Week 2 Flashcards
1
Q
A 65-year-old undomiciled man presents to your emergency department with complaints of fever, productive cough, and shortness of breath. He has a 40-pack-year history of smoking and daily alcohol consumption. His chest radiograph demonstrates a right upper lobe lung infiltrate with an air-fluid level. What is the most likely etiology for this finding?
A
Klebsiella pneumoniae
- gram-negative encapsulated organism
- Patients with klebsiella pneumonia commonly present with shaking chills, cyanosis, pleuritic chest pain, and a productive cough with characteristic currant-jelly sputum
- Chest radiography reveals an infiltrate that is often in the upper lobes (most commonly the right) and is associated with a bulging fissure. If untreated, the infiltrate will progress into a necrotizing lesion with air-fluid levels, and can ultimately lead to development of an empyema.
2
Q
What is a typical chest radiograph finding in acute mitral regurgitation?
A
Normal cardiac silhouette with severe pulmonary edema.
3
Q
Which of the following is the most common location of aspirated foreign bodies in children?
A
Right main bronchus
4
Q
Hemoptysis+hx of tobacco use, weight loss
A
malignancy
5
Q
What is the study of choice in an unstable patient to confirm the diagnosis of aortic dissection?
A
Transesophageal echocardiogram.
6
Q
A 17-year-old girl with a history of well-managed cystic fibrosis is being evaluated for a steadily worsening chronic cough with shortness of breath and wheezing. She is producing copious purulent malodorous sputum and occasional hemoptysis. Crackles are heard at her bilateral lung bases. Which of the following findings would be most expected on this patient’s chest radiograph?
ADilated, thickened bronchi with “tram-track” marks
BLow lung volumes and ground glass opacities
CLung hyperinflation with flattening of the diaphragm
DNormal chest radiograph
A
ADilated, thickened bronchi with “tram-track” marks
Dilated, thickened bronchi are classic radiograph findings in patients with bronchiectasis,
Antibiotics are usually needed with the choice being guided by sputum cultures. Haemophilus influenza, Streptococcus pneumonia, and Staphylococcus aureus are often isolated. In addition to proper antibiotic coverage, bronchiectasis should be treated with daily chest physiotherapy and inhaled bronchodilators.
7
Q
Carcinoid tumors commonly secrete which of the following substances?
AAcetylcholine
BCalcium
CMelatonin
DSerotonin
A
DSerotonin
8
Q
A 72-year-old man is sent to the interventional radiology department by his primary care doctor to undergo a thoracentesis after a chest radiograph revealed a moderate left-sided pleural effusion. Analysis reveals a pleural fluid/serum protein ratio > 0.9 and a pleural fluid/serum LDH ratio > 0.8. Based on these findings, what is the most likely diagnosis?
A
Malignancy
- malignancy is the only one associated with an exudative effusion.
- exudative effusions are protein rich.
- They occur due to increased permeability of the pleura or impaired lymphatic drainage.
9
Q
A 23-year-old woman presents with a dry cough, malaise, sore throat, and subjective fever for the last two weeks. She was seen at an urgent care four days ago and was prescribed amoxicillin. She has been taking this, along with an over-the-counter cough syrup. Physical examination reveals diffuse crackles. Vital signs are within normal limits. Which of the following is the most appropriate treatment?
PE will show rales with auscultation of lung fields
A
Azithromycin
- Azithromycin is the treatment of choice for atypical pneumonia in this age group.
- The most common pathogen that causes community acquired pneumonia (CAP) is Strep pneumonia;
- however, the most common pathogen causing atypical CAP in this age group is Mycoplasma pneumoniae which responds to macrolide treatment.
10
Q
the most common dysrhythmia in cardiac arrest patients is?
A
Ventricular fibrillation
11
Q
A 74-year-old woman presents with complaints of fever, productive cough with bloody sputum, shortness of breath, and headache. These symptoms developed and worsened drastically over the past 3 days. She recently recovered from an influenza infection 1 week ago. Her medical history otherwise includes only well-controlled hypertension. Vital signs on presentation are as follows: T 39°C, HR 106, BP 110/75, RR 30, oxygen sat 95% RA. A chest radiograph is obtained and a subsequent CT scan of the chest demonstrates multiple cavitary lung lesions. Which of the following organisms is most likely responsible for this patient’s presentation?
Clostridum perfringens
Escherichia coli
Mycobacterium tuberculosis
Staphylococcus aureus
A
This patient’s presentation of pneumonia with multiple cavitary lesions on imaging is consistent with a post-viral secondary necrotizing pneumonia. The most common organism in necrotizing pneumonia, particularly after a viral upper respiratory infection, is S. aureus.
tx: vancomycin or linezolid, piperacillin/tazobactam
A preceding viral infection brings a large number of immune cells to the lung tissue, such that when secondary bacterial infection strikes, there is a catastrophic activation and destruction of immune mediators that damage lung tissue and lead to necrotizing pneumonia.
12
Q
A 55-year-old man presents to his pulmonologist with progressive shortness of breath over the past year. He was previously healthy and now can barely make it up the stairs in his home. A chest radiograph shows enlargement of the pulmonary arteries with a normal sized cardiac shadow and normal-appearing lung fields. An echocardiogram is performed showing a normal-shaped left ventricle and thickened myocardium in the right ventricle. Which diagnosis is most likely in this patient?
A
Primary pulmonary hypertension
Given the clear lung fields with enlargement of the pulmonary arteries on chest radiograph and the thickened right ventricle on the echocardiogram, this patient most likely has primary pulmonary hypertension.
13
Q
Beta-2-agonists promote bronchodilation by increasing cyclic adenosine monophosphate
A
Beta-2-agonists promote bronchodilation by increasing cyclic adenosine monophosphate
14
Q
Which of the following features can differentiate myocardial infarction from pericarditis?
A
Reciprocal ST-segment depressions should never be seen in patients with pericarditis; therefore, an ECG with this finding should always be assumed to be from myocardial ischemia or infarction.
15
Q
A 67-year-old woman presents with one month of progressive wheezing. On review of systems she also reports recent diarrhea. Which of the following findings on this patient’s physical exam is most consistent with the diagnosis of carcinoid tumors?
A
Flushed skin
- Carcinoid tumors are rare neuroendocrine tumors
- These tumors secrete vasoactive material such as serotonin, histamine, catecholamine, prostaglandins, and peptides resulting in a variety of symptoms.
- The diagnosis of carcinoid syndrome is best confirmed by measuring the 24-hour excretion of 5-hydroxyindoleacetic acid (5-HIAA) in the patient’s urine
16
Q
ST elevations in V1 and V2
A
Location: Septal involvement is reflected by changes in V1 and V2
Vessel: Left anterior descending (LAD)
17
Q
Lung hyperinflation with flattening of the diaphragms (
A
expected finding in chronic obstructive pulmonary disease (COPD).
18
Q
A 70-year-old woman with a history of hypertension presents to the Emergency Department with a complaint of abdominal pain. On physical examination, there is a pulsatile mass in the midline of her abdomen. Which of the following is the most common risk factor for the development of this condition?
