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Select the ONE answer that is BEST in each case.
A 47-year-old woman develops accelerated hypertension (blood pressure 210/105 mm Hg) but no clinical symptoms except frequent headaches. Which of the following findings are most likely on examination of the fundii?
Cotton wool spots, hemorrhage, and papilledema are common. Fibrinoid necrosis occurs on the arterioles of many organs. Earlier manifestations of arteriosclerosis include thickening of the vessel wall. This is manifested by obscuring of the venous column at arterial crossings.
A 32-year-old man presents for rountine evaluation. He has no symptoms but has noticed some new “nodules” on his legs. Physical examination reveals lumps on his Achillis tendon, yellow lesions around his eyes, and pigmentation of his iris. Which of the following is the most likely diagnosis?
Early atherosclerosis with tendon xanthomas, xanthelasma, and arcus senilis are characteristics of familial hypercholesterolemia. The disorder is inherited in an autosomal dominant manner.
A 22-year-old woman develops idiopathic pericarditis, with a resultant pericardial effusion. Which of the following features determines the patient’s clinical course and prognosis?
Acute pericarditis is most often idiopathic and is typically self-limited (usually within 2–6 weeks). While small effusions are common, tamponade is unusual, as are heart failure and constriction. Other diseases causing pericarditis should be searched for, and may influence the prognosis.
A 65-year-old man complains of postural hypotension with dizziness. His blood pressure is 110/80 mm Hg supine and 85/70 mm Hg standing (after 2 minutes), the pulse rate remains the same at 80/min. Which of the following is the most likely diagnosis?
Orthostatic hypotension (systolic dropping by 20 mm or more) is particularly common in the elderly and in diabetics because of autonomic neuropathy. Management includes avoidance of precipitating factors, simple adaptive maneuvers, volume expansion, and pharmacologic agents.
The echocardiogram of a 22-year-old woman reveals mitral valve prolapse. Which of the following is the most common physical finding in this condition?
In mitral valve prolapse, the first heart sound is usually preserved followed by a systolic click and late systolic murmur. The click is actually the most common finding. General physical examination may reveal scoliosis, pectus excavatum, straightened thoracic spine, or narrow anteroposterior diameter of chest.
A 36-year-old man is seen because of palpitations. He admits to precordial discomfort, weakness, and anxiety. His pulse is 150/min, and his blood pressure is 124/70 mm Hg. Heart sounds are normal. Carotid sinus pressure gradually changes the rate to 75/min, but when released, the pulse rate returns to 150/min. Which of the following is the most likely diagnosis?
The symptoms and signs are like any sudden paroxysmal tachycardia, but the ventricular rate is the clue, after carotid pressure, to the diagnosis of atrial flutter with 2:1 block.
A 25-year-old man complains of left precordial chest pain that radiates to the left shoulder but not down the left arm. The pain is accentuated by inspiration and relieved by sitting up. The pain is accompanied by fever and chills. His blood pressure is 105/75 mm Hg, pulse 110/min and regular, and temperature 37.5°C. Aside from the tachycardia, there are no abnormal physical findings in the heart or lungs. The ECG shows STsegment elevation in all leads except aVR and VI. On the third hospital day, the patient’s blood pressure falls, JVP rises, and he goes into CHF. Which of the following is the most likely diagnosis?
Management of acute viral or idiopathic pericarditis includes analgesia (usually aspirin every 3–4 hours initially) and rest if the pain is severe. Occasionally, nonsteroidal antiinflammatory drugs (NSAIDs) are required (e.g., ibuprofen or indomethacin). Careful observation for increasing effusion and tamponade are essential. The classic findings of cardiac tamponade include arterial hypotension and pulsus paradoxus.
A 80-year-old man with Type II diabetes and hypertension presents with increasing dyspnea. He appears short of breath, blood pressure is 170/95 mm Hg, pulse 100/min and regular. The JVP is at 7 cm; there is a loud second heart sound and a systolic ejection murmur at the right sternal border, which does not radiate. The lungs have bibasilar crakles up to the scapula. The CXR has bilateral infiltrates and vascular redistribution. His echocardiogram reports aortic sclerosis, concentric left ventricular hypertrophy (LVH), and normal ejection fraction. Which of the following is the most likely mechanism for this condition?
Diastolic dysfunction is an important cause of heart failure in the elderly. It is commonly associated with a history of hypertension and diabetes. Normal ejection fraction and aortic sclerosis rule out either systolic or valvular heart disease as causes. In HOCM there is nonconcentric hypertrophy.
A 68-year-woman with hypertension and dyslipidemia presents with 30 minutes of retrosternal chest pain radiating to her neck. She is diaphoretic and in moderate distress. The ECG shows ST-segment elevation in the inferior leads. Which of the following mechanisms is the most likely cause of her condition?
Acute rupture of an atherosclerotic plaque is now recognized as the most common cause of ST-elevation MI. Pericarditis has diffuse ST elevation in multiple leads and aortic stenosis does cause angina but not ST elevation.
A 62-year-old man with a prosthetic aortic valve develops fevers and malaise. His valve was replaced 5 years ago because of aortic stenosis from a bicuspid valve. He has a systolic ejection murmur but no other abnormalities on examination. Blood cultures are most likely to grow which of the following?
S. epidermidis is still the most frequent early and late cause of endocarditis in patients with prosthetic heart valves. The other organisms are seen less frequently in late prosthetic valve endocarditis.
A 58-year-old man with no prior cardiac history presents with retrosternal chest pain starting at rest and lasting 30 minutes. The pain radiates to the left arm and is associated with diaphoresis and dyspnea. His blood pressure is 150/90 mm Hg, pulse 100/min, the heart sounds are normal, and the lungs are clear to auscultation. Which of the following is the next most appropriate investigation?
This man has acute coronary syndrome (ACS) until proven otherwise. The ECG is the most useful initial investigation since it identifies individuals with ST-segment elevation who may be candidates for either thrombolysis or primary angioplasty (PCI). The troponins are important in diagnosing myocardial necrosis. The other investigations may be important in looking for alternate causes of chest pain once ST-elevation MI has been ruled out.
The laboratory results shown in Table 1–1 are obtained from the investigation of a 37-year-old African-American woman who has a blood pressure at rest of 140/100 mm Hg. Which of the following is the most likely diagnosis?
Essential hypertension is the most likely diagnosis. Asecondary cause for hypertension is found in only 10% of patients, with 90% labeled as essential. Current recommendations for initial workup of a hypertensive patient include serum chemistry (glucose, potassium, creatinine), urinalysis, and ECG.
A 58-year-old man whom you have followed dies suddenly, spurring you into doing some research on sudden death. Which of the following is the most likely cause for this individual?
Sudden death, defined as death within 1 hour of onset of symptoms, is usually caused by cardiac disease in middle-aged and elderly patients, but in younger age groups noncardiac causes predominate. There is a bimodal distribution in the population, with the first peak before 6 months of age (sudden infant death syndrome). The most common coronary artery finding is extensive chronic coronary atherosclerosis, although acute syndromes do occur.
You have a large number of patients in your practice with hypertension. If the diagnosis in an individual is essential hypertension, which of the following statements is correct?
Over 90% of hypertensives in the general population have essential hypertension. Only about 60% of hypertensives are very sensitive to salt. About 20% of hypertensives have low-renin essential hypertension. This is more common in Blacks. Male sex, Black race, youth, smoking, DM, excess alcohol ingestion, hypercholesterolemia, more severe hypertension, and evidence of end-organ damage are among the factors that suggest a poor prognosis