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CEA Prep: Full Practice Exam The patient is exhibiting a productive cough and a low-grade fever. Chest X-ray on PA view shows a left lower chest area of consolidation adjacent to the left border of the heart approximately 2 rib spaces above the costophrenic angle. The lateral x-ray view shows this lesion absent of the window posterior to the cardiac silhouette. Which is the most likely location of this area of focal consolidation? *Left upper lobe apex *Right middle lobe *Left upper lobe lingula *Left lower lobe Left upper lobe lingula Ratonale: Lingular consolidation is described in this question precisely. If the cardiac margin/silhouette is obliterated by the mass, the lesion is either right middle lobe or left upper lobe lingula. The inability to fully relax the myocardium during relaxation is a trademark of which of the following diagnoses? Diastolic dysfunction Rationale: The inability for the heart to relax is a trademark of the diagnosis of diastolic dysfunction and is common in patients with thickened hypertrophic myocardium. An otherwise healthy African American adult male has been diagnosed with hypertension. He has been restricting his salt intake, eating a DASH (Dietary Approaches to Stop Hypertension) diet, and exercising more, but his blood pressure is still elevated. Which is the BEST medication to prescribe him? Calcium channel blocker Rationale: African American patients per JNC8 Hypertension Guidelines should be managed with a dihydropyridine calcium channel blocker such as amlodipine (Norvasc) as first line management therapy for hypertension not at goal with DASH and lifestyle modifications. Your patient has been diagnosed with a 4.5cm ascending aortic aneurysm. Which medical imaging is considered standard of care for serial surveillance? CT angiography of the chest Rationale: CT angiography is considered the standard of care for measuring vascular luminal dimensions with contrast. CT PE protocol is not timed properly for the aorta (it's timed for the pulmonary artery). Although a plain film is able to catch large aneurysms at times, they are not able to provide multi-axis reconstruction needed to accurately measure the size. Transesophageal echo is not needed to accurately measure the aorta and requires the patient to undergo sedation which is unnecessary. Which of the following medications does not cause beta 1 stimulation? phenylephrine Rationale: Phenylephrine only stimulates alpha 1 receptors. The remaining three all have beta receptor activity. A 50-year-old woman with a history of hypertension presents with dyspnea on exertion and orthopnea. On examination, she has jugular venous distention and bilateral crackles on lung auscultation. What is the most likely diagnosis? Congestive heart failure Rationale: Of the available options, the most accurate response is congestive heart failure as it is signifying both a right ventricular back up with jugular venous extension and crackles on lung assault, which are suggestive of left ventricular back up. it is possible the patient may have an acute myocardial infarction that precipitated this, however, a patient has not described that, rather is only describing dyspnea on exertion and orthopnea, which both speak to a state of fluid overload. The only appropriate response of these available is congestive heart failure. Your patient with a history of HFrEF (heart failure with reduced ejection fraction) with an ejection fraction of 40% who is also not on optimal medical therapy has been diagnosed with a myocardial infarction this admission and received emergent placement of a drug-eluting stent to the left anterior descending artery. As the medical home who will manage this patient after discharge, which medication strategy would you expect to be a priority in the patient's care? Ordering a transthoracic echocardiogram and order a Lifevest if EF is less than 35% Rationale: The patient should have a protective mechanism such as an implantable automated cardioverter defibrillator (AICD) or a Lifevest if the EF is less than 35% due to the increased risk of sudden cardiac death with low EF states. Since most patients are not eligible for 90 days for an AICD in this state, optimizing their medication regimen and repeating an echo in 2-3 months to re-evaluate for improvement in their EF is required by most insurance companies. A baseline echo is needed at discharge to provide a baseline for improvement vs their repeat echo in 2-3 months. Dual anti-platelet therapy is required for 12 months minimum post-MI. A Holter monitor does not provide any conceivable benefit for this patient as presented. Which of the following people groups represent the least risk of cardiac disease? Caucasians Rationale: Statistically African Americans, Native Hawaiians, and American Indians are at at increased risk of cardiac disease due to higher rates of hypertension, diabetes, and obesity than Caucasians. A 65-year-old woman presents for a follow-up examination. She is a smoker, and her hypertension is now adequately controlled with medication. Her mother died at age 40 f