Summative Exam Questions and answers, 100% rated A+Test Bank

Summative Exam Questions and answers, 100% rated A+Test Bank Document Content and Description Below Summative Exam Questions and answers, 100% rated A+Test Bank An 80-year-old man was treated for ventricular arrhythmias. He presents 1 month later with joint pain. He also has an unusual mask-lik e rash over his face and body. Discontinuation of drug therapy causes the symptoms to abate. What drug was most likely administered to this patient? 1 Tocainide 2 Quinidine 3 Procainamide 4 Phenytoin 5 Propranolol - Procainamide - often prescribed for long-term control of arrhythmias. May cause lupus like SE. A 62-year-old woman with a long-standing history of hypertension presents with severe headache; it started this morning and is rapidly worsening. During the interview, she suddenly collapses. Your brief examination shows that she responds with extensor posturing on external stimuli. Her deep tendon reflexes are 3, and you elicit Babinski bilaterally. You also notice that her breathing has a peculiar pattern: deep inspiration with a pause at full inspiration, followed by a brief insufficient release and the end-inspiration pause. How do you best describe her respiratory pattern? Answer Choices 1 Cheyne-Stokes 2 Apneusis 3 Ataxic 4 Cluster 5 Central neurogenic hyperventilation - Her breathing pattern is apneustic. Apneustic breathing pattern characterizes *deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release and the end-inspiration pause before expiration.* What is the mechanism of LMWH? - Both unfractionated heparin and low molecular weight Heparin act by *forming a complex with antithrombin III.* A 5-day-old male infant has subtle, unusual facial features (i.e., a triangular face, hypertelorism, and down-slanting eyes). He also has a webbed neck and low-set ears. Suspecting a congenital disorder, you order a complete work-up, including a CBC, coagulation profile, cardiac evaluation, karyotyping, and mutation analysis. PTPN11 (protein-tyrosine phosphatase, nonreceptor-type 11) mutations are detected. Echocardiography detects a cardiac defect. What's most likely to be found on echo? - This neonate most likely has Noonan syndrome (NS). Pulmonary stenosis is the most common cardiac defect in this condition. Noonan syndrome is a sporadic, or autosomal dominant, congenital disorder with typical phenotypical features that may not be visible to the casual onlooker. The most common facial features include hypertelorism and low-set, backward-rotated ears with a thick helix. The philtrum is deeply grooved in more than 90% of cases. Congenital cardiac defects, bleeding disorders, mental retardation, webbed neck, and a short stature are other features. A 35-year-old woman presents for follow-up. She has a 6-month past medical history of hypertension; it has responded poorly to lifestyle approaches. She denies using any medications; she does not smoke or use illicit drugs. Her review of systems is notable for muscular weakness, paresthesias, headaches, polyuria, and polydipsia. On physical exam, her blood pressure is 155/95 mm Hg. She has generalized muscular weakness that is measured in all 4 extremities. The remainder of her exam is unremarkable. Laboratory analysis reveals hypokalemia and a hemoglobin A1c level of 5.5. What dx test result is most likely? 1 Metabolic alkalosis 2 Low serum aldosterone to plasma renin activity ratio 3 Hyponatremia 4 Increased erythrocyte sedimentation rate 5 Hypoglycemia - The correct response is metabolic alkalosis. This patient is demonstrating signs and symptoms consistent with primary hyperaldosteronism, which is most commonly caused by a unilateral adrenocortical adenoma (Conn's syndrome), but in a minority of patients, it is caused by adrenal hyperplasia. A 40-year-old man presents with atrial flutter with 2:1 atrioventricular (AV) conduction, giving him a pulse of 150 per minute, which is perfectly regular. His blood pressure is 70/40 mm Hg. He takes no medications regularly. You plan to provide him with urgent direct current cardioversion with conscious sedation. What would be an appropriate level of energy for cardioversion in order to restore sinus rhythm in this patient? 1. 