A
Smoking history
Smoking is the most common risk factor associated with the development of an abdominal aortic aneurysm (AAA).
19
Q
A 42-year-old woman who spent two days hospitalized after she underwent an appendectomy three weeks ago presents with cough, green sputum and fever. Her vitals are T 100.7°F, HR 94, BP 123/76, RR 18, and oxygen saturation 97%. She is well appearing and her blood work (CBC and BMP) is unremarkable. A chest X-ray shows a left lower lobe infiltrate. Which of the following represents the best management for this patient?
A
Start IV antibiotics and admit
This patient has a health-care associated pneumonia (HCAP) requiring IV antibiotics and admission. HCAP is defined as infection occurring within 90 days of a 2-day or longer hospitalization; in a nursing home or long-term care residence; within 30 days of receiving intravenous antibacterial therapy, chemotherapy, or wound care or after a hospital or hemodialysis clinic visit.
Treatment: (one from each category 1, 2, 3)
- Cefepime, Ceftazidime, Pipercillin/Tazo, or imipenem/cilastatin
- Ciprofloxacin, Levofloxacin, Azitrhomycin
- Vancomycin, Linezolid
20
Q
A 65-year-old woman presented to the emergency department with sub-sternal chest pain and dyspnea. Her cardiac biomarkers were mildly elevated and there was ST-segment elevation in the anterior leads. Apical ballooning was seen on echocardiography and coronary angiography revealed normal coronary arteries. She has no past medical history and takes no medications. Recently the patient lost her husband of 40 years. What is the most likely diagnosis?
A
- Stress-induced cardiomyopathy, also called Takotsubo cardiomyopathy and “broken heart” syndrome, is an increasingly reported syndrome characterized by transient cardiac dysfunction with ventricular apical ballooning, usually triggered by intense emotional or physical stress.
- This syndrome mimics acute myocardial infarction, but in the absence of obstructive coronary artery disease.
21
Q
A 57-year-old man presents to your clinic complaining of two days of productive cough, fever, and dyspnea on exertion. He describes his sputum as foul smelling. He denies chest pain. He admits to drinking six to eight alcohol drinks per day and often experiences “blackouts” at night. Vital signs are BP 145/75, HR 114, T 100.8°F, RR 22, and pulse oxygenation 95 percent on room air. On exam, you note poor dentition and right-sided pulmonary rales. A chest X-ray is seen above. Which of the following is the most likely diagnosis?
A
Pneumonia caused by anaerobic bacteria
- Right upper lobe infiltrates
- Treatment is clindamycin
- Comments: Most common cause of lung abscess
22
Q
A 67-year-old man with diabetes mellitus, chronic lower back pain and previously stable systolic heart failure now has increasing orthopnea and shortness of breath. Physical exam reveals pulmonary crackles, jugular venous distention and lower extremity edema. He is on carvedilol, lisinopril, furosemide, insulin and ibuprofen. Which of the following is appropriate for management of this patient?
AAdd a calcium channel blocker
BDecrease the dosage of furosemide
CDiscontinue the carvedilol
DDiscontinue the ibuprofen
A
DDiscontinue the ibuprofen
Non-steroidal anti-inflammatory drugs (e.g. ibuprofen) can worsen symptoms of heart failure.
23
Q
What is the most common causative organism in community acquired pneumonia?
A
Streptococcus pneumoniae;
Streptococcus pneumoniae is a gram positive cocci and is the most common organism causing community acquired pneumonia.
most common, rusty colored sputum, rigors, gram+ paired lancets
24
Q
A transudative pleural effusion is identified after thoracentesis. Which of the following clinical scenarios is most consistent with this type of effusion?
27-year-old woman with a lupus flare
47-year-old woman alcoholic with an elevated lipase
65-year-old man with an ejection fraction of 15% and pulmonary edema
72-year-old man recently diagnosed with lung cancer
A
65-year-old man with an ejection fraction of 15% and pulmonary edema
25
Mycoplasma pneumoniae tx
Clarithromycin/ azithromycin
\_\_\_
Atypical Pneumonia
Patient will be complaining of gradual onset of dry cough, dyspnea, and extra-pulmonary symptoms such as headache, myalgias, fatigue, and GI disturbance
PE will show rales with auscultation of lung fields
Most commonly caused by Mycoplasma pneumoniae
26
acute presentation of sarcoidosis characterized by the triad of hilar adenopathy, erythema nodosum and polyarthralgia, with or without parenchymal infiltrates or fever, and is seen primarily in women with sarcoidosis.
Löfgren syndrome
27
Which of the following medications can be used in the treatment of hemodynamically stable atrial fibrillation with concomitant Wolff-Parkinson-White syndrome?
AAdenosine
BDiltiazem
CIbutilide
DMetoprolol
CIbutilide
Ibutilide can be used for rhythm control in hemodynamically stable atrial fibrillation with concomitant Wolff-Parkinson-White syndrome, which is also referred to as preexcited atrial fibrillation.
28
ST depressions in V1, V2, large R waves
Location: Posterior wall infarctions
Vessel: n/a
29
What is the INR range for patients taking warfarin for atrial fibrillation?
INR 2-3.
30
Which of the following conditions is most suggestive of an asymptomatic abdominal aortic aneurysm?
Abdominal mass
An abdominal mass is most suggestive of an asymptomatic abdominal aortic aneurysm. An abdominal aortic aneurysm is defined as a focal, full-thickness dilation of the aorta that is greater than 50% larger than its normal diameter.
Risk population: Any man between the ages of 65 and 75 years who has ever smoked.
31
ST elevation in leads V5–V6 , I , and aVL
Location: Lateral wall infarctions
Vessel:
1. left anterior descending
2. right coronary
3. left circumflex
32
***Hemoptysis***+trauma
pulmonary contusion
33
A 55-year-old man presents to the emergency department complaining of palpitations, nausea, and dizziness for 30 minutes. He is afebrile, his pulse is 140 beats per minute, and his blood pressure is 78/50 mm Hg. As the nurse attaches him to the cardiac monitor, you see the rhythm strip seen above. What is the most appropriate treatment?
Rhythm: wide complex tachycardia
Synchronized cardioversion at 200 joules
Clinically, he is hypotensive and unstable, which necessitates the use of electrical rather than pharmacologic treatment. Synchronized cardioversion is indicated for the treatment ofunstable tachydysrhythmias, including certain supraventricular dysrhythmias as well as monomorphic ventricular tachycardia.
34
A 47-year-old woman presents with several months of a persistent cough that recently resulted in hemoptysis. A review of system also confirms episodes of diarrhea, rash, and flushing. Physical exam is normal with the exception of focal wheezing over the right upper lobe. Which of the following is the most likely diagnosis?
Bronchial carcinoid tumors commonly cause persistent coughing with hemoptysis and focal wheezing.
35
Which of the following is the most common dysrhythmia associated with the diagnosis of pulmonary embolism?
Sinus tachycardia
36
What is the treatment for influenza?
