Cardiology — MCQs

A previously healthy 10-year-old boy is brought to the emergency department for the evaluation of one episode of vomiting and severe headache since this morning. His mother says he also had difficulty getting dressed on his own. He has not had any trauma. The patient appears nervous. His temperature is 37°C (98.6°F), pulse is 100/min, and blood pressure is 185/125 mm Hg. He is confused and oriented only to person. Ophthalmic examination shows bilateral optic disc swelling. There is an abdominal bruit that is best heard at the right costovertebral angle. A complete blood count is within normal limits. Which of the following is most likely to confirm the diagnosis?

A 26-year-old male professional soccer player is brought to the emergency department due to an episode of syncope during a game. He has felt increasing shortness of breath during the past 3 months. During the past week, he has been feeling chest pain upon exertion. He also tells the doctor that his brother had a sudden death a couple of years ago. His heart rate is 98/min, respiratory rate is 18/min, temperature is 36.5°C (97.7°F), and blood pressure is 110/72 mm Hg. On physical examination, there is a harsh crescendo-decrescendo systolic murmur immediately after S1; it is best heard at the left lower sternal border. There is also a holosystolic murmur at the apex that radiates to the axilla. When the Valsalva maneuver is performed, the murmur becomes louder. An ECG and an echocardiogram are performed, which confirm the diagnosis. What is the most likely cause of this patient's condition?

A 39-year-old woman comes to the physician because of progressive pain and swelling of her wrists and hands for the past 2 months. Her hands are stiff in the morning; the stiffness decreases as she starts her chores. She also reports early-morning neck pain at rest for the past 3 weeks. She has no history of serious illness and takes no medications. Her sister has systemic lupus erythematosus. Vital signs are within normal limits. Examination shows bilateral swelling and tenderness of the wrists, second, third, and fourth metacarpophalangeal joints; range of motion is limited by pain. There is no vertebral tenderness. Cardiopulmonary examination shows no abnormalities. Neurologic examination shows no focal findings. Laboratory studies show: Hemoglobin 12.8 g/dL Leukocyte count 9,800/mm3 Erythrocyte sedimentation rate 44 mm/h Serum Glucose 77 mg/dL Creatinine 1.1 mg/dL Total bilirubin 0.7 mg/dL Alkaline phosphatase 33 U/L AST 14 U/L ALT 13 U/L Rheumatoid factor positive Which of the following is the most appropriate next step in management?

A 62-year-old man returns to his physician for a follow-up examination. During his last visit 1 month ago splenomegaly was detected. He has had night sweats for the past several months and has lost 5 kg (11 lb) unintentionally during this period. He has no history of a serious illness and takes no medications. The vital signs are within normal limits. The physical examination shows no abnormalities other than splenomegaly. The laboratory studies show the following: Hemoglobin 9 g/dL Mean corpuscular volume 95 μm3 Leukocyte count 12,000/mm3 Platelet count 260,000/mm3 Ultrasound shows a spleen size of 15 cm (5.9 in) and mild hepatomegaly. The peripheral blood smear shows teardrop-shaped and nucleated red blood cells (RBCs) and immature myeloid cells. The marrow is very difficult to aspirate but reveals hyperplasia of all 3 lineages. The tartrate-resistant acid phosphatase (TRAP) test is negative. Clonal marrow plasma cells are not seen. JAK-2 is positive. The cytogenetic analysis is negative for translocation between chromosomes 9 and 22. Which of the following is the most appropriate curative management in this patient?

A 24-year-old previously healthy man comes to his physician because of dyspnea and hemoptysis for the past week. Examination shows inspiratory crackles at both lung bases. The remainder of the examination shows no abnormalities. His hemoglobin concentration is 14.2 g/dL, leukocyte count is 10,300/mm3, and platelet count is 205,000/mm3. Urine dipstick shows 2+ proteins. Urinalysis shows 80 RBC/hpf and 1–2 WBC/hpf. An x-ray of the chest shows pulmonary infiltrates. Further evaluation is most likely to show increased serum titers of which of the following?

