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  #1  
Old 10-25-2011
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Heart Cardiology 5 Questions 10/25

1.A 56-year-old man comes to the clinic for a return visit. During his last three visits, he has had an elevated blood pressure in the range of 150-160 mm Hg systolic pressure over 90-95 mm Hg diastolic. Despite 3-6 months of a new diet and exercise program, he has not been able to get his blood pressure under control. His past medical history, except for his high blood pressure, is unremarkable. He is concerned about high blood pressure, as his older brother had high blood pressure and died from a heart attack in his mid 60s. Today his blood pressure is 162/92 mm Hg. Which of the following is the most appropriate, cost-effective, first-line treatment for this patient?
A. Acetazolamide
B. Clonidine
C. Felodipine
D. Hydrochlorothiazide
E. Lisinopril
F. Metoprolol
G. None, continue diet and exercise
H. Spironolactone
I. Terazosin
J. Triamterene

2.A 62-year-old man comes to the clinic complaining of urinary hesitancy, 3-4 episodes of nocturia per night, and a weak urinary stream. His past medical history is significant for stage I hypertension that persists despite diet and exercise. Physical examination confirms the patientís mild hypertension and a suspected enlarged, symmetric, and non-nodular prostate. In considering antihypertensive treatment, which of the following is a medication that can treat this patientís urinary symptoms and his mild hypertension?
A. Atenolol
B. Doxazosin
C. Felodipine
D. Finasteride
E. Hydrochlorothiazide

3.A 40-year-old woman comes to the clinic for a routine health examination. She has no specific complaints, but a review of systems reveals some mild fatigue over the last 6 months as well as reduced exercise tolerance and increasing dyspnea on exertion. Past medical history is unremarkable. On cardiac examination a loud, split second heart sound is heard, which is a finding not present on this patientís previous exams. The split heart sound is constant with inspiration and is associated with a 1/6 midsystolic murmur heard best over the left upper sternal border. Which of the following findings is most consistent with this examination finding?
A. A chest radiograph revealing enlarged pulmonary hila and main pulmonary artery
B. An EKG showing a wide, flattened QRS pattern most prominent in the lateral leads
C. Echocardiography results that reveal severe aortic stenosis with ventricular hypertrophy
D. Family history of hypertrophic obstructive cardiomyopathy
E. Sphygmomanometer reading that shows severe systolic hypertension


4.A 68-year-old woman is admitted to the orthopedic surgery service after sustaining a fall and a right hip fracture. You are asked to evaluate the patient to provide preoperative clearance. The patient denies prior cardiac or pulmonary complications. She denies chest pain, shortness of breath, or palpitations. She is not receiving any medications. She reports good exercise tolerance. She is able to climb a flight of stairs without developing shortness of breath. Furthermore, she is able to walk a mile with no difficulty. Her blood pressure is 120/80 mm Hg and pulse is 80/min. Lungs are clear. Heart is regular. She has a non-radiating systolic ejection murmur at the base. She has a normal S1 and a physiologically split S2. She has 2+ carotid upstrokes with no bruit. Which of the following is the most appropriate management of this patient?
A. Clear the patient for surgery
B. Obtain an echocardiogram
C. Obtain a 24-hour Holter monitor report
D. Prescribe atenolol, 25 mg daily
E. Schedule an exercise stress test

5.You are considering purchasing a treadmill for your office in hopes of evaluating your patients for ischemia. You ask a medical student working in your office to look through patient charts to determine the approximate number of your current patients that would benefit from a treadmill exercise stress test. You explain to the student that this is a useful test to establish the possibility of reversible ischemia in a patient presenting with chest pain, and that not all patients would benefit from this type of diagnostic study. Which of the following patients should be sent for a routine treadmill stress test?
A. A 49-year-old lawyer with long-standing uncontrolled hypertension
B. A high-school teacher with new-onset angina that always happens while having breakfast
C. A 42-year-old football coach with a cast on his left arm due to a fracture of his left humerus 1 week ago who presents with chest pain after running 2 to 3 blocks; his resting ECG is normal
D. A 65-year-old patient with current chest pain and ECG changes showing 2 mm of ST elevation in leads II, III, and aVF
E. A 35-year-old pilot with left-sided chest pain and a normal ECG
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  #2  
Old 10-25-2011
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1-d , 2-b , 3- d , 4-b , 5-b
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D. Hydrochlorothiazide
B. Doxazosin
A. A chest radiograph revealing enlarged pulmonary hila and main pulmonary artery
A. Clear the patient for surgery or B.ECHOprobably she is fit
B. A high-school teacher with new-onset angina that always happens while having breakfast
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i thought the 3rd answer was due to anemia n not HOCM...as in HOCM A2 should be delayed and the split wont b wider right???infact it gets reversed ???in anemia P2 gets prolonged n so split is wider???
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1-d
2-b
3-a
4-b echo i think
5-a i don't know y!!
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answer plz
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1) D- Ihe meets the criteria for HTN (ie over 140/90 multiple times) tried diet and excersize so next step is thiazide diuretics.

