sports
d. All of the above

d. All of the above

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XX is a 72 year old African American female coming to you looking for natural ways to treat her atrial fibrillation. Her onset occurred after a MI 6 years ago and required a pacemaker implant. She has been recently placed on Warfarin. She is seeking your help because she feels lightheaded, tired, weak, and shaky. She is currently taking carvediol and amiodarone. Her cardiologist has suggested CoQ10 supplementation. Her PE is remarkable for a soft S1 with an irregular rythym, increased JVP, hepatomegaly and pulmonary rales, bilaterally. She keeps saying, “I just feel so tired, can you make me feel not tired anymore?” Your suggestion for her would be:

a. A tincture including garlic, ginger, hawthorne, and Siberian ginseng
b. A ketogenic diet
c. 400 mg of Magnesium chelate, daily
d. Turmeric 300 mg daily

c. 400 mg of Magnesium chelate, daily

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TG is a 48 year old male seeing you because he just doesn’t feel right lately. He can’t pinpoint what doesn’t feel right and says he would feel better if the doc would give him a clean bill of health so his mind can rest. He currently smokes cigarettes occasionally, drinks 2 beers every night and eats “his good ole meat and potatoes diet”. ROS was pertinent for intermittent heartburn, frequent urination with burning, and “needs to go to the eye doc because his eyes are getting old”. PE: BP: 190/120, funduscopic exam, cardiovascular, respiratory, abdominal exam is WNL. UA shows glucose, WBC and nitrites. You decide that this is a hypertensive emergency and instruct the patient to go the ER. What should happen next?

a. Receive 1000 mg of IV Mg medication to treat hypertension.
b. He is in renal failure and will be sent to ICU.
c. He will be sent home and asked to follow up with his doctor, as this wasn’t a hypertensive emergency.
d. Prescribe amiodarone.

c. He will be sent home and asked to follow up with his doctor, as this wasn’t a hypertensive emergency.

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KL is a 39 year old Caucasian male who is seeking help for natural ways to deal with his cholesterol. His recent labs showed the following: TGL: 200 mg/dl, LDL- 220 mg/dl, HDL: 31 mg/dl. He has no history of diabetes. His vitals in office were: HR 68, weight: 202 lbs, ht: 6’4”, BP: 138/78. His family history includes: father passed away from MI at 53, grandfather had a stroke at 58. With all of this information you have, you decide you are going to determine his ASCVD risk percentage. Which of these values is not needed to calculate his risk for his case?

a. Systolic blood pressure
b. LDL
c. Family history
d. None, as he doesn’t meet the parameters to calculate his ASCVD risk.

d. None, as he doesn’t meet the parameters to calculate his ASCVD risk.

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ABC is a 86 year old female coming in for a ROC for weight gain concerns. Her weight gain started about 3 months ago. She reports being cold, tired, nauseated, constipated, having a nasty dry cough, and feels the need to use two pillows instead of one at night for her head as it helps her sleep better. PE shows a respiratory rate of 24, skin pallor as well as cool to touch, pitting edema of her feet. Her cardiac exam reveals S3 sounds. Which of these labs are the most appropriate to order:

a. TSH
b. BNP
c. CMP
d. Wellness panel and BNP

d. Wellness panel and BNP

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DT is a 5 year old male who is in your office with his mother for his well child exam. He was playing soccer with his pee wee team and fell pretty hard to the ground, yesterday. Since then, he has been holding his chest and told his dad his heart hurts really bad. His mother tells you he has been turning “blue” because he is holding his breath due to the pain. In office the child is alert, holding on to his mother’s waist. His blood pressure is in the 89th percentile for his age and height. His cardiac exam revealed a systolic, diamond shaped, blowing murmur in the 2nd left intercostal space. Skin, respiratory exams are WNL. Your most likely diagnosis from your differential diagnosis is:

a. Cardiomyopathy
b. Pathologic murmur, most likely due to ASD
c. Muscle strain of the intercostal muscles
d. Hypertension stage 1 and he should refrain from team sports.

c. Muscle strain of the intercostal muscles

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A 67 year old African American male presents to office complaining of a “fluttering feeling” in his chest for the last several hours. He is slightly anxious in office. He denies feeling dizzy or faint. He has experienced 4-5 of these episodes over the last several months. He was diagnosed with hypertension 6 years ago, but has not taken the medications prescribed. He has never smoked and drinks 2-3 drinks on the weekends with friends.
On physical exam you find that he is afebrile, with a pulse of 110 bpm with an irregularly irregular rhythm and a blood pressure of 168/98. He is alert and oriented. You note that he is wearing shorts and flip-flops despite it being quite cold out.

What are your next step(s) with this patient?

A. You assure the patient his palpitations are due to anxiety and refer him for biofeedback
B. This patient should immediately be transported to the ER for catheter ablation
C. Run an ECG, CMP, thyroid panel and CBC
D. The diagnosis can be made on his presentation, you use the CA2DS-VASC to asses risk and begin treatment with 81mg aspirin, CoQ10 and decreased caffeine intake

C. Run an ECG, CMP, thyroid panel and CBC

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What is the best explanation for this patient’s symptoms?

A. Atrial fibrillation exacerbated by hyperthyroidism
B. Panic attack
C. Premature ventricular contractions
D. Wolfe-Parkinson White Syndrome

A. Atrial fibrillation exacerbated by hyperthyroidism

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The patient returns to office 2 weeks later and wants your help to get his blood pressure under control. He does not have CDK or diabetes. What is his target blood pressure and what medications are recommended for this patient according to the JNC-8?

A. < 150/90 mmHg; Furosamide
B. < 150/90 mmHg; Lisinopril
C. < 150/90 mmHg; Amlodipine
D. All of these are recommended treatments either alone or in combination

C. < 150/90 mmHg; Amlodipine

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A 63 year old female presents to office with nausea and some SOB that began last night (8 hours ago). She tells you she just wanted to come see you because she “feels like something is really off”. She is anxious and diaphoretic in office. You decide to send her to the ER to rule out MI.

In the ER they run an ECG. Which of the following ECG findings is NOT suggestive of an MI?

A. ST segment elevation of > 1mm in more than 2 leads
B. Reciprocal ST depression in a lead “opposite” to where the MI is occurring
C. T wave inversion or “peaking”
D. Delta waves

D. Delta waves

Wolff–Parkinson–White syndrome) (WPW

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The ECG is ran 9 hours after the onset of symptoms and is found to be normal. At this time they also decide to run cardiac enzymes. At this time, which of the following findings would rule out an MI?

A. Negative CK-MB
B. A normal ECG
C. Negative Myoglobin
D. All of these would rule out an MI

A. Negative CK-MB

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A 62yo woman with a history of angina experiences crushing chest pains, sweating, and tachycardia while driving to the airport. She pulls over, takes a sublingual nitroglycerine (NG), and then continues to drive. The pain is not improved so she pulls over twice more and takes more NG. Still feeling chest pain, she boards her 5 hour flight and chews four aspirin. After she gets to her destination she goes to the ER and she is diagnosed with an MI. The doctor tells her the aspirin probably saved her life. Which of the following cardiac enzymes is least likely to be elevated in the ER (>8 hrs after event)?

a. CK
b. CK-MB
c. Myoglobin
d. Troponin I and T

c. Myoglobin

Increase 2-3 hrs after MI

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A 34-year-old African American female presents with recent-onset headaches, blurred vision, and dyspnea. On physical examination, she appears very ill and has difficulty concentrating and answering questions. Her blood pressure reading in office is 190/130. What is the appropriate management for this patient?

a. This is hypertensive urgency. You perform an ophthalmoscope exam, full cardiac and respiratory PE, then perform an in-office UA and order a CMP to help you determine the most appropriate treatment.
b. This is hypertensive urgency. You call 911; she needs IV sodium nitroprusside treatment.
c. This is a hypertensive crisis. You perform an ophthalmoscope exam, full cardiac and respiratory PE, then perform an in-office UA and order a CMP to help you determine the most appropriate treatment.
d. This is a hypertensive emergency. You call 911; she needs IV sodium nitroprusside treatment.

d. This is a hypertensive emergency. You call 911; she needs IV sodium nitroprusside treatment.

