A 42-year-old man presents with a chief complain of severe, sharp chest pain that started suddenly while lifting heavy objects. The pain began in a midsternal location, then radiated to both shoulders as well as to his back. It has been constant for 18 hours but started to get worse during the past 2 hours. On physical examination, the patient is in severe distress, with a temp of 36.9C, BP of 160/90 mmHg, pulse of 92/min, and respirations of 18/min. Heart sounds are normal without rubs or murmur. An ECG reveals a normal tracing. Which of the following is the most appropriate next step in diagnosis?

A 47 year-old woman comes to the physician because she has had several episodes of severe chest pain that awoke her in the early morning. She has no history of major physical illness or drug abuse, drinks alcohol only occasionally, and does not smoke. Her temperature is 37C, BP is 126/78 mmHg, pulse is 78/min and regular,and respiration are 12/min. An ECG reveals no abnormalities. No further studies are undertaken, and the physician tells the patient that her pain is probably of psychological origin. After a few days, the patient comes to the ED at 5AM complaining of chest pain. An ECG reveals sinus rhythm with ST segment elevation. The patient is admitted, and coronary arteriography is performed, revealing no stenotic lesions. Intravenous administration of ergonovine during arteriography trigger chest pain accompanied by ST elevation on ECG. Which of the following is the most likely diagnosis?

A 73-year-old man presents to the ED after a syncopal episode. He had been resting in bed for approximately one week after injuring his right knee. This morning, his knee felt better and he attempted to get up from bed. However, upon attempting to stand, he sustained a brief loss of consciousness. He had no symptoms or medical history prior to the knee injury. Medications include acetaminophen and ibuprofen for knee pain. On exam, his pulse is 73/min, respirations are 14/min, and blood pressure is 136/83 mmHg. Which of the following is the most likely cause of this patient's syncope?

A 24-year-old man experiences syncope while shoveling snow. He regains consciousness within 1 minute. He has had some shortness of breath and chest pains recently, related primarily to exercise. He denies illicit drug use, His temperature is 37.2°C, blood pressure is 126/76 mmHg, pulse is 76/min, and respirations are 14/min. Physical examination shows a well-built man in no apparent distress. Lungs are clear. A crescendo decrescendo systolic murmur is heard along the left sternal border without carotid radiation. Chest x-ray is normal. Which of the following is the most likely cause of his syncopal episode?

A 46-year-old man comes to the emergency department complaining of weakness and chest tightness on and off over the last 24 hours. He has no past medical history. He does not use tobacco, alcohol, or illicit drugs. The patient's father had a myocardial infarction at age 68, and his mother has myasthenia gravis. An ECG is performed: This patient should be evaluated for which of the following?

A 45-year-old white male presents to the ED after an episode of syncope. His medical history is unremarkable except for an upper respiratory infection one week ago. On physical examination, his temperature is 37.2° C, pulse is 90/min, blood pressure is 100/60 mmHg and respirations are 13/min. His neck veins are distended and his heart sounds are distant. His lungs are clear to auscultation bilaterally. Chest x-ray reveals small bilateral pleural effusions and an enlarged cardiac silhouette. Which of the following EKG findings is fairly specific for his condition?

A 78-year-old man is brought to the emergency department after a brief episode of syncope. Since yesterday, he has been fatigued and lightheaded. The patient has no chest pain or palpitations. He has a history of hypertension, stable coronary artery disease, type 2 diabetes mellitus, and hyperlipidemia. The patient's blood pressure is 82/44 mm Hg. He appears mildly lethargic but answers questions appropriately. Lungs are clear on auscultation. The patient's extremities are cold and capillary refill is 3 seconds. ECG is shown In the Image. Which of the following Is the most appropriate next step in management of this patient?

A 22-year-old woman is brought to the office by her mother due to recurrent syncopal episodes. The first episoce occurred about a year ago when her roommate committed suicide. The patient has had several similar episodes since then, often provoked by strong emotion. The episodes are preceded by lightheadedness, weakness, and blurred vision, last about 3 minutes, and end with rapid recovery of consciousness. She has had no significant injuries related to syncope except once when she had superficial bruises. Her medical history is insignificant. The patient takes no medications and does not use alcohol or illicit drugs. Her blood pressure is 110/70 mm Hg while supine and 108/70 mmHg while standing. Physical examination findings are within normal limits. ECG performed a month ago was normal. Which of the following is the best next step in management of this patient?

A 55-year-old man has had crushing substernal chest pain on exertion over the past 6 weeks. He had a myocardial infarction 2 months ago. He takes nitroglycerin as needed and one aspirin daily. He has smoked two packs of cigarettes daily for 30 years. Examination shows normal heart sounds and no carotid or femoral bruits. Treatment with a ß-adrenergic blocking agent is most likely to improve his symptoms due to which of the following mechanisms?

A 14-year-old African Amencan boy comes to the physician after his older brother experienced sudden cardiac arrest during a hiking trip. He has no current complaints and does not use tobacco, alcohol, or illicit drugs. His blood pressure is 110/60 mm Hg and pulse is 75/min. Physical exammation shows a supple neck with no jugular venous distension. Carotic pulse seems to have a dual upstroke. There is strong apical impulse, and a systolic ejection murmur is heard along the left sternal border. The lungs are clear to auscultation. Which of the following is most likely to increase the murmur intensity in this patient?

A 67-year-old man comes to the ED with lightheadedness and generalized weakness for the last 2 days. He has chronic stable angina with exertion. However, over the last 2 days he has also had occasional chest discomfort at rest. The patient's medical problems include hypertension and bronchial asthma. He has no shortness of breath, cough, or peripheral edema. His only medications are aspirin and isosorbide dinitrate. Blood pressure is 105/66 mm Hg. ECG obtained in the emergency departent is shown here. Which of the following is the best next step in management of this patient?

