Medicine1 (1).pdf - Chest Pain and Cardiac Dysrhythmias Questions 1 A 59-year-old man presents to the emergency department(ED complaining of new onset

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Unformatted text preview: Chest Pain and Cardiac Dysrhythmias Questions 1. A 59-year-old man presents to the emergency department (ED) complaining of new onset chest pain that radiates to his left arm. He has a history of hypertension, hypercholesterolemia, and a 20-pack-year smoking history. His electrocardiogram (ECG) is remarkable for T-wave inversions in the lateral leads. Which of the following is the most appropriate next step in management? a. Give the patient two nitroglycerin tablets sublingually and observe if his chest pain resolves. b. Place the patient on a cardiac monitor, administer oxygen, and give aspirin. c. Call the cardiac catheterization laboratory for immediate percutaneous intervention (PCI). d. Order a chest x-ray; administer aspirin, clopidogrel, and heparin. e. Start a β-blocker immediately. 2. A 36-year-old woman presents to the ED with sudden onset of leftsided chest pain and mild shortness of breath that began the night before. She was able to fall asleep without difficulty but woke up in the morning with persistent pain that is worsened upon taking a deep breath. She walked up the stairs at home and became very short of breath, which made her come to the ED. Two weeks ago, she took a 7-hour flight from Europe and since then has left-sided calf pain and swelling. What is the most common ECG finding for this patient’s presentation? a. b. c. d. e. S1Q3T3 pattern Atrial fibrillation Right-axis deviation Right-atrial enlargement Tachycardia or nonspecific ST-T–wave changes 1 2 Emergency Medicine 3. A 51-year-old man with a long history of hypertension presents to the ED complaining of intermittent chest palpitations lasting for a week. He denies chest pain, shortness of breath, nausea, and vomiting. He recalls feeling similar episodes of palpitations a few months ago but they resolved. His blood pressure (BP) is 130/75 mm Hg, heart rate (HR) is 130 beats per minute, respiratory rate (RR) is 16 breaths per minute, and oxygen saturation is 99% on room air. An ECG is seen below. Which of the following is the most appropriate next step in management? a. b. c. d. e. Sedate patient for immediate synchronized cardioversion with 100 Joules Prepare patient for the cardiac catheterization laboratory Administer Coumadin Administer amiodarone Administer diltiazem Chest Pain and Cardiac Dysrhythmias 3 4. A 54-year-old woman presents to the ED because of a change in behavior at home. For the past 3 years she has end-stage renal disease requiring dialysis. Her daughter states that the patient has been increasingly tired and occasionally confused for the past 3 days and has not been eating her usual diet. On examination, the patient is alert and oriented to person only. The remainder of her examination is normal. An initial 12-lead ECG is performed as seen below. Which of the following electrolyte abnormalities best explains these findings? a. b. c. d. e. Hypokalemia Hyperkalemia Hypocalcemia Hypercalcemia Hyponatremia 4 Emergency Medicine 5. A 29-year-old tall, thin man presents to the ED after feeling short of breath for 2 days. In the ED, he is in no acute distress. His BP is 115/70 mm Hg, HR is 81 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 98% on room air. Cardiac, lung, and abdominal examinations are normal. An ECG reveals sinus rhythm at a rate of 79. A chest radiograph shows a small right-sided (less than 10% of the hemithorax) spontaneous pneumothorax. A repeat chest x-ray 6 hours later reveals a decreased pneumothorax. Which of the following is the most appropriate next step in management? a. Discharge the patient with follow-up in 24 hours b. Perform needle decompression in the second intercostal space, midclavicular line c. Insert a 20F chest tube into right hemithorax d. Observe for another 6 hours e. Admit for pleurodesis 6. A 42-year-old man found vomiting in the street is brought to the ED by emergency medical services (EMS). He has a known history of alcohol abuse with multiple presentations for intoxication. Today, the patient complains of acute onset, persistent chest pain associated with dysphagia, and pain upon flexing his neck. His BP is 115/70 mm Hg, HR is 101 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 97% on room air. As you listen to his heart, you hear a crunching sound. His abdomen is soft with mild epigastric tenderness. The ECG is sinus tachycardia