10 Joules 2. 15 Joules 3. 50 Joules 4. 200 Joules 5. 300 Joules 6. 360 Joules - Of all of the arrhythmias, both supraventricular and ventricular, atrial flutter is the easiest to cardiovert back to a regular sinus rhythm. Direct cardioversion is usually successful with low energy - 25 to 100 Joules. There is no need to apply especially high energies such as 200 Joules, 300 Joules, or 360 Joules as the initial energy for cardioversion in case of atrial flutter, as higher energies have a greater probability of causing burns or broken bones. On the other hand, 10 or 15 Joules is unlikely to result in a successful cardioversion. *50* A 48-year-old man is brought to the ER complaining of difficulty breathing, fatigue, and intermittent chest pain for the past month. On further questioning, he states that the breathing seems to worsen when lying down. On physical exam, you note elevated respiratory and heart rates and pale, sweaty skin. On auscultation, rales are noted as well as a 3rd heart sound. Which of the following is the most likely diagnosis? 1 Right Ventricular failure 2 Pulmonary Embolism 3 Mitral Valve Stenosis 4 Left Ventricular failure 5 Chronic Obstructive Pulmonary Disease (COPD) - Left Ventricular failure The clinical picture is suggestive of left ventricular failure (LVF). Clinical presentation includes dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. The patient may also have hemoptysis, chest pain, fatigue, nocturia, and confusion. On physical exam, the patient may present with cold, pale sweaty skin, tachypnea and tachycardia, rales, and 3rd and 4th heart sounds. This is diagnostically different from right ventricular failure. Right ventricular failure (RVF) has a clinical picture of shortness of breath, pedal edema, and abdominal pain. On PE, RVF will present with a S3, jugular venous distention (JVD) and may have signs of LVF. A 41-year-old woman presents for follow-up regarding elevated blood pressure. This is her third visit to the office, and her blood pressure has been elevated on multiple readings at each visit. She has a history of eczema but is otherwise healthy. Labs reveal the following: WBC: 14.5 k/uL Hgb: 13.5 g/dL HCT: 41% PLT: 152 k/uL Na: 135 mmol/L K: 2.8 mmol/L Cl: 99 mmol/L CO2: 32 mmol/L BUN: 10 mmol/L Cr: 1.02 mmol/L What lab abnormality is most likely to be causing her secondary htn? - *Hypokalemia is correct.* Patients with primary hypertension should not have abnormalities in serum electrolytes. The patient's hypokalemia suggests a secondary cause of hypertension. *The most common cause of secondary hypertension is renal artery stenosis caused by fibrosmuscular dysplasia.* If the adult is middle-aged, then the most common secondary cause of hypertension would be *aldosteronism and a highly recommended initial diagnostic test would be an aldosterone/renin ratio.* Age is incorrect. This patient is 41 years old. Secondary hypertension is more likely in patients under 30 years old or over 50 years old. Female gender is incorrect. Primary hypertension is more common in middle-aged males than middle-aged females. The gender distribution for secondary hypertension varies with the specific cause of secondary hypertension. Hypokalemia is the most suggestive risk factor of secondary hypertension in this patient. Eczema is incorrect. Eczema is not a risk factor for secondary hypertension Leukocytosis is incorrect. Leukocytosis is not associated with secondary hypertension. A 78-year-old man with known left-sided congestive heart failure presents with a complaint of cough, worsening dyspnea with exertion, and orthopnea. What is the most direct cause of his symptoms? 1. Tricuspid insufficiency 2. Left ventricular hypertrophy 3 .Decreased peripheral vascular resistance 4. Increased pulmonary venous pressure 5. Mucus plugging - Increased pulmonary venous pressure In left-sided congestive heart failure, the predominant feature is *low cardiac output and elevated pulmonary venous pressure, resulting in dyspnea.