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Worksheetsusmle bonus tim
Total questions: 53
Worksheet time: 27mins
Name
Class
Date
1.
A 74-year-old woman suddenly became delirious 1 hour ago. She was well until 5 days ago, when she tripped and injured her right leg; she has been bedridden since the accident. On examination, her temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 32/min. Her heart, lungs, and abdomen are normal, and there are no focal motor or sensory deficits. Passive flexion of her right hip causes obvious pain. Pulse oximetry shows an oxygen saturation of 80%, and a chest x-ray is normal. An ECG shows sinus tachycardia. Which of the following is the most likely diagnosis?
a)
Acute cerebral hemorrhage
b)
Acute cerebral infarction
c)
Myocardial infarction
d)
Pulmonary infarction
e)
Pulmonary thromboembolism
2.
Due to a recent and sudden death of a rival college football player, a local university wishes to implement changes in its health care policies. The school is particularly concerned about the risk for sudden cardiac death in players with previously undiagnosed heart conditions. A preparticipation evaluation is to be performed on all of the school's athletes. Which of the following is considered the most cost-effective method of screening young athletes at risk for sudden cardiac death?
a)
Careful medical history and examination
b)
Chest x-ray
c)
Echocardiography
d)
Exercise electrocardiography
e)
Resting electrocardiography
3.
A 20-year-old male college student is participating in the New York City Marathon and collapses one third of the way through the race. He is a well developed, athletic man who frequently plays basketball and tennis. He has no past medical history, except for a tonsillectomy at 9 years of age. There were no symptoms before he collapsed to the ground and lost consciousness. The patient is immediately rushed to the nearest emergency room but is pronounced dead on arrival. Which of the following is the most likely underlying cause of his sudden death?
a)
Aortic stenosis
b)
Arrhythmogenic right ventricular dysplasia
c)
Coronary anomalies
d)
Hypertrophic cardiomyopathy
e)
Isolated left ventricular hypertrophy
4.
A 64-year-old man has been admitted to the hospital with palpitation and lightheadedness for the past several days. He has experienced palpitations previously, but recently they have seemed sustained and “uncomfortable “. The patient has had no chest pain or shortness of breath. He has a history of coronary artery disease and prior percutaneous coronary Interventions. He is treated with metoprolol, lisinopril, aspirin, clopidogrel, and rosuvastatin. EchocardIogram shows mild left ventricular dilation, a left ventricular EF of 30%, and no major valvular abnormality. Serum potassium is 4.2 mEq/L and magnesium is 1.9 mg/dl. On day 2 of hospitalization, the patient develops sudden-onset palpitations that feel like "fluttering in my chest“. Blood pressure is 122/60 mmHg. He is alert and does not appear to be in distress. Examination shows clear lungs bilaterally. His ECG is shown below: Which of the following Is the best next step in management of this patient?
a)
Amiodarone
b)
Carotid sinus massage
c)
Digoxin
d)
Electrical cardioversion
e)
Esmolol
5.
Which of the following is most likely to benefit a patient's risk of coronary disease?
a)
Administration of estrogen replacement at the time of menopause.
b)
Stopping tamoxifen.
c)
Stopping aromatase inhibitors.
d)
Regular exercise.
e)
Relaxation methods such as meditation
6.
A 75-yo man comes to the clinic due to a 6-month history of periodic substernal 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 120/78mmHg 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 left ventricular 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)
Altered myocardial calcium level
b)
Coronary artery vasodilation
c)
Decreased cardiac afterload
d)
Decreased cardiac preload
e)
Decreased myocardial contractility
7.
A 39-year-old man presents to the emergency department with acute onset of shortness of breath, hemoptysis, and left-sided pleuritic chest pain. His past medical history includes medication-controlled asthma, peptic ulcer disease, and a recent onset of idio- pathic nephrotic syndrome. His blood pressure is 180/100 mm Hg, pulse is 110/min, and respirations are 28/min. Cardiac and lung examinations are normal. Laboratory data are remarkable for a serum lactate dehydrogenase of 300 U/L. An ECG shows sinus tachy- cardia, prominent S waves in lead 1, inversions of the T wave, and a prominent Q wave in lead III. Which of the following is the most likely cause of the chest pain?
a)
Aortic dissection
b)
Esophageal spasm
c)
Myocardial infarction
d)
Pneumonia
e)
Pulmonary embolism
8.