A 42-year-old man presents to the clinic for a second evaluation of worsening blackened ulcers on the tips of his toes. His past medical history includes diabetes mellitus for which he takes metformin and his most recent HbA1c was 6.0, done 3 months ago. He also has hypertension for which he's prescribed amlodipine and chronic obstructive pulmonary disease (COPD) for which he uses an albuterol-ipratropium combination inhaler. He is also a chronic tobacco user with a 27-pack-year smoking history. He first noticed symptoms of a deep aching pain in his toes. Several months ago, he occasionally felt pain in his fingertips both at rest and with activity. Now he reports blackened skin at the tips of his fingers and toes. Evaluation shows: pulse of 82/min, blood pressure of 138/85 mm Hg, oral temperature 37.0°C (98.6°F). He is thin. Physical examination of his feet demonstrates the presence of 3, 0.5–0.8 cm, eschars over the tips of his bilateral second toes and right third toe. There is no surrounding erythema or exudate. Proprioception, vibratory sense, and monofilament examination are normal on both ventral aspects of his feet, but he lacks sensation over the eschars. Dorsal pedal pulses are diminished in both feet; the skin is shiny and hairless. Initial lab results include a C-reactive protein (CRP) level of 3.5 mg/dL, leukocytes of 6,000/mm3, erythrocyte sedimentation rate (ESR) of 34 mm/hr, and negative antinuclear antibodies. Which part of the patient's history is most directly associated with his current problem?

A 17-year-old girl is brought to the physician for a physical examination prior to participating in sports. She has no history of serious illness. She is on the school's cheerleading team and is preparing for an upcoming competition. Menarche was at 13 years of age, and her last menstrual period was 4 months ago. She is 167 cm (5 ft 6 in) tall and weighs 45 kg (99 lb); BMI is 16.1 kg/m2. Examination shows pale skin with thin, soft body hair. The patient is at increased risk for which of the following complications?

A 59-year-old man is brought to the emergency department by his wife for a 1-hour history of sudden behavior changes. They were having lunch together when, at 1:07 PM, he suddenly dropped his sandwich on the floor. Since then, he has been unable to use his right arm. She also reports that he is slurring his speech and dragging his right foot when he walks. Nothing like this has ever happened before. The vital signs include: pulse 95/min, blood pressure 160/90 mm Hg, and respiratory rate 14/min. The physical exam is notable for an irregularly irregular rhythm on cardiac auscultation. On neurological exam, he has a facial droop on the right half of his face but is able to elevate his eyebrows symmetrically. He has 0/5 strength in his right arm, 2/5 strength in his right leg, and reports numbness throughout the right side of his body. Angiography of the brain will most likely show a lesion in which of the following vessels?

A 58-year-old woman presents to the clinic with an abnormal sensation on the left side of her body that has been present for the past several months. At first, the area seemed numb and she recalls touching a hot stove and accidentally burning herself but not feeling the heat. Now she is suffering from a constant, uncomfortable burning pain on her left side for the past week. The pain gets worse when someone even lightly touches that side. She has recently immigrated and her past medical records are unavailable. Last month she had a stroke but she cannot recall any details from the event. She confirms a history of hypertension, type II diabetes mellitus, and bilateral knee pain. She also had cardiac surgery 20 years ago. She denies fever, mood changes, weight changes, and trauma to the head, neck, or limbs. Her blood pressure is 162/90 mm Hg, the heart rate is 82/min, and the respiratory rate is 15/min. Multiple old burn marks are visible on the left hand and forearm. Muscle strength is mildly reduced in the left upper and lower limbs. Hyperesthesia is noted in the left upper and lower limbs. Laboratory results are significant for: Hemoglobin 13.9 g/dL MCV 92 fL White blood cells 7,500/mm3 Platelets 278,000/mm3 Creatinine 1.3 U/L BUN 38 mg/dL TSH 2.5 uU/L Hemoglobin A1c 7.9% Vitamin B12 526 ng/L What is the most likely diagnosis?

A 40-year-old man comes to the physician because of fatigue, increased sweating, and itching in his legs for the past 2 years. He has chronic bronchitis. He has smoked two packs of cigarettes daily for 24 years and drinks one to two beers every night. His only medication is a tiotropium bromide inhaler. His vital signs are within normal limits. He is 175 cm (5 ft 9 in) tall and weighs 116 kg (256 lb); BMI is 38 kg/m2. Physical examination shows facial flushing and bluish discoloration of the lips. Scattered expiratory wheezing and rhonchi are heard throughout both lung fields. Abdominal examination shows no abnormalities. Laboratory studies show: Erythrocyte count 6.9 million/mm3 Hemoglobin 20 g/dL Mean corpuscular volume 91 μm3 Leukocyte count 13,000/mm3 Platelet count 540,000/mm3 Serum Ferritin 8 ng/mL Iron 48 μg/dL Iron binding capacity 402 μg/dL (N: 251 - 406 μg/dL) Which of the following is the most appropriate next step in treatment?