without ST-T–wave abnormalities. On chest x-ray, you note lateral displacement of the left mediastinal pleural. What is the most likely diagnosis? a. b. c. d. e. Aspiration pneumonia Acute pancreatitis Pericarditis Esophageal perforation Aortic dissection Chest Pain and Cardiac Dysrhythmias 5 7. A 65-year-old man with a history of chronic hypertension presents to the ED with sudden-onset tearing chest pain that radiates to his jaw. His BP is 205/110 mm Hg, HR is 90 beats per minute, RR is 20 breaths per minute, and oxygen saturation is 97% on room air. He appears apprehensive. On cardiac examination you hear a diastolic murmur at the right sternal border. A chest x-ray reveals a widened mediastinum. Which of the following is the preferred study of choice to diagnose this patient’s condition? a. b. c. d. e. Electrocardiogram (ECG) Transthoracic echocardiography (TTE) Transesophageal echocardiography (TEE) Computed tomography (CT) scan Magnetic resonance imaging (MRI) 8. A 47-year-old man with a history of hypertension presents to the ED complaining of continuous left-sided chest pain that began while snorting cocaine 1 hour ago. The patient states he never experienced chest pain in the past when using cocaine. His BP is 170/90 mm Hg, HR is 101 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 98% on room air. The patient states that the only medication he takes is alprazolam to “calm his nerves.” Which of the following medications is contraindicated in this patient? a. b. c. d. e. Metoprolol Diltiazem Aspirin Lorazepam Nitroglycerin 6 Emergency Medicine 9. A 32-year-old woman presents to the ED with a persistent fever of 101°F over the last 3 days. The patient states that she used to work as a convenience store clerk but was fired 2 weeks ago. Since then, she has been using drugs intravenously daily. Cardiac examination reveals a heart murmur. Her abdomen is soft and nontender with an enlarged spleen. Chest radiograph reveals multiple patchy infiltrates in both lung fields. Laboratory results reveal white blood cells (WBC) 14,000/μL with 91% neutrophils, hematocrit 33%, and platelets 250/μL. An ECG reveals sinus rhythm with first-degree heart block. Which of the following is the most appropriate next step in management? a. Obtain four sets of blood cultures, order a transthoracic echocardiogram (TTE), and start antibiotic treatment. b. Order a monospot test and recommend that the patient refrain from vigorous activities for 1 month. c. Administer a nonsteroidal anti-inflammatory drug (NSAID) and inform the patient she has pericarditis. d. Administer isoniazid (INH) and report the patient to the Department of Health. e. Order a Lyme antibody and begin antibiotic therapy. Chest Pain and Cardiac Dysrhythmias 7 10. A 61-year-old woman was on her way to the grocery store when she started feeling chest pressure in the center of her chest. She became diaphoretic and felt short of breath. On arrival to the ED by EMS, her BP is 130/70 mm Hg, HR is 76 beats per minute, and oxygen saturation is 98% on room air. The nurse gives her an aspirin and an ECG is performed as seen below. Which of the following best describes the location of this patient’s myocardial infarction (MI)? a. b. c. d. e. Anteroseptal Anterior Lateral Inferior Posterior 8 Emergency Medicine 11. A 31-year-old man who works for a moving company presents to the ED because he thought he was having a heart attack. He does not smoke, and jogs 3 days a week. His father died of a heart attack in his sixties. He describes a gradual onset of chest pain that is worse with activity and resolves when he is at rest. His HR is 68 beats per minute, BP is 120/70 mm Hg, and RR is 14 breaths per minute. On examination, his lungs are clear and there is no cardiac murmur. You palpate tenderness over the left sternal border at the third and fourth rib. An ECG reveals sinus rhythm at a rate of 65. A chest radiograph shows no infiltrates or pneumothorax. Which of the following is the most appropriate next step in management? a. Administer aspirin and send for a troponin. b. Administer aspirin, clopidogrel, and heparin and admit for acute coronary syndrome (ACS). c. Administer ibuprofen and reassure the patient that he is not having a heart attack. d. Inject corticosteroid into the costochondral joint to reduce inflammation. e. Observe the patient for 6 hours. 