Oseltamivir if used within 48 hours of symptoms onset
37
The X-ray would show a sharp cut-off of pulmonary vessels with distal hypoperfusion.
Westermark sign is a rare indication of pulmonary embolus (PE) on X-ray.
38
Which of the following murmurs is associated with an increase in right atrial pressure?
Tricuspid regurgitation
In tricuspid regurgitation, there is incomplete forward flow from the right atrium into the right ventricle and blood flows from the right ventricle into the right atrium during systole. This backflow of blood results in increased right atrial pressure.
39
A 55-year-old business executive comes to the emergency department with a 6-hour history of shortness of breath, cough, and chest pain. He smokes 1 to 2 packs of cigarettes daily and drinks 2 to 3 alcoholic beverages every night. He occasionally uses cocaine for recreational purposes. Physical examination reveals an erythematous and edematous right calf and a palpable cord. Auscultation of the lungs reveals rales and decreased breath sounds on the right side. Which of the following is the most likely diagnosis?
Pulmonary embolism
40
Uveitis, bilateral hilar adenopathy, and a dry cough most likely indicate
sarcoidosis
Elevated levels of serum angiotensin converting enzyme (ACE) are typically elevated in about 75% of patients with sarcoidosis.
41
A 55-year-old man presents complaining of a 2-day history of cough, fatigue and fever which came on suddenly. He denies chronic medical problems and takes no medications. He does not smoke. He is ill-appearing, though in no distress. His temperature is 101.6°F; pulse 112; BP 122/78; RR 24; and pulse oximetry 92% on room air. Physical exam is remarkable for rales along the right side of his lung fields. What is the most appropriate next step in evaluating his condition?
Chest X-ray
dx: community-acquired bacterial pneumonia (CAP).
MC bacteria: Streptococcus pneumoniae
tx: azithromycin or doxycycline if allergic
42
A patient presents with acute dyspnea and pleuritic chest pain. You suspect pulmonary embolism. Which of the following is the most appropriate test to confirm the diagnosis of a pulmonary embolus?
Computed tomography angiography
Pulmonary angiography is the definitive, or “gold standard”, test for the diagnosis of PE.
\_\_\_\_
Pulmonary Embolism
* Patient will be complaining of dyspnea (most common symptom)
* PE will show tachypnea (most common sign)
* ECG will show sinus tachycardia, nonspecific ST segment and T wave changes, right heart strain, S1Q3T3 (classic finding)
* CXR will show nonspecific abnormalities, Hampton's hump (pleural-based wedge infarct), Westermark's sign (vascular cutoff sign)
* Diagnosis is made by CT pulmonary angiography (test of choice in moderate to high probability cases)
* Most commonly originate in the lower extremities and pelvis
* Treatment is anticoagulation (heparin, LMWH), supportive care, thrombolytics in hemodynamically unstable patients
* Comments: In low clinical suspicion: negative D-dimer excludes PE
43
A 26-year-old man presents with a 2-week history of fever and a cough. He was diagnosed with HIV four months ago and is not on any antiretroviral medications. His vital signs are BP 122/76, HR 78, RR 16, oxygen saturation 92% on room air, and temperature 99.2°F. Chest X-ray demonstrates diffuse interstitial infiltrates bilaterally. Given this presentation, it is suspected that he has pneumonia secondary to Pneumocystitis jiroveci. Which of the following antibiotics is used to treat suspected pneumonia caused by Pneumocystitis jiroveci?
Trimethoprim-sulfamethoxazole
44
Pneumonia in the settin gof chronic lung disease/mechanical ventilation
Pseudomonas aeruginosa
45
A 33-year-old man presents to the clinic with a sudden onset of dry cough, fever, myalgias, nasal congestion, and headache. He has a benign past medical history. His physical exam is remarkable for a temperature of 38.4°C, pharyngeal injection, conjunctival injection, and clear rhinorrhea. His lung sounds are clear to auscultation and there are no adventitious sounds heard. Which of the following diagnostic tests would be most useful at this time?
Nasopharyngeal swab
A nasopharyngeal swab can be sent for rapid immunofluorescence assay to detect influenza.
tx: Oseltamivir
46
A 25-year-old man presents for evaluation of fever and cough. He reports last week that he was diagnosed with influenza. In the last two days he developed a worsening cough productive of large amounts of sputum. Vital signs are T 101°F, HR 98, BP 120/60, RR 18, and 95% oxygen saturation on room air. His chest X-ray demonstrates a lobar infiltrate in the left lower lobe. Which of the following would you most likely expect to see on the patient’s Gram stain?
Gram positive cocci in clusters
Staphylococcus aureus pneumonia as Postinfluenza Pneumonia
47
**_Blood Transfusion Reactions_**
Urticaria or hives
Allergic reaction
Symptomatic care; antihistamines
likely due to antibody-mediated response to donor's plasma
48
Most common cause of CAP
Streptococcus pneumoniae
49
ECG is abnormal in 90% of cases and abnormalities include left ventricular hypertrophy, “dagger-like” Q waves in the inferior and lateral leads, and nonspecific ST segment changes.
Hypertrophic cardiomyopathy
diagnosis: echocardiogram
vignette:
A 32-year-old man presents after a syncopal episode. He was running on the track when he developed shortness of breath followed by witnessed syncope. He was not post-ictal and had no seizure activity. He reports that his father’s brother died while playing basketball. Physical examination is notable for a midsystolic crescendo-decrescendo murmur
50
**_Blood Transfusion Reactions_**
Rash, elevated LFT's and pancytopenia [deficiency of all three cellular components of the blood (red cells, white cells, and platelets)]
Transfusion-associated graft versus host disease
STOP TRANSFUSION; Supportive care
immunocompromised patients; use irradiated blood products
51
A 19-year-old college student presents dead-on-arrival to the ED. An autopsy reveals significant calcification of the **aortic valve cusps**. Upon review of his medical history, you would most likely find documentation of a murmur heard in which of the following locations?
Proper cardiac auscultation begins with an understanding of which chest wall location is associated with which valve-sound. The aortic valve is best appreciated in the right, second intercostal space just lateral to the sternum.
52
A 33-year-old man presents with five days of gradual onset nonproductive cough, fatigue, and fever. He also notes a 15 pound weight loss over the last month. He is tachypneic with a heart rate of 105 beats/minute, temperature of 38.2oC, and an oxygen saturation of 89% on room air. On examination, white plaques are noted on his tongue and his lungs are clear on auscultation. His chest X-ray is shown above. Which of the following is the most likely causative agent?
Pneumocystis jiroveci
Pneumocystis jiroveci (formerly carinii) pneumonia (PCP) is an opportunistic fungal pathogen which primarily affects immunocompromised patients including those with HIV/AIDS, as well as cancer and organ transplant patients on immunosuppressants. PCP is one of the most common AIDS-defining opportunistic infections.
CD4 counts are typically \< 200 cells/mm3.
**tx: Intravenous trimethoprim-sulfamethoxazole is the antibiotic of choice**
53
What is the most likely culprit lesion in patients with acute ST elevation in lead aVR?
Left main coronary artery.