A 22-year-old man is brought to the ED after he passed out on the field while playing soccer. The episode lasted only 2 minutes and was not associated with any post-event confusion, sleepiness, or weakness. The patient describes himself as "healthy" but on detailed review of systems admits to occasional lightheadedness and vague chest discomfort while playing active sport. His grandfather died suddenly at age 40 from a "heart attack." BP is 128/74 mmHg and heart rate is 67/min and regular. On examination, a S4 is heard at the cardiac apex. There is a 3/6 midsystolic murmur best heard at the left lower sternal border that does not radiate to the base of the heart or to the neck. The patient will most likely benefit from which of the following medications?

A 55-year-old man has had crushing substernal chest pain on exertion over the past 6 weeks. He had a myocardial infarction 2 months ago. He takes nitroglycerin as needed and one aspirin daily. He has smoked two packs of cigarettes daily for 30 years. Examination shows normal heart sounds and no carotid or femoral bruits. Treatment with a ß-adrenergic blocking agent is most likely to improve his symptoms due to which of the following mechanisms?

A 48-year-old woman comes to the office with chest pain that has been occurring over the last several weeks. The pain is not reliably related to exertion. She is comfortable now. The location of the pain is retrosternal. She has no hypertension, and the EKG is normal. What is the most appropriate next step in management?

Correcting which of the following risk factors for CAD will result in the most immediate benefit for the patient?

A man with atypical chest pain is found to have normal nuclear isotope uptake in his myocardium at rest. On exercise, there is decreased uptake in the inferior wall. Two hours after exercise, the uptake of nuclear isotope returns to normal. What is the right thing to do?

A 75-yo man comes to clinic due to a 6-month history of periodic substemal chest pressure, which he experiences when walking uphill or climbing 2 flights of stairs. His medical history is significant for hyperlipidemia and he takes atorvastatin. The patient smokes a pack of cigarettes a day and occasionally consumes alcohol. BP is 120/78 mmHg and pulse is 75/min. Physical examination shows no abnormalities. Resting ECG is normal. Treadmill stress test shows horizontal ST-segment depression in leads II, III, and aVF at 73% of maximally predicted heart rate, Echocardiography demonstrates normal resting LV systolic function. The patient prefers medical management and is started on aspirin and as needed sublingual nitroglycerin; a third medication is prescribed to help prevent his symptoms. This third medication most likely acts through which of the following primary mechanisms?

A 55-year-old woman presents to the ED because of chest pain. The pain, which has lasted 3 hours, is substernal and dull in nature, with no relation to respiration or position. The pain does not radiate and is accompanied by weakness, lightheadedness, and nausea. She has received oxygen, aspirin, a continuous infusion of nitroglycerin, and a beta blocker. Her chest x-ray film is normal, and her ECG is remarkable for inverted T waves in lead II, III, aVF. Which of the following is the most important next step in management?

A 34-year-old man is being evaluated for a 3-month history of chest pain. He describes frequent episodes of substernal squeezingtype chest discomfor that radiates to his neck. The episodes are not related to any particular activity, often occur at rest, and last up to 2 hours. He has no shortness of breath, wheezing, palpitations, syncope, or leg swelling. The patient does not use tobacco, alcohol, or illicit drugs. Family history is unremarkable. His blood pressure is 123/72 mm Hg, and pulse is 76/min. BMI is 32 kg/m2. ECG is normal. Exercise stress test shows no abnormalities. Which of the following is the most likely cause of this patient's chest pain?

An 82-year-old woman comes to the ED with sudden-onset epigastric pain. The pain started an hour ago and is 8/10 in severity. The patient has been nauseated and vomited twice in the past hour. Her past medical history includes type 2 diabetes mellitus, hyperlipidemia, hypertension, peptic ulcer disease 10 years ago, and cholelithiasis. She has a 40-pack-year smoking history and drinks alcohol occasionally. Her temp is 36.8 C, BP is 140/80 mmHg, pulse is 90/min, and respirations are 14/min. The lungs are clear to auscultation. Abdominal examination shows a soft abdomen with no tenderness. Murphy's sign is negative. Which of the following studies should be performed first in this patient?

A postmenopausal woman develops chest pain immediately on hearing the news of her son's death in a war. She develops acute chest pain, dyspnea, and ST segment elevation in leads V2 to V4 on ECG. Elevated levels of troponin confirm an acute MI. Coronary angiography is normal including an absence of vasospasm on provocative testing. Echocardiography reveals apical left ventricular "ballooning.” What is the presumed mechanism of this disorder?

A man comes to the emergency department with chest pain for the last hour that is crushing in quality and does not change with respiration or the position of his body. An EKG shows ST segment depression in leads V2 to V4. Aspirin has been given. What is the most appropriate next step in the management of this patient?

A 55-year-old woman presents to the ED because of chest pain. The pain, which has lasted 3 hours, is substernal and dull in nature, with no relation to respiration or position. The pain does not radiate and is accompanied by weakness, lightheadedness, and nausea. She has received oxygen, aspirin, a continuous infusion of nitroglycerin, and a beta blocker. Her chest x-ray film is normal, and her ECG is remarkable for inverted T waves in lead II, III, aVF. Which of the following is the most important next step in management?

A 70-year-old woman comes to the ED with crushing substernal chest pain for the last hour. An EKG shows ST segment elevation in V2 to V4. Aspirin has been given to the patient to chew. What is the most appropriate next step in the management of this patient?

A 70-year-old woman comes to the emergency department with crushing substernal chest pain for the last hour. The pain radiates to her left arm and is associated with anxiety, diaphoresis, and nausea. She describes the pain as “sore” and “dull” and clenches her fist in front of her chest. She has a history of hypertension. Which of the following is most likely to be found in this patient?

