Cardiology — MCQs

A 27-year-old woman with a history of a "heart murmur since childhood" presents following a series of syncopal episodes over the past several months. She also complains of worsening fatigue over this time period, and notes that her lips have begun to take on a bluish tinge, for which she has been using a brighter shade of lipstick. You do a careful examination, and detect a right ventricular heave, clubbing of the fingers, and 2+ pitting edema bilaterally to the shins. Despite your patient insisting that every doctor she has ever seen has commented on her murmur, you do not hear one. Transthoracic echocardiography would most likely detect which of the following?

A 47-year-old man is brought to the emergency department by his wife 30 minutes after the onset of nausea, sweating, and palpitations. On the way to the hospital, he had an episode of non-bloody vomiting and intravenous fluid resuscitation has been started. He has no history of similar symptoms. For the past 2 weeks, he has been trying to lose weight and has adjusted his diet and activity level. He eats a low-carb diet and runs 3 times a week for exercise; he came home from a training session 3 hours ago. He was diagnosed with type 2 diabetes mellitus 2 years ago that is controlled with basal insulin and metformin. He appears anxious. His pulse is 105/min and blood pressure is 118/78 mm Hg. He is confused and oriented only to person. Examination shows diaphoresis and pallor. A fingerstick blood glucose concentration is 35 mg/dL. Shortly after, the patient loses consciousness and starts shaking. Which of the following is the most appropriate next step in management?

A 38-year-old male presents to his primary care physician complaining of increasing shortness of breath over the past 2 months. He reports experiencing an extended illness of several weeks as a child that required him to miss school. He is unsure but believes it involved a sore throat followed by a fever and joint pains. He does not recall seeing a physician or receiving treatment for this. Today, on physical examination, cardiac auscultation reveals an opening snap after the second heart sound followed by a diastolic murmur. A follow-up echocardiogram is conducted. Which of the following best explains the pathophysiology of this patient's condition?

A 45-year-old woman presents with headaches. She says the headaches started about a month ago, and although initially, they were intermittent, over the past 2 weeks, they have progressively worsened. She describes the pain as severe, worse on the left than the right, and relieved somewhat by non-steroidal anti-inflammatory drugs (NSAIDs). The headaches are usually associated with nausea, vomiting, and photophobia. She denies any changes in vision, seizures, similar past symptoms, or focal neurologic deficits. Past medical history is significant for a posterior communicating artery aneurysm, status post-clipping 10 years ago. Her vital signs include: blood pressure 135/90 mm Hg, temperature 36.7°C (98.0°F), pulse 80/min, and respiratory rate 14/min. Her body mass index (BMI) is 36 kg/m2. On physical examination, the patient is alert and oriented. Her pupils are 3 mm on the right and mid-dilated on the left with subtle left-sided ptosis. Ophthalmic examination reveals a cup-to-disc ratio of 0.4 on the right and 0.5 on the left. The remainder of her cranial nerves are intact. She has 5/5 strength and 2+ reflexes in her upper extremities bilaterally and her left leg; her right leg has 3/5 strength with 1+ reflexes at the knee and ankle. The remainder of the physical examination is unremarkable. Which of the following findings in this patient most strongly suggests a further diagnostic workup?

A 52-year-old woman comes to the physician because of swelling of her legs for 2 months. She has noticed that her legs gradually swell up throughout the day. Two years ago, she underwent a coronary angioplasty. She has hypertension and coronary artery disease. She works as a waitress at a local diner. Her father died of liver cancer at the age of 61 years. She has smoked one pack of cigarettes daily for 31 years. She drinks one to two glasses of wine daily and occasionally more on weekends. Current medications include aspirin, metoprolol, and rosuvastatin. Vital signs are within normal limits. Examination shows 2+ pitting edema in the lower extremities. There are several dilated, tortuous veins over both calves. Multiple excoriation marks are noted over both ankles. Peripheral pulses are palpated bilaterally. The lungs are clear to auscultation. Cardiac examination shows no murmurs, gallops, or rubs. The abdomen is soft and nontender; there is no organomegaly. Which of the following is the most appropriate next step in management?