2) B- you need an alpha blocker.

3) Its a symptomatic ASD (shows up around 3rd decade normally) So let to right shunt = increase pulmonary volume

As a side point i tried thinking of any cause of a Wide Flattend QRS but couldnt think of any. a wide QRS though is VT and WPW

4) A- She looks good to me But im getting confused with the carotid upstoke part. I havent really seen a number associated with carotid upstoke or maybe im just being stupid right now. the systolic murmum over the base is only 1/6 and non radiating . It makes me think more of a rumble as in astiff heart and its filling than a real mummur ,since its not symptomatic i choose to ignore it. :P

5) stress test is done after an EKG is found to be non diagnostic in a pt of chest pain of unknown etiology,

Out of the options A wont be tested, nor D , As A doesnt have chest pain and D is a clear case already. This leave the other 3 option
option B i have no idea what that is angina after breakfast only?? but since it doenst mention an EKG done i will also discount it

option C sounds like a good candidate as his EKG is normal now but he did have chest pain while excersizing previously.
and E well to be honest i again havent a clue he does have chest pain thats current and his EKG is normal so it can be an option also.

Still im choosing C
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1. D. Hydrochlorothiazide

2. B. Doxazosin

3.
A. A chest radiograph revealing enlarged pulmonary hila and main pulmonary artery

4.
B. Obtain an echocardiogram

5.
C. A 42-year-old football coach with a cast on his left arm due to a fracture of his left humerus 1 week ago who presents with chest pain after running 2 to 3 blocks; his resting ECG is normal
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Old 10-26-2011
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1.The correct answer is D. Thiazide diuretics have been shown to be as effective as ACE inhibitors and calcium channel blockers and are significantly cheaper. Hydrochlorothiazide is a tried and true first-line antihypertensive medication that is also one of the most cost-effective drugs available.

Acetazolamide (choice A) is a weak diuretic that inhibits luminal carbonic anhydrase activity. Although it has a variety of uses, including reduced CSF production and treating metabolic alkalosis, it is generally not an effective hypertensive agent.

Clonidine (choice B) is a centrally acting alpha-2 agonist. It is generally not a first-line agent as it has a short half-life (though it comes in a transdermal form) and can cause severe rebound hypertension if inadvertently stopped. In hard to control hypertension, it can be a useful adjunct.

Felodipine (choice C) is a calcium channel blocker and is useful in controlling hypertension. In recent head-to-head trials it was not proven more beneficial than the significantly cheaper thiazide diuretics.

ACE inhibitors such as lisinopril (choice E) are good antihypertensives that also provide cardiac and renal benefits. Patients with a history of myocardial infarction (MI) and reduced systolic ejection fraction and patients at risk for diabetic nephropathy benefit from ACE inhibition. As this patient does not fit these categories there is no reason to choose an ACE inhibitor as a first-line therapy over cheaper thiazide diuretics.

Metoprolol (choice F) is a beta-blocker that has good antihypertensive effects. It is beneficial in patients with documented coronary artery disease in whom a reduction in myocardial oxygen demand and sympathomimetic-induced toxicity protects the myocardium.

Continued diet and exercise alone (choice G) is unlikely to provide further benefit, though it should continue to be encouraged. After a trial of 3-6 months it is appropriate to start treatment.

Spironolactone (choice H) is a weak diuretic that works by way of aldosterone antagonism, and in addition to its direct diuretic effects it can help reduce cardiac remodeling in patients with systolic dysfunction. Although it has been proven to reduce mortality in patients with congestive heart failure, it has little direct effect on blood pressure.

Terazosin (choice I) is an alpha-blocker that is a weak antihypertensive used mainly for treating benign prostatic hyperplasia (BPH). In a patient with mild hypertension and BPH it may be an appropriate treatment.

Triamterene (choice J) is a potassium sparing diuretic that works on the distal convoluted tubule. It often is given as an adjunct therapy (is commonly combined with hydrochlorothiazide) to help prevent potassium wasting.

2.The correct answer is B. Alpha-1 blockers rarely are used as first-line agents in the treatment of hypertension. They are appropriate, however, in patients with mild hypertension and symptoms of benign prostatic hyperplasia (BPH), in whom one medication can relax the vasculature and the prostatic urethra, both of which have alpha-1-mediated constriction.

Atenolol (choice A) is a beta-blocker that has good antihypertensive effects. It is beneficial in patients with documented coronary artery disease in whom a reduction in myocardial oxygen demand and sympathomimetic-induced toxicity protects the myocardium.

