Cardiology — MCQs

A 74-year-old man returns to his physician to follow-up on laboratory studies obtained for anemia 2 weeks ago. He has no complaints. He has a 20-year history of hypertension and several years of knee osteoarthritis. He walks 2 miles a day. He does not smoke. He drinks alcohol moderately. He takes hydrochlorothiazide, losartan, and pain killers, including ibuprofen. The vital signs include: temperature 37.1°C (98.8°F), pulse 68/min, respiratory rate 12/min, and blood pressure 110/70 mm Hg. The physical examination shows no abnormalities. The laboratory studies show the following: Laboratory test Hemoglobin 10 g/dL Mean corpuscular volume 75 μm3 Leukocyte count 5,000/mm3 Platelet count 350,000/mm3 ESR 18 mm/hr Serum Ferritin 5 μg/L Iron 30 μg/L Total iron-binding capacity 500 μg/dL Calcium (Ca+) 9 mg/dL Albumin 4 g/dL Urea nitrogen 14 mg/dL Creatinine 0.9 mg/dL Monoclonal protein on serum electrophoresis is 12 g/L (non-IgM). Clonal bone marrow plasma cells comprise 4% of the total number of cells. Skeletal survey with magnetic resonance imaging reveals no pathologic findings. In addition to iron deficiency anemia, which of the following diagnosis is most appropriate to consider?

A 29-year-old woman comes to her primary care physician hoping she is pregnant. She reports that she had been taking oral contraceptive pills, but she stopped when she began trying to get pregnant about 7 months ago. Since then she has not had her period. She took a few home pregnancy tests that were negative, but she feels they could be wrong. She says she has gained 4 lbs in the past month, and her breasts feel full. Today, she expressed milk from her nipples. She complains of fatigue, which she attributes to stress at work, and headaches, to which she says “my sister told me she had headaches when she was pregnant.” She denies spotting or vaginal discharge. Her last menstrual period was at age 22, prior to starting oral contraceptive pills. Her medical and surgical history are non-significant. She has no history of sexually transmitted infections. She reports she and her husband are having intercourse 3-4 times a week. Her family history is significant for breast cancer in her mother and an aunt who died of ovarian cancer at 55. On physical examination, no breast masses are appreciated, but compression of the nipples produces whitish discharge bilaterally. A bimanual pelvic examination is normal. A urine pregnancy test is negative. Which of the following is the best initial step in management for this patient?

A 45-year-old woman presents to the office complaining of bilateral joint pain and stiffness in her hand joints for the past 3 months. She reports increasing difficulty holding a coffee cup or pen due to stiffness, especially in the morning. Over-the-counter ibuprofen partially relieves her symptoms. Past medical history is significant for dysthymia and gastroesophageal reflux disease. Vital signs are normal except for a low-grade fever. On examination, there is mild swelling and tenderness in the proximal interphalangeal and metacarpophalangeal joints and wrists. Nontender and non-pruritic nodules near the elbows are noted. Chest and abdominal examination are normal. X-rays of the hands reveal soft tissue swelling, joint space narrowing, and bony erosions. Her hematocrit is 32%, and her erythrocyte sedimentation rate is 40 mm/hr. This patient is at greatest risk for which of the following?

A 42-year-old man presents to the emergency department with persistent cough. The patient states that for the past week he has been coughing. He also states that he has seen blood in his sputum and experienced shortness of breath. On review of systems, the patient endorses fever and chills as well as joint pain. His temperature is 102°F (38.9°C), blood pressure is 159/98 mmHg, pulse is 80/min, respirations are 14/min, and oxygen saturation is 98% on room air. Laboratory values are ordered as seen below. Hemoglobin: 12 g/dL Hematocrit: 36% Leukocyte count: 7,500/mm^3 with normal differential Platelet count: 107,000/mm^3 Serum: Na+: 138 mEq/L Cl-: 101 mEq/L K+: 4.2 mEq/L HCO3-: 24 mEq/L BUN: 32 mg/dL Glucose: 99 mg/dL Creatinine: 1.9 mg/dL Ca2+: 10.0 mg/dL AST: 11 U/L ALT: 10 U/L Urine: Color: Amber, cloudy Red blood cells: Positive Protein: Positive Which of the following is the best next step in management?