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Ranjit is a 54yo Indian male who comes to see you for fatigue, SOB, peripheral edema, bloating, low appetite and a history of hemochromatosis. You strongly suspect Restrictive Cardiomyopathy (RCM). Which test is diagnostic for RCM?

a. ECG
b. Echocardiogram
c. Cardiac catheterization with biopsy
d. Angiogram

c. Cardiac catheterization with biopsy

Hemochromatosis:
Excess iron can poison organs, which can lead to conditions such as cancer, irregular heartbeat, and cirrhosis of the liver.

Symptoms are related to conditions that arise from iron overload such as diabetes, darkening of the skin, abnormal heart rhythm, or arthritis.

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Joan brings in her 4yo daughter, Ella, concerned because she keeps saying her “heart hurts”. Which of the following is lowest on your ddx?

a. Myocardial ischemia
b. Esophagitis
c. Costochondritis
d. Psychogenic

a. Myocardial ischemia

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Roberta is a 55yo Caucasian female presenting for annual physical. Aside from occasional DOE (dyspnea on exertion) and a history of rheumatic fever, there are no pertinent subjective findings. On PE, you palpate a small volume pulse, S1 and S2. On auscultation, you note the first heart sound (S1) is accentuated and you think you hear a low pitch diastolic rumble. As you set up the ECG, which of the following is highest on your ddx?

a. Aortic stenosis
b. Mitral stenosis
c. Mitral valve prolapse
d. Mitral Regurgitation

b. Mitral stenosis

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A 64 year-old male, with a long history of COPD, presents with increasing fatigue over the last three months. The patient has stopped playing golf and also complains of decreased appetite, chronic cough and a bloated feeling.

Physical examination reveals distant heart sounds, questionable gallop, lungs with decreased breath sounds at lung bases and the abdomen reveals RUQ tenderness with the liver two finger-breadths below the costal margin, the extremities show 2+/4+ pitting edema.

Labs reveal the serum creatinine level 1.6 mg/dl, BUN 42 mg/dl, liver function test’s mildly elevated and the CBC to be normal. Which of the following is the most likely diagnosis?

A. Right ventricular failure
B. Pericarditis
C. Exacerbation of COPD
D. Cirrhosis

A. Right ventricular failure

Signs of right ventricular failure are fluid retention i.e. edema, hepatic congestion and possibly ascites.

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A 55 year-old male is seen in follow-up for a complaint of chest pain. Patient states that he has had this chest pain for about one year now. The patient further states that the pain is retrosternal with radiation to the jaw.

“It feels as though a tightness, or heaviness is on and around my chest”.

This pain seems to come on with exertion however, over the past two weeks he has noticed that he has episodes while at rest. If the patient remains non-active the pain usually resolves in 15-20 minutes. Patient has a 60-pack year smoking history and drinks a martini daily at lunch. Patient appears overweight on inspection.

Based upon this history what is the most likely diagnosis?

A. Acute myocardial infarction
B. Prinzmetal variant angina
C. Stable angina
D. Unstable angina

D. Unstable angina

Pain in unstable angina is precipitated by less effort than before or occurs at rest.

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Which of the following ECG findings is consistent with hyperkalemia?

A. Prolonged QT interval
B. Delta wave
C. Peaked T waves
D. Prominent U waves

C. Peaked T waves

Narrowing and peaking of T waves are the beginning EKG changes associated with hyperkalemia.

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You’re evaluating a 35-year-old man who presents to your office with a headache. On physical examination, his blood pressure is 240/120 mmHg. On fundoscopic examination, you note the presence of papilledema. What’s this person’s underlying diagnosis?

A. Hypertensive emergency 
B. Hypertensive urgency
C. Stage I hypertension
D. Stage III hypertension
E. Prehypertension

A. Hypertensive emergency
(This person has a headache and papilledema, which is a sign of damage due to hypertension. This is called hypertensive emergency.

A blood pressure >= 180 mmHg systolic with no symptoms is an example of a hypertensive urgency (B).

Stage I hypertension, Choice (C), is a systolic blood pressure of 140–159 mmHg and/or a diastolic blood pressure of 90–99 mmHg.

There’s no Stage III hypertension, Choice (D), only Stages I and II.

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You’re evaluating a 25-year-old woman who presents with palpitations. On examination, you hear a midsystolic click. Which one of the following would you recommend concerning evaluation of her heart condition? A. She should be screened for major depressive disorder. B. She should be screened for a bleeding diathesis. C. She should be screened for rheumatic fever. D. Her murmur would decrease with a Valsalva maneuver. E. She may need a beta blocker if the palpitations continue.

E. She may need a beta blocker if the palpitations continue. (This person has mitral valve prolapse, as seen with a midsystolic click. It’s associated with panic disorder. If palpitations occur with mitral valve prolapse, a beta blocker is first-line medication.) For choice (C), you can see mitral stenosis and tricuspid stenosis with rheumatic fever. Mitral valve prolapse would increase in the setting of a Valsalva maneuver, Choice (D). -->(Decreases w/ Wolff–Parkinson–White syndrome)

Mrs. Jones is a 68 y/o female that presents to office today for an annual wellness exam. Past medical history is positive for gallbladder surgery when she was 38, diabetes (12 year history, well controlled) and cataracts. Her blood pressure at this visit is 170/100mmHg. She was seen on a homeopathy visit one week ago and her blood pressure was 165/98mmHg at that visit. Which of the following is NOT true about the management of her care? A. Because her blood pressure is 20/10 higher than target blood pressure, it is most appropriate to start her on two medications for the management of her care. B. The first standard medications choices for her care are an ACEi or ARB as well as a CCB. C. We want to follow up and re-assess her medication every 2-4 weeks to add or change the medications until her blood pressure is well managed. D. We should recommend a DASH diet for her, which emphasizes whole fruits and vegetables and low sodium as a cornerstone of the diet.

D. We should recommend a DASH diet for her, which emphasizes whole fruits and vegetables and low sodium as a cornerstone of the diet. (The DASH diet works well when combined with a low sodium diet but it does not emphasize low sodium specifically.)

A six year old boy presents to the office today with a chief complaint of chest pain. When he is asked where the pain is, he points very specifically to his left sternal border, around the level of T5. Which of the following is NOT an appropriate next step? A. Because the specific location, ask more questions to rule out muscle strain or chostochondritis (recent injuries, recent vomiting, sports activities). B. The fact that the child can point to the specific spot indicates that this is musculoskeletal in origin and no additional diagnostic workup is indicated. C. Perform a cardiovascular exam and listen to his heart and lungs. While it is unlikely to be cardiac in origin, a cardiovascular exam is still merited. D. Perform a tuning fork test over the area to see if it recreates the pain. This will increase the likelihood that the problem is musculoskeletal in origin if positive.

B. The fact that the child can point to the specific spot indicates that this is musculoskeletal in origin and no additional diagnostic workup is indicated. #B is incorrect. A complete workup to rule out other conditions is still merited.

Your 35 year old patient presents to the office after experiencing a pulmonary embolism after developing a DVT on an international flight. At the ER, they diagnosed her with factor V leiden mutation. She now presents to your office and wants you to manage her care. Which of the following is NOT an appropriate next step? A. Have your patient avoid leafy green vegetables and vitamin K supplements, put her on daily low dose aspirin and inform her that you are happy to manage her condition. B. Encourage your patient to avoid OCPs. C. Encourage your patient to stop smoking. D. Require that your patient also work with a hematologist in conjunction with your care.

#A is incorrect. We should not solely manage these on our own.

A 10 year old boy presents to the office for his annual wellness exam. At today’s visit, his BMI is over the 95% for his height and age. Which of the following is NOT the best next step? A. Encourage his family to go on a diet and to compete with weekly weigh ins. Give rewards and incentives when he successfully loses weight each week. B. Refer the family to a local cooking class and encourage more fruits and vegetables in their diet. Recommend that they spend fewer hours each day on screens. C. Explore movement that he enjoys, whether that is walking, biking, sports, etc. Try to help him integrate those into his weekly activities. E. Discuss health risks with the family and encourage the entire family to participate to improve everyone’s health. De-emphasize physical appearance as a motivator.