54
***Hemoptysis***+immunodeficiency or immigrant
TB
55
A 64-year-old man presents with a headache and cough for the last one week. Physical exam shows facial edema, facial plethora, and prominent venous distention of the chest. History is significant for lung cancer. What is the most likely diagnosis?
Superior vena cava syndrome
Superior vena cava syndrome is secondary to elevated venous pressure in the upper body resulting from obstruction of blood flow through the superior vena cava (SVC). Usually this is caused by extrinsic compression and is commonly caused by tumors associated with lung cancer.
Initial management includes elevation of the head to decrease venous pressure in the upper body.
56
A 27-year-old woman presents to the emergency department with complaints of fever, rash, and myalgias. She also admits to night sweats and nausea. On exam, there are multiple scars in her left antecubital fossa, scattered petechiae, and tender nodules on the tips of her digits. Cardiac auscultation reveals a murmur. Which of the following is the most likely diagnosis?
Bacterial endocarditis
57
A 53-year-old man comes to the emergency department complaining of a 5-day history of a cough and shortness of breath. His temperature is 37.6°C (99.8°F). Auscultation of the lungs shows rhonchi and wheezing. Chest X-ray shows thickening of the bronchial walls in both lower lobes. Laboratory studies show a slightly elevated white blood count. Which of the following is the most likely diagnosis?
Acute bronchitis
Acute bronchitis is a self-limited inflammation of the bronchi and typically presents with mucopurulent cough for more than 5 days. Chest X-ray will show thickening of the bronchial walls in the lower lobes and auscultation of the lungs usually reveals wheezing and rhonchi. Acute bronchitis is typically caused by viruses
58
Which of the following conditions requires droplet precautions?
Influenza
59
Pneumonia in the setting of ethanol abuse, diabetes
Klebsiella pneumoniae
60
Low lung volumes with ground glass opacities
interstitial lung disease. Interstitial lung disease usually causes dyspnea and a nonproductive cough
61
Which of the following physical exam findings is consistent with pleural effusion?
Dullness to percussion
62
A 72-year-old man presents for evaluation of palpitations. He has a regular, wide complex tachycardia at a rate of 140 bpm. Which of the following supports a diagnosis of ventricular tachycardia?
ADiscordance of the QRS axis in the precordial leads
BFusion beats
CLeftward axis
DST elevation greater than 5 mm
BFusion beats
Fusion beats occur when impulses from two different locations (one within the ventricle and one in a supraventricular location) activate the ventricle. The result is a QRS complex with morphology resembling a hybrid of a sinus beat and intraventricular beat. These are diagnostic of VT because they represent AV dissociation.
63
A 54-year-old man presents to the hospital in acute respiratory distress. He was released from the hospital three days ago after undergoing a cardiac stent placement secondary to an acute myocardial infarction. His hospital course was uncomplicated. On exam, his BP is 110/60 mm Hg, HR is 115, RR is 28, and pulse oximetry is 91% on room air. Cardiopulmonary exam reveals a midsystolic murmur with bibasilar crackles. An ECG shows sinus tachycardia. Which of the following is the most likely diagnosis?
Acute mitral regurgitation
Acute mitral regurgitation is the result of rupture of the chordae tendineae, papillary muscle, or valve leaflet. Its etiology can be idiopathic due to acute ischemia, a complication of infective endocarditis, or trauma.
Patients typically present in fulminant pulmonary edema rapid in onset. It is associated with a midsystolic murmur.
64
Cavitary pneumonia in a setting of MRSA
Staphylococcus aureus
65
Which of the following is the most common opportunistic respiratory infection in patients with acquired immunodeficiency syndrome?
Pneumocystis jiroveci
tx: Trimethoprim-sulfamethoxazole (TMP-SMX)
CD4 \< 200 cells/microL
66
You are treating a 50-year-old coal-miner’s hypertension with lisinopril. He has been complaining of 3-months of progressive dyspnea. You order a chest radiograph which shows bilateral upper lobe honeycombing. A high resolution computed tomogram shows multiple small, round opacities only in the upper lobes. The lower lobes appear normal. Which of the following is the most likely diagnosis?
## Footnote
SOB + nonproductive cough + chronic hypoxia
CXR: interstitial fibrosis
Pneumoconiosis is an occupational respiratory disease due to inhalation of inorganic dusts.
## Footnote
**Asbestos:** from the roof, but affects the base (lower lobes)
**Silica, coal:** from the base (earth), but affect the roof (upper lobes)
67
Which of the following can cause an exudative pleural effusion?
ACirrhosis
BCongestive heart failure
CNephrotic syndrome
DSystemic lupus erythematosus
**Systemic lupus erythematosus** can cause an exudative pleural effusion. A pleural effusion is an accumulation of fluid in the pleural space and can either be exudative or transudative. Exudates result primarily from pleural and lung inflammation which result in increased capillary and pleural membrane permeability. It can also be caused by impaired lymphatic drainage of the pleural space.
68
An obese 34-year-old woman is brought to the Emergency Department with respiratory distress. Two months ago she was in the hospital for knee surgery. Paramedics report an acute onset of dyspnea and pleuritic chest pain. She also complains of a tender thigh on the same side of her knee surgery. She is tachycardic and tachypneic, and mildly hypotensive. Examination reveals decreased breath sounds but no hyperresonance. An emergent chest radiograph is relatively normal except for some mild atelectasis. Which of the following is the most likely diagnosis?
Pulmonary embolism
Pulmonary Embolism
* Patient will be complaining of dyspnea (most common symptom)
* PE will show tachypnea (most common sign)
* ECG will show sinus tachycardia, nonspecific ST segment and T wave changes, right heart strain, S1Q3T3 (classic finding)
* CXR will show nonspecific abnormalities, Hampton's hump (pleural-based wedge infarct), Westermark's sign (vascular cutoff sign)
* Diagnosis is made by CT pulmonary angiography (test of choice in moderate to high probability cases)
* Most commonly originate in the lower extremities and pelvis
* Treatment is anticoagulation (heparin, LMWH), supportive care, thrombolytics in hemodynamically unstable patients
* Comments: In low clinical suspicion: negative D-dimer excludes PE
69
You prescribe ramipril to a 65-year-old man with uncontrolled hypertension and severe renovascular disease. At a follow-up visit four weeks later his creatinine is noted to be 2.3. His creatinine before starting the ramipril was 1.0. By what mechanism did the ACE inhibitor cause this change?
AActivating the arachidonic acid pathway
BDecreasing glomerular blood flow
CIncreasing angiotensin II activity
DIncreasing serum kinin levels
BDecreasing glomerular blood flow
One of the actions of angiotensin II is to vasoconstrict efferent arterioles as they leave the glomerulus. This vasoconstriction stabilizes renal perfusion pressure and helps maintain normal creatinine levels. ACE Inhibitors block the conversion of angiotensin I to angiotensin II which causes a modest reduction in renal blood flow.