* As dyspnea worsens, the patient will also begin to experience shortness of breath at rest, which is worsened in the supine position. Tricuspid function is not related to CHF. Peripheral vascular resistance typically increases in CHF, which is designed to help maintain perfusion to vital organs. Mucus plugging is not associated with CHF. A 58-year-old woman presents with a 3-month history of postprandial abdominal pain. This crampy pain occurs 30 minutes after eating, every time. Due to these symptoms, the patient has lost 30 pounds and is afraid to eat. Her past medical history includes hypertension treated with enalapril, coronary artery disease for which she has undergone a right coronary artery stent, and she underwent a carotid endarterectomy for symptomatic carotid stenosis. She has smoked 2 packs of cigarettes a day for 30 years. What is the best initial test for this patient? 1 Mesenteric angiogram 2 Mesenteric duplex ultrasound 3 Computerized tomography (CT) 4 Magnetic resonance angiography (MRA) 5 Computerized tomography angiography (CTA) - The symptoms of chronic mesenteric ischemia have a typical presentation, including a cachectic, middle-aged patient with crampy abdominal pain after eating. The risk factors for chronic mesenteric ischemia are the same as those for atherosclerosis. Treatment aimed at restoration of mesenteric blood flow is required to restore blood supply, prevent bowel necrosis, and restore normal weight. *Mesenteric duplex ultrasound is an excellent screening test to detect chronic mesenteric ischemia;* however, angiography allows for confirmation of the diagnosis. Combined B-mode and color Doppler ultrasound analyze flow though the mesenteric arteries and identifies stenosis as an elevated velocity. Limiting factors include obesity and intestinal gas, which may obstruct the ability to obtain a good ultrasound image. A 73-year-old man with no significant past medical history presents with a 1-month history of light-headedness, dizziness, and near-faintness; it has been occurring in response to sitting up and standing from a supine position. He denies chest pain, palpitations, shortness of breath, cough, loss of consciousness, vision or speech changes, nausea or vomiting, numbness, tingling, paresthesias, and focal weakness. His physical exam is noteworthy for a drop of systolic blood pressure of 24 mm Hg from a supine to standing position. What test is most helpful in identifying the cause of this patient's symptoms? 1. Hemoglobin A1c 2. Tilt-table test 3. Cardiac enzymes 4. CT scan of the head 5. Urinalysis. - The correct response is tilt-table test. This patient is presenting with signs and symptoms consistent with orthostatic hypotension. It is defined as a reduction in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg within 3 minutes of standing or head-up tilt on a tilt table. It is a manifestation of sympathetic vasoconstrictor (autonomic) failure. A 62-year-old woman presents with extreme fatigue and shortness of breath. The symptoms began about 24 hours ago and have progressively worsened within the last 4 hours. Vital signs on arrival are as follows: HR 90 beats per minute; BP 165/72 mm Hg; RR16/min; SpO2 98% on 4L/min supplemental oxygen by nasal cannula. 12-lead ECG demonstrates ST-segment elevation of 2 mm in leads V4-V6. In addition to an aspirin tablet, what medication would be most appropriate in the emergency management of this patient? 1. Dobutamine 2. Dopamine 3. Morphine 4. Nitroglycerin 5. Vasopressin - Nitroglycerin The patient's presentation is consistent with acute myocardial infarction. Emergency department management of patients with acute coronary syndromes - which include acute myocardial infarction and unstable angina - should consist of supplemental oxygen to maintain SpO2 >90%, oral aspirin 160-325 mg, and sublingual nitroglycerin unless contraindicated (for example, in the context of hypotension). A 48-year-old man with hypertension and coronary artery disease presents with protracted fever, fatigue, anorexia, weight loss, night sweats, and non-specific, non-radiating joint pains. These symptoms began insidiously following a routine dental cleaning, but they have progressed over the past 4 weeks. He denies any chills, myalgias, sore throat, palpitations, shortness of breath, pleurisy, cough, wheezing, abdominal pain, nausea, vomiting, diarrhea, peripheral edema, trauma, travel, insect bites, or sexual contact within the past year. His physical exam