A 71-year old man is brought to the emergency department because of progressively worsening shortness of breath and fatigue for 3 days. During the last month, he has also noticed dark colored urine. He had an upper respiratory infection 6 weeks ago. He underwent a cholecystectomy at the age of 30 years. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. He immigrated to the US from Italy 50 years ago. Current medications include simvastatin, lisinopril, and metformin. He appears pale. His temperature is 37.1°C (98.8°F), pulse is 96/min, respirations are 21/min, and blood pressure is 150/80 mm Hg. Auscultation of the heart shows a grade 4/6 systolic murmur over the right second intercostal space that radiates to the carotids. Laboratory studies show: Leukocyte count 9,000/mm3 Hemoglobin 8.3 g/dL Hematocrit 24% Platelet count 180,000/mm3 LDH 212 U/L Haptoglobin 15 mg/dL (N=41–165) Serum Na+ 138 mEq/L K+ 4.5 mEq/L CL- 102 mEq/L HCO3- 24 mEq/L Urea nitrogen 20 mg/dL Creatinine 1.2 mg/dL Total bilirubin 1.8 mg/dL Stool testing for occult blood is negative. Direct Coombs test is negative. Echocardiography shows an aortic jet velocity of 4.2 m/s and a mean pressure gradient of 46 mm Hg. Which of the following is the most appropriate next step in management to treat this patient's anemia?
AAortic valve replacement
BAdministration of corticosteroids
CDiscontinuation of medication
DAdministration of hydroxyurea
ESupplementation with iron
Two days after admission for myocardial infarction and subsequent coronary angioplasty, a 65-year-old man becomes distressed and diaphoretic in the cardiac intensive care unit. Suddenly he is no longer responsive. Pulse oximetry does not show a tracing. He has a history of hypertension and depression. Prior to his admission, his medication included ramipril and aripiprazole. Examination shows no carotid pulse. An ECG is shown. After beginning chest compressions, which of the following is the most appropriate step in management of the patient?
AIntravenous procainamide
BCardiac catheterization
CIntravenous amiodarone
DIntravenous magnesium sulfate
EDefibrillation
A 32-year-old woman comes to the physician because of worsening fatigue and shortness of breath. Her symptoms began 8 months ago and have progressively worsened since then. She had recurrent episodes of joint pain and fever during childhood. She does not smoke or drink alcohol. She emigrated from the Congo with her parents when she was 12 years old. Her temperature is 37.4°C (99.3°F), pulse is 90/min and regular, respirations are 18/min, and blood pressure is 140/90 mm Hg. There is an opening snap followed by a diastolic murmur at the fifth left intercostal space in the midclavicular line. If left untreated, this patient is at greatest risk for which of the following complications?
APulmonary edema
BSystemic thromboembolism
CPulmonary hypertension
DRight heart failure
EAtrial fibrillation
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