A 55-year-old man with a past medical history of obesity and hyperlipidemia suddenly develops left-sided chest pain and shortness of breath while at work. He relays to coworkers that the pain is intense and has spread to his upper left arm over the past 10 minutes. He reports it feels a lot like the “heart attack” he had a year ago. He suddenly collapses and is unresponsive. Coworkers perform cardiopulmonary resuscitation for 18 minutes until emergency medical services arrives. Paramedics pronounce him dead at the scene. Which of the following is the most likely cause of death in this man?
Q72
A 62-year-old man is brought to the emergency department because of syncope. He reports sudden onset of palpitations followed by loss of consciousness while carrying his groceries to his car. He is unable to recall any further details and does not have any chest pain or dizziness. He has a history of hypertension, type 2 diabetes mellitus, gastroparesis, and osteoarthritis of the knees. Medications include lisinopril, metformin, and ondansetron as needed for nausea. He also takes methadone daily for chronic pain. Apart from an abrasion on his forehead, he appears well. His temperature is 37.2 °C (98.9 F), heart rate is 104/min and regular, and blood pressure is 135/70 mm Hg. While he is in the emergency department, he loses consciousness again. Telemetry shows polymorphic ventricular tachycardia with cyclic alteration of the QRS axis that spontaneously resolves after 30 seconds. Results of a complete blood count, serum electrolyte concentrations, and serum thyroid studies show no abnormalities. Cardiac enzymes are within normal limits. Which of the following is the most likely underlying cause of this patient's syncope?
Q73
A 45-year-old woman comes to the physician because of multiple episodes of dizziness over the past 3 months. Episodes last between 20 minutes and 1 hour. During the episodes she experiences the sudden onset of spinning sensations and imbalance, associated with a ringing in her left ear. She also reports progressive left-sided hearing loss and is unable to follow conversations in noisy surroundings. She has had an upper respiratory infection for the past 5 days, which is being treated with erythromycin. She has been otherwise healthy. Her vital signs are within normal limits. Examination shows no abnormalities. Pure tone audiometry shows a combined low- and high-frequency sensory loss of the left ear with normal hearing in the mid frequencies. Which of the following is the most appropriate initial step in management?
Arrhythmias US Medical PG Practice Questions and MCQs
Question 71: A 55-year-old man with a past medical history of obesity and hyperlipidemia suddenly develops left-sided chest pain and shortness of breath while at work. He relays to coworkers that the pain is intense and has spread to his upper left arm over the past 10 minutes. He reports it feels a lot like the “heart attack” he had a year ago. He suddenly collapses and is unresponsive. Coworkers perform cardiopulmonary resuscitation for 18 minutes until emergency medical services arrives. Paramedics pronounce him dead at the scene. Which of the following is the most likely cause of death in this man?
A. Pericarditis
B. Aortic dissection
C. Atrial fibrillation
D. Ventricular tachycardia (Correct Answer)
E. Free wall rupture
Explanation: ***Ventricular tachycardia***
- The patient's history of MI **1 year ago** creates a substrate of **scarred myocardium** that predisposes to life-threatening ventricular arrhythmias.
- The current presentation of sudden chest pain radiating to the arm suggests **acute re-infarction**, which triggers electrical instability in already compromised myocardium.
- **Ventricular tachycardia (VT)** degenerating to **ventricular fibrillation (VF)** is the **most common cause of sudden cardiac death** in patients with prior MI, especially during acute ischemic events.
- The rapid collapse and death within minutes, despite CPR, is classic for fatal ventricular arrhythmia.
*Free wall rupture*
- Free wall rupture is a **mechanical complication** that occurs **3-14 days** (typically days 3-7) after an **acute MI**, not 1 year later.
- By 1 year post-MI, the ventricular wall has either healed with fibrous scar tissue or formed a chronic ventricular aneurysm.
- While this would cause sudden death via cardiac tamponade, the **timing makes this unlikely** in this scenario.
*Pericarditis*
- Pericarditis causes **pleuritic chest pain** that is sharp, positional, and typically relieved by leaning forward.
- It is **not an immediate cause of sudden cardiac death** and would not explain the rapid collapse and unresponsiveness.
- While post-MI (Dressler) pericarditis can occur weeks after MI, it doesn't cause this presentation.
*Aortic dissection*
- Aortic dissection presents with **sudden, severe, tearing chest pain** often radiating to the back.
- While potentially fatal, the patient's description of pain "a lot like the heart attack he had a year ago" and his cardiac risk factors make **recurrent MI with fatal arrhythmia more likely**.
- No mention of blood pressure differential or pulse deficits that would suggest dissection.
*Atrial fibrillation*
- Atrial fibrillation is a **supraventricular arrhythmia** that causes palpitations, dyspnea, and irregular pulse.
- It is **not typically immediately fatal** in isolation and does not cause sudden collapse and death within minutes.
- While AF can lead to stroke or heart failure over time, it doesn't explain this acute sudden cardiac death.