is remarkable for a fever of 101.3°F. His fundoscopic examination is notable for cytoid bodies and hemorrhages, while his oral mucosa displays conjunctival petechiae. There is a palpable purpuric skin rash of the lower extremities, reduced bilateral radial and ulnar pulsations, linear hemorrhages under the nails not reaching the nail margin, as well as tender, erythematous nodules occurring in the of the fingers. His cardiac exam demonstrates a soft, medium-pitched holosystolic murmur located at the apex with radiation to the axilla, while his foot exam reveals the findings in the attached image. A comparison to the patient's last physical exam reveals no abnormal physical exam findings. What pharmacotherapeutic agent is most appropriate for this patient? 1 Penicillin G 2 Rifampin 3 Linezolid 4 Doxycycline 5 Ampicillin - This patient's presentation is most consistent with native valve endocarditis caused by Viridans group streptococci ( -hemolytic streptococci). These are a frequent cause of community-acquired native valve endocarditis. Viridans streptococci are normal residents of the oropharynx and easily gain access to the circulation after dental or gingival trauma. Adult native valve endocarditis caused by penicillin-susceptible S. viridans, S. bovis, and other streptococci should be treated with one of the following regimens: penicillin G at 12 - 18 million U/d IV by continuous pump or in 6 equally divided doses for 4 weeks, ceftriaxone at 2 g/d IV for 4 weeks, or penicillin G or ceftriaxone and gentamicin at 1 mg/kg (based on ideal body weight) every 8 hours for 2 weeks. The emergence of methicillin-resistant S. aureus (MRSA) and penicillin-resistant streptococci has led to a change in empiric treatment with liberal substitution of vancomycin in lieu of a penicillin antibiotic. A 75-year-old African-American man presents with a 5-month history of gradually progressive dyspnea that is especially pronounced when climbing stairs. He also has been noticing that his ankles and lower legs have "gotten larger" over roughly the same time period, which no longer allows him to fit into his sneakers. He denies fever, chills, chest pain, palpitations, cough, pleurisy, calf pain, abdominal complaints, sick contacts, or travel. His psychosocial history is noteworthy for chronic alcohol use. His physical exam reveals bibasilar rales, JVD of 5cm, an S3 gallop, a holosystolic murmur at the apex that radiates to the left axilla, and 2+ pitting edema to the level of the mid-calves bilaterally. A bedside echocardiogram was remarkable for biventricular enlargement. What additional physical exam finding would be expected in this patient? 1 Tachycardia 2 Fever 3 Asymmetric upper extremity blood pressures 4 Warm, moist skin 5 Acanthosis nigricans - This patient's presentation is significant for dilated cardiomyopathy. Dilated cardiomyopathy occurs more often in African Americans than Caucasians, and it occurs in men more frequently than women. Often no cause can be identified, but chronic alcohol abuse, major catecholamine discharge, myocarditis, postpartum, and doxorubicin are frequent causes. Chronic tachycardia may also precipitate a dilated cardiomyopathy that may improve over time if rate control can be achieved. Amyloidosis, sarcoidosis, hemochromatosis, and diabetes may rarely present as dilated cardiomyopathies, as well as the more classic restrictive picture. A 62-year-old man has a 15-year history of hypertension, hyperlipidemia, myocardial infarction, and congestive heart failure. He presents with a 10-day history of shortness of breath. He finds it difficult to walk short distances due to shortness of breath. He also notes cough, orthopnea, nocturnal dyspnea, and generalized abdominal discomfort. He has been taking large doses of his furosemide without relief. He denies cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, nausea, vomiting, diarrhea, rashes, lightheadedness, and syncope. On physical examination, the patient is acutely dyspneic at rest. He is afebrile, but tachypnic and diaphoretic. There is a diminished first heart sound, S3 gallop, laterally displaced PMI; the lungs have bibasilar rales. The abdominal exam reveals distension with hepatomegaly in the right upper