70
a chest wound or laceration that allows inspiration of air but not expiration. This causes mediastinal shift to the contralateral side and cardiovascular compromise.
tension pneumothorax
tx: A large-bore needle is inserted into the chest to allow expiration of air, before placement of a chest tube.
**CONTRALATERAL SIDE**
71
Small pleural effusions are most easily detected on which type of x ray?
lateral decubitus film with the affected side down
72
How do you treat Chronic obstructive pulmonary disease (COPD)?
Tiotropium
## Footnote
Treatment is based on the severity of the disease. Long-acting anticholinergics such as tiotropium are the mainstay of therapy.
73
the most common cause of hemoptysis (responsible for 15%-30% of cases)
bronchitis
74
ST elevations in V3, V4
Location: Anterior wall myocardial infarction
***If V1-V4 it is anteroseptal***
Vessel: Left anterior descending (LAD)
75
A 22-year-old woman presents with dyspnea. She has a history of asthma and noted increased difficulty breathing starting yesterday. She says she has been using her albuterol inhaler every 15 minutes for the last four hours without relief. What laboratory abnormality is likely to be found in this patient?
Hypokalemia
Albuterol, a beta-2-adrenergic agonist, is a widely used medication in the treatment of asthma and chronic obstructive pulmonary disease. Beta-2-adrenergic agonists work selectively on the beta-2 receptors on bronchial smooth muscle resulting in bronchodilation. The most common side effects include tremor and tachycardia. Overuse of these medications can also result in hypokalemia due to increased activity of Na-K-ATPase pumps in skeletal muscle which drive potassium intracellularly.
76
Which beta blocker is contraindicated in the treatment of Prinzmetal’s angina?
Propanolol.
77
ST elevations in V4R, V5R
Location: Right ventricular
78
A 19-year-old man presents with a sore throat and difficulty swallowing. He has had four days of worsening sore throat and fever but today he was unable to swallow any liquids. Physical examination reveals a muffled voice, difficulty tolerating saliva, and minimal pharyngeal erythema with a midline uvula. He also has tenderness over the hyoid bone. Which of the following is the best management of this patient?
Intravenous antibiotics and admission (ceftriaxone and ampicillin-sulbactam are first-line)
This patient presents with symptoms and signs concerning for epiglottitis and should have antibiotics started and admission for further monitoring. Epiglottitis is a localized cellulitis of the supraglottic structures including the aryepiglottic folds, arytenoids, lingual tonsils, epiglottis and base of the tongue. It may be caused by viral or bacterial agents (Haemophilus influenzae type b is the most common).
* Epiglottitis is a clinical diagnosis but may be aided by plain radiographs of the neck, which shows edema of the epiglottis (thumb sign).
* Patient will be complaining of rapid onset of fever and dysphagia
* PE will show patient leaning forward, drooling, inspiratory stridor
79
Standard therapy for latent tuberculosis infection (LTBI)
What should be co-administered with the above medication?
isoniazid (INH)
Pyridoxine (vitamin B6) to prevent peripheral neuropathy.
80
A 50-year-old woman presents to the Emergency Department following a syncopal episode. On physical exam she is diaphoretic, but alert and orientated. Her blood pressure is 100/50 mm Hg, heart rate 46 beats per minute, and respirations 12 per minute. Her rhythm strip is shown above. What is the most appropriate treatment for this patient’s condition?
Rhythm: sinus bradycardia
Atropine
81
***Hemoptysis***+diastolic murmur
mitral stenosis
82
Pulmonary Tuberculosis (TB) tx
Pulmonary Tuberculosis (TB)
RFs: immunodeficiency, immigrant, close contact
Latent/primary TB: asymptomatic
Active/reactivation TB: fever, night sweats, weight loss, productive cough, hemoptysis
Erythema nodosum
Primary TB CXR: Ghon focus
Active/reactivation TB: upper lobes, cavitary lesions
Dx: sputum smears for acid-fast bacilli (AFB), sputum/tissue culture for AFB (gold standard)
Latent TB dx: PPD or interferon-gamma release assay
Latent rx: 9 months of INH
Primary rx: Rifampin, INH, Pyrazinamide, Ethambutol (RIPE)
83
An 81-year-old man with 10 years of coronary artery disease presents with chest pain and altered mental status. His ECG shows consecutive, large and wide QRS complexes. P waves cannot be appreciated. His pulse is 188 bpm. Which of the following is the most likely diagnosis?
* **Ventricular tachycardia**
* Ventricular tachycardia is described electrocardiographically as “continuous PVCs”, or more specifically, consecutive, fast, large and wide QRS complexes.
* A wide QRS complex clues one in that the underlying electrical problem is in the ventricles.
84
A 67-year-old man with a history of hypertension and remote abdominal aortic aneurysm repair presents to the emergency department after four episodes of gross hematemesis. He had an episode of emesis with some blood last week but dismissed it as a “stomach bug”. He denies any history of alcohol abuse or liver disease. His vital signs on arrival are T 38.5°C, HR 111, BP 100/80, RR 27. His stool is guaiac positive. Which of the following is the most likely cause this patient’s symptoms?
AAortoenteric fistula
BEsophageal varices
CMallory-Weiss tear
DPeptic ulcer disease
AAortoenteric fistula
* An aortoenteric fistula is an abnormal communication between the aorta and the gastrointestinal tract.
* The most common risk factors for aortoenteric fistulas are abdominal aortic aneurysm and a history of aortic surgery.
* Gastrointestinal bleeding, including hematemesis, hematochezia, and melena, is often the presenting symptom.
* The classic triad of gastrointestinal bleeding, abdominal pain, and a palpable mass is rarely present and a history of aortic aneurysm is rarely known at the time of presentation.
* Fever and sepsis may be present due to seeding of the blood with gastrointestinal flora.
* Management of aortoenteric fistulas is emergent surgical repair.
85
A 45-year-old woman presents to the Emergency Department with a fever, productive cough, and diarrhea. Her chest X-ray shows a patchy unilobar infiltrate and her sodium is 127 mmol/L. Which of the following organisms is most likely to be responsible for these symptoms?
Legionella pneumophila
* Common symptoms include a fever, cough, diarrhea, and confusion.
* Chest X-ray findings vary but often show a patchy unilobar infiltrate.
* Laboratory abnormalities are common with hyponatremia being the classic finding.
* First-line treatment includes either respiratory quinolones (e.g. levofloxacin) or macrolides (e.g. azithromycin).
86
A 63-year-old man is brought to the ED by paramedics secondary to aphasia that began 30 minutes prior to arrival. The man is unable to give any history and has never been to your hospital. His vital signs are T 37°C, BP 180/98, HR 90, and RR 20. His exam is unremarkable except for profound expressive aphasia. Capillary blood glucose is 124 mg/dL. His ECG shows normal sinus rhythm with normal ST segments and T waves. CT scan of the head is normal. Sixty minutes after arriving to the ED, the patient’s aphasia resolves. Which of the following are the most appropriate diagnosis, treatment, and disposition for this patient?