Felodipine (choice C) is a calcium-channel blocker with antihypertensive effects. It has no effect on the prostate.

Finasteride (choice D) is a 5-alpha-reductase inhibitor used to treat BPH. It works by inhibiting the conversion of testosterone to dihydrotestosterone, which is believed to drive growth of prostate tissue. It is not an antihypertensive medication.

Hydrochlorothiazide (choice E) is a cheap and proven treatment for hypertension and is often an excellent first-line agent. It will not relieve this patient’s urinary symptoms, however.

3.
The correct answer is A. A fixed-split S2 represents delayed pulmonic closure, which may result from increased right-sided volume, such as with an atrial-septal defect; or from reduced right ventricular function, such as right ventricular failure. Additionally, if the pressure gradient is increased, such as in pulmonary hypertension, it will take longer to develop the necessary systolic pressure to eject right-sided volume, resulting in delayed pulmonic closure as well as a loud pulmonic component to the second heart sound as the valve is “slammed shut” by the high pressure. Pulmonary hypertension may be seen on a chest radiograph that reveals engorged pulmonary arteries.

A left bundle branch block pattern appears as a wide, flattened QRS pattern most prominent in lateral leads (choice B), particularly lateral prechordial leads. It will result in delayed left-sided ejection and delayed aortic valve closure. Aortic valve closure is delayed relative to pulmonic valve closure. However, during inspiration, when right-sided volume increases, P2 is delayed and the two heart sounds occur together. Thus, the splitting is maximal during expiration, and reduced during inspiration, creating a “reversed” or paradoxical split. Aortic stenosis (choice C) and hypertrophic obstructive cardiomyopathy (choice D) will also delay left-sided ejection and can result in a paradoxical split.

Systolic hypertension (choice E), as measured by a sphygmomanometer will increase the loudness of the aortic component of the second heart sound.

4.
The correct answer is A. This patient has an excellent exercise capacity. She is able to climb a flight upstairs and walk a mile without difficulty. She denies any cardiac symptoms. The only risk factor is her age. Given the absence of major clinical predictors of risk, she is at low risk for complications from this orthopedic procedure.

This patient’s heart murmur raises concern for significant valve disease. Because the murmur is non-radiating and the heart sounds are normal, however, it is unlikely that the patient has aortic stenosis. Furthermore, given the absence of carotid bruits, this diagnosis is unlikely. An echocardiogram therefore is not necessary (choice B).

A Holter monitor (choice C) typically is obtained to investigate arrhythmia in a patient. This patient denies palpitations, syncope, or lightheadedness. Such a study therefore would not be necessary in this patient.

Prescribing atenolol (choice D) would be advisable if this patient had other risk factors, such as high blood pressure, decreased exercise tolerance, diabetes, or any indication that she would be at risk for cardiovascular complications.

Because this patient has excellent exercise capacity there is no good reason to suspect significant heart disease. An exercise stress test therefore is not necessary (choice E)


5.The correct answer is C. This 42-year-old football coach with what seems to be stable angina should undergo an exercise stress test. The cast on his left arm should not impede a stress test. If he were unable to walk, then a pharmacologic stress test would be indicated.

The 49-year-old lawyer with long-standing uncontrolled hypertension (choice A) should not have a routine treadmill exercise stress test because he will have left ventricular hypertrophy due to the hypertension, and this will make an ECG stress test nondiagnostic.

The high-school teacher with new-onset angina that always happens during breakfast (choice B) is having unstable angina—namely, new-onset angina at rest. This is a contraindication to a stress test and this patient should undergo cardiac catheterization.

The 65-year-old patient with current chest pain and ECG changes showing 2 mm of ST elevation in leads II, III, and aVF (choice D) is having what appears to be an acute myocardial infarction; therefore, a stress test would not be indicated. This patient should be treated for the MI first.

The 35-year-old pilot with left-sided chest pain and a normal ECG (choice E) has a safe-sensitive job, as do air traffic controllers, bus drivers, etc. These patients should go directly to cardiac catheterization and bypass a stress test altogether.
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Old 10-26-2011
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Thanks for the answers but can someone explain 3 points to me .

1) What is a 2+ carotid upstroke? what is the normal value and what is a low/high abnormal ? ( all i know about carotid upstroke is its either brisk or delayed i never heard of numbers with it)

2) As regards tot he guy with angina a breakfast only. How the hell do you get angina at a specific time related to one specific meal only? why not at lunch or dinner ( since those oare more heavy meals ?? )

3) The air traffic controller please explain that point furthur i have never heard the term safe sensative job and furthur am i to assume anyone with chest pain with those jobs are autimatically cathaterizeed when they have chest pain??
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Old 10-26-2011
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lol i knew about tht being c!! nw i knw y i compulsively do 3 questions wrong in each block which i can easily get right!
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