A 37-yo woman comes to the clinic due to occasional episodes of nocturnal substernal chest pain that wake her during sleep. The pain is occasionally associated with sweating, palpitations, and nausea but no dyspnea. The pain episodes resolve spontaneously after 10-15 minutes. She leads a sedentary lifestyle but states that she can climb 2 flights of stairs w/o any discomfort. The patient has no history of hypertension or diabetes. She smokes half a pack of cigarettes daily. She does not use alcohol or illicit drugs. BP is 134/70 mmHg, pulse is 75/min and regular, and respirations are 14/min. There is no jugular venous distension. The thyroid is normal. There is no carotid bruit. Heart sounds are normal without murmurs. Lungs are clear. Extremities have no edema. Extended ambulatory ECG monitoring shows transient ST-segment elevation in leads I, aVL,and V4-V6 during her episodes of pain. She is referred for coronary angiogram,which shows no significant coronary obstruction. Which of the following is the best treatment for this patient?
a)
Aspirin and rosuvastatin
b)
Cilostazol
c)
Diltiazem
d)
Lorazepam
e)
Omeprazole
9.
A 67-year-old man comes to the office for a new patient evaluation after recently relocating to a retirement community. The patient has a history of hypertension treated with losartan. He is a former smoker with a 40-pack-year history and drinks alcohol occasionally. He is a retired school teacher. Blood pressure is 130/80 mmHg and pulse is 80/min. Examination reveals a bruit in the right side of the neck, but the remainder of the examination is normal Duplex ultrasonography of the neck arteries reveals a 60% stenosis at the right common carotid artery bifurcation. The left common carotid artery has a 40% lesion. Which of the following is the best next step in management of this patient's arterial abnormalities?
a)
Antiplatelet and statin therapy
b)
Bilateral carotid artery stenting
c)
Bilateral carotid endarterectomy
d)
Close monitoring with no intervention
e)
Right carotid artery stenting
10.
A 68-year-old man is brought to the emergency department after he passed out during an early morning jog. The patient felt lightheaded while jogging and sat down on the curb to prevent a fall. He was not confused after the episode and did not have bowel or bladder incontinence. A similar episode occurred 4 weeks ago; he felt lightheaded while climbing stairs but did not pass out. He has been having some exertional shortness of breath for the past few months but does not have any headache, blurry vision, or chest pain. The patient has hypertension controlled with hydrochlorothiazide but is healthy otherwise. He has a 20-pack-year smoking history and occasionally drinks a glass of wine. His blood pressure is 142/90 mm Hg, pulse is 80/min, and respirations are 16/min. Carotid pulse is delayed. S2 is diminished and an S4 is present. A grade 3/6 systolic ejection murmur is heard in the right second intercostal space. Neurological examination reveals no focal findings and there are no signs of head trauma. An electrocardiogram shows normal sinus rhythm with left ventricular hypertrophy. The first set of cardiac enzymes is negative. Which of the following is the most appropriate next step in management of this patient?
a)
24-hour electrocardiographic monitoring
b)
CT scan of the head
c)
Echocardiogram
d)
Exercise stress test
e)
Tilt table testing
11.
A 36-yo woman comes to the ED due to chest pain that started suddenly while she was shopping at the mall. She also has shortness of breath, palpitations, and diaphoresis . The pain is retrosternal and radiates to the left arm. There are no aggravating or relieving factors. She appears to be in mild discomfort. On review of systems, the patient reports having had a runny nose, sore throat, and dry cough for the past 3 days. Her other medical problems include panic attacks treated with paroxetine and dysfunctional uterine bleeding treated with estrogen. Family history is significant for her father's sudden death at age 44 from a heart attack. The patient has a 15-pack-year smoking history_ Her BP is 144/90 mmHg and pulse is 104/min and regular. Her BMI is 29 kg/m2. Which of the following is the most appropriate initial therapy for this patient?
a)
Acetaminophen
b)
Aspirin
c)
Heparin
d)
ibuprofen
e)
Lorazepam
12.
A 73-year old man presents with a chief complaint of three episodes of fainting over the past month. He also relates several episodes of left-sided chest pain that occurred with exertion and resolved on resting. Furthermore, he has noticed increasing leg edema and orthopnea. He has no prior cardiac history and is not on any medications. His blood pressure is 130/70 mm Hg, and his pulse is 70/min. Pitting edema is present in both lower extremities. The carotid upstroke is delayed. Cardiac examination is remarkable for a normal S1 and a soft, single S2. A harsh, late peaking systolic ejection murmur is heard in the right upper sternal border. An ECG shows signs of left ventricular hypertrophy. Which of the following is the most likely diagnosis?
a)
Aortic insufficiency
b)
Aortic stenosis
c)
Mitral insufficiency
d)
Mitral stenosis
e)
Tricuspid insufficiency
13.