A 51-year-old woman comes to the physician because of worsening chest pain on exertion. She was diagnosed with coronary artery disease and hyperlipidemia 3 months ago. At the time of diagnosis, she was able to walk for 15 minutes on the treadmill until the onset of chest pain. Her endurance had improved temporarily after she began medical treatment and she was able to walk her dog for 30 minutes daily without experiencing chest pain. Her current medications include daily aspirin, metoprolol, atorvastatin, and isosorbide dinitrate four times daily. Her pulse is 55/min and blood pressure is 115/78 mm Hg. Treadmill walking test shows an onset of chest pain after 18 minutes. Which of the following is most likely to improve this patient’s symptoms?

A 39-year-old woman comes to the physician because of a 5-month history of episodic retrosternal chest pain. She currently feels well. The pain is unrelated to exercise and does not radiate. The episodes typically last less than 15 minutes and lead to feelings of anxiety; resting relieves the pain. She has not had dyspnea or cough. She has hyperlipidemia treated with simvastatin. She does not smoke, drink alcohol, or use illicit drugs. Her temperature is 37°C (98.6°F), pulse is 104/min, respirations are 17/min, and blood pressure is 124/76 mm Hg. Cardiopulmonary examination shows no abnormalities. An ECG shows sinus tachycardia. Which of the following is the most appropriate next step in the evaluation of coronary artery disease in this patient?

A 61-year-old woman comes to her physician for a burning sensation and numbness in her right hand for 4 weeks. The burning sensation is worse at night and is sometimes relieved by shaking the wrist. In the past week, she has noticed an exacerbation of her symptoms. She has rheumatoid arthritis and type 2 diabetes mellitus. Her medications include insulin, methotrexate, and naproxen. Her vital signs are within normal limits. Examination shows swan neck deformities of the fingers on both hands and multiple subcutaneous nodules over bilateral olecranon processes. There is tingling and numbness over the right thumb, index finger, and middle finger when the wrist is actively flexed. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next best step in management?

A 26-year-old man is brought to the emergency department due to right-sided facial and upper extremity weakness and aphasia. The patient was in his usual state of health until two hours prior to presentation, when he was eating breakfast with a friend and acutely developed the aforementioned symptoms. Medical history is unremarkable except for mild palpitations that occur during times of stress or when drinking coffee. Physical examination is consistent with the clinical presentation. Laboratory testing is unremarkable and a 12-lead electrocardiogram is normal. A non-contrast head CT and diffusion-weighted MRI shows no intracranial hemorrhage and an isolated superficial cerebral infarction. Transthoracic echocardiography with agitated saline mixed with air shows microbubbles in the left heart. There is a possible minor effusion surrounding the heart and the ejection fraction is within normal limits. Which of the following is most likely the cause of this patient's clinical presentation?

A 25-year-old female presents to a physician's office with complaints of having no energy for the last 2 weeks and sometimes feeling like staying home all day. She works for a technology start-up company and is attending graduate school part-time in the evening. She is very concerned about her health and tries to eat a balanced diet. She runs daily and takes yoga classes 3 times a week. She gets together with her friends every weekend and has continued to do so the last few weeks. Her schedule is quite hectic, and she is always on the go. There have been no changes in her sleep, appetite, or daily routine. She denies having flu-like symptoms, headaches, body aches, indigestion, weight loss, agitation, or restlessness. She admits to moderate drinking and marijuana use but has never smoked cigarettes. The medical history is unremarkable, and she takes no medications other than vitamin C for cold prevention. A friend suggested she take an herbal product containing ginseng and St. John's wort for her decreased energy levels. Her body mass index (BMI) is 22 kg/m2. The physical examination reveals no findings and lab testing shows the following: Sodium 138 mEq/L Potassium 3.9 mEq/L Chloride 101 mEq/L Thyroid stimulating hormone 3.5 μU/mL Hemoglobin (Hb%) 13.5 g/dL Mean corpuscular hemoglobin (MCH) 31 pg Mean corpuscular volume (MCV) 85 fL Leucocyte count 5000/mm3 Platelet count 250,000/mm3 The physician advises her to reduce the alcohol consumption and marijuana use. What else should she be advised?