12. A 21-year-old woman presents to the ED complaining of lightheadedness. Her symptoms appeared 45 minutes ago. She has no other symptoms and is not on any medications. She has a medical history of mitral valve prolapse. Her HR is 170 beats per minute and BP is 105/55 mm Hg. Physical examination is unremarkable. After administering the appropriate medication, her HR slows down and her symptoms resolve. You repeat a 12-lead ECG that shows a rate of 89 beats per minute with a regular rhythm. The PR interval measures 100 msec and there is a slurred upstroke of the QRS complex. Based on this information, which of the following is the most likely diagnosis? a. b. c. d. e. Ventricular tachycardia Atrial flutter with 3:1 block Atrial fibrillation Lown-Ganong-Levine (LGL) syndrome Wolff-Parkinson-White (WPW) syndrome Chest Pain and Cardiac Dysrhythmias 9 13. A 55-year-old man presents to the ED with worsening weakness, muscle cramps, and paresthesias. His past medical history is significant for hypertension and diabetes. He smokes one pack of cigarettes per day. On examination, the patient is alert and oriented and diffusely weak. An ECG is seen below. Which of the following is the most important next step in management? a. b. c. d. e. Administer calcium gluconate. Administer insulin and dextrose. Administer aspirin and call the catheterization laboratory. Order an emergent head CT scan and get a neurology consult. Collect a sample of his urine to test for ketones. 14. While eating dinner, a 55-year-old man suddenly feels a piece of steak “get stuck” in his stomach. In the ED, he complains of dysphagia, is drooling, and occasionally retches. On examination, his BP is 130/80 mm Hg, HR is 75 beats per minute, RR is 15 breaths per minute, and oxygen saturation is 99% on room air. He appears in no respiratory distress. Chest x-ray is negative for air under the diaphragm. Which of the following is the most appropriate next step in management? a. Administer 1-mg glucagon intravenously while arranging for endoscopy. b. Administer a meat tenderizer such as papain to soften the food bolus. c. Administer 10-mL syrup of ipecac to induce vomiting and dislodge the food bolus. d. Perform the Heimlich maneuver until the food dislodges. e. Call surgery consult to prepare for laparotomy. 10 Emergency Medicine 15. A 59-year-old man presents to the ED with left-sided chest pain and shortness of breath that began 2 hours prior to arrival. He states the pain is pressure-like and radiates down his left arm. He is diaphoretic. His BP is 160/80 mm Hg, HR 86 beats per minute, and RR 15 breaths per minute. ECG reveals 2-mm ST-segment elevation in leads I, aVL, V3 to V6. Which of the following is an absolute contraindication to receiving thrombolytic therapy? a. b. c. d. e. Systolic BP greater than 180 mm Hg Patient on Coumadin and aspirin Total hip replacement 3 months ago Peptic ulcer disease Previous hemorrhagic stroke 16. A 67-year-old woman is brought to the ED by paramedics complaining of dyspnea, fatigue, and palpitations. Her BP is 80/50 mm Hg, heart is 139 beats per minute, and RR is 20 breaths per minute. Her skin is cool and she is diaphoretic. Her lung examination reveals bilateral crackles and she is beginning to have chest pain. Her ECG shows a narrow complex irregular rhythm with a rate in the 140s. Which of the following is the most appropriate immediate treatment for this patient? a. b. c. d. e. Diltiazem Metoprolol Digoxin Coumadin Synchronized cardioversion 17. A 61-year-old woman with a history of congestive heart failure (CHF) is at a family picnic when she starts complaining of shortness of breath. Her daughter brings her to the ED where she is found to have an oxygen saturation of 85% on room air with rales halfway up both of her lung fields. Her BP is 185/90 mm Hg and pulse rate is 101 beats per minute. On examination, her jugular venous pressure (JVP) is 6 cm above the sternal angle. There is lower extremity pitting edema. Which of the following is the most appropriate first-line medication to lower cardiac preload? a. b. c. d. e. Metoprolol Morphine sulfate Nitroprusside Nitroglycerin Oxygen Chest Pain and Cardiac Dysrhythmias 11 18. A 27-year-old man who is otherwise healthy presents to the ED with a laceration on his thumb that he sustained while cutting a bagel. You irrigate and repair the wound and are about to discharge the patient when he asks you if he can receive an ECG. It is not busy in the ED so you perform the ECG, as seen below. Which of the following is the most appropriate next step in management? (Reproduced, with permission, from Tintinalli J, Kelen G, Stapczynski J. Emergency Medicine A Comprehensive Study Guide. New York, NY: McGraw-Hill, 2004:193) a. b. c. d. e. Admit the patient for placement of a