A 68-year-old woman comes to the emergency department due to sudden onset of chest pain associated with 2 episodes of vomiting. Past medical history includes hypertension for which she takes hydrochlorothiazide. Blood pressure is 80/50 mm Hg, pulse is 60/min, and respirations are 14/min. Examination shows diaphoresis, elevated jugular venous pressure, and a positive Kussmaul's sign. Her lungs are clear to auscultation. ECG shows 2-mm ST-segment elevation in leads II, Ill and aVf and 1-mm ST-segment depression in leads I and aVL. Which of the following is the most likely cause of this patient's hypotension?
a)
Interentricular septum rupture
b)
intravascular volume depletion
c)
Pulmonary embolism
d)
Right ventricular infarction
e)
Variant angina
14.
A 63-year-old man comes to the emergency department with substernal chest pain and diaphoresis. The pain started one hour ago and was not relieved with antacids. His medical problems include asthma, for which he uses inhaled fluticasone, and peptic ulcer disease, for which he takes omeprazole. Blood pressure is 160/100 mmHg and pulse is 90/min. A bruit is heard over the right carotid artery, and a mild systolic murmur is present at the cardiac apex. Sublingual nitroglycerin and aspirin are administered and within minutes the patient reports resolution of pain. Which of the following most likely accounts for the improvement in his symptoms?
a)
Alteration in heart rate
b)
Decreased left ventricular ejection fraction
c)
Decreased left ventricular end-diastolic volume
d)
Increased cardiac preload
e)
increased left ventricular compliance
15.
A 55-year-old male smoker with diabetes and hyperten- sion presents with complaints of chest pain on exertion. Exercise stress testing shows reversible ischemia in the anteroseptal portion of the heart after exercising 4 min- utes. Cardiac catheterization reveals an 80% stenosis of the left main coronary artery. Which of the following is the most appropriate intervention?
a)
Re-examination in 6 months or sooner if symptoms worsen
b)
Beta blocker
c)
Sublingual nitroglycerin as needed
d)
Percutaneous balloon angioplasty
e)
Coronary artery bypass grafting
16.
A 60-year-old white man is evaluated by a physician because of weight gain and increasing abdominal girth of several months' duration, despite no change in diet. His temperature is 37.1 C (98.8 F), blood pressure is 70/40 mm Hg, pulse is 120/min, and respirations are 18/min. Head and neck examination is remarkable for "bags" under the eyes and jugular venous distension. Chest examination demonstrates pulmonary rales and a third heart sound. Abdominal examination reveals an enlarged, tense abdomen with a palpable fluid wave; abdominal organ palpation is inadequate because of the tension. Examination of the extremities demonstrates pitting edema at the ankles. Which of the following is the most likely diagnosis?
a)
Alcoholic cirrhosis
b)
Chronic hepatitis B infection
c)
Congestive heart failure
d)
Gastric carcinoma
e)
Hypothyroidism
17.
A 45-year-old man presents to the emergency depart- ment, complaining of the sudden onset of left substernal chest pain. He describes this as a chest pressure that rates 8 on a scale of 1 to 10. He has never had these symptoms before. He has a history of hypercholes- terolemia, for which he takes a lipid lowering drug. On physical examination, he appears anxious and is diaphoretic. His blood pressure is 100/90 mm Hg, and his pulse is 110/min. The remainder of the physical examination is unremarkable. He undergoes an ECG, which reveals ST elevation in leads II, III, and aVF. He is diagnosed with an acute myocardial infarction. On cardiac catheterization, which of the following vessels will most likely be occluded?
a)
Circumflex artery
b)
Left anterior descending artery
c)
Left coronary artery
d)
Posterior descending artery
e)
Right coronary artery
18.
A 52-year-old man with a 30-pack-year history of cigarette smoking presents to a physician after moving to a new city. He was told that he had "high cholesterol" about 2 years ago, and he has a history of mild hyper- tension for which he has never been treated. He had a myocardial infarction (MI) 6 months ago. His post-MI course has been uncomplicated, his exercise stress test was satisfactory, and he has experienced no subsequent chest pain. His medications include one aspirin tablet every other day. Physical examination is normal except for a fourth heart sound. Which of the following is the most appropriate next step in management to prevent significant morbidity and mortality?
a)
Add a beta blocker
b)
Add enalapril
c)
Add nifedipine
d)
Increase the aspirin to one tablet three times daily
e)
Prescribe nitroglycerin for angina
19.