#A is incorrect. Weight centered focus can be harmful.

Your 67 year old male patient presents today after being released from the ER after an acute MI. He wants your recommendations for naturopathic recovery. All of the suggestions below can help recovery except one. Which treatment should be avoided? A. CoQ10 B. L-carnitine C. Fish Oil D. Hawthorne

C- Fish oil should be avoided.

A 55 year old female presents to your office by herself. She is has had worsening shortness of breath for the last 2 hours. She is not experiencing chest pain or back pain, headache, nausea or visual disturbances. This is her first such episode. Four years ago, she was diagnosed with essential hypertension, but she has not been managing her medications well, neither has she had any follow up visits. No other co-morbidities are present. ``` On Physical Exam: Vitals: Pulse: 120bpm RR: 28/min BP: 230/145 mm Hg Temp: 98.6°F ``` Cardiovascular: 3rd heart sound, gallop rhythm, cardiomegaly, peripheral pulses normal; JVP is 7 cm above the sternal angle. Fundi: Grade II hypertensive retinopathy. No papilledema noted. Respiratory: bilateral fine crackles up to mid zones ECG: Normal RR with left ventricular hypertrophy Troponin T-assay: negative What is the most likely diagnosis and the most appropriate next step? a. She is experiencing an acute myocardial infarction. Refer her for emergency medical services. b. Unable to diagnose at this time. Run an ECG. c. She is experiencing a hypertensive emergency. Refer her for emergency medical services. d. She has signs and symptoms of anxiety. Manage in office with mindfulness-based stress reduction.

c. She is experiencing a hypertensive emergency. Refer her for emergency medical services.

A 55 year old female presents to your office by herself. She is has had worsening shortness of breath for the last 2 hours. She is not experiencing chest pain or back pain, headache, nausea or visual disturbances. This is her first such episode. Four years ago, she was diagnosed with essential hypertension, but she has not been managing her medications well, neither has she had any follow up visits. No other co-morbidities are present. ``` On Physical Exam: Vitals: Pulse: 120bpm RR: 28/min BP: 230/145 mm Hg Temp: 98.6°F ``` Cardiovascular: 3rd heart sound, gallop rhythm, cardiomegaly, peripheral pulses normal; JVP is 7 cm above the sternal angle. Fundi: Grade II hypertensive retinopathy. No papilledema noted. Respiratory: bilateral fine crackles up to mid zones ECG: Normal RR with left ventricular hypertrophy Troponin T-assay: negative After initial management of patient’s condition, which of the following is the most appropriate? a. Avoid carvedilol, as beta blocker will further depress cardiac function and worsen the heart failure. b. Prescribe hydrochlorothiazide, a potassium sparing diuretic, to manage the patient’s hypertension. c. Prescribe furosemide, a loop diuretic, to manage the patient’s hypertension. d. Both A and C are correct.

d. Both A and C are correct.

A 55 year old female presents to your office by herself. She is has had worsening shortness of breath for the last 2 hours. She is not experiencing chest pain or back pain, headache, nausea or visual disturbances. This is her first such episode. Four years ago, she was diagnosed with essential hypertension, but she has not been managing her medications well, neither has she had any follow up visits. No other co-morbidities are present. ``` On Physical Exam: Vitals: Pulse: 120bpm RR: 28/min BP: 230/145 mm Hg Temp: 98.6°F ``` Cardiovascular: 3rd heart sound, gallop rhythm, cardiomegaly, peripheral pulses normal; JVP is 7 cm above the sternal angle. Fundi: Grade II hypertensive retinopathy. No papilledema noted. Respiratory: bilateral fine crackles up to mid zones ECG: Normal RR with left ventricular hypertrophy Troponin T-assay: negative After your patient’s condition has been stabilized, you want to recommend a naturopathic therapy. Which of the following has been shown to decrease systolic blood pressure up to 17 mmHg (you can expect a drop of 5-10 mmHg)? a. magnesium b. niacin c. beta carotene d. CoQ10

d. CoQ10

Your new patient is a 40 year old male who is in office for an annual wellness exam. His past medical history is non-remarkable for cardiovascular conditions. He notes that he was often sick as a child, but has been very healthy in adulthood. Recently, however, he has noticed occasional dyspnea with exercise. Physical Exam reveals an accentuated and snapping S1, an opening snap, low-pitch diastolic rumble at the apex, and a pre-systolic accentuation. The rest of his cardiovascular exam was non-remarkable, as were his respiratory, abdominal, and HEENT exams. Based on PE and history, what is the most likely valve pathology in this patient? a. mitral stenosis b. pulmonic stenosis c. aortic stenosis d. aortic regurgitation

a. mitral stenosis

Your new patient is a 40 year old male who is in office for an annual wellness exam. His past medical history is non-remarkable for cardiovascular conditions. He notes that he was often sick as a child, but has been very healthy in adulthood. Recently, however, he has noticed occasional dyspnea with exercise. Physical Exam reveals an accentuated and snapping S1, an opening snap, low-pitch diastolic rumble at the apex, and a pre-systolic accentuation. The rest of his cardiovascular exam was non-remarkable, as were his respiratory, abdominal, and HEENT exams. Which is NOT a complication of this patient’s valve condition? a. congestive heart failure b. coarctation of the aorta c. atrial fibrillation d. systemic emobilization

b. coarctation of the aorta

A 74 year old man presents to your office with dyspnea on exertion. He was previously well, but now has to stop to catch his breath with even a short walk around the block. He denies chest pain. He reports that he must be propped up with 3-4 pillows in order to sleep at night. Physical Exam reveals: P = 82, BP = 120/74, JVP = 8 cm. Lungs: bilateral fine crackles up mid way up the lungs Cardiac exam: Normal S1, soft S2, audible S3 with summation gallop, 4/6 late peaking systolic murmur at the right upper sternal border. No thrills on palpation. Physical Exam findings and this patient’s history indicate which valve pathology? a. triscuspid regurgitation b. rheumatic mitral stenosis c. aortic stenosis d. aortic regurgitation

c. aortic stenosis

A 74 year old man presents to your office with dyspnea on exertion. He was previously well, but now has to stop to catch his breath with even a short walk around the block. He denies chest pain. He reports that he must be propped up with 3-4 pillows in order to sleep at night. Physical Exam reveals: P = 82, BP = 120/74, JVP = 8 cm. Lungs: bilateral fine crackles up mid way up the lungs Cardiac exam: Normal S1, soft S2, audible S3 with summation gallop, 4/6 late peaking systolic murmur at the right upper sternal border. No thrills on palpation. Given this patient’s signs of heart failure and the above valvular condition, what is his current life expectancy? a. His survival expectancy is not affected b. 5 years c. 2-3 years d. 1-2 years

d. 1-2 years

Jack is a 62-year-old male who comes to you with symptoms of shortness of breath, left sided shoulder pain. He has a 10-year history of high blood pressure and ascites is present on physical exam. He had an episode of chest pain earlier in the day, but is currently pain free, sat up looking undistressed with a blood pressure of 150/90 and LDL of 200. When you use this information to calculate a 10-year risk with the ASCVD calculator, you find his risk is 7.9. Which is the most appropriate statement about Jack's case? a) The ASCVD calculator isn’t reliable with an LDL >190 b) Assess for familial hypercholesterolemia because of LDL level c) Prescribe Furosemide, a loop diuretic to help d) A and B are correct

d) A and B are correct

Maxwell is 48 years old and arrives in office on 3 hypertension medications with a blood pressure that is still uncontrolled at 155/100. You ordered a test for Renin/Aldosterone ratio to see if he could possibly have primary aldosteronism. Suddenly you realize, the only way to get accurate reading is for Maxwell to not be on BP medications (for 3-5 days), and you don’t feel comfortable taking him off his medication for the test. Instead, what is the best drug to be administered to help rule out primary aldosteronism? a) ACEi b) spironolactone c) oral corticosteroids d) propanolol

b) spironolactone

You have a 55-year-old patient with a 1 year history of high blood pressure presenting with a reading of 170/100. You discover their goal blood pressure range is 150/90. After you check vitals and ask the patient key ROS questions to assess for emergency room referral like any end organ damage, you find there is no other symptoms and the patient has been feeling fine. Patient also is shocked to find their blood pressure this high. You wonder if their blood pressure drug isn’t effectively working. When would you start someone like this patient in office on dual therapy? a) Start dual therapy with top choices of ACE inhibitor and calcium channel blocker b) Start dual therapy because it’s probably primary aldosterone issue and they need spironolactone c) Don’t start dual therapy because the blood pressure is okay for age range and there’s no end organ damage d) Don’t start dual therapy because dual therapy has too many side effects and should only be used after a person visits the emergency room

a) Start dual therapy with top choices of ACE inhibitor and calcium channel blocker