A 65-year-old man comes to the ED with substemal chest pain, severe shortness of breath, and diaphoresis that began suddenly 40 minutes ago. The pain radiates to his left arm and does not remit with sublingual nitroglycerin. The patient has vomited twice since the pain stared. ECG shows 2-mm ST elevations in the anterior leads. On physical examination, the patient's temperature is 36.9 C, BP is 110/70 mm Hg. pulse is 60/min, respirations are 32/min, and oxygen saturation is 90% on 4 L/min oxygen by nasal canula. Cardiac examination shows an S3. Lung examination shows basilar crackles that extend halfway up the lung fields bilaterally. He is given 325 mg of aspirin, 600 mg of clopidogrel, and 80 mg of atorvastatin. Which of the following is the best next step in management of this patient?

A 70-year-old woman comes to the ED with crushing substernal chest pain for the last hour. Which of the following EKG findings would be associated with the worst prognosis?

A 55-year-old woman presents to the ED because of chest pain. The pain, which has lasted 3 hours, is substernal and dull in nature, with no relation to respiration or position. The pain does not radiate and is accompanied by weakness, lightheadedness, and nausea. She has received oxygen, aspirin, a continuous infusion of nitroglycerin, and a beta blocker. Her chest x-ray film is normal, and her ECG is remarkable for inverted T waves in lead II, III, aVF. Which of the following is the most important next step in management?

A 65-year-old man is brought to the ED due to chest discomfort and diaphoresis that began suddenly an hour ago while he was resting in a chair and watching television. He describes the discomfor as "squeezing", it is associated with right arm numbness and nausea. En route to the hospital, he was given oral aspirin and sublingual nitroglycerin. The patient has never had similar symptoms and has no medical history. He has smoked a pack of cigarettes daily for the past 40 years. Temp is 36.9 C, BP is 165/95, pulse is 50/min, and respirasions are 16/min. The first and second heart sounds are normal, and a fourth heart sound is heard. The lungs are clear to auscultation. There is no jugular venous distension or pedal edema. A tracing from his initial ECG is shown in the exhibit. Immediate interventions aimed at achieving which of the following goals would most improve this patient's long-term prognosis?

A 68-year-old man is recovering in the ICU after CABG surgery. 2 weeks ago, he was seen in the office for progressive exertional angina and SOB. The patient underwent coronary angiography, which indicated severe extensive CAD. After discussion about the risks and benefits, he agreed to proceed with open heart surgery. The patient has a family history of CAD but no sudden cardiac death, heart failure, or bleeding. On postoperative day 1, the nurses report that the patient is confused and has had reduced urine output. Temp is 35.6 C, BP is 80/50, pulse is 118/min and regular, and respirations are 22/min. There is no drainage from his sternal wound, and there has been no drainage in the chest tube over the last 4 hours. The lung fields are clear. No heart murmurs are appreciated. The abdomen is soft. His extremities are cool. ECG shows sinus tachycardia and nonspecific T-wave changes. Pulmonary artery catheter readings are as follows: Right atrium 20 mmHg (normal: 2-8 mmHg), right ventricle 35/20 mmHg (15-30/ 12-8 mmHg), and pulmonary capillary wedge pressure 20 mmHg (6-12 mmHg). Which of the following is the most appropriate next step in management of this patient?

A 60-year-old man comes to the ED due to 2 weeks of progressive exertional dyspnea and fatigue. He has difficulty falling asleep and can hardly walk to the bathroom without becoming short of breath. The patient has no chest pain,syncope, cough, or extremity edema. 2 months ago, he was hospitalized with an anterior wall MI but was not revascularized due to late presentation. He was discharged home on aspirin, clopidogrel, metoprolol, lisinopril, and atorvastatin. His temp is 36.6 C, BP is 100/67, and pulse is 67/min and regular. Examination shows bilateral crackles in the lower lung fields. The apical impulse is displaced to the left. A faint systolic murmur is heard over the apex. ECG shows normal sinus rhythm and deep Q waves in leads I, aVL, and V2-V5 with a 2-mm ST-segment elevation; the ECG tracings are unchanged compared to those at discharge 2 months ago. Which of the following is the most likely underlying cause of this patient's symptoms?

A 47-year-old man develops sudden onset of mid-sternal chest pain and diaphoresis during a meeting in his office. While waiting for emergency medical personnel to arrive, he complains of dizziness and becomes unresponsive. His coworkers perform cardiopulmonary resuscitation and he regains consciousness after 60 seconds. The patient has a history of diet-controlled type 2 diabetes mellitus, hypertension, and hyperlipidemia. In the emergency department, his BP is 142/88 mmHg and pulse is 92/min, ECG shows normal sinus rhythm, venticular premature complexes, and a 3-mm ST-segment elevation in leads V1-V3. What is the most likely primary pathophysiologic mechanism responsible for this patient's syncopal episode?

A 76-year-old man is admitted to the CCU after an episode of substernal chest pain. His other medical problems include HTN, hyperlipidemia, and type 2 DM. He has a history of a diverticular bleed 2 years ago. After initial workup, cardiac catheterization is performed and shows 70% LM coronary artery stenosis, 90% proximal LAD, and 80% RCA stenosis. Antiplatelet agents are stopped, and the patient is continued on a heparin drip in preparation for coronary arterbypass surgery the next day. 5 hours after the catheterization, his BP is 75/60 and pulse is 120/min and regular. He complains of some generalized weakness and back pain but denies chest pain, SOB, nausea, and abdominal discomfort. On physical examination, he appears diaphoretic and clammy. Neck veins are flat. Heart sounds are normal, and the chest is clear to auscultation. The right groin arterial puncture site is mildly tender, without any swelling or bruits. He receives 1000ml of NS with symptomatic improvement. His BP is 96/60 and pulse is 85/min. His repeat ECG is unchanged from the initial ECG at presentation. Which of the following is the most appropriate next step in managing this patient?

Which of the following is the most common adverse effect of statin medications?