A 47-year-old Brazilian immigrant presents with fatigue and dyspnea. He has been healthy for the past 10 years. The patient denies fever, cough, chills, or weight loss. On physical examination there are no murmurs, the pulse and the rhythm are regular, S₁ is normal, and S₂ is split. This split increases with inspiration and per- sists with expiration. Which of the following ECG find- ings is most consistent with the auscultatory findings in this patient?
a)
Acute ST segment elevation in the anterior leads
b)
Decreased PR interval
c)
Early repolarization
d)
Marked T wave inversion
e)
Right bundle branch block
20.
A 40-year-old woman comes to the physician because of a 6-month history of increasing respiratory difficul- ty that occurs during mild exercise, such as walking uphill. She is 165 cm (65 in) tall and weighs 58 kg (129 lb), but says that she has lost 4 kg (9 lb) over the past 3 months. Her blood pressure is 120/75 mm Hg, pulse is 85/min, and respirations are is 16/min. Chest examina- tion reveals crackles at both lung bases and a diastolic murmur near the cardiac apex. The characteristics of the murmur change with the patient's position. Echocardiography reveals a solid mass that partially fills the left atrium and results in obstruction of the mitral flow. Which of the following is the most likely diagnosis?
a)
Fibroelastoma
b)
Metastasis
c)
Mural thrombus
d)
Myxoma
e)
Sarcoma
21.
A 45-year-old man presents to a physician because of repeated episodes of fainting. The radial pulse is erratic, with multiple skipped beats at a rate of 45 beats/min. An ECG shows a normal sinus rhythm at a rate of 60/min. An echocardiogram reveals a 2-cm mass that is acting like a "ball valve" to produce intermittent obstruction of flow. Which of the following is the most likely location of this patient's lesion?
a)
Aorta
b)
Left atrium
c)
Left ventricle
d)
Right atrium
e)
Right ventricle
22.
A healthy 4-year-old girl is brought for a well-child examination. A grade 2/6 systolic ejection murmur is heard along the upper left sternal border. S2 is widely split and does not vary with respiration. A soft mid-diastolic murmur is heard along the lower left sternal border. Examination shows no other abnormalities. Which of the following is the most likely diagnosis?
a)
Aortic stenosis
b)
Atrial septal defect
c)
Normal heart
d)
Mitral valve prolapse
e)
Patent ductus arteriosus
23.
A previously healthy 22-year-old man comes to medical attention because of progressive exertional dyspnea punctuated by episodes of precordial pain. The patient's father and one of his elder siblings died of chronic heart disease in middle age. The most significant findings on physical examination include presence of a loud S₁ and a harsh systolic murmur. The latter increases with the Valsalva maneuver and decreases with squatting. Bibasilar rales are heard on lung auscultation. Blood pressure, pulse, and respiratory rate are within normal limits. A chest x-ray film shows no appreciable alterations in car- diac silhouette, but the ECG shows left axis deviation. Echocardiography reveals marked thickening of the interventricular septum, associated with delayed relax- ation and filling of the left ventricle during diastole. Which of the following is the most appropriate initial step in management?
a)
Beta blockers
b)
Digitalis
c)
Long-acting nitrates
d)
Aortic valve replacement
e)
Partial excision of myocardial septum
24.
A 20-year-old male college student is participating in the New York City Marathon and collapses one third of the way through the race. He is a well developed, athletic man who frequently plays basketball and ten- nis. He has no past medical history, except for a ton- sillectomy at 9 years of age. There were no symptoms before he collapsed to the ground and lost conscious- ness. The patient is immediately rushed to the nearest emergency room but is pronounced dead on arrival. Which of the following is the most likely underlying cause of his sudden death?
a)
Aortic stenosis
b)
Arrhythmogenic right ventricular dysplasia
c)
Coronary anomalies
d)
Hypertrophic cardiomyopathy
e)
Isolated left ventricular hypertrophy
25.
An 18-yo man is brought to the ED 10 minutes after he sustained a stab wound to his chest. On arrival, he is unresponsive to painful stimuli. His pulse is 130/min, respirations are 8/min and shallow, and palpable systolic blood pressure is 60 mm Hg. He is intubated and mechanically ventilated, and an infusion of 0.9% saline is begun. After 5 minutes, his pulse is 130/min, and BP is 70/40 mmHg. Examination shows a 2-cm wound at the left sixth intercostal space at the midclavicular line. There is jugular venous distention. Breath sounds are normal. The trachea is at the midline. Heart sounds are not audible. Which of the following is the most appropriate next step in management?
a)
Chest x-ray
b)
Echocardiography
c)
Bronchoscopy
d)
Pericardiocentesis
e)
Placement of a right chest tube
26.