Transient ischemic attack; administer aspirin and dipyridamole; admit to stroke unit
87
A 28-year-old man presents to the Emergency Department with dyspnea. On an anterior-posterior chest X-ray, you notice a visceral pleural line with a radiolucent area devoid of vascular and pulmonary markings on the right side only. What is the most likely diagnosis?
## Footnote
**TALL, THIN MALES**
Pneumothorax
A pneumothorax is characterized by unilateral findings of a visceral pleural line with no vascular pulmonary markings in between this line in the chest wall on chest X-ray. A pneumothorax is a collection of air in the pleural space between the lung and the chest wall. The cause may be spontaneous, iatrogenic, or traumatic.
tx: A small pneumothorax may resolve spontaneously, but most require placement of a chest tube.
88
A 40-year-old woman complains of recurrent chest pain that occurs shortly after she wakes up in the morning. She has a history of migraine headaches and Raynaud's phenomenon. She admits to tobacco abuse and smokes 1 pack-per-day. Her chest pain is not reproducible with palpation. An ECG during an episode reveals ST-elevation in multiple leads and cardiac biomarkers are normal. Which of the following is the most likely diagnosis?
Prinzmetal angina
* Prinzmetal angina, or variant angina, is the most likely diagnosis in this patient.
* Prinzmetal angina is characterized by spontaneous episodes of angina in association with ST-segment elevation on ECG.
* The cause is a transient, abrupt, and marked reduction in the luminal diameter of an epicardial coronary artery due to spasm which leads to transient myocardial ischemia.
* Unlike most other causes of chest pain and ST-segment elevation, the ST-segment returns to baseline rapidly upon resolution of symptoms.
89
**_Blood Transfusion Reactions_**
immediate fever/chills, headache, N/V, dark urine, hypotension
Hemolytic transfusion reaction
STOP TRANSFUSION; crystalloid infusion, diuretic therapy to maintain urine output
ABO incompatability
90
vasculitic interstitial lung disease whose imaging reveals necrotizing granulomas.
Granulomatosis with polyangiitis (GPA)
91
A young woman with Raynaud’s phenomenon presents with a 3 month history of cyclical short episodes of chest pain. Her social history is positive for intermittent cocaine use. The pain occurs most commonly after she wakes in the morning, lasts for 20 minutes, then resolves. This pain occurs at rest and is not worse with exercise or increased activity. Which of the following would you most expect to find during an evaluation of these symptoms?
ACoronary artery stenosis
BNormal exercise stress test
CPain relief during ergonivine administration
DST-segment depression
BNormal exercise stress test
Prinzmetal’s angina, also known as variant angina, is due to endothelium dysfunction and coronary vasospasm. It can occur in normal or diseased arteries.
* Predisposing factors in developing coronary vasospasm include cocaine and tobacco use, cold weather and psychological stress.
* Symptoms include cyclical angina that occurs at rest, most commonly in the early morning and late evening hours, and is not made worse with exercise or other cardiac loading.
* CONTRAINDICATED: Propanolol
\_\_\_\_\_\_\_
Prinzmetal Angina (Variant Angina)
* Patient with a history of HTN, smoking, DM, obesity, or cocaine use
* Complaining of squeezing, pressure-like chest discomfort at rest
* ECG will show transient ST-segment elevations and cardiac enzymes will be normal
* Diagnosis is made by cardiac stress test
* Most commonly caused by coronary artery spasm
* Treatment is calcium channel blockers and nitrates
92
A 39-year-old stonemason presents with dyspnea that has been present for several months. A chest X-ray shows an eggshell calcification of the hilar lymph nodes and multiple small 1-2 mm nodules throughout the lung. Which of the following is the most likely diagnosis?
Silicosis
93
A 66-year-old man with a history of alcoholism and poor dentition presents with 1 week of fever, dyspnea, and cough productive of purulent sputum. Chest radiographs reveal infiltrates in the posterior segments of the upper lobes. If untreated, what is the most likely complication of this disease?
Hypertrophic cardiomyopathy
Infective endocarditis
Lung abscess
Lung cancer
The patient has aspiration pneumonia, and lung abscess is a common complication of aspiration pneumonia
94
What finding on high resolution computed tomographic imaging of the chest is most consistent with idiopathic pulmonary fibrosis?
bibasilar crackles and finger clubbing
Honeycombing
Idiopathic pulmonary fibrosis (IPF) is a type of fibrosing interstitial pneumonia of unknown cause. It is characterised by a chronic nonproductive cough and gradual exertional dyspnea that usually develops over several months. IPF is most common in men, aged 60-70 years, with a history of cigarette smoking.
95
**_Blood Transfusion Reactions_**
Indistinguishable from acute respiratory distress syndrome (ARDS)
Transfusion-related acute lung injury (TRALI)
STOP TRANSFUSION; supportive care, with low tidal volumes for mechanical ventilation and maintenance of euvolemia.
96
**_Blood Transfusion Reactions_**
Fall in HgB; rise in bili
Delayed transfusion reaction
Supportive care
(May occur 3-4 weeks after transfusion; primary response to RBC antigen)
97
A 30-year-old woman who recently returned home from a six hour road trip presents to the ED complaining of shortness of breath and chest pain associated with deep breaths. Past medical history significant for GERD. Medication list includes omeprazole and an oral contraceptive which she started taking one month prior. Physical exam reveals diaphoresis. Vital signs are temperature 37°C, heart rate 110 beats per minute, respiratory rate 20 breaths per minute, blood pressure 100/70 mm Hg, and pulse oximetry 89% on room air. Auscultation reveals a split S2 and lungs are clear bilaterally. ECG shows sinus tachycardia. Chest X-ray is normal. Based on the most likely diagnosis, which of the following is the most appropriate diagnostic test?
CT pulmonary angiography
acute pulmonary embolism
98
A 54-year-old woman presents with dyspnea on exertion. She states that it has been progressively worsening over the last few months and she is losing her ability to complete activities that she was able to do before without sitting down to “catch her breath.” Cardiac auscultation over the apex reveals a low-pitched, diastolic murmur and an opening snap. Which of the following is the most likely diagnosis?
Mitral stenosis
Mitral stenosis is best auscultated at the apex of the heart. The murmur is described as low-pitched and diastolic. An opening snap of the valve leaflets is heard at the beginning of S2 and can sometimes be confused with a splitting of the second heart sound. The sounds are diminished with inspiration and exaggerated with expiration.
ages 20 and 50 years
99
What is the most appropriate therapy for carcinoid syndrome?
Octreotide
Symptomatic control primarily involves the use of somatostatin analogues such as octreotide.
100
What drug is safe to administer to a patient with wide complex irregular tachycardia?
Procainamide.
101
A 58-year-old man ran out of his congestive heart failure medications. He presents with significant dyspnea and altered mental status. Examination reveals bibasilar crackles and jugular venous distension. An electrocardiogram shows sinus rhythm with low voltage complexes. Which of the following is most appropriate at this time?
AAmiodarone
BDisopyramide
CFurosemide
DVentricular assist device
CFurosemide
dx: Acute or decompensated congestive heart failure
* In-house care is comprised of oxygen, nitrates, and furosemide.
