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Chest Pain and Cardiac Dysrhythmias-2
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1. A 59-year-old man presents to the ED with left-sided chest pain and shortness of breath that began 1 hour Initial vital signs are BP 85/45 mm Hg, HR 105 beats per minute, RR 20 breaths per minute, and oxygen saturation 94% on room air. An ECG is seen below. Which of the following is the most appropriate definitive treatment?
- Administer metoprolol or diltiazem
- Electrical cardioversion
- Administer calcium gluconate
- Thrombolytic therapy
- Percutaneous angioplasty
2. A 55-year-old man presents to the ED at 2:00 AM with left-sided chest pain that radiates down his left He takes a b-blocker for hyperten- sion, a proton pump inhibitor for gastroesophageal reflux disease, and an antilipid agent for high cholesterol. He also took sildenafil the previous night for erectile dysfunction. His BP is 130/70 mm Hg and HR is 77 beats per minute. Which of the following medications is contraindicated in this patient?
- Unfractionated heparin
- Morphine sulfate
3. A 31-year-old kindergarten teacher presents to the ED complaining of acute-onset substernal chest pain that is sharp in nature and radiates to her The pain is worse when she is lying down on the stretcher and improves when she sits up. She smokes cigarettes occasionally and was told she has borderline diabetes. She denies any recent surgeries or long travel. Her BP is 145/85 mm Hg, HR is 99 beats per minute, RR is 18 breaths per minute, and temperature is 100.6°F. Examination of her chest reveals clear lungs and a friction rub. Her abdomen is soft and nontender to palpa- tion. Her legs are not swollen. Chest radiography and echocardiography are unremarkable. Her ECG is shown below. Which of the following is the most appropriate next step in management?
- Anticoagulate and CT scan to evaluate for a PE.
- Prescribe a NSAID and discharge the patient.
- Aspirin, heparin, clopidogrel, and admit for ACS.
- Administer thrombolytics if the pain persists.
- Prescribe antibiotics and discharge the patient.
4. A 71-year-old man is playing cards with some friends when he starts to feel a pain in the left side of his His fingers in the left hand become numb and he feels short of breath. His wife calls the ambulance and he is brought to the hospital. In the ED, an ECG is performed. Which of the fol- lowing best describes the order of ECG changes seen in an MI?
- Hyperacute T wave, ST-segment elevation, Q wave
- Q wave, ST-segment elevation, hyperacute T wave
- Hyperacute T wave, Q wave, ST-segment elevation
- ST-segment elevation, Q wave, hyperacute T wave
- ST-segment elevation, hyperacute T wave, Q wave
5. A 63-year-old insurance agent is brought to the ED by paramedics for shortness of breath and an RR of 31 breaths per The patient denies chest pain, fever, vomiting, or diarrhea. His wife says he ran out of his “water pill” 1 week ago. His BP is 185/90 mm Hg, HR is 101 beats per minute, oxygen saturation is 90% on room air, and temperature is 98.9°F. There are crackles midway up both lung fields and 2+ pitting edema mid- way up his legs. An ECG shows sinus tachycardia. The patient is sitting up and able to speak to you. After placing the patient on a monitor and inserting an IV, which of the following is the most appropriate next step in management?
- Obtain blood cultures and complete blood cell (CBC) count, and begin empiric antibiotic therapy.
- Order a statim (STAT) portable chest x-ray.
- Administer oxygen via nasal cannula and have the patient chew an aspirin.
- Administer oxygen via non-rebreather, furosemide, nitroglycerin, and consider noninvasive respiratory therapy.
- Rapid sequence endotracheal intubation.
6. Which of the following patients has the lowest clinical probability for the diagnosis of pulmonary embolism (PE)?
- A 21-year-old woman 2 days after a cesarean delivery.
- A 55-year-old woman on estrogen replacement therapy who underwent a total hip replacement procedure 3 days ago.
- A 39-year-old man who smokes cigarettes occasionally and underwent an uncomplicated appendectomy 2 months ago.
- A 62-year-old man with pancreatic cancer.
- A 45-year-old man with factor V Leiden deficiency.
7. While playing a match of tennis, a 56-year-old man with a medical history significant only for acid reflux disease starts to feel substernal chest pain that radiates into his left arm and shortness of His pain feels better after drinking antacid, but since it is not completely resolved, his partner calls 911. Upon arrival, EMS administers aspirin and sublingual nitroglycerin. After 20 minutes, the man’s symptoms resolve. He is brought to the ED for further evaluation where his ECG shows sinus rhythm with- out any ischemic abnormalities. You order a chest radiograph and send his blood work to the laboratory for analysis. Which of the following state- ments regarding the diagnosis of acute MI is most accurate?