Question 72: A 62-year-old man is brought to the emergency department because of syncope. He reports sudden onset of palpitations followed by loss of consciousness while carrying his groceries to his car. He is unable to recall any further details and does not have any chest pain or dizziness. He has a history of hypertension, type 2 diabetes mellitus, gastroparesis, and osteoarthritis of the knees. Medications include lisinopril, metformin, and ondansetron as needed for nausea. He also takes methadone daily for chronic pain. Apart from an abrasion on his forehead, he appears well. His temperature is 37.2 °C (98.9 F), heart rate is 104/min and regular, and blood pressure is 135/70 mm Hg. While he is in the emergency department, he loses consciousness again. Telemetry shows polymorphic ventricular tachycardia with cyclic alteration of the QRS axis that spontaneously resolves after 30 seconds. Results of a complete blood count, serum electrolyte concentrations, and serum thyroid studies show no abnormalities. Cardiac enzymes are within normal limits. Which of the following is the most likely underlying cause of this patient's syncope?
A. Prinzmetal angina
B. Fast accessory conduction pathway
C. Brugada syndrome
D. Prolonged QT interval (Correct Answer)
E. Hypomagnesemia
Explanation: ***Prolonged QT interval***
- The patient experienced **polymorphic ventricular tachycardia** with cyclic alteration of the **QRS axis** (Torsades de Pointes), which is characteristic of a prolonged QT interval.
- **Methadone is known to prolong the QT interval**, and the patient's history of syncope preceded by palpitations is consistent with this arrhythmia.
*Prinzmetal angina*
- Prinzmetal angina involves **coronary artery spasm**, leading to **transient myocardial ischemia**, typically causing chest pain, not primarily syncope from polymorphic VT.
- While it can cause arrhythmias, the characteristic EKG finding would be **ST-segment elevation during pain**, which is not described.
*Fast accessory conduction pathway*
- A fast accessory pathway (e.g., in Wolfe-Parkinson-White syndrome) can lead to **AV reentrant tachycardia** or **pre-excitation** with atrial fibrillation, but not typically polymorphic VT with cyclic QRS alteration.
- The EKG would show a **delta wave** and a short PR interval, which is not mentioned.
*Brugada syndrome*
- Brugada syndrome is an inherited channelopathy **characterized by specific EKG patterns** (e.g., coved-type ST elevation in V1-V3) and an increased risk of sudden cardiac death due to ventricular arrhythmias.
- The patient's EKG findings of polymorphic VT with cyclic QRS alteration are not typical of Brugada syndrome-induced arrhythmia.
*Hypomagnesemia*
- While **hypomagnesemia can prolong the QT interval** and lead to Torsades de Pointes, the patient's **serum electrolyte concentrations were normal**, ruling out this direct cause.
- Magnesium levels would need to be critically low for such an effect, and this is typically detected on blood tests.
Question 73: A 45-year-old woman comes to the physician because of multiple episodes of dizziness over the past 3 months. Episodes last between 20 minutes and 1 hour. During the episodes she experiences the sudden onset of spinning sensations and imbalance, associated with a ringing in her left ear. She also reports progressive left-sided hearing loss and is unable to follow conversations in noisy surroundings. She has had an upper respiratory infection for the past 5 days, which is being treated with erythromycin. She has been otherwise healthy. Her vital signs are within normal limits. Examination shows no abnormalities. Pure tone audiometry shows a combined low- and high-frequency sensory loss of the left ear with normal hearing in the mid frequencies. Which of the following is the most appropriate initial step in management?
A. Begin topiramate therapy
B. Perform Epley maneuver
C. Reduce caffeine intake (Correct Answer)
D. Discontinue erythromycin
E. Begin fluoxetine therapy
Explanation: ***Reduce caffeine intake***
- The patient presents with classic **Ménière's disease**: episodic vertigo lasting 20 minutes to 1 hour, unilateral tinnitus, progressive unilateral sensorineural hearing loss, and characteristic audiometry showing low- and high-frequency loss with preserved mid-frequencies.
- **Lifestyle modifications** including **reducing caffeine, alcohol, and sodium intake** are the **most appropriate initial step** in management and represent evidence-based first-line conservative treatment.
- These dietary changes help reduce endolymphatic pressure and may decrease the frequency and severity of attacks.
- The symptoms have been present for **3 months**, predating the recent URI and erythromycin use by months, supporting a primary vestibular disorder rather than drug-induced pathology.
*Discontinue erythromycin*
- While macrolide antibiotics can rarely cause ototoxicity, this typically occurs with **high-dose intravenous erythromycin**, not standard oral doses for URI.
- The patient's symptoms began **3 months ago**, well before starting erythromycin **5 days ago**, making drug-induced ototoxicity unlikely.
- Aminoglycosides, loop diuretics, and platinum-based chemotherapy are the classic ototoxic agents, not typical oral erythromycin.
*Begin topiramate therapy*
- **Topiramate** is used for **migraine prophylaxis**, which may be considered for vestibular migraine, but there is no evidence of migraine features in this presentation.
- Not indicated as initial management for Ménière's disease.
*Perform Epley maneuver*
- The **Epley maneuver** is specific for **benign paroxysmal positional vertigo (BPPV)**, characterized by brief (seconds to minutes) episodes triggered by specific head positions.
- This patient's episodes last **20 minutes to 1 hour**, are associated with tinnitus and hearing loss, and are not positionally triggered, making BPPV unlikely.
*Begin fluoxetine therapy*
- **Fluoxetine** may be used for chronic vestibular disorders with comorbid anxiety or depression, or as part of vestibular migraine management.
- Not appropriate as initial management for Ménière's disease without evidence of psychiatric comorbidity.