A 46-yo man comes to the physician with exertional dyspnea and dry cough. He also has occasional episodes of suffocating nighttime coughs that are only relieved by sitting up. Past medical history is significant for MI 6 months ago and hypercholesterolemia. uCurrent 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 and pulse is 60/min. Chest examination shows bibasilar crackles. The cardiac apex is palpated in the left sixth ICS. Bilateral pitting leg edema is present. Which of the following is most likely to be associated with this patient's condition?
a)
Constriction of the efferent renal arterioles
b)
Decreased intraglomerular pressure
c)
Decreased renal venous pressure
d)
Decreased plasma colloid pressure
e)
Increased renal blood flow
27.
A 34-yo woman comes to the ED with difficulty breathing and dizziness. An arterial line is placed and her BP tracing is shown below: Which of the following is most appropriate ?
a)
Aortic regurgitation
b)
Lobar pneumonia
c)
Mitral stenosis
d)
Panic attack
e)
Severe asthma
28.
A 46-year-old woman complains of dyspnea on exertion and orthopnea that started 7 months ago. She has a prior history of pericarditis, which had been treated with indomethacin. An ECG shows low voltage in the limb leads. A chest radiograph reveals pericardial calci- fication, and echocardiography shows pericardial thick- ening. Cardiac catheterization reveals equal pressures in the four cardiac chambers during diastole with all pressures elevated. Which of the following findings on her physical examination would be consistent with a diagnosis of constrictive pericarditis?
a)
Increased neck vein distention on inspiration
b)
Exaggerated first and second heart sounds (S1 and S2)
c)
Extra third heart sound (S3)
d)
Extra fourth heart sound (S4)
e)
Predominance of left-sided symptoms over right- sided symptoms
29.
A 40-year-old man with type 1 diabetes mellitus for 10 years was recently found to have mild hypertension (stage 1) and microalbuminuria. Renal function tests are otherwise normal. There is evidence of mild left ventricu- lar hypertrophy on ECG and echocardiographic studies. Blood lipids are within normal limits. Which of the fol- lowing is the most appropriate pharmacologic treatment for this case of hypertension?
a)
ACE inhibitors
b)
Beta blockers
c)
Calcium channel blockers
d)
Central alpha-agonist, e.g., clonidine
e)
Thiazide diuretics
30.
A 44-years-old woman presents with episodes of headaches, associated with anxiety, sweating and a slow pulse rate. At the time of her initial consultation, her blood pressure was 150/95 mmHg seated, but 24 hour ambulatory monitoring shows a peak of 215/130 mmHg, associated with the symptoms described above. Which of the following would be your initial diagnostic procedure?
a)
Glucose tolerance test
b)
MRI scans of the abdomen and pelvis
c)
Measurement of random plasma catecholamines
d)
Measurement of urinary metanephrines over several 24 h periods
31.
A 74-year-old man comes to the office to establish care. The patient has no complaints and states he has been in good health. He has not been to a primary care provider for several years. uMedical history includes right knee osteoarthritis, for which he occasionally takes ibuprofen. He does not use tobacco or alcohol. His BP is 165/75 and pulse is 70/min. Examination shows a 2/6 systolic ejection murmur at the right sternal border without radiation. Peripheral pulses are full without delay, ECG reveals left ventricular hypertrophy with secondary ST-segment and T wave changes. Echocardiogram shows moderate left ventricular hypertrophy without any significant abnormalities. The ejection fraction is 60%. Which of the following is the most likely cause of hypertension in this patient?
a)
Aortic insufficiency
b)
Elevated plasma renin activity
c)
increased cardiac output
d)
increased intravascular volume
e)
Rigidity of the arterial wall
32.
A 67-yo woman came to the physician because of dizziness for 6 weeks. When she stands up suddenly, she becomes light-headed and has to steady herself for approximately 1 to 2 minutes before she is able to walk. She has hypertension and type 2 diabetes mellitus. Current medications include glyburide, a diuretic, a ẞ-adrenergic blocking agent, and an ACE inhibitor. Her pulse is 55/min. Her BP is 110/70 mmHg in the right arm and 70/50 mmHg in the left arm while supine; her BP is 70/50 mmHg in the right arm and 50/30 mmHg in the left arm immediately after standing. Neurologic examination shows no focal findings. An ECG shows sinus bradycardia with no evidence of ischemia. Carotid duplex ultrasonography shows reverse flow in the left vertebral artery with no evidence of occlusion. Which of the following is the most appropriate next step in management?
a)
Cardiac stress scintigraphy
b)
Adjusting her medication regimen
c)
Warfarin therapy
d)
Transesophageal echocardiography
e)
Coronary arteriography
33.