* Furosemide is a loop diuretic that inhibits the transporter at the loop of Henle in the kidneys leading to free water clearance.
* Inotropic medications, such as dobutamine and dopamine, may also be necessary if there is evidence of impaired perfusion.
* Severe cases may require an intraaortic balloon pump or a ventricular assist device.
102
Which of the following organisms is most associated with pneumonia and bullous myringitis?
Streptococcus pneumoniae
The presence of otalgia should prompt evaluation for bullous myringitis
Bullous myringitis is a presentation of acute otitis media in which bullae are seen on the tympanic membrane.
103
A man presents to the ED with angina during exertion that has increased in intensity and duration over the past 18 hours. An ECG shows T wave inversion in 4 leads. Which of the following risk stratification tools is used in the acute management of this type of angina?
TIMI Score
Thrombolysis in Myocardial Infarction (TIMI) risk tool.
104
classically present with several weeks of cough, fever, pleuritic chest pain, weight loss, and night sweats. There may be cough productive of putrid sputum.
## Footnote
CXR will show area of dense consolidation with an air-fluid level inside a thick-walled cavitary lesion
lung abscess
Infectious lung abscesses typically occur in the basal segments of the lower lobes or the posterior segment of the upper lobes.
What is the most common cause of lung abscess? Aspiration pneumonia.
Those who abuse alcohol or have other conditions associated with the potential for aspiration are at greatest risk for lung abscess development.
tx: clindamycin
105
Which of the following is the treatment of choice in antidromic atrioventricular reciprocating tachycardia in a hemodynamically stable patient?
Adenosine
Diltiazem
Electrical cardioversion
Procainamide
Procainamide
Procainamide is the treatment of choice in hemodynamically stable wide-complex tachydysrhythmias in WPW syndrome.
***Drugs that slow conduction through the AV node, such as adenosine, calcium channel blockers, and beta blockers, should be avoided as they may enhance conduction through the accessory tract, leading to ventricular fibrillation.***
106
A 38-year-old man presents with fever, fatigue, cough, and increasing dyspnea. The patient denies chills or night sweats. On physical exam, lungs are clear to auscultation bilaterally. Hepatosplenomegaly is noted on abdominal exam. Chest X-ray findings include bilateral hilar adenopathy and diffuse reticular infiltrates. Labs reveal leukocytopenia, hypercalcemia, and elevated erythrocyte sedimentation rate. What is the most likely diagnosis in this patient?
SarcoidosisSarcoidosis is a multi-organ disease, usually of idiopathic origin. It is more common in the African American population and the European caucasian population. Patients commonly present with respiratory symptoms, including cough, dyspnea, and chest discomfort. Patients may also have malaise, fever, and multiple non-pulmonary symptoms. Sarcoidosis is characterized by **_noncaseating granulomatous inflammation_** in multiple affected organs.
107
**_Blood Transfusion Reactions_**
Fever, chills, malaise
Febrile transfusion reaction (most common)
Supportive care, acetaminophen
108
collagen vascular disease whose pulmonary findings include lower lobe fibrosis and pulmonary hypertension
Scleroderma
109
A 49-year-old man presents with chest pain. His medical history does not list any cardiac murmur, however, during examination, you hear a mitral regurgitant murmur. Blood pressure is equal in both the left and right arms. Although you have none to compare to, you order an electrocardiogram and notice ST segment depression in three different leads and T-wave inversion in two different leads. No other abnormalities are appreciated. A chest radiograph is read as normal. Initial lab testing shows an elevated troponin level. Which of the following is the most correct diagnosis?
AAortic dissection
BNon ST-segment elevation myocardial infarction
CST-segment elevation myocardial infarction
DUnstable angina
BNon ST-segment elevation myocardial infarction
* Myocardial infarction encompasses both non-ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI). It is defined as myocardial cell death and necrosis as diagnosed by a rise and fall in cardiac enzymes (in association with appropriate clinical presentation) or by pathologic findings of prior myocardial infarction (e.g. new Q waves on ECG).
* NSTEMI represents subtotal coronary thrombosis and myocardial ischemia infarct.
* Common symptoms include angina less than 30 minutes duration, dyspnea, diaphoresis and palpitations.
* Myocardial insult is also associated with a new-onset mitral regurgitation murmur, newly-auscultated S4 and a paradoxical S2.
* New infarcts can be identified with a positive troponin on laboratory testing.
110
A 65-year-old smoker with no documented cardiac disease presents with several months of worsening cough and exertional dyspnea. He denies exposure to inhalation toxins or dusts. Examination reveals bibasilar inspiratory crackles and fingernail clubbing. Spirometry reveals a restrictive lung pattern. A chest computed tomography scan is read as “honeycombing in the periphery and bases.” A bronchoalveolar lavage report is only significant for lymphocytosis and a histological classification of usual interstitial pneumonia. Which of the following is the most likely diagnosis?
Idiopathic pulmonary fibrosis
Restrictive disease encompassesabnormalities of the parenchyma and chest wall. Idiopathic pulmonary fibrosis (IPF) represents a main subclassification of the more than 200 interstitial lung diseases. IPF is a chronic progressive, and often fatal, interstitial lung disease which affects adults over 50 years of age (men \> women and smokers \> non-smokers).
Patients experience a progressive dry cough, exertional dyspnea, inspiratory “velcro-like” crackles and fingernail clubbing.
111
Which of the following characteristics of transfusion-related acute lung injury (TRALI) differentiates it from transfusion-associated circulatory overload (TACO)?
## Footnote
High fever
Hypertension
Hypoxemia
Pulmonary edema
High fever
## Footnote
**_Transfusion-related acute lung injury (TRALI) :_** acute neutrophilic response that leads to endothelial damage and massive capillary leak in the pulmonary vasculature. TRALI is characterized by hypoxemia (oxygen saturation \<90% on room air), and bilateral pulmonary infiltrates presenting within 6 hours of blood transfusion. There should not be any evidence of pulmonary artery hypertension or generalized fluid overload. Hypotension, tachycardia, and fever are common.
***Treatment of TRALI is supportive, with low tidal volumes for mechanical ventilation and maintenance of euvolemia. Despite the initial appearance of fluid overload, these patients are normovolemic or intravascularly depleted secondary to the increase in vascular permeability and extravasation. Diuresis may lead to further deterioration and shock.***
\_\_\_\_\_\_\_
Fever is not common in transfusion-associated circulatory overload (TACO).