A 46-year-old man comes to the physician for a routine health maintenance visit. He has no medical problems. He smokes a pack of cigarettes daily and does not drink alcohol. His mother has hypertension, and his father died of prostate cancer at age 70. The patient's BP is 128/76 mm Hg and pulse is 80/min. His body mass index is 29 kg/m2. Laborator results are as follows: Total cholesterol 262 mg/dL; High-density lipoprotein 50 mg/dL; Low-density lipoprotein 162 mg/dL; Triglycerides 150 mg/dL; Fasting glucose 100 mg/dL; His calculated 10-year risk of cardiovascular disease is 9%. Which of the following is the most appropriate next step in management of this patient's dyslipidemia?

Which of the following is the most dangerous to a patient in terms of risk for CAD?

A 52-yo woman with alcoholism comes to the physician after a serum cholesterol concentration of 290 mg/dL was found on a routine screening. She drinks a pint of vodka daily. She takes captopril for hypertension and glyburide for type 2 DM. She also has intermittent episodes of gout. Fasting serum studies show: Total cholesterol 252 mg/dL; HDL-cholesterol 80 mg/dL Triglycerides 300 mg/dL Glucose 118 mg/dL Thyroid-stimulating hormone 4.5 µU/mL Which of the following is the most appropriate next step in management?

A 47-year-old man comes to the physician for a routine health examination. He has no symptoms except for mild increase in frequency of urination. He has a history of elevated glucose levels but no other medical problems and takes no medications. His family history is significant for type 2 diabetes mellitus. The patient does not use tobacco, alcohol, or illicit drugs. He works as an editor for a local magazine company. His temperature is 36.7 C, BP is 132/80, pulse is 72/min, and respirations are 16/mm. BMI is 30 kg/m2. Fasting laboratory results are as follows: Glucose 165 mg/dl; HbA1C 7.2% Total cholesterol 210 mg/dl; Triglycerides 140 mg/dl; HDL 35 mg/dl; LDL 140 mg/dl. Serum creatinine 1.1 mg/dl Which of the following is the most appropriate next step in management of this patient?

A 55-year-old man comes to the office due to worsening cramping in his left leg that he has noted during his morning exercise routines. He has no chest discomfort, shortness of breath, palpitations, or syncope. His medical history is unremarkable and he takes no medications. He is an ex-smoker with a 20-pack-year history. The patient does not use alcohol or illicit drugs. He exercises twice a week and eats a low-fat diet. His father had a MI at age 60 and died from a second MI at age 65. His BP is 145/95 and pulse is 85/min. His cardiac, pulmonary, and abdominal examinations are within normal limits. Peripheral pulses are decreased in the left leg. ABI is 0.65 in the left and 1.1 in the right. His ECG is within normal limits. The fasting serum lipid profile shows a total cholesterol of 220 mg/dl, triglycerides of 150 mgldl, LDL of 135 mg/dl, and HDL of 50 mg/dL. His fasting blood glucose is 88 mg/dL. Which of the following is the most appropriate next step in management of this patient?

A 64-year-old man comes to the ED due to intermittent, burning midline chest pain over the last 2 hours. He has never had similar pain. The patient's medical history includes hyperension and hyperlipidemia. An immediate ECG shows sinus rhythm with ST-segment elevations in leads II, III, and aVF. Temp is 37.8C, BP is 115/70 mmHg, pulse is 65/min, and respirations are 15/min. He is given sublingual nitroglycerin, and the on-call cardiologist is notified. Three minutes later, the patient reports lightheadedness and extreme weakness. His repeat BP is 75/50 mmHg and pulse is 85/min. The patient is diaphoretic and his extremities are cold. Jugular venous pulse is 3 cm above the sternal angle in the semirecumbent position. The lungs are clear, and no murmurs are heard on auscultation. Which of the following is the best next step in management of this patient?

A 62-year-old man comes to the physician because of episodic chest pain that manifests as a sensation of precordial tightness, occurs after physical exertion, and is relieved promptly by rest. The patient has noted that the amount of activity sufficient to trigger the pain is relatively constant, such as climbing three flights of stairs or walking uphill for a few minutes. An ECG recorded at rest, however, fails to show any abnormalities. Which of the following is the most appropriate next step in diagnosis?

Which of the following is the most common cause of death from CHF?

A 74-year-old African American man with a history of dilated cardiomyopathy secondary to MI in the past is seen in the office for routine evaluation. He is asymptomatic and is maintained on lisinopril, furosemide, metoprolol, aspirin, and digoxin. Lab tests reveal a persistently elevated potassium level. The EKG is unchanged. What is the best management?

A 46-yo man comes to the physician with exertional dyspnea and dry cough. He also has occasional episodes of suffocating nighttime cough that is only relieved by sitting up. Past medical history is significant for MI 6 months ago and hypercholesterolemia. Current medications:metoprolol, aspirin, rosuvastatin. The patient does not use tobacco or illicit drugs but drinks alcohol on social occasions. His father died of a stroke and his mother has type2 DM. His BP is 150/100 mmHg and pulse is 60/min. Chest examination shows bibasilar crackles. The cardiac apex is palpated in the left sixth intercostal space. Bilateral pitting leg edema is present. Which of the following is most likely to be associated with this patient's condition?

A 62-yo man comes to the physician because of a 2-month history of progressive fatigue and ankle swelling. He had an anterior MI 3 years ago and has had shortness of breath with mild exertion since then. Current medications include labetalol and daily aspirin. He has smoked one-half pack of cigarettes daily for 30 years. His pulse is 100/min and regular, respirations are 20/min, and BP is 130/75 mm Hg. There are jugular venous pulsations 5 cm above the sternal angle. Crackles are heard at both lung bases. Cardiac examination shows an S3 gallop. There is edema from the midtibia to the ankle bilaterally. Further evaluation of this patient is most likely to show which of the following findings?