A 64-year-old woman presents to her primary care physician complaining of difficulty maintaining her balance while walking. Her husband comes along to the appointment with her, because he feels that she has not been acting herself at home lately. After further questioning him, it is noted that she has recently been voiding urine unintentionally at inappropriate times. If there is suspicion for an intracranial process, what would most likely be seen on MRI and what is the treatment?

A 52-year-old woman presents with fatigue and pain of the proximal interphalangeal and metacarpophalangeal joints for the past 6 months. She also has knee and wrist pain that has been present for the past 2 months, with morning stiffness that improves over the course of the day. Physical examination is significant for subcutaneous nodules. Laboratory tests are significant for the following: Hemoglobin 12.5 g/dL Red blood cell count 4.9 x 106/µL White blood cell count 5,000/mm3 Platelet count 180,000/mm3 Coombs' test Negative C-reactive peptide (CRP) Elevated Erythrocyte sedimentation rate (ESR) Elevated Anti-cyclic citrullinated peptide antibody (anti-CCP antibody) Moderately positive Anti-nuclear antibody (ANA) Negative Rheumatoid factor (RF) Negative What is the most likely human leukocyte antigen (HLA) subtype associated with this disease?

A 27-year-old woman presents to the emergency department for sudden, bilateral, painful loss of vision. She states that her symptoms started last night and have persisted until this morning. The patient has a past medical history of peripheral neuropathy which is currently treated with duloxetine and severe anxiety. Her temperature is 99.5°F (37.5°C), blood pressure is 100/60 mmHg, pulse is 100/min, respirations are 15/min, and oxygen saturation is 98% on room air. On physical exam, the patient demonstrates 4/5 strength in her upper and lower extremities with decreased sensation in her fingers bilaterally. Towards the end of the exam, the patient embarrassingly admits to having an episode of urinary incontinence the previous night. An MRI is obtained and is within normal limits. Which of the following represents the best next diagnostic step and its most likely result for this patient?

A 70-year-old male patient comes into your office because of leg pain. The patient states that his calves have been hurting more and more over the last two months. The pain isn't present at rest, but the pain develops as the patient starts walking and exerting himself. He states that stopping to rest is the only thing that relieves the pain. Of note, the patient's medical history is significant for 30-pack-years of smoking, hypertension, hyperlipidemia, and a previous myocardial infarction status-post angioplasty and stent. On exam, the patient's lower legs (below knee) have glossy skin with loss of hair. The dorsalis pedis pulses are barely palpable bilaterally. Which of the following is the best initial therapy for this patient?

A 62-year-old man presents to the emergency department with increased fatigue and changes in his vision. The patient states that for the past month he has felt abnormally tired, and today he noticed his vision was blurry. The patient also endorses increased sweating at night and new onset headaches. He states that he currently feels dizzy. The patient has a past medical history of diabetes and hypertension. His current medications include insulin, metformin, and lisinopril. His temperature is 99.5°F (37.5°C), blood pressure is 157/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Cardiopulmonary exam is within normal limits. HEENT exam reveals non-tender posterior and anterior chain lymphadenopathy. Abdominal exam reveals splenomegaly and hepatomegaly. There are large, non-tender palpable lymph nodes in the patient's inguinal region. Neurological exam is notable for decreased sensation in the patient's hands and feet. He also complains of a numb/tingling pain in his extremities that has been persistent during this time. Dermatologic exam is notable for multiple bruises on his upper and lower extremities. Which of the following is most likely to be abnormal in this patient?

A 27-year-old woman presents to your office complaining of difficulty swallowing, and she describes that "there is something in the back of her throat". Furthermore, she also feels an "achy" chest pain that has been getting progressively worse over the last few weeks. She denies having any fever, shortness of breath, cough, abdominal pain, heartburn, nausea, or vomiting. The patient has a history of wrist fracture as a child, migraines, and a recent diagnosis of myasthenia gravis. Which of the following is the most likely diagnosis?