A 26-year-old librarian presents with chronic daytime somnolence, which has frequently caused him to fall asleep at work. He does not smoke but drinks 1 to 2 glasses of wine daily. He says he frequently awakens at night but denies any visual or auditory hallucinations on falling asleep. His height is 186 cm (73 in), and his weight is 60% greater than expected. Chest examina- tion reveals no specific findings other than distant breath sounds. Arterial blood gas analysis during nor- mal ventilation shows: PaO2 82 mm Hg PaCO2 55 mm Hg After the patient voluntarily hyperventilates for 1 minute, blood gas analysis returns within normal limits. Which of the following will have the greatest benefit on this patient's symptoms?
a)
Benzodiazepines at bedtime
b)
Daily acetazolamide
c)
Morning administration of dextroamphetamine
d)
Supplemental oxygen at night
e)
Weight loss
34.
A patient presents to the emergency department with a blood pressure of 180/130 mmHg, headache, and confusion. Which additional finding is consistent with a diagnosis of hypertensive emergency?
a)
Retinopathy
b)
Urinary retention
c)
Jaundice
d)
Bradycardia
35.
A third-year medical student is examining a patient who has acute onset of abdominal pain. The patient is a 65-year-old smoker with HTN and DM who has had dull abdominal pain gradually building for the last 12 hours. It is not related to food nor relieved by taking famotidine (antihistamin H2). On physical examination, auscultation reveals a bruit. Palpation shows a pulsatile mass. While lightly palpating the epigastrium, the patient suddenly becomes hypotensive and passes out. What is the most likely diagnosis?
a)
Ruptured abdominal aortic aneurysm.
b)
Ruptured peptic ulcer.
c)
Hemorrhagic gastritis.
d)
Narcolepsy.
36.
A 69-year-old man with a 50 pack-year smoking history is brought to the ER by his wife, who reports he seems “confused.” He feels weak and has mid-abdominal pain. He is a pale, elderly male in moderate distress. BP is 84/55 mmHg; pulse is 120 bpm. There is a palpable, pulsatile mass in the patient's abdomen. What is the most likely diagnosis?
a)
Ruptured peptic ulcer.
b)
Hemorrhagic gastritis.
c)
Hemorrhagic pancreatitis.
d)
Ruptured abdominal aortic aneurysm
37.
A 67-year-old man comes to the emergency department with the sudden onset of chest pain. He also has pain between his scapulae. He has a history of hypertension and tobacco smoking. His blood pressure is 169/108. What is the most accurate test?
a)
MRA.
b)
Transesophageal echocardiogram.
c)
Transthoracic echocardiogram.
d)
CT angiogram.
e)
Angiogram.
38.
A 72-year-old man presents to his primary care provide's office for a health maintenance exam. He currently feels well and does not have any complaints, aside from occasional pain in his knees. His medical history is significant for hypertension and osteoarthritis, for which he takes hydrochlorothiazide, lisinopril, and occasionally, acetaminophen. He has a 20-pack-year smoking history, but quit 30 years ago. He does not drink alcohol. He is a retired plumber, and lives with his wife in a retirement community. At the end of the visit, he reveals that a friend recently had an abdominal aortic aneurysm repaired. He is wondering whether he should be screened for this disease. Which of the following is the most appropriate next step in the management of this patient?
a)
Obtain an abdominal ultrasound
b)
Obtain a CT scan of the abdomen
c)
Obtain MRI of the abdomen
d)
Obtain an echocardiogram
e)
No further testing is needed
39.
A 67-year-old man comes to the emergency department with the sudden onset of chest pain. He also has pain between his scapulae. He has a history of hypertension and tobacco smoking. His blood pressure is 169/108. What is the best initial test?
a)
Chest x-ray.
b)
Chest CT.
c)
Angiography
d)
Transthoracic echocardiogram
e)
CT angiogram.
40.
A 47-year-old man is brought to the ED 2 hours after the sudden onset of shortness of breath, severe chest pain, and sweating. He has no history of similar symptoms. He has hypertension treated with hydrochlorothiazide. He has smoked one pack of cigarettes daily for 30 years.His pulse is 110/min, respirations are 24/min, and blood pressure is 110/50 mmHg. A grade 3/6, diastolic blowing murmur is heard over the left sternal border and radiates to the right sternal border. Femoral pulses are decreased bilaterally. An ECG shows left ventricular hypertrophy. Which of the following is the most likely diagnosis?
a)
Acute myocardial infarction
b)
Aortic dissection
c)
Esophageal rupture
d)
Mitral valve prolapse
e)
Pulmonary embolism
41.