A very ill 70-year-old male comes into your office for heart palpitations. He presents with no history of coronary artery disease and has had episodes of presyncope sporadically, on 2 occasions over the last 3 months. Today he arrives worried and feels a sense of fear over his near-fall from feeling like fainting. You check his blood pressure and it is at 135/90 with a pulse of 80. All of the following would be a medical emergency except: a) Patient is experiencing syncope with bradycardia b) A documented ventricular arrhythmia or atrial fibrillation with slow rates c) an ECG that shows a sustained supraventricular tachycardia (SVT) d) An ECG the shows a PVC with no ST elevation but missing a P wave

d) An ECG the shows a PVC with no ST elevation but missing a P wave

Frank is a 63-year-old male that is a former alcoholic, but hasn’t had a drink in 10 years after successfully completing AA and building a strong relationship with his sponsor. He reports mild shortness of breath, that gets worse when he walks quickly or over long distances. Chest x-ray presents with an enlarged heart shadow that is bigger than 50% of the total width of his diaphragm. The patient reports with a thiamine deficiency, his doctor told him was related to chronic alcohol abuse when he was in his 20’s and 30’s. Based on symptom picture and chest x-ray, he is diagnosed with dilated cardiomyopathy. Which finding would NOT characteristically be a part of the diagnosis of dilated cardiomyopathy? a) Severe migraine headaches with fatigue b) Chest pain from ischemia c) Paroxysmal nocturnal dyspnea with dyspnea on exertion d) Orthopnea

a) Severe migraine headaches with fatigue

JT a 45yo m recently diagnosed with type 2 diabetes. On his most recent lab work his LDL-C was 161mg/dL. He presents to you for guidance and what he can do to better his health. Taking into consideration his most recent diagnosis and lab values, which of the following is most likely to be of benefit for lowering risk of heart disease? A. Smoking Cessation, Lisinopril, slow steady weight loss at 1-2lbs/week B. Atorvastatin, reduction of 1pt in BMI, Asana Yoga Therapy C. Creatine, 30-60 mins of mod intensity aerobic exercise most days, Mediterranean Diet D. Plant based diet, Beta-carotene, 1 hr of stress management per week

B. Atorvastatin, reduction of 1pt in BMI, Asana Yoga Therapy

JT a 45yo m recently diagnosed with type 2 diabetes. On his most recent lab work his LDL-C was 161mg/dL. He presents to you for guidance and what he can do to better his health. Taking into consideration his most recent diagnosis and lab values, which of the following is most likely to be of benefit for lowering risk of heart disease? ``` With the treatment you chose for JT (Atorvastatin) to help lower his risk of heart disease, what would be the target LDL score to ideally achieve? A. > 130 mg/dL B. < 130 mg/dL C. > 100 mg/dL D. < 100 mg/dL ```

D. < 100 mg/dL

GH 70yo f presenting with shortness of breath. She says, normally, it's worse at night, and has needed to lay with 2 pillows to prop herself up so she can sleep and keep herself from coughing. Lately, she now feels it when going up stairs or "doing too much." On PE, patient has BL pitting edema of the lower extremities, jugular venous distension, BP 135/89, thin body habitus with distended abdomen, S3 ventricular gallop. Based on the information gained through P.E., what would best support your diagnosis? A. BNP B. ECG C. Cardiac catheterization D. Chest X-ray

A. BNP Brain natriuretic peptide (B-type) test is a blood test that measures levels of a protein called BPN that is made by your heart and blood vessels. BNP levels are higher than normal when you have heart failure.

Suppose after work up, it's discovered that GH has a reduced Ejection Fraction. What would be the most appropriate treatment moving forward? A. NSAIDs, Creatine, fish oil B. Digitalis, ACE Inhibitor, consistent exercise C. ACE Inhibitor, Betablocker, Diuretic D. Licorice, Digitalis, Diuretic

C. ACE Inhibitor, Betablocker, Diuretic

MJ is a 20yo female presenting with occasional "skipped beats." They have been present since high school, she first noticed them when running but thought nothing of it so never told anyone. Recently they have been happening more frequently, and they come with no apparent trigger, sometimes lying down, sometimes just "sitting around," sometimes when running. She decided to google her symptoms and got scared so decided to come to you. ECG shows:? What is the most appropriate thing to tell MJ? A. There will be an immediate referral to the ER. B. No treatment is indicated/required at this time, this finding is common in healthy individuals, if symptoms continue to increase come in for reevaluation. C. This finding shows an increased risk for V-fib, I'll write you a prescription for Flecainide. D. We'll need to schedule a catheter ablation ASAP, this finding may develop further life-threatening complications

B. No treatment is indicated/required at this time, this finding is common in healthy individuals, if symptoms continue to increase come in for reevaluation.

Out of the following patients, which has the greatest risk factors for atrial fibrillation? A. 26 yo Olympic athlete who works out 6 days a week B. 54 yo male, BMI of 24, who eats a standard American diet C. 21 yo college student who has a couple alcoholic drinks occasionally on weekends D. 36 yo woman with a family history of diabetes mellitus type II

A. 26 yo Olympic athlete who works out 6 days a week. Athletes: AFib is common in athletes and can be triggered by a rapid heart rate called a supraventricular tachycardia (SVT).

Which of the following is NOT a life-threatening situation for your patient with arrhythmia? A. Wide complex sustained rhythms B. Syncope in patients with an AV block C. Atrial fibrillation D. Family history of heart failure

D. Family history of heart failure

Which of the following is the most UNLIKELY to be a possible cause of hypertension? A. Sleep Apnea B. Hypothyroidism C. Parathyroid disease D. Renal artery stenosis

B. Hypothyroidism

A 68 yo F patient with a history of coronary artery disease presents in office with left shoulder pain after taking a short walk around the block last night. She has a slight elevation in her blood pressure but otherwise feels fine. What is your WORST course of action at this point in the case? A. Give the patient an in-office ECG B. Give the patient 325mg aspirin C. Auscultation of the chest D. Give her a prescription for NSAIDs to help with her pain

D. Give her a prescription for NSAIDs to help with her pain

Which of the following is NOT a symptom of right-sided heart failure? A. Congestion without cardiomegaly B. Depressed left ventricular ejection fraction C. Left ventricular hypertrophy D. Fourth heart sound

B. Depressed left ventricular ejection fraction

A 12 year old female comes to your office with her parents because she has just been diagnosed as having Factor V Leiden inherited Thrombophilia. She would like you to tell her more about this disease. You remember back when Dr. Smith talked about it in cardiovascular class and tell her that Factor V Leiden is the most common inherited Thrombophilia which leads to a 2.2 times higher risk of thrombosis than those without this inherited defect. Which of the answers below would you also tell her about Factor V Leiden? a. It is a Factor V Leiden deficiency ONLY. b. It is a genetic mutation of Factor V Leiden ONLY. c. It is a genetic mutation of Factor V Leiden that changes its dynamics, however, people can sometimes have a Factor V Leiden deficiency along with the genetic mutation. d. It is prevalent enough in the population that screening asymptomatic patients is necessary.

c. It is a genetic mutation of Factor V Leiden that changes its dynamics, however, people can sometimes have a Factor V Leiden deficiency along with the genetic mutation.