- A normal ECG rules out the diagnosis of acute MI.
- One set of negative cardiac enzymes is sufficient to exclude the diagnosis of MI in this patient.
- Troponin may not reach peak levels for at least 12 hours.
- Relief of symptoms by antacids essentially rules out a cardiac cause of his chest pain.
- Epigastric discomfort and indigestion is a rare presentation of ACS.
8. A 62-year-old woman presents to the ED with general weakness, short- ness of breath, and substernal chest pain that radiates to her left Her BP is 155/80 mm Hg, HR is 92 beats per minute, and RR is 16 breaths per minute. You suspect that she is having an acute MI. Which of the following therapeutic agents has been shown to independently reduce mortality in the setting of an acute MI?
- Unfractionated heparin
9. A 22-year-old college student went to the health clinic complaining of a fever over the last 5 days, fatigue, myalgias, and a bout of vomiting and The clinic doctor diagnosed him with acute gastroenteritis and told him to drink more fluids. Three days later, the student presents to the ED complaining of substernal chest pain that is constant. He also feels short of breath. His temperature is 100.9°F, HR is 119 beats per minute, BP is 120/75 mm Hg, and RR is 18 breaths per minute. An ECG is performed revealing sinus tachycardia. A chest radiograph is unremark- able. Laboratory tests are normal except for slightly elevated WBCs. Which of the following is the most common cause of this patient’s diagnosis?
- Streptococcus viridans
- Influenza A
- Coxsackie B virus
- Atherosclerotic disease
- Cocaine abuse
10. A 51-year-old woman presents to the ED after 5 consecutive days of crushing substernal chest pressure that woke her up from sleep in the morning. The pain resolves spontaneously after 20 to 30 She is an avid rock climber and jogs 5 miles daily. She has never smoked ciga- rettes and has no family history of coronary disease. In the ED, she experi- ences another episode of chest pain. An ECG reveals ST-segment elevations and cardiac biomarkers are negative. The pain is relieved with sublingual nitroglycerin. She is admitted to the hospital and diagnostic testing reveals minimal coronary atherosclerotic disease. Which of the following is the most appropriate medication to treat this patient’s condition?
- Calcium channel blocker (CCB)
11. A 23-year-old woman who is an elementary school teacher is brought to the ED after syncopizing in her classroom while Prior to pass- ing out, she describes feeling light-headed and dizzy and next remembers being in the ambulance. There was no evidence of seizure activity. She has no medical problems and does not take any medications. Her father died of a “heart problem” at 32 years of age. She does not smoke or use drugs. BP is 120/70 mm Hg, pulse rate is 71 beats per minute, RR is 14 breaths per minute, and oxygen saturation is 100% on room air. Her physical exami- nation and laboratory results are all normal. A rhythm strip is seen below. Which of the following is the most likely diagnosis?
- Wolff-Parkinson-White syndrome
- Long QT syndrome
- Lown-Ganong-Levine syndrome
- Complete heart block
- Atrial flutter
12. While discussing a case presentation with a medical student, a nearby patient who just returned from getting an ankle radiograph done yells out in You walk over to him and ask what is wrong. He states that since returning from the radiology suite, his automatic implantable cardioverter- defibrillator (AICD) is discharging. You hook him up to the monitor and note that his rhythm is sinus. You observe a third shock while the patient is in sinus rhythm. Which of the following is the most appropriate next step in management?
- Send the patient back to the radiology suite for another radiograph to desensi- tize his AICD.
- Administer pain medication and wait until the device representative arrives at the hospital to power off the AICD.
- Admit the patient to the telemetry unit to monitor his rhythm and find the cause of his AICD discharge.
- Place a magnet over the AICD generator to inactivate it and thereby prevent further shocks.
- Make a small incision over his chest wall and remove the AICD generator and leads.
13. A 55-year-old man presents to the ED with chest pain and shortness of His BP is 170/80 mm Hg, HR is 89 beats per minute, and oxygen satu- ration is 90% on room air. Physical examination reveals crackles midway up both lung fields and a new holosystolic murmur that is loudest at the apex and radiates to the left axilla. ECG reveals ST elevations in the infe- rior leads. Chest radiograph shows pulmonary edema with a normalsized cardiac silhouette. Which of the following is the most likely cause of the cardiac murmur?