quadrant. There is 2+ pitting edema of the lower extremities to the level of the mid-calf. What is the most likely expected diagnostic test result in this case? 1 Hyponatremia 2 Reduced BUN levels 3 Hyperchloremia 4 Hyperalbuminemia 5 Hyperkalemia - his patient is experiencing an acute exacerbation of congestive heart failure. In cases of severe heart failure, prolonged, rigid sodium restriction, coupled with intensive diuretic therapy and the inability to excrete water, may lead to dilutional hyponatremia. This occurs because of a substantial expansion of extracellular and intravascular fluid volume and a normal or increased level of total body sodium. A 74-year-old man with a past medical history of diabetes mellitus, hypertension, and hyperlipidemia presents with severe chest pain and dyspnea. On examination, he is confused, agitated, pale, apprehensive, and diaphoretic. His pulse is weak and tachycardic, with a systolic blood pressure of 80 mmHg. He has a narrow pulse pressure, tachypnea, a weak apical impulse, significant jugular venous distention, and pulmonary crackles. Bedside electrocardiogram reveals ST-segment elevations in the anterior and septal leads, while a portable chest X-ray notes diffuse pulmonary congestion. What is the most appropriate step in the management of this patient? 1 Crystalloid infusion 2 Initiate intravenous β-Blocker therapy 3 Begin phenylephrine 4 Nitrates and morphine 5 Emergent percutaneous coronary intervention - This patient's exhibits signs and symptoms of cardiogenic shock due to myocardial infarction with pulmonary edema. Treatment of cardiogenic shock includes general supportive measures of oxygen, aspirin, heparin, and "gentle" fluid challenges (250 cc) if there is no overt pulmonary edema. In cardiogenic shock, early revascularization with percutaneous coronary intervention (angioplasty) or coronary artery bypass graft is the treatment of choice. Survival from cardiogenic shock is highest with emergency coronary intervention, followed by intra-aortic balloon pump combined with thrombolytic therapy, and with thrombolytic therapy alone being least effective in reducing mortality. The greatest short-term benefit is reported in patients <75 years of age, those without previous MI, and those treated within 6 hours of symptom onset. A 32-year-old man with no significant past medical history presents to his primary care provider with a 2-month history of increased dyspnea upon exertion, which becomes apparent following walking 10 city blocks. He denies any other associated symptoms such as fever, chills, changes in weight, chest pain, abdominal pain, nausea, or vomiting. He further denies any history of cigarette smoking, occupational risk factors, sick contacts, or recent travel. His physical exam revealed normal vital signs and no distension of his jugular vein. However, there was a prominent right ventricular impulse along the lower-left sternal border associated with a palpable pulmonary artery and a midsystolic ejection murmur at the upper left sternal border that does not vary in intensity with respiration. There is a fixed split second heart sound. The remainder of his examination is normal. Following diagnostic testing, this patient was referred for surgical repair. What is the major long-term complication that requires monitoring following surgical repair? 1 Hypertension 2 Myocardial infarction 3 Mitral valve prolapse 4 Supraventricular arrhythmia 5. TIA - This patient's presentation represents an atrial septal defect. The major long-term complication following surgical transcatheter device closure of ASD is the development of supraventricular arrhythmias, although the risk is lowered when the ASD is closed in childhood. The persistence of this risk despite relief of right-sided volume overload is thought to be related to incomplete atrial remodeling or due to the presence of the atriotomy scar. Longer follow-up is required to determine whether device closure alters the risk of atrial dysrhythmias. A 12-year-old presents with an injury of his left arm and leg. He states that he felt dizziness during the 2nd mile of the long distance run organized by the school. He fell and lost the consciousness for several seconds, but after that he felt "normal". His father has been diagnosed with Emery-Dreifuss muscular dystrophy type 1. On examination, you find a few superficial excoriations; there is also symmetric humero-peroneal weakness involving the biceps, triceps, and peroneal muscles. There is also atrophy and contractures of Achilles-heel, elbows, and posterior neck. After taking care of his injuries, what test should you order? 