A 38 year old female comes into your office because of pain and swelling in her right leg. You do a full intake with her and discover that she is a smoker, has been on OCPs for the past 10 years and that her mother tested positive for Factor V Leiden with a direct genomic DNA blood test years ago. You do PE and suspect that she has a venous thromboembolism based on all the information you have from the visit. All of these are appropriate as a treatment plan in her case EXCEPT: a. Refer to a hematologist. b. There is no need to do anticoagulation therapy. c. Avoidance of OCPs. d. Avoidance of smoking.

b. There is no need to do anticoagulation therapy.

A 67 year old male comes in for a ROC for evaluation and management of hypertension. His BP has steadily been 160/95 the last 4 visits and along with diet and lifestyle recommendations you are discussing possible medications for him to help bring down his BP. Which of the drugs listed below are best matched with their mode of action? a. CCB’s: cardio-inhibitory. Active on the actual cardiac tissue (both smooth vessels and cardiac). Causes vasodilation, decreased myocardial force, decreased heart rate, and decreased conduction velocity. Caution combining non-dihydropyridine CCB’s with beta-blockers. b. Beta-blockers: cardio-inhibitory. Active on Beta-1 receptors in cardiac nodal tissue, the conducting system, and contracting myocytes. Active on Beta-2 receptors in vascular and nonvascular smooth muscle, causes relaxation of muscle. Causes decreased heart rate, contractility, smooth muscle contraction, electrical conduction and relaxation rate. Contraindicated for sinus bradycardia and partial AV block, COPD, and asthma. c. Central acting sympatholytics: Activates alpha-2 adrenoreceptors in the medulla of the spinal cord. Causes decreased sympathetic tone throughout the body. Long term use may see edema and need concurrent diuretic. Examples are Clonidine, and Rauwolfia. d. All of these are correct.

d. All of these are correct.

A 32 year old male comes into your office due to heart palpitations and an episode of syncope. He does not look well so you perform an ECG on him and assess that he has ventricular tachycardia so you call 911 and have him taken to the emergency room. What did you see on the ECG that indicated this? a. > 30 seconds of a rate > 100 bpm. b. > 30 seconds of a rate = 95 bpm. c. < 10 seconds of a rate > 95 bpm. d. >10 seconds of a rate < 90 bpm.

a. > 30 seconds of a rate > 100 bpm.

A 65 year old female comes into your office complaining of dyspnea that’s not exertional and substernal pain that is sharp. She says that the pain increases with inspiration and lying down, and decreases with sitting up or leaning forward. She also has fever and malaise. Based on these symptoms your top dx is? a. Restrictive cardiomyopathy b. Angina c. Acute pericarditis d. Myocardial infarction

c. Acute pericarditis

D. Acute Myocardial Infarction

You show up to work to see that you have an add-on this morning for your 61yo male patient with a chief complaint of ‘heartburn’. In-office, the patient complains of waking up last night at 3am with severe, retrosternal pressure that felt like the “worse heartburn” he had ever experienced, so he scheduled an appointment online right away. He attributes it to the pasta with meat sauce and wine he had for dinner. He has no recent illnesses, has a history of hypercholesterolemia that is controlled with medications, and a current cigarette smoker of 45-years (½ pack/day). On examination, he seems to be uncomfortable, diaphoretic, and has pallor of the skin. Vitals are as follows: HR 112bpm, BP: 164/100, RR 23, O2-sat 96% on room air. Auscultation reveals clear lung fields, a regular cardiac rhythm with an S4 heart sound present, no murmurs or rubs present. You decide to run an EKG in-office to confirm your suspicion, which reveals ST elevation >1mm in >2 contiguous precordial leads. Which of the following is the most correct approach to handling this situation? A. Prescribe antacids and a diet diary, schedule an ROC for 1-month from now, and instruct the patient to avoid eating 3-hours before bed as to not cause further heartburn. B. Call 911 immediately. Administer aspirin (324mg po) or nitroglycerin (0.4mg q 5-mins), if the patient has it. Get patient to lay down. Monitor pulse-ox, and administer oxygen if needed. Perform CPR if patient losses consciousness. C. Call 911 immediately. Administer an NSAID (Naproxen, 550mg po) or nitroglycerin (0.4mg q 5-mins), if the patient has it. Get the patient to lay down. Administer oxygen via high-flow nasal cannula (HFNC) since the patient’s O2-sat is abnormal. Perform CPR if patient losses consciousness. D. Call 911 immediately. Administer an NSAID (Naproxen, 550mg po) or nitroglycerin (0.4mg q 5-mins), if the patient has it. Get patient to lay down. Monitor pulse-ox, and administer oxygen if needed. Perform CPR if patient losses consciousness.

B. Call 911 immediately. Administer aspirin (324mg po) or nitroglycerin (0.4mg q 5-mins), if the patient has it. Get patient to lay down. Monitor pulse-ox, and administer oxygen if needed. Perform CPR if patient losses consciousness.

Patient was transported to the hospital by ambulance where he remained for the next 5-days. Now he is back in your office, 2-weeks later, to follow-up with care. He says that this experience has been “eye-opening” to him and in an effort to take control of his health he visited the local supplement store to buy “natural products”. Of the following supplements, which would not be recommended given his recent diagnosis? (Choose the one that he should not be taking right meow.) A. L-carnitine B. Fish Oil C. N-Acetyl Cysteine D. Co-Q10

B. Fish Oil

Regarding long-term management of this patient’ recent diagnosis, all of the following must be considered except which one? (All are correct except one.) A. Evaluate the psychosocial status of the patient (symptoms of depression, anxiety, sleep disorders). B. Re-evaluate the patient’s list of current medications and supplements. C. Review and emphasize the principles of secondary prevention with the patient. D. Emphasize the importance of the patient continuing with their normal daily schedule to include their physical activity, return to work, resumption of sexual activity, including driving and flying.

D. Emphasize the importance of the patient continuing with their normal daily schedule to include their physical activity, return to work, resumption of sexual activity, including driving and flying.

In counseling your patient, you discuss factors that may increase his risk of coronary heart disease and mortality. Of the following modifiable risk factors, which is the most important factor to consider for this particular patient? A. Smoking cessation B. High cholesterol C. Diet & Nutrition D. Alcohol

A. Smoking cessation

A 46 year old African American women presents to your office experiencing SOB on exertion and mild swelling of her lower extremities. Her recent HDl was 35, Total cholesterol was 220, BP in office today is 137/76 and she is not diabetic. Her current medications include atorvastatin and Paxil. When you login to calculate her 10 year ASCVD risk which piece of information is not relevant- A. HDL B. Total cholesterol C. Diabetes status D. Diastolic BP

D. Diastolic BP

A 51 year old woman presents to your clinic complaining of intermittent chest pain that usually happens at night and last for about 20 minutes and is relieved by movement. She does not have an current medications and has no significant cardiac history. What is she most likely experiencing- A. Unstable angina B. Stable angina C. Myocardial infarction D. Prinzmental angina

D. Prinzmental angina

A 49 year old male presents to your clinic with what he calls palpitations which have been happening for several days. He generally feels unwell with less energy but he states that his wife just got over the flu and he hasn’t been drinking very much water recently either. All of the following are red flags when trying to rule out an arrhythmia EXCEPT- A. Syncope/presyncope B. Family h/o sudden cardiac death C. Use of methadone or diuretics D. Total cholesterol above 250

D. Total cholesterol above 250

Your patient just returned from his cardiology appointment and told you that he was diagnosed with a polymorphic ventricular tachycardia, specifically Torsade-de-pointes. You know from cardio class that this puts him at a higher risk for all of the following EXCEPT- A. Heart failure B. Loss of consciousness C. Renal failure D. Sudden death

B. Loss of consciousness

An older, male patient presents with mild chest pain in office and you decide to run an EKG which shows 3 distinct p waves in the same lead, variable PP/PR intervals and an isoelectric line between P waves. What is the most likely diagnosis- A. Myocardial infarction B. Atrial fibrillation C. Multifocal tachycardia D. Ventricular tachycardia

C. Multifocal tachycardia

Fifty year old male comes in to your office with chest pain. He says it is better with rest and worse with exercise. You also ask him to lie down, stay upright and also asked him to take deep breadth to see anything changes. You decide to do ECG and you are thinking to give him nitroglycerine and watch. You suspect this might be case of angina. If this was angina of case, all of the following is true EXCEPT: A. Giving nitroglycerine and seeing if the pain goes away. If it does, you might suspect angina. B. ST depression or /and ST elevation on ECG can be found. C. DDX include MI, pericarditis, aortic aneurysm, herpes, and pulmonary embolism and so on. D. Stress test is the best diagnostic test for angina. E. Angina pain is made worse by lying down or taking a deep breath and better by sitting up.