A 32-yo woman comes to the clinic due to progressively worsening dyspnea a month after returning from a vacation in Texas. The symptoms started with SOB on exertion and have progressed to the point that she now wakes during the night with a choking sensation that improves only with sitting up. The patient has had a very active lifestyle for years, but currently she is markedly limited in her activities. She has no associated chest pain, skin rash, or joint pain. The patient has no significant medical history. Family history significant for thyroid cancer in her aunt and lung cancer in her father. There is no family history of CAD, HF, or sudden cardiac death. She does not use illicit drugs. The patient currently lives in New York City. Temp is 37.2C, BP is 110/70, pulse is 96/min, and respirations are 14/min. Bilateral pitting ankle edema is present. The liver is enlarged 2cm below the right costal margin. Lung auscultation reveals decreased breath sounds at the bases bilaterally. Cardiac examination reveals the presence of a S3. Chest x-ray reveals an enlarged cardiac silhouette, small bilateral pleural effusions. ECG shows nonspecific ST segment changes. Which of the following is the most likely cause of this patient's symptoms?

In a large clinical trial, patients with recent myocardial infarction and heart failure were randomized to a study medication or placebo. The average left ventricular ejection fraction of the study subjects was 33%. Most patients in both groups were concomitantly treated with a beta blocker and an ACE inhibitor or angiotensin receptor antagonist. The long-term, all-cause mortality curves are shown in the image below, with the solid line representing the study medication. Which of the following is the most likely medication used in the clinical trial?

A 69-year-old man with a history of congestive heart failure secondatry to hypertention and atrial fib comes to the physician because of increasing nausea, headache, and blurred vision in both eyes over the past 3 day. He also complains of seeing "yellow halos around lights". His medications include hydrochlorothiazide, enalapril, and digoxin. His BP is 132/84 mmHg, pulse is 56/min with irregular rhythm, and respirations are 16/min. Which of the following is the most likely cause of these symptoms?

A 62-year-old man comes to the clinic with complaints of increasing fatigue and shortness of breath over the past 4 months. He notes that he now becomes short of breath after walking one block, whereas he previously could walk several blocks without difficulty. He also reports waking up at night feeling short of breath and needing to sleep with three pillows. He denies chest pain. Past medical history includes hypertension and type 2 diabetes mellitus. He has a 30-pack-year smoking history. Vital signs are within normal limits. Physical examination reveals jugular venous distension at 10 cm H₂O, bilateral basilar crackles, an S3 gallop, and 1+ bilateral pedal edema. Chest X-ray shows cardiomegaly and mild pulmonary vascular congestion. ECG reveals left ventricular hypertrophy. Laboratory studies show normal electrolytes and creatinine. B-type natriuretic peptide (BNP) is elevated at 580 pg/mL (normal <100). Which of the following is the most appropriate next step to confirm the diagnosis?

A 70-year-old man presents to the clinic with progressively worsening shortness of breath over the past 6 months. He reports dyspnea on exertion and occasional wheezing, especially at night. He also mentions waking up short of breath and needing to sleep with two pillows. He denies chest pain or fever. His medical history includes hypertension and hyperlipidemia. He smoked 1 pack per day for 40 years and quit 5 years ago. On physical examination, his vital signs are normal. He has decreased breath sounds and end-expiratory wheezes bilaterally. There is no peripheral edema or jugular venous distension. Heart sounds are normal, without murmurs or gallops. Chest X-ray shows hyperinflated lungs with flattened diaphragms. BNP is 90 pg/mL (normal <100). ECG is normal. Which of the following is the most appropriate next diagnostic test to clarify the diagnosis?

A 32-yo woman comes to the clinic due to progressively worsening dyspnea a month after returning from a vacation in Texas. The symptoms started with SOB on exertion and have progressed to the point that she now wakes during the night with a choking sensation that improves only with sitting up. The patient has had a very active lifestyle for years, but currently she is markedly limited in her activities. She has no associated chest pain, skin rash, or joint pain. The patient has no significant medical history. Family historis significant for thyroid cancer in her aunt and lung cancer in her father. There is no family history of CAD, HF, or sudden cardiac death. She does not use illicit drugs. The patient currently lives in New York City. Temperature is 37.2C, BP is 110/70, pulse is 96/min, and respirations are 14/min. Bilateral pitting ankle edema is present. The liver is enlarged 2cm below the right costal margin: Lung auscultation reveals decreased breath sounds at the bases bilaterally. Cardiac examination reveals the presence of a S3. Chest x-ray reveals an enlarged cardiac silhouette, small bilateral pleural effusions. ECG shows nonspecific ST segment changes. Which of the following is the most likely cause of this patient's symptoms?

A 74-year-old woman comes to the emergency department with the acute onset of shortness of breath, respiratory rate of 38 per minute, rales to her apices, S3 gallop, and jugulovenous distension. What is the best initial step in the management of this patient?

A 56-year-old man comes to the ED due to 5 days of dyspnea. He wakes up during the night with difficulty breathing that keeps him from going back to sleep. He has never had these symptoms before. The patient's medical history is signifcant for long-standing hypertension and noncompliance with his antihypertensive therapy. He was diagnosed with deep-vein thrombosis 8 years ago after surgery for a tibial fracture; he received 6 months of anticoagulation. He has a 30 pack-year smoking history. BP is 182/109 mmHg and pulse is 110/min and regular. Oxygen saturation is 90% on room air. Lung auscultation shows bibasilar crackles and scattered wheezes. Which of the following is the most appropriate next step in management of this patient?

A 65-yo female is admitted to the hospital with increasing SOB, weight gain and lower extremity edema. She has a history of hyperension, nonischemic cardiomyopathy with an EF of 30%, and hyperlipidemia. Her home medications include oral aspirin, digoxin, Furosemide, metoprolol, lisinopril and atorvastatin. She is started on intravenous furosemide. On day three of hospitalization telemetry reveals six beats of wide complex ventricular tachycardia. Physical examination now shows decreased leg edema and clear lungs. Which of the following is the most appropnate next step in the management of this patient's tachycardia?