An 84-year-old man is brought to the emergency department because of 1 hour of severe back pain. He also had syncope that lasted <1 minute. Before arriving at the hospital, he had an episode of gross hematuria, which he has never had before. He also complains of some shortness of breath. He denies chest pain, cough, nausea, vomiting, headache, and neck pain. His blood pressure is 72/55 mm Hg and pulse is 112/min and regular. His pulse oximetry shows 92% on room air. His ECG shows sinus tachycardia with prominent horizontal ST-segment depression in the anterior chest leads. Which of the following is the most likely diagnosis?
a)
Abdominal aortic aneurysm rupture
b)
Acute mesenteric ischemia
c)
Acute myocardial infarction
d)
Massive pulmonary embolism
e)
Nephrolithiasis with renal colic
42.
A 55-year-old man comes to the physician because of chronic leg problems. He has had multiple medical problems and is unable to get good medical care due to lack of insurance. A photograph of his legs is shown below: Which of the following is the most likely cause of his condition?
a)
Arterial thrombosis
b)
Arterial spasm
c)
Venous hypertension
d)
Peripheral neuropathy
e)
Posterior spinal cord lesion
43.
A 65-year-old man with a history of peripheral vascular disease develops thromboembolic disease in his left leg accompanied by dry gangrene. Laboratory tests show elevated serum lactic acid, and his arterial pH is 7.27. An ECG in this patient is most likely to show which of the following?
a)
Peaked T waves
b)
QT prolongation
c)
ST depression
d)
T wave inversion
e)
U waves
44.
For 8 weeks, a 52-yo man with a 5-year history of type 2 DM has had deep burning pain in the ball of his right foot and big toe when the foot is raised above chest concentration. He also has cramping in his right calf when he walks more than 50 feet. He has smoked two packs of cigarettes daily for 30 years. Femoral pulses are palpable; pedal pulses are absent. Which of the following is the most likely diagnosis?
a)
Aortoiliac stenosis
b)
Femoral popliteal stenosis
c)
Venous stasis
d)
Vasculitis
45.
An 18-year-old man is referred for evaluation of hyper- tension. On examination, he appears in no apparent discomfort and states that he has never had any health problems. His height is 175 cm (69 in), and his weight is 70 kg (154 lb). There is no pitting edema in the lower legs or jugular vein distention. The lungs are clear to auscultation. Blood pressure is 162/80 mm Hg in the upper extremities and 115/77 mm Hg in the lower extremities. Femoral pulses are weaker than radial puls- es. A systolic murmur is appreciated at the base of the heart and is particularly intense in the back. The ECG shows changes consistent with left ventricular hyper- trophy, and a chest x-ray film reveals notching of the inferior margins of the ribs. Which of the following is the most likely diagnosis?
a)
Atrial septal defect (ASD)
b)
Coarctation of the aorta
c)
Congenital aortic stenosis
d)
Congenital pulmonary stenosis
e)
Patent ductus arteriosus
46.
A 64-year-old man is brought to the emergency depart- ment because of sudden onset of tearing chest pain that seems to originate in the anterior chest and radiate to the back in the interscapular region. A few weeks ago, he had a dental abscess, which resolved with extraction followed by a full course of ampicillin. On examination, he is oriented to person, place, and time; however, he appears in acute distress, is diaphoretic, and is breath- ing with difficulty. His temperature is 37.1 C (98.8 F), blood pressure is 174/68 mm Hg, pulse is 206/min, and respirations are 25/min. There is no jugular vein disten- tion or hepatomegaly. Auscultation reveals a diastolic murmur along the left sternal border. The lungs are clear to auscultation. The ECG shows no signs of myocardial ischemia. A chest x-ray film demonstrates widening of the mediastinum. Which of the following is the most likely diagnosis?
a)
Aortic dissection
b)
Acute mediastinitis
c)
Acute pericarditis
d)
Cardiac tamponade
e)
Myocardial infarction
47.
A 61-year-old man is hospitalized after receiving an implantable cardiac defibrillator (ICD). The patient has a long history of coronary disease and sustained an anteri- or wall myocardial infarction 3 years ago. Two weeks ago, he had an episode of pulseless ventricular tachycardia and was successfully resuscitated. This episode led to the ICD placement. In addition to the ICD, the cardiologist also plans to initiate antiarrhythmic therapy with amio- darone. Which of the following is the most important side effect of this therapy?
a)
Hypotension
b)
Pulmonary fibrosis
c)
Prolongation of the QT interval
d)
Recurrent ventricular arrhythmia
e)
Skin discoloration
48.