E. Angina pain is made worse by lying down or taking a deep breath and better by sitting up. Answer: E (this is true for pericarditis)

55 year old female presents to your office regarding management of her heart condition. Her recent history include angina and now she is motivated to make changes in life. You look closely at her chart and decide that she is a patient with clinical ASCVD. You recommend initiating statin and diet/ lifestyle modification therapy. ``` What kind of prevention this falls under? A. Primary Prevention B. Primordial prevention C. Secondary prevention D. Tertiary prevention ```

C. Secondary prevention

40 year old female comes in with chief complaint of nausea and headache. She is in apparent distress and slightly diaphoretic. She hasn’t travelled recently. She has heart burn like symptoms and says it might be because she hasn’t eaten all day. You think this might be MI. You decide to send her to ER and ED runs cardiac enzymes. Which of the following is false for cardiac enzymes in case of MI? A. Troponin may not be elevated for six hours after the event. B. Myoglobin can be detected as early as 2 hours post MI. C. CKMB will certainly detect all infarcts including small infarcts because it lasts for 72 hours. D. Single negative troponin( Tnl or tnt), CKMB after 8 to 12 hours of symptom onset can be used to rule out MI

C. CKMB will certainly detect all infarcts including small infarcts because it lasts for 72 hours. Answer: C (CKMB may miss small infarcts)

46 year old male comes in to your office for annual visit. He says he is pretty healthy except he has headaches once in a while. He says he is motivated and likes to make more changes in his diet and lifestyle and needs some help with it. He wants to quit smoking. His family history involves hypertension and depression. He is also curious about stress management tools as he mentions becoming very stressed at work. His vitals were 120/80, pulse: 70, and temp: 98.7. All of the following could be your next steps except: A. It is emergency situation; you should send him to ER immediately. B. Start on ACE and ARB combination. Initiate diet and lifestyle counseling including providing resource around smoking cessation. You should also provide DASH diet handout and recommend regular exercise. C. It is not emergency situation but his BP is high that needs management. You should run his lipid panel, CMP for more information and monitor his BP for follow up visits. In addition, put him in cardiotone, hibiscus tea and counsel on salt restriction and diet and lifestyle modification. D. You should run UA in office today. Do his eye exam, vascular exam, cardiac exam and if you find any signs of end organ damage, you should send him to ER.

A. It is emergency situation; you should send him to ER immediately.

37 year old male comes in with chief compliant of shortness of breath. He also had fatigue, weakness, edema in lower extremity on ROS and PE. In PE, you find s4, midsystolic aortic murmur. You run an EKG and see abnormal finding like ST wave and T wave abnormalities. You are not sure what is going on and decide to send him to cardiologist and the cardiologist orders echo and you see left ventricular hypertrophy and other abnormalities. His family history includes hypertension, no valvular disease and he is negative for other CVD diseases. He drinks on rare occasion and has never smoked. What is the likely diagnosis and what is your therapeutics that you can offer? A. Hypertrophic cardiomyopathy ; B blocker are standard therapy B. Hypertrophic cardiomyopathy; Calcium channel blocker for patients who don’t respond to B blocker C. Dilated Cardiomyopathy: Surgery, pacemaker and genetic counseling are also other options depending on the severity. D. All of the above E. A and B are correct answers

E. A and B are correct answers

6. Match the following ECG descriptions with its correct pathology: A. Atrial rate of 240 to 340bpm and “Saw tooth” like appearance in ECG B. Usually rapid irregularly regular rhythm arising from pulmonary veins C. ST elevation, pathologic Q waves, T wave inversion D. Prolonged QT interval E. PR interval less than 0.12 and presence of Delta wave in ECG 1. Medications like methadone, antiarrhythmic and antipsychotics, antibiotics, diuretics can cause ventricular tachycardia. 2. Atrial Flutter 3. Wolf Parkinson white syndrome 4. Atrial fibrillation 5. Myocardial infarction

Answers: A: 2, B: 4, C: 5, D: 1, E: 3 2. Atrial Flutter==> A. Atrial rate of 240 to 340bpm and “Saw tooth” like appearance in ECG 4. Atrial fibrillation==>B. Usually rapid irregularly regular rhythm arising from pulmonary veins 5. Myocardial infarction==>C. ST elevation, pathologic Q waves, T wave inversion 1. Medications like methadone, antiarrhythmic and antipsychotics, antibiotics, diuretics can cause ventricular tachycardia.==>D. Prolonged QT interval 3. Wolf Parkinson white syndrome==>E. PR interval less than 0.12 and presence of Delta wave in ECG

45 year old male is coming to see you because in the last 3 months he’s been having chest pain. He went to his PCP and he prescribed nitroglycerin which hasn’t been helping with the chest pain. When he was younger he was an active runner and casually played football every weekend in a small leave. He reports to have some fainting spells when he was playing sports in this youth and contributed it to his vegetarian diet. Now he wants to train his children 8 and 10 year old boys to play soccer and football. He hasn’t been to a doctor for 20 years, and worried about his chest pain. Vital signs: HR 135bpm, BP 138/88, Pulse Ox 98%, Resp 16 bpm, Temp 98.4˚ ``` 1. You think he’s having an angina. What are signs of angina? A. Levine’s sign and increased HR B. increased HR and elevated BP C. Levine’s sign D. On auscultation heart sounds near ```

B. increased HR and elevated BP

45 year old male is coming to see you because in the last 3 months he’s been having chest pain. He went to his PCP and he prescribed nitroglycerin which hasn’t been helping with the chest pain. When he was younger he was an active runner and casually played football every weekend in a small leave. He reports to have some fainting spells when he was playing sports in this youth and contributed it to his vegetarian diet. Now he wants to train his children 8 and 10 year old boys to play soccer and football. He hasn’t been to a doctor for 20 years, and worried about his chest pain. Vital signs: HR 135bpm, BP 138/88, Pulse Ox 98%, Resp 16 bpm, Temp 98.4˚ Which of the following is not necessary to measure, order, or ask to be able to use ASCVD Risk Calculator? A. Order cholesterol panel B. Measure BP C. Ask about smoking status D. Ask about their physical activity

D. Ask about their physical activity

45 year old male is coming to see you because in the last 3 months he’s been having chest pain. He went to his PCP and he prescribed nitroglycerin which hasn’t been helping with the chest pain. When he was younger he was an active runner and casually played football every weekend in a small leave. He reports to have some fainting spells when he was playing sports in this youth and contributed it to his vegetarian diet. Now he wants to train his children 8 and 10 year old boys to play soccer and football. He hasn’t been to a doctor for 20 years, and worried about his chest pain. Vital signs: HR 135bpm, BP 138/88, Pulse Ox 98%, Resp 16 bpm, Temp 98.4˚ His most likely diagnosis is _____, but also need to consider______. A. Hypertrophic cardiomyopathy, MI B. Unstable angina, Stable angina C. MI, unstable angina unresponsive to nitro D. Restrictive cardiomyopathy, Acute pericarditis