A 70-year-old woman with a history of diabetes mellitus, hypertension, chronic obstructive lung disease, and congestive heart failure is admitted to the hospital for a deep vein thrombosis of the right lower extremity. Heparin is started at the time of admission. Her outpatient medications include NPH insulin, furosemide, albuterol, and metoprolol. Admission laboratories show an elevated potassium level (6.0 mEq/L), which is confirmed on repeat testing. Which of the following medications should be discontinued?

A 32-yo woman comes to the ED due to progressive weakness and SOB over the last several weeks. The patient has had no chest pain, palpitations, or syocope. She has not had any recent upper respiratory infection. Medical history is significant for migraine headaches for which she takes ibuprofen a few times per week. She does not take any other OTC or prescription medications. The patient has had 2 cesarean sections, most recently 2 years ago. She has smoked a pack of cigarettes a day since age 17 and uses methamphetamine. The patient has no family history of heart disease or sudden cardiac death. Temp is 36.1 C, BP is 88/60, pulse is 105/min and regular, and respirations are 22/min. Pulse oximetry is 91% on room air. She is sitting upright in bed and appears uncomfortable. Examination reveals diffuse crackles throughout the lung fields and dullness to percussion at the right lung base. Apical impulse is palpated along the lefl anterior axillary line. There is an extra low-pitched sound in early diastole, best heard with the bell of the stethoscope placed on the apex. The patient's legs are cool and pulses are diminished. There is 1+ bilateral peripheral edema. Laboratory results are as follows: Na+:134; K+:4.0; chloride: 100; bicarbonate:18; BUN:40; creatinine: 1.9; calcium:8.6; glucose:80. Pregnancy test is negative. In addition to other appropriate therapy, the patient is given an IV medication that acts by primarily stimulating beta-1 adrenergic receptors. Which of the following is the most likely mechanism by which this medication may improve her condition?

A 52-year-old woman has had dyspnea and hemoptysis for 1 month. She has a history of rheumatic fever as a child and has had a cardiac murmur since early adulthood. Her temperature is 36.7°C, pulse is 130/min and irregularly irregular, respirations are 20/min, and BP is 98/60 mmHg. Jugular venous pressure is not increased. Bilateral crackles are heard at the lung bases. There is an opening snap followed by a low-pitched diastolic murmur at the third left intercostal space. An x-ray of the chest shows left atrial enlargement, a straight left cardiac border, and pulmonary venous engorgement. Which of the following is the most likely explanation for these findings?

A 72-year-old man presents to the clinic with progressive fatigue and exertional dyspnea over the past 6 months. He also reports occasional chest tightness when walking uphill. He has a history of hypertension and hyperlipidemia. On physical examination, he has a delayed carotid upstroke and a harsh crescendo-decrescendo systolic murmur best heard at the right upper sternal border, radiating to the carotids. Echocardiography shows an aortic valve area of 0.7 cm² and a mean gradient of 45 mmHg. Which of the following is the most appropriate next step in management?

A 54-year-old woman presents with progressively worsening shortness of breath, particularly when lying flat or during exertion. She also reports occasional palpitations. She recently immigrated from Southeast Asia. On physical examination, she has a diastolic rumbling murmur best heard at the apex, preceded by an opening snap. There is no radiation of the murmur to the neck. ECG shows atrial fibrillation. Chest X-ray reveals left atrial enlargement. Which of the following findings would most help differentiate this patient's condition from aortic stenosis?

A 75-year-old man presents to the clinic with progressive dyspnea on exertion and occasional dizziness when walking. He also reports chest discomfort with activity. Physical exam reveals a harsh, late-peaking systolic murmur heard best at the right upper sternal border, radiating to the carotids. Echocardiogram reveals severe aortic stenosis with an aortic valve area of 0.7 cm² and mean gradient of 45 mmHg. Left ventricular ejection fraction is 55%. He has a history of hypertension and type 2 diabetes mellitus. Surgical risk assessment shows that he is at high risk for open-heart surgery due to frailty and poor functional status. What is the most appropriate next step in management?

A 28-year-old man presents to the ED with complaints of fever, chills, and malaise for the past 3 days. He also complains of nausea, headaches, and anorexia. The patient denies any homosexual practices but admits to occasional IV drug use. Examination of his palms and soles reveals painless macules; on auscultation, a loud holosystolic murmur is noted. Which of the following is the most appropriate next step in diagnosis?

A 40-year-old man presents to the physician because of exertional dyspnea of recent onset. The patient appears comfortable at rest but says that he becomes short of breath with minimal effort. His temp is 37C, BP is 162/65 mmHg, pulse is 92/min with a rapid rise and fall, and respirations are 15/min. chest examination reveals a prominent and laterally displaced apical impulse. A soft diastolic decrescendo murmur is heard along the left sternal border. Bilateral crackles are present at the lung base. The liver is not palpable, and there is no sign of peripheral edema. Which of the following is the most likely diagnosis?

A 23-year-old woman comes to the physician for a health maintenance examination. She enjoys good health and exercises regularly. Her height is 172cm and weight is 66kg. Her BP is 120/80 mmHg, pulse is 74/min, and respirations are 12/min. Physical examination is unremarkable except for heart auscultation, which reveals an isolated midsystolic click. Which of the following is the most common cause of this auscultatory finding?

A 48-year-old woman presents with progressive shortness of breath on exertion, orthopnea, and palpitations. She has a history of rheumatic fever in childhood. On physical examination, she has a diastolic murmur best heard at the apex with the patient in the left lateral decubitus position. An opening snap is heard after S2. ECG shows atrial fibrillation. Which of the following is the most likely underlying mechanism of her current symptoms?