- Critical aortic stenosis
- Papillary muscle rupture
- Pericardial effusion
- Aortic dissection
14. An 82-year-old woman is brought to the ED by her daughter for wors- ening fatigue, dizziness, and light-headedness. The patient denies chest pain or shortness of She has not started any new medications. Her BP is 140/70 mm Hg, HR is 37 beats per minute, and RR is 15 breaths per minute. An IV is started and blood is drawn. An ECG is seen below. Which of the following is the most appropriate next step in management?
- Bed rest for the next 48 hours and follow-up with her primary-care physician.
- Administer aspirin, order a set of cardiac enzymes, and admit to the cardiac care unit (CCU).
- Place a magnet on her chest to turn off her pacemaker.
- Admit for Holter monitoring and echocardiogram.
- Place on a cardiac monitor, place external pacing pads on the patient, and admit to the CCU.
15. A 22-year-old man presents to the ED with a history consistent with an acute His ECG reveals ST elevations and his cardiac biomarkers are positive. He has been smoking half a pack of cigarettes per day for the last 3 months. He drinks alcohol when hanging out with his friends. His grand- father died of a heart attack at 80 years of age. The patient does not have hypertension or diabetes mellitus and takes no prescription medications. A recent cholesterol check revealed normal levels of total cholesterol, low- density lipoprotein (LDL), and high-density lipoprotein (HDL). Which of the following is the most likely explanation for his presentation?
- Cigarette smoking
- Family history of heart attack at age 80 years
- Incorrectly placed leads on the ECG
- Undisclosed cocaine use
- Alcohol use
16. A 29-year-old man is brought to the ED by EMS for a syncopal episode that occurred during a basketball A friend states that the patient just dropped to the ground shortly after scoring a basket on a fast break. On examination, you note a prominent systolic ejection murmur along the left sternal border and at the apex. An ECG reveals left ventricular hypertrophy, left atrial enlargement, and septal Q waves. You suspect the diagnosis and ask the patient to perform the Valsalva maneuver while you auscultate his heart. Which of the following is most likely to occur to the intensity of the murmur with this maneuver?
- Remain unchanged.
- The intensity stays the same, but the heart skips a beat.
17. A 57-year-old man complains of chest palpitations and light-headedness for the past Five years ago he underwent a cardiac catheterization with coronary artery stent placement. He smokes half a pack of cigarettes daily and drinks a glass of wine at dinner. His HR is 140 beats per minute, BP is 115/70 mm Hg, and oxygen saturation is 99% on room air. An ECG reveals a wide complex tachycardia at a rate of 140 that is regular in rhythm. An ECG from 6 months ago shows a sinus rhythm at a rate of 80. Which of the following is the most appropriate medication to treat this dysrhythmia?
18. A 55-year-old man with hypertension and a one-pack-per-day smoking history presents to the ED complaining of three episodes of severe heavy chest pain this morning that radiated to his left In the past, he experienced chest discomfort after walking 20 minutes that resolved with rest. The episodes of chest pain this morning occurred while he was read- ing the newspaper. His BP is 155/80 mm Hg, HR 76 beats per minute, and RR 15 breaths per minute. He does not have chest pain in the ED. An ECG reveals sinus rhythm with a rate of 72. A troponin I is negative. Which of the following best describes this patient’s diagnosis?
- Variant angina
- Stable angina
- Unstable angina
- Non–ST-elevation MI
- ST-elevation MI (STEMI)
19. A 58-year-old man is brought to the ED for a syncopal episode at His wife states that he was well until she found him suddenly slumping in the chair and losing consciousness for a minute. The patient recalls having some chest discomfort and shortness of breath prior to the episode. His rhythm strip, obtained by EMS, is shown below. Which of the following best describes these findings?
- Mobitz type I
- Mobitz type II
- First-degree atrioventricular (AV) block
- Atrial flutter with premature ventricular contractions (PVCs)
- Sinus bradycardia
20. As you are examining the patient described in the previous question, he starts to complain of chest discomfort and shortness of breath and has another syncopal His ECG is shown below. Which of the follow- ing is the most appropriate next step in management?
- Call cardiology consult
- Cardiovert the patient
- Administer metoprolol
- Administer amiodarone
- Apply transcutaneous pacemaker