A. Hypertrophic cardiomyopathy, MI

45 year old male is coming to see you because in the last 3 months he’s been having chest pain. He went to his PCP and he prescribed nitroglycerin which hasn’t been helping with the chest pain. When he was younger he was an active runner and casually played football every weekend in a small leave. He reports to have some fainting spells when he was playing sports in this youth and contributed it to his vegetarian diet. Now he wants to train his children 8 and 10 year old boys to play soccer and football. He hasn’t been to a doctor for 20 years, and worried about his chest pain. Vital signs: HR 135bpm, BP 138/88, Pulse Ox 98%, Resp 16 bpm, Temp 98.4˚ 4. Based on your diagnosis what should be your next step? A. Order EKG, refer to cardiologist for Echo, have him talk to his family about genetic possibility of his children having the disease too, prescribe ß blockers and CCB B. Order biopsy with catheterization and prescribe spironolactone C. Call 911 for immediate ER transport D. Prescribe ß blockers, ACE-I, he will may have to have a heart transplant in the future

A. Order EKG, refer to cardiologist for Echo, have him talk to his family about genetic possibility of his children having the disease too, prescribe ß blockers and CCB

45 year old male is coming to see you because in the last 3 months he’s been having chest pain. He went to his PCP and he prescribed nitroglycerin which hasn’t been helping with the chest pain. When he was younger he was an active runner and casually played football every weekend in a small leave. He reports to have some fainting spells when he was playing sports in this youth and contributed it to his vegetarian diet. Now he wants to train his children 8 and 10 year old boys to play soccer and football. He hasn’t been to a doctor for 20 years, and worried about his chest pain. Vital signs: HR 135bpm, BP 138/88, Pulse Ox 98%, Resp 16 bpm, Temp 98.4˚ 5. In the office his blood pressure was 138/88, and it is considered: A. White coat syndrome B. Hypertensive C. Prehypertensive D. Hypertensive emergency

A. White coat syndrome

A 75 year old female patient presents with her chief complaints of fainting and palpitation episodes. The onset has been 6 months ago. The frequency is described to be "spontaneous" as she doesn't recall any rhyme or reason to her symptom events. She denies having any panic attacks. Her mother has passed away from Brugada syndrome. The duration is longer than 5 minutes. She has a history of HTN, DMII, and dyslipidemia. You go over ROS and she denies ever having a history of anxiety, CHF, stroke, TIA, valvular disease, rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair. You run a 12-lead ECG and see irregularly irregular ventricular rhythm. You decide to calculate her CHA2DS2-VASc Score, which comes out to be 5 points! Her recent labs has ruled out hyperthyroidism and anemia. Her most likely diagnosis and sequelae, respectively, is: A. Longstanding persistent, nonvalvular Atrial Fibrillation; MI B. Longstanding persistent, valvular Atrial Fibrillation; stroke C. Paroxysmal, valvular Atrial Fibrillation; MI D. Paroxysmal, nonvalvular Atrial Fibrillation; stroke

D. Paroxysmal, nonvalvular Atrial Fibrillation; stroke

A 42 year old asymptomatic female comes in for a pap smear. Before the pap, you check vitals and what alarms you the most is her BP of 200/140 mmHg. You discover that she has previous diagnoses, consisting of obesity, uncontrolled insulin-dependent DMII, hyperlipidemia, and alcohol abuse. You perform an ophthalmoscope exam, full cardiac and respiratory PE, perform an in-office UA and order a CMP. In the eye exam, you noticed floaters in both eyes. You recheck BP and it read 197/140 mmHg. Your patient is having a(n): A. White-coat effect B. Hypertensive crisis C. Hypertensive urgency D. Hypertensive emergency

C. Hypertensive urgency

A 55 year old male presents with shortness of breath along with chest pain. He is currently a smoker and has a history of HTN, DMII, and hyperlipidemia. He currently is on a HTN med and occasionally uses a nitroglycerin spray whenever he has these SOB episodes; however, he complains that the spray doesn’t seem to be working as well as it used to. His last episode occurred yesterday while he was working in his workshop doing nothing strenuous. You are suspecting he had an MI and immediately call 911 to run an ECG. The following day he returns with MI having been ruled out by the ER physician. You run the ASCVD risk calculator and notice his risk is greater than 7.5%, which you then decide to put him on statins. His recent lipid panel came back with LDL-C levels at 200 mg/dL. Which group and specific statin is the most appropriate for him? A. Moderate-intensity statin: Pravastatin at 15 mg daily B. Moderate-intensity statin: Simvastatin at 40 mg daily C. High-intensity statin: Atorvastatin at 80 mg daily D. High-intensity statin: Lovastatin at 20 mg daily

C. High-intensity statin: Atorvastatin at 80 mg daily

A 54 year old female presents with shortness of breath upon exertion along with coughing fits. She rates her energy level low as she complains that she always feels tired and weak. When you ask about her sleep, she mentions that she sometimes wakes up with shortness of breath. She denies nausea, bloating, or fainting during exertion. You note pitting edema in both lower extremities and order imaging and EKG. When you get the CXR results and notice that her heart shadow is > 50% compared to her diaphragm. Her EKG are normal. What is her diagnosis? A. Hypertrophic cardiomyopathy B. Dilated cardiomyopathy C. Restrictive cardiomyopathy D. None of the above

B. Dilated cardiomyopathy

A previously healthy 52 year old male presented with symptoms consistent with a stroke. After admittance to the ER he was evaluated and it was determined that his stroke was an ischemic small vessel occlusion. 1. Which of the following is NOT a risk factors that predisposes this patient to a stroke? A. Carotid artery stenosis B. Atrial fibrillation C. Pericarditis D. Obstructive sleep apnea

C. Pericarditis

V5 of his ECG shows an irregularly- irregular ventricular rhythm. Which of the following would be best to follow up the ECG with if the suspected diagnosis is atrial fibrillation? A. Holter monitor B. Wingate test C. Plain chest films D. Cardiac catheterization

A. Holter monitor

A previously healthy 52 year old male presented with symptoms consistent with a stroke. After admittance to the ER he was evaluated and it was determined that his stroke was an ischemic small vessel occlusion. Further workup determines the patient is in atrial fibrillation. When you inquire about possible palpitations he notes that the last year he started to notice symptoms. He says he retired last year and took a few weeks off from physical activity (his work had been manual labor) but when he started doing yard work and things around the house he noticed that he could feel his heart pounding and that he just didn’t seem to have much energy. He thought he was just getting older, but now realizes the atrial fibrillation started shortly after he retired. 3. Which of the following would be the best approach to controlling the arrhythmia? A. Rate control is most appropriate due to the long standing atrial fibrillation B. Cardioversion with direct current electrical shock C. Cardioversion with antiarrhythmic pharmacologic agents D. Neither rate control or cardioversion is an optimal choice, he should be put on a calcium channel blocker immediately.

A. Rate control is most appropriate due to the long standing atrial fibrillation

A previously healthy 52 year old male presented with symptoms consistent with a stroke. After admittance to the ER he was evaluated and it was determined that his stroke was an ischemic small vessel occlusion. Further workup determines the patient is in atrial fibrillation. When you inquire about possible palpitations he notes that the last year he started to notice symptoms. He says he retired last year and took a few weeks off from physical activity (his work had been manual labor) but when he started doing yard work and things around the house he noticed that he could feel his heart pounding and that he just didn’t seem to have much energy. He thought he was just getting older, but now realizes the atrial fibrillation started shortly after he retired. From a naturopathic perspective what would you recommend? A. Green tea, ginger and garlic B. Naturopathic recommendations can not be given as it isn’t known how it will affect the INR C. 60 minutes of vigorous exercise at least 5 times each week D. Fish oil, magnesium and CoQ10

D. Fish oil, magnesium and CoQ10

A previously healthy 52 year old male presented with symptoms consistent with a stroke. After admittance to the ER he was evaluated and it was determined that his stroke was an ischemic small vessel occlusion. Further workup determines the patient is in atrial fibrillation. When you inquire about possible palpitations he notes that the last year he started to notice symptoms. He says he retired last year and took a few weeks off from physical activity (his work had been manual labor) but when he started doing yard work and things around the house he noticed that he could feel his heart pounding and that he just didn’t seem to have much energy. He thought he was just getting older, but now realizes the atrial fibrillation started shortly after he retired. If this patient was physically active, which medication would you prescribe for ventricular rate control? A. Digoxin B. Beta blocker C. Calcium channel blocker D. It isn’t appropriate to prescribe a medication for ventricular rate control with atrial fibrillation