112
***Hemoptysis***+renal dysfunction
Goodpasture syndrome or Wegener's granulomatosis (Granulomatosis with polyangitis)
113
Corticosteroids are used as adjunct therapy in HIV-positive patients with moderate to severe PCP (now known as Pneumocystis jiroveci pneumonia), defined by a room air arterial oxygen partial pressure (PaO2) of **less than 70 mm Hg (severe disease is less than 60 mm Hg)** or an alveolar-arterial oxygen gradient that **exceeds 35 mm Hg (exceeding 45 mm Hg for severe disease).**
Corticosteroids are used as adjunct therapy in HIV-positive patients with moderate to severe PCP (now known as Pneumocystis jiroveci pneumonia), defined by a room air arterial oxygen partial pressure (PaO2) of **less than 70 mm Hg (severe disease is less than 60 mm Hg)** or an alveolar-arterial oxygen gradient that **exceeds 35 mm Hg (exceeding 45 mm Hg for severe disease).**
114
***Hemoptysis***+sudden SOB and chest pain
PE
115
1. Earliest ECG sign of MI: \_\_\_\_\_\_\_\_\_
2. Highest S/S of MI: \_\_\_\_\_\_\_\_\_\_\_
1. **Earliest ECG sign of MI:** hyperacute T waves
2. **Highest S/S of MI:** troponin I
116
interstitial lung disease characterized by alveolar hemorrhage and glomerulonephritis
Goodpasture’s syndrome
117
A 36-year-old African American woman presents to the clinic complaining of a gradual worsening of dyspnea, dry cough, fatigue and numerous maculopapular lesions on the face. Additionally, she notes enlarged, non-tender lymph nodes in her neck. She is a non-smoker. Laboratory evaluation reveals an elevated serum angiotensin converting enzyme level and erythrocyte sedimentation rate level. Which of the following is most likely to be seen on chest radiograph?
Bilateral hilar adenopathy
Bilateral hilar adenopathy is a classic finding in sarcoidosis
multisystem disease of unknown etiology characterized by tissue infiltration with noncaseating granulomas
118
A 72-year-old woman presents to the ED with an acute onset of dyspnea and palpitations that began four hours prior to arrival. Vital signs include a heart rate of 144 beats per minute, blood pressure of 80/50 mm Hg, respiratory rate of 28 breaths per minute, temperature of 37.0°C, and a pulse oximetry of 88% on room air. The above 12-lead ECG is obtained. What is the most appropriate next step in the management of this patient?
Rhythm: atrial fibrillation
Synchronized cardioversion
atrial fibrillation with a rapid ventricular rate and is hemodynamically unstable. In such circumstances, emergent synchronized cardioversion is required.
119
A patient with acute pancreatitis is noted to have a pleural effusion on chest radiography. Which of the following findings would you expect to find on pleural fluid analysis?
Elevated amylase concentrations would be expected on pleural fluid analysis in the setting of acute pancreatitis.
Acute Pancreatitis
* Patient will be complaining of epigastric pain radiating to the back, nausea, and vomiting
* PE will show ecchymosis of left flank (GreyTurner sign), umbilical ecchymosis (Cullen sign)
* Labs will show elevated lipase (best) and amalyse
* Diagnosis is made by US and Ranson's criteria
* Most commonly caused by gallstones \> alcohol
* Treatment is IV fluids
120
A man presents to the emergency department with a blood pressure of 200/136 mm Hg and laboratory evidence of acute renal failure. Which of the following medications and initial blood pressure response rates are the most appropriate at this time?
Intravenous labetalol, to goal within 1 to 2 hours
Intravenous nicardipine, to goal within 6 to 12 hours
Oral clonidine, to a goal within 3 to 6 days
Oral magnesium sulfate, to a goal within 1 to 2 days
Intravenous labetalol, to goal within 1 to 2 hours
* . In most hypertensive emergencies, the mean arterial pressure (MAP) should be reduced by about 10-20% in the first hour, followed by a gradual reduction during the next 23 hours. The treatment goal is to achieve a final pressure reduction by 25%compared with baseline.
121
***Massive hemoptysis \>600 mL of blood/24 hours treatment***
patient in bleeding side down position, mainstem bronchus intubation
122
CXR: cardiomegaly, cephalization, Kerley B lines, effusions
Acute Decompensated Heart Failure
tx: furosemide
123
Which of the following treatments is most appropriate for a patient with acutely symptomatic sarcoidosis?
Prednisone
124
Pneumonia with history of COPD
Haemophilus influenzae
125
Which of the following is the most common cause of a pleural effusion in developed countries?
Heart failure
Pleural effusions occur when fluid accumulates between the parietal and visceral pleurae.
Common causes of transudates (low protein) include congestive heart failure, cirrhosis, and nephrotic syndrome.
126
A 47-year-old woman, with no past medical history and no hospitalizations, presents with cough, green sputum, and fever. Her vitals are T 100.7°F, HR 94, BP 123/76, RR 18, oxygen saturation 97%. She is well appearing and her blood work (CBC and BMP) is unremarkable. A chest X-ray shows a left lower lobe infiltrate. Which of the following represents the best management for this patient?
Discharge home with oral antibiotics and follow up
127
A 62-year old man presents complaining of crushing substernal chest pain for the last two hours associated with diaphoresis, nausea, and lightheadedness. His pain improved with sublingual nitroglycerin. Electrocardiogram obtained in triage shows deep Q waves and ST segment elevation in leads V1–V4, with ST depression in leads III and aVF. This pattern on electrocardiogram represents infarction of which area of myocardium?
Anterior
* Anterior wall myocardial infarction is characterized by ST elevation in leads V1–V4, with reciprocal changes in the inferior leads (III and aVF).
* Septal involvement is reflected by changes in V1 and V2.
* The left anterior descending artery serves the anterior wall.
128
Which of the following signs or symptoms is most likely to be associated with a patient with chronic venous insufficiency?
How is it diagnosed? What is the tx?
* Chronic venous insufficiency is the inability of the extremities to return blood to the heart which leads to a pooling in the lower extremities and edema.
* The condition is diagnosed with venous duplex ultrasound.
* First line treatment includes: diet and exercise, compression stockings and elevation of the affected limb above the level of the heart.
* Pharmacologic therapy may include sulodexide which is a potent, long acting antithrombotic.
129
ST elevation in leads II, III, and aVF
Location: Inferior wall infarctions
Vessel:
1. right coronary artery (right dominant)
2. left circumflex artery (left dominant)
130
Which of the following physiologic responses would occur after application of noninvasive positive pressure ventilation in a patient presenting with an acute exacerbation of chronic obstructive pulmonary disease?
Increased afterload
Increased alveolar dead space
Increased tidal volumes
Increased venous return
Increased tidal volumes
Noninvasive positive pressure ventilation applies a consistently positive airway pressure to increase laminar flow. This leads to airway stenting, elimination of dead space through alveolar recruitment, and an increase in tidal volumes and minute ventilation. The beneficial effects of positive pressure ventilation are not only realized in the pulmonary system but also in the cardiovascular system. Patients with pulmonary edema from decompensated heart failure benefit from the increased intrathoracic pressure which **_decreases venous return and increases left heart output_** and thus decreases afterload.
131
A 55-year-old man is being evaluated for sudden onset of chest pain. He describes the pain as sharp that is improved by sitting up and leaning forward. The chest pain is made worse by inspiration or coughing. An ECG shows new widespread ST segment elevation. Auscultation over the left sternal border is heard in the above audio clip. Which of the following is the most likely diagnosis?
Pericarditis
A pericardial friction rub is most commonly associated with pericarditis. It resembles the sound of squeaky leatherand is often described as grating, scratching, or rasping.