A 2-year-old man presents for evaluation of a heart murmur found during a routine check-up. He denies chest pain, dyspnea, or syncope. His blood pressure is 130/75 mmHg, and pulse is 70/min. Cardiac auscultation reveals a systolic ejection murmur best heard at the right upper sternal border, radiating to the carotid arteries. There is no opening snap or diastolic rumble. Echocardiography shows a congenital anomaly of the aortic valve. Which of the following is the most likely diagnosis?

A 21-year-old woman presents to the ED with several days of fever and fatigue. Her temp is 39C, her pulse is 90/min, and her blood pressure is 96/64 mmHg. Her chest is clear to auscultation, and her abdomen is soft and nontender. A grade III/IV holosystolic murmur that increases on inspiration is best heard along the left sternal border. A CBC shows normochromic normocytic anemia. Chest x-ray films reveal several well-circumscribed, round infiltrates in multiple lobes. Echocardiography and blood cultures suggest a diagnosis of acute bacterial endocarditis limited to the tricuspid valve. Which os the following is the most likely explanation for these findings?

A 24-yo woman comes to the office due to pressure-like, substernal chest pain that occurs when she exercises. The patient began noticing the pain approximately 6 months ago when she started to exercise to lose weight. Prior to that, her lifestyle was largely sedentary. She has no associated nausea, vomiting, diaphoresis, dyspnea, palpitations, or syncope. The patient has no significant past medical history but was told as a child that she has a "murmur." She has no significant family history of heart disease. BP is 130/70mm Hg on the right and 105/55mmHg on the left, and pulse is 72/min and regular. BMI is 29kg/m2. A palpable thrill is present in the suprasternal notch. There is a loud midsystolic murmur best heard at the first right intercostal space. The lungs are clear to auscultation. What is the most likely cause of this patient's chest pain?

A 15-yo boy collapses suddenty while playing basketball with his friends .The boy played basketball every weekend without any symptoms and was in his usual state of health prior to this event. He has no known past medical history and takes no medications. Family history is significant for a maternal uncle who died at age 25 for unknown reasons. Cardiopulmonary resuscitation is unsuccessful and the patient is pronounced dead. Post-mortem examination would most likely show which of the following?

A 78-year-old man with a history of lung cancer comes to the ED with several days of increasing shortness of breath. He became somewhat lightheaded today, and that is what has brought him to the hospital. On physical examination, he has a BP of 106/70; pulse of 112; jugulovenous distention; and the lungs are clear to auscultation. The BP drops to 92/58 on inhalation. Which of the following is the most appropriate to confirm the diagnosis?

A 52-year-old man presents with a 6-month history of slowly progressive exertional dyspnea and swelling of his legs. He admits to heavy alcohol abuse for the past 20 years. His blood pressure is 135/84 mm Hg, pulse is 103/min, and respirations are 18/min. Chest examination shows bilateral rales at the lung base and a gallop rhythm with an S3. The liver margin is palpable 3 cm below the costal margin, and there is mild splenomegaly. Pitting edema is present in the lower extremities. A chest x-ray film reveals dilatation of the veins in the upper pulmonary lobes and cardiac biventricular enlargement. ECG shows low QRS voltage and occasional premature ventricular beats. Blood studies show: Alanine aminotransferase (ALT): 60 U/L Aspartate aminotransferase (AST): 76 U/L Bilirubin, total: 1.0 mg/dL; Albumin, serum: 4.2 g/dL Prothrombin time (PT): 14 sec; Ferritin, serum: 100 ng/mL Endocrine studies of pituitary and thyroid functions are within normal limits. Which of the following is the most likely diagnosis?

A 45-year-old man presents with progressive dyspnea on exertion, peripheral edema, and abdominal fullness. Physical exam reveals elevated jugular venous pressure with a prominent y-descent, a loud S4, and no pericardial knock, ECG shows LV hypertrophy with repolarization abnormalities. Echocardiography reveals a thickened interventricular septum, preserved ejection fraction, and no respiratory variation in mitral inflow velocity. Cardiac MRI shows late gadolinium enhancement in the interventricular septum without evidence of pericardial thickening. Which of the following best distinguishes this condition from constrictive pericarditis?

A 46-year-old man comes to medical attention because of slowly progressive dyspnea on exertion over a 6-month period. His BP is 110/75 mmHg, pulse is 106/min, and respirations are 18/min. The patient underwent radiation therapy for a mediastinal neoplasm 10 years ago. On examination, the liver is palpable 3cm below the right costal margin. Heart sounds are decreased in intensity, and jugular veins appear distended, especially during inspiration. Bibasilar crackles that clear with coughing are detected on chest auscultation. A chest x-ray film shows calcifications around the heart, which appears of normal size. Echocardiography reveals a thickened pericardial sac, but the ventricular wall appears normal. Which of the following is the most likely diagnosis?

A 22-yo man is brought to the ED after he passed out on the field while playing soccer. The episode lasted only 2 minutes and was not associated with any post-event confusion, sleepiness, or weakness. The patient describes himself as "healthy" but on detailed review of systems admits to occasional lightheadedness and vague chest discomfort while playing active sport. His grandfather died suddenly at age 40 from a "heart attack." Blood pressure is 128/74 mmHg and heart rate is 67/min and regular. On examination, a S3 is heard at the cardiac apex. There is a 3/6 midsystolic murmur best heard at the left lower sternal border that does not radiate to the base of the heart or to the neck. The patient will most likely benefit from which of the following medications?

A patient is diagnosed with primary hypertension. When taking the patient's history, the healthcare provider anticipates the patient will report which of the following?

A 45-year-old woman present to clinic for health maintenance visit. She has no complaints but has a history of diabetes and a family history of hypertension. On physical examination, the patient's blood pressure is 150/100mmHg. Laboratory results are normal. Which of the following agents would be most appropriate for the management of her hypertension

Which of the following is a combination that can't be used?