pacemaker. Admit the patient for a 24-hour observation period. Administer aspirin and send cardiac biomarkers. Repeat the ECG because of incorrect lead placement. Discharge the patient home. 19. A 56-year-old woman with a history of ovarian cancer presents to the ED with acute onset of right-sided chest pain, shortness of breath, and dyspnea. Her BP is 131/75 mm Hg, HR is 101 beats per minute, respirations are 18 breaths per minute, and oxygen saturation is 97% on room air. You suspect this patient has a pulmonary embolism (PE). Which of the following tests is most likely to be abnormal? a. b. c. d. e. Arterial blood gas Oxygen saturation ECG Chest radiograph D-dimer 12 Emergency Medicine 20. A 61-year-old woman with a history of diabetes and hypertension is brought to the ED by her daughter. The patient states that she started feeling short of breath approximately 12 hours ago and then noticed a tingling sensation in the middle of her chest and became diaphoretic. An ECG reveals ST-depression in leads II, III, and aVF. You believe that the patient had a non–ST-elevation MI. Which of the following cardiac markers begins to rise within 3 to 6 hours of chest pain onset, peaks at 12 to 24 hours, and returns to baseline in 7 to 10 days? a. b. c. d. e. Myoglobin Creatinine kinase (CK) Creatinine kinase-MB (CK-MB) Troponin I Lactic dehydrogenase (LDH) 21. A 27-year-old man complains of chest palpitations and lightheadedness for the past hour. He has no past medical history and is not taking any medications. He drinks a beer occasionally on the weekend and does not smoke cigarettes. His HR is 180 beats per minute, BP is 110/65 mm Hg, and oxygen saturation is 99% on room air. An ECG reveals a HR of 180 beats per minute with a QRS complex of 90 msec with a regular rhythm. There are no discernable P waves. Which of the following is the most appropriate medication to treat this dysrhythmia? a. b. c. d. e. Digoxin Lidocaine Amiodarone Adenosine Bretylium Chest Pain and Cardiac Dysrhythmias 13 22. A 59-year-old man presents to the ED with left-sided chest pain and shortness of breath that began 1 hour ago. 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? a. b. c. d. e. Administer metoprolol or diltiazem Electrical cardioversion Administer calcium gluconate Thrombolytic therapy Percutaneous angioplasty 23. A 55-year-old man presents to the ED at 2:00 AM with left-sided chest pain that radiates down his left arm. He takes a β-blocker for hypertension, 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 medication is contraindicated in this patient? a. b. c. d. e. Aspirin Unfractionated heparin Nitroglycerin Metoprolol Morphine sulfate 14 Emergency Medicine 24. 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 back. 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 palpation. 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? (Reproduced, with permission, from Fuster V et al. Hurst’s The Heart. New York, NY: McGraw-Hill, 2004: 304) a. b. c. d. e. 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 25. A 71-year-old man is playing cards with some friends when he starts to feel a pain in the left side of his chest. 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 following best describes the order of ECG changes seen in an MI? a. b. c. d. e. 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 Chest Pain and Cardiac Dysrhythmias 15 26. A 63-year-old insurance agent is brought to the ED by paramedics for shortness of breath and a RR of 31 breaths per minute. 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 midway 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? a. Obtain blood cultures, complete blood cell (CBC) count, and begin empiric antibiotic therapy. b. Order a statim (STAT) portable chest x-ray. c. Administer oxygen via nasal cannula and have the patient chew an aspirin. d. Administer oxygen via non-rebreather, furosemide, nitroglycerin, and consider noninvasive respiratory therapy. e. Rapid sequence endotracheal intubation. 27. A 23-year-old man is brought to the ED after collapsing during a basketball game. His BP is 80/palp. His father died from a “heart-condition” at a young age. He is placed on a monitor and the rhythm is shown below. Which of the following choices best describes this rhythm? a. b. c. d. e. Ventricular fibrillation Atrial fibrillation Wolf-Parkinson-White syndrome Supraventricular tachycardia Torsades de pointes 16 Emergency Medicine 28. Which of the following patients has the lowest clinical probability for t...
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