C. Calcium channel blocker (exercise is best tolerated with this class) B. Beta blocker- is best option (not sure?)

A 45 yo male presents in your office with an odd sensation of skipped heartbeats in his chest. You execute an cardiovascular exam and an ECG. The findings lead you to believe that he has premature ventricular contraction. Which of the following system should be used to categorize the severity of this diagnosis? A. Lown Grading system B. Levine Scale C. New York Heart Association Classification D. Fisher Grading system

A) Lown Grading system

A 16 yo male comes in for a physical. He states that he feels healthy except that he often times feel anxiety and sensations of rapid, fluttering or pounding heartbeats. You do an ECG and the results are as follows: PR interval is less than 0.12 seconds and Delta waves. What condition is highest on your DDx list, and what is the primary therapy for this condition? A. Wolf-Parkinson White Syndrome – Catheter ablation therapy B. Wolf-Parkinson White Syndrome – Class 1 antiarrthythmics C. Lown-Ganong-Levine syndrome - Catheter ablation therapy D. This finding is normal – he does not need treatment

A. Wolf-Parkinson White Syndrome – Catheter ablation therapy (Catheter ablation is a procedure used to selectively destroy areas of the heart that are causing a heart rhythm problem. Thin, flexible wires called catheters are inserted into a vein, typically in the groin or neck. They are threaded up through the vein and into the heart.)

A slender 16yo male previously diagnosed with Marfan syndrome presents in your office. He reports that he has been experiencing more fatigue and difficulty breathing, especially during exercise. You execute a cardiovascular exam and hear a mid-systolic click. Which of the following valvular abnormality should be highest on your DDx list? A. Mitral Valve Prolapse B. Mitral stenosis C. Pericarditis D. Aortic Stenosis

A. Mitral Valve Prolapse

A 60yo female was diagnosed with left ventricular hypertrophy, hypertension and aortic stenosis. Upon auscultation, you hear a heart sound that occurs when vigorous contraction is required to augment filling compliant left ventricle. Which of the following heart sound is being referenced? A. S1 B. S2 C. S3 D. S4

D. S4

A 60 yo female is diagnosed with heart failure. She wishes to be on more Naturopathic treatments, specifically herbs. Which of the following herbal treatment is contraindicated for heart failure? A. Convallaria majalis B. Terminalia arguno bark C. Crataegus spp leaf & flower D. Glycyrrhiza glabra

D. Glycyrrhiza glabra

Bill is a 54 year old presenting with a chief complaint of chest pain. He reports having experienced chest pain before when playing basketball, but it normally goes away after he stops activity. The chest pain he is having now is much more severe in intensity and seems to be progressing. While in office you note he is diaphoretic and he suddenly vomits. His blood pressure is 160/95, HR 106, RR 22. ``` 1. Which of the following is LEAST likely on your differential: A. Hypertensive emergency B. Pneumothorax C. Aortic dissection D. Myocardial infarction ```

A. Hypertensive emergency Correct answer: Hypertensive emergency; his blood pressure is not high enough and his complaints are much more acute.

You are concerned Bill is having a myocardial infarction, what would you do first? A. Immediately start oxygen and call 911 B. Administer aspirin at a dose of 325mg, have him lie down on the table while you call 911 C. Measure pulse ox and if it’s higher than 90%, complete an EKG in-office to determine severity of condition D. Administer oral magnesium and wait to see if this relieves chest pain before calling 911

B. Administer aspirin at a dose of 325mg, have him lie down on the table while you call 911 Correct answer: Administer Aspirin (or nitro if the patient has sublingual) and call 911

The EKG results come back indicating a myocardial infarction; what does this look like? A. ST segment widening, abnormal P-waves B. ST segment shortening, with delta waves C. ST segment elevation, pathologic Q-waves D. ST segment depression, elevated R wave

C. ST segment elevation, pathologic Q-waves Correct answer: ST segment elevation (with T-wave inversion) , pathologic Q-waves,

A 59 y/o female comes in with a chief complaint of increasing fatigue and decreased exercise tolerance. She seems short of breath in office while talking and you find out she must prop herself up on 3 pillows in order to be able to breath easily in bed at night. Physical exam reveals bilateral pitting edema +2, that extends halfway up her lower leg, as well as displaced apical impulse (about 11 cm from the midline of the sternum) with visible heaves and lifts. Cardiac auscultation reveals an S3 gallop and respiratory rales are heard in the lower lobes bilaterally. Jugular vein distention is noted while the patient is sitting upright and measures 5 cm with patient reclined at 45 degrees. Blood pressure 155/93. 1. You run a stat EKG in office which shows residual Q waves, ST segment pathology, increased amplitude of waves, and increased QRS voltage. What does this indicate? a. She is having a myocardial infarction b. She has had a past myocardial infarction which has led to heart failure and cardiac hypertrophy c. she has dilated cardiomyopathy, likely from toxins or alcohol consumption d. she has coronary artery disease secondary to hyperlipidemia

b. She has had a past myocardial infarction which has led to heart failure and cardiac hypertrophy correct answer: residual Q waves indicate a previous MI; signs of hypertrophy are consistent with congestive heart failure

Residual Q waves indicate a previous MI; signs of hypertrophy are consistent with congestive heart failure Given the results of the EKG and her signs and symptoms, which of the following is most correct? ``` A. She has class 1 congestive heart failure and needs to be started on lisinopril B. She has chronic hypertension and needs to start chlorthalidone C. She has class 3 congestive heart failure and needs to start with lisinopril and carvedilol D. She has class 4 congestive heart failure and would need to start with 3 medications, so should be referred to cardiologist. ```

C. She has class 3 congestive heart failure and needs to start with lisinopril and carvedilol Correct answer: She has stage C / class 3 congestive heart failure and would benefit most from starting 2 diff medications (ACE inhibitor and Beta-blocker most indicated).

A 59 y/o female comes in with a chief complaint of increasing fatigue and decreased exercise tolerance. She seems short of breath in office while talking and you find out she must prop herself up on 3 pillows in order to be able to breath easily in bed at night. Physical exam reveals bilateral pitting edema +2, that extends halfway up her lower leg, as well as displaced apical impulse (about 11 cm from the midline of the sternum) with visible heaves and lifts. Cardiac auscultation reveals an S3 gallop and respiratory rales are heard in the lower lobes bilaterally. Jugular vein distention is noted while the patient is sitting upright and measures 5 cm with patient reclined at 45 degrees. Blood pressure 155/93. What are some additional labs you might consider running for this patient? ``` A. BNP, Cholesterol panel, Hg A1c, thyroid panel B. CMP, GFR, hs-CRP, C. CK-MB, Myoglobin, cardiac troponins, D. All of these options are indicated E. Both A and B would be indicated ```

E. Both A and B would be indicated

A 59 y/o female comes in with a chief complaint of increasing fatigue and decreased exercise tolerance. She seems short of breath in office while talking and you find out she must prop herself up on 3 pillows in order to be able to breath easily in bed at night. Physical exam reveals bilateral pitting edema +2, that extends halfway up her lower leg, as well as displaced apical impulse (about 11 cm from the midline of the sternum) with visible heaves and lifts. Cardiac auscultation reveals an S3 gallop and respiratory rales are heard in the lower lobes bilaterally. Jugular vein distention is noted while the patient is sitting upright and measures 5 cm with patient reclined at 45 degrees. Blood pressure 155/93. What does your naturopathic treatment plan look like for this patient? A. Taurine 500mg TID; Carnitine 2000mg QD; CoQ10 200mg QD to improve ejection fraction and exercise capacity B. Lycopene 30mg/day to increase exercise tolerance and dandelion as a diuretic C. Magnesium 1500mg/day to supplement deficiency D. Aspirin 325mg/day to prevent clotting

Correct answer: A A. Taurine 500mg TID; Carnitine 2000mg QD; CoQ10 200mg QD to improve ejection fraction and exercise capacity

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