1 CK 2 LDH 3. EKG 4. EEG 5. CT - Both family history and clinical presentation in this patient are consistent with Emery-Dreifuss muscular dystrophy. Cardiac disease in Emery-Dreifuss muscular dystrophy is nearly universal. It usually begins after the onset of weakness, and it manifests as syncope in the 2nd or 3rd decade of life; it can also be a cause of sudden cardiac death. Cardiac disease can take form of the bradycardia, atrial arrhythmias (including atrial fibrillation/flutter), AV conduction defect, or even atrial or ventricular cardiomyopathy. Pacemakers are often needed by the age of 30. Minimal follow up requirements in patients are annual cardiac assessment (ECG, Holter, echocardiography) and the monitoring of respiratory function. While doing rounds one morning, you come upon a 42-year-old man suspected of having an infective endocarditis and currently undergoing an extensive workup. Which of the following represents the most definitive diagnosis of Infective Endocarditis based on Modified Duke Criteria? 1. 1 positive blood culture with Staphylococcus aureus with Osler's nodes and Roth spots 2. 2 positive blood cultures with Streptococcus pneumoniae with cutaneous hemorrhages and glomerulonephritis 3. Evidence of endocardial vegetation on echocardiography with Osler's nodes 4. 2 positive blood cultures with Staphylococcus aureus and development of a new regurgitant murmur 5. Fever >100.4 degrees Fahrenheit (38 degrees Celsius) with evidence of endocardial vegetation on echocardiography and glomerulonephritis - Clinical criteria is also known as the Modified Duke criteria and is widely utilized to establish the diagnosis of endocarditis. The criteria are classified as either Major criteria (two positive blood cultures for a microorganism that is typical to cause endocarditis; evident of endocardial involvement via an echocardiogram ((vegetation, abscess)); development of a new regurgitant murmur. Minor criteria include: vascular phenomena (skin hemorrhages, emboli, aneurysms, or pulmonary infarction), fever >100.4 degrees Fahrenheit (38 degrees Celsius), immunologic phenomenon (glomerulonephritis, Osler's nodes, Roth spots, rheumatoid factor), and positive blood cultures that do not meet the specifics of the major criteria. The correct answer is 2 positive blood cultures with Staphylococcus aureus and development of a new regurgitant murmur. Since two Major criteria are identified, a definitive diagnosis of infective endocarditis can be made with 80% accuracy. The presence of one major criterion and three minor criteria or even if there are five minor criteria listed can also qualify in this 80% accuracy diagnosis range. The diagnosis is possible but not highly likely to be infective endocarditis if the patient displays the following: one major and one minor criterion or three minor criterions are met. Any less than these should lead a healthcare provider to suspect a different diagnosis. Choice A only has one minor criterion; Choice B has one major and only two minor criteria; Choice C has only one major and one minor criterion and finally Choice D only has two minor criteria. A 4-year-old boy presents with poor weight gain, small size for his age, and dyspnea upon feeding. His mother notes that the child suffers from frequent upper respiratory tract infections. On physical exam, the child is underweight for his age. You note a precordial bulge, a prominent right ventricular cardiac impulse, and palpable pulmonary artery pulsations. You also find a widely split and fixed second heart sound as well as a mid-diastolic rumble at the left sternal border. What pharmacologic agent would be most appropriate in the medical management of this patient at this time? 1 Lasix (Furosemide) 2 Coumadin (Warfarin) 3 Procardia (Nifedipine) 4 Inderal (Propranolol) 5 Indocin (Indometha