A 30-year-old woman comes to the physician because of intermittent throbbing headaches, sweating, and pallor over the past 3 months. She has had several blood pressure measurements that fluctuate from 110/80 mm Hg to 160/108 mm Hg. Her pulse is 100/min, and blood pressure now is 138/88 mm Hg. Serum studies show: Na+ 140 mEq/L; CI- 110 mEq/L; K+ 4.5 mEq/L; HCO3- 26 mEq/L Urea nitrogen 14 mg/dL; Creatinine 1 mg/dL Which of the following is the most likely location of the abnormality?

A 63-yo woman comes to the office due to leg swelling that is especially bothersome in the evening. Her symptoms have gradually worsened over the last year. Her medical problems include hypertension treated with lisinopril and obstructive sleep apnea for which she uses continuous positive airway pressure during sleep. She was hospitalized 2 years ago for a chest infection that was treated with antibiotics. The patient has smoked a pack of cigarettes daily for 30 years and does not drink alcohol. BP is 160/90 and pulse is 80/min. BMI is 32. Jugular venous pulsation is seen 2 cm above the sternal angle with the head of the bed elevated to 45°. Chest examination shows bilateral scattered wheezes and prolonged expirations. Her abdomen is soft and nondistended. She has bilateral 2+ pitting edema in her lower extremities to the midshin with dilated and tortuous superficial veins. A small ulcer is noted on the left medial ankle. All peripheral pulses are palpable. Which of the following is most likely to relieve this patient's current symptoms?

A 77-yo man is brought to the physician because of a 12-hour history of word-finding difficulty and weakness and sensory loss of the right arm and leg. He has no history of similar symptoms. He has type 2 DM, hypertension, and atrial fibrillation. Current medications include metformin, lisinopril, and aspirin. He is alert. His pulse is 80/min and irregular, respirations are 16/min, and BP is 170/90 mmHg. He follows commands but has nonfluent aphasia. There is moderate weakness and decreased sensation of the right upper and lower extremities. Deep tendon reflexes are 2+bilaterally. Babinski sign is present on the right. His serum glucose concentration is 162 mg/dL. Which of the following is the most appropriate next step in diagnosis?

A 40-year-old man comes to the emergency department with slowly progressive headaches, dyspnea, and blurry vision over the last 2 days. His other medical problems include hypertension treated with hydrochlorothiazide and lisinopril for the past 2 years. He has been noncompliant with his medical regimen and physician follow-ups. He smokes 1 pack a day and occasionally consumes alcohol. On initial evaluation, his BP is 220/140 mm Hg and pulse is 75/min. Which of the following establishes the diagnosis of malignant hyprtension in this patient?

During a routine examination, a 32-year-old man has a BP of 120/80 mmHg. He is concerned because his father, grandfather, and two uncles have hypertension. He works as a systems programmer for a large computer company and frequently has to meet tight deadlines. He has smoked one pack of cigarettes daily for 10 years. He is 4.5 kg overweight and drinks three cups of coffee daily. Which of the following measures is most likely to reduce this patient's risk for hypertension over the next 5 years?

A 50-yo woman presents to your office complaining of lower extremity edema that started several weeks ago, and slowly progressed thereafter. Her past medical history is signifiant for HTN, treated with metoprolol for 2 years. Amlodipine was added recently because of inadequate control of BP with metoprolol alone. She does not smoke or consume alcohol. She has no known drug allergies. Her BP is 130/80 and her heart rate is 64/min. The physical examination reveal bilateral symmetric 3+ pitting edema of both lower extremities, without any skin changes or varicosities. Her neck vein pulsation is normal. Other physical findings are within normal limits. Her laboratory studies reveal the following: Serum albumin 45g/dl; Total serum bilirubin 0.8mg/dl; Serum Na+ 140mEqIL; Serum K+ 4.0; Serum creatinine 0.8mg/dl. Urinalysis is within normal limits. What Is the most likely cause of the edema in this patient?

A 48-year-old woman was diagnosed with essential hypertension and was commenced on treatment three months ago. She presented to you with a dry cough which has not been getting better despite taking anti-hypertensive and antibiotics. You assess the patient's medication history. Which of the following antihypertensive medications is responsible for the patient's symptoms ?

A 47-year-old woman comes to the physician because of persistent nonproductive cough for 6 weeks. She has not had fever or weight loss. She has hypertension treated with enalapril for the past 3 months. She does not smoke. There is no history of lung disease. She weighs 54 kg and is 163 cm tall. Her temperature is 37°C, BP is 130/80 mmHg, pulse is 70/min, and respirations are 12/min. Examination and an x-ray of the chest show no abnormalities. Which of the following is the most likely mechanism of this patient's cough?

A 36-year-old man comes to the physician for a routine pre-employment physical. He has no complaints except for occasional morning headaches. His father died suddenly at age 54. The patient's blood pressure is 175/103 mmHg in the right arm and 180/105 in the left, and pulse is 82/min. The lungs are clear bilaterally and heart sounds are normal. Bilateral, nontender, upper abdominal masses are palpated on examination. His hemoglobin level is 15.2 g/dl and creatinine concentration is 0.8 mg/dL. Which of the following is the most appropriate next step in evaluating this patient's condition?

A 48-year-old man comes to the ED due to severe chest pain that started 2 hours ago. He has difficulty localizing the pain, saying that it "hurts all over my chest." He has had no shortness of breath, lightheadedness, syncope, or palpitations. The patient has no known medical problems. He is a lifetime nonsmoker and does not use any illicit drugs. His father died suddenly at age 52 from a presumed heart attack. His temperature is 36.7 C, BP is 178/102 mmHg, pulse is 105/min and regular, and respirations are 16/min. On physical examination, the lungs are clear to auscultation and heart sounds are normal. ECG shows sinus tachycardia, voltage criteria for LV hypertrophy, and T wave inversion in leads V5 and V6. A CT image of his chest is shown below: In addition to pain control, which of the following is the most appropriate immediate pharmacotherapy for this patient?