A 72-year-old man suffers severe pleuritic chest pain on the seventh postoperative day after surgical pinning of an intertrochanteric hip fracture. He was not on antico- agulants at the time. He is hemodynamically stable, but is short of breath and has distended neck veins. Spiral CT scan shows the presence of a pulmonary embolus on the left side, and echocardiogram does not show signs of right ventricular strain. Which of the following is the most appropriate management at this time?
a)
Anticoagulation with heparin
b)
Infusion of thrombolytic agents into the left pul- monary artery
c)
Insertion of vena cava filter
d)
Surgical embolectomy
e)
Systemic infusion of thrombolytic agents
49.
A 55-year-old male smoker with diabetes and hyperten- sion presents with complaints of chest pain on exertion. Exercise stress testing shows reversible ischemia in the anteroseptal portion of the heart after exercising 4 min- utes. Cardiac catheterization reveals an 80% stenosis of the left main coronary artery. Which of the following is the most appropriate intervention?
a)
Re-examination in 6 months or sooner if symptoms worsen
b)
Beta blocker
c)
Sublingual nitroglycerin as needed
d)
Percutaneous balloon angioplasty
e)
Coronary artery bypass grafting
50.
A 71-year-old woman is admitted to the hospital for dehydration. She has a history of coronary artery dis- ease, rheumatoid arthritis, hyperthyroidism, hyperten- sion, and renal artery stenosis, but has been well over the past few months. She was brought to the hospital by her daughter, who found her weak and nauseated. The patient reports that, with the onset of summer, she had been feeling quite fatigued and has had signifi- cantly decreased oral intake and progressive nausea. Current medications include digoxin, atenolol, aspirin, acetaminophen, prednisone, fluoxetine, levothyroxine, and nifedipine. Admission laboratory tests show: Sodium 132 mEq/L Potassium 3.4 mEq/L Bicarbonate 30 mEq/L Chloride 98 mEq/L Urea nitrogen 52 mg/dL Creatinine 1.9 mg/dL Leukocytes 5300/μm³ Hematocrit 48% Her last set of laboratory data, obtained 7 months ago, revealed completely normal values. On the basis of these admission laboratory values, which of her medi- cations requires dosing adjustment?
a)
Acetaminophen
b)
Atenolol
c)
Digoxin
d)
Fluoxetine
e)
Levothyroxine
51.
A 45-year-old man presents to the ED, complaining of the sudden onset of left substernal chest pain. He describes this as a chest pressure that rates 8 on a scale of 1 to 10. He has never had these symptoms before. He has history of hypercholesterolemia, for which he takes a lipid lowering drug. On physical examination,he appears anxious and is diaphoretic. His BP is 100/90 mmHg, and his pulse is 110/min. The remainder of the physical examination is unremarkable. He undergoes an ECG, which reveals ST elevation in leads II. III, and aVF. He is diagnosed with an acute myocardial infarction. On cardiac catherization, which of the following vessels will most likely be occluded?
a)
Circumflex artery
b)
Left anterior descending artery
c)
Left coronary artery
d)
Right cornonary artery
52.
A 39-year-old man presents to the ED with acute onset of shortness of breath, hemoptysis, and left-side pleuritic chest pain. His past medical history includes medication-controlled asthma, peptic ulcer disease, and a recent onset of idiopathic nephrotic syndrome. His BP is 180/100 mmHg, pulse is 110/min, and respirations are 28/min. Cardiac and lung examinations are normal. Laboratory data are remarkable for a serum lactate dehydrogenase of 300U/L. An ECG shows sinus tachycardia, prominent S waves in lead 1, inversion of the T wave, and a prominent Q wave in lead III. Which of the following is the most likely cause of the chest pain?
a)
Aortic dissection
b)
Unstable angina
c)
Pulmoary embolism
d)
NSTEMI
53.
A 60-year-old white man is evaluated by physician because of weight gain and increasing abdominal girth of several month's duration, despite no change in diet. His temp is 37.1C, blood pressure is 70/40 mmHg, pulse is 120/min, and respirations are 19/min. head and neck examination is remarkable for “bag” under the eyes and jugular venous distension. Chest examination demonstrates pulmonary rales and a third heart sound. Abdominal examination reveals an enlarged, tense abdomen with a palpable fluid wave; abdominal organ palpation is inadequate because of the tension. Examination of the extremities demonstrates pitting edema at the ankles. Which of the following is the most likely diagnosis?
a)
Hypothyroidism
b)
Alcoholic cirrhosis
c)
Congestive heart failure
d)
Chronic hepatitis B infection
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