Multiple Choice Questions (MCQ)

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Category: Cardiology--->Pulmonary Hypertension And Pericardium
Page: 7

Question 31# Print Question

A 44-year-old white man with rheumatoid arthritis is referred to your office for evaluation after his rheumatologist heard a loud heart sound. On questioning, the patient mainly reports joint pains in his fingers. He denies any chest discomfort or shortness of breath. He has been on methotrexate and prednisone for the past year. His examination is significant for mild erythema and swelling of his distal interphalangeal joints, rheumatoid nodules on his right forearm, clear lungs, distant heart sounds with a loud friction rub, and moderate peripheral edema. You order a TTE to further assess his heart. Selective images are shown in Figure below.

What is your recommendation?

A. Because he currently has no cardiac symptoms, no further treatment is needed except to continue methotrexate and prednisone
B. You want the patient to start indomethacin, continue methotrexate and prednisone, and follow up in 4 weeks
C. The best treatment at this time for his pericardial effusion is drainage with the instillation of steroids to prevent recurrence
D. A surgical evaluation for pericardiectomy is necessary because the findings on his TTE indicate that he will develop problems in the future if this is not taken care of soon

Question 32# Print Question

A 55-year-old white man presents for evaluation of chest pain. He has no prior medical problems, but he has noted burning epigastric and chest discomfort for the past few months for which he was taking antacids with some relief of his symptoms. However, because the symptoms persisted, he sought medical attention and was referred for an esophagogastroduodenoscopy, which was performed earlier today. He was found to have a fundal hiatal hernia with a gastric ulcer that was cauterized, and he was started on omeprazole. On returning home, he noted a new sharp anterior chest pain, somewhat positional related, that was not relieved with antacids or omeprazole. This pain progressively worsened over the next few hours, and he came to the emergency department. Examination in the emergency department revealed a temperature of 38.1°C, an HR of 110 bpm, and a BP of 120/70 mmHg. Lung sounds were clear. Heart sounds appeared normal with the patient sitting upright, but they were diminished with the patient lying in the supine position. An ECG did not show any acute ST-T wave abnormalities to suggest infarction. A CXR was performed, as shown in Figure below.

You are called to further assess the patient. After reviewing the available data, which of the following is your next step?

A. Immediate surgical consultation
B. Immediate pericardiocentesis
C. Start a nonsteroidal anti-inflammatory medication and admit him for observation
D. No further treatment is needed because his symptoms are caused by the hiatal hernia

Question 33# Print Question

A 71-year-old man presents to the hospital with palpitations of 2 to 3 days’ duration. He has no known medical history, and he is not on any medications. Initial evaluation is unremarkable except for a BP of 160/90 mmHg and an ECG showing atrial fibrillation with a ventricular rate of 120 to 130 bpm. Given the duration of his symptoms, he is treated with βblockers for rate control and heparin for anticoagulation. On hospital day 2, he is referred for early transesophageal-guided cardioversion. The TEE reveals normal LV and RV function. There are no echocardiographic contraindications for cardioversion. An uneventful cardioversion is performed, and the patient converts to NSR. On hospital day 3, the patient is found in marked respiratory distress. On physical examination, he has a regular HR with a loud audible click over the precordium. A CXR is performed, as shown in Figure below.

What does this patient have?

A. He has a pulmonary embolism and should be treated with thrombolytics
B. He has a hiatal/diaphragmatic hernia with compression of the heart by the fundus of stomach
C. He has an iatrogenic pneumohydropericardium; immediate drainage and surgical attention are needed
D. He has a recurrence of atrial fibrillation

Question 34# Print Question

A 59-year-old woman with a history of chronic renal insufficiency presents to the emergency department with anterior left-sided chest pain. She reports that the chest pain started after her last dialysis 7 days ago. She appears lethargic and in mild respiratory distress. The physical examination demonstrates a BP of 160/90 mmHg and an HR of 100 bpm. On cardiac auscultation, a loud friction rub is heard. An ECG is obtained (Fig. below).

What is the most important next step in this case?

A. Perform emergency dialysis
B. Obtain an echocardiogram
C. Prepare for pericardiocentesis
D. Admit the patient to the cardiac care unit to rule out MI

Question 35# Print Question

A 29-year-old woman with known insulin-dependent diabetes mellitus was found unconscious 1 hour after an office party. Initial assessment by the emergency medical service team showed a BP of 90/60 mm Hg. Her pulse was 120, and her blood sugar was 870 mg/dL. She was given SC insulin and rushed to the emergency department. You are called to see her because of her abnormal ECG (Fig. below).

She is noted to be semiconscious. The emergency physician has already started her on IV insulin drip and hydration. What is your recommendation at this juncture?

A. She is having an acute MI, and immediate restoration of coronary flow is essential
B. She has ECG evidence of hyperkalemia, and she needs IV calcium and, possibly, dialysis
C. Continue the current management; the ECG will improve with the resolution of ketoacidosis
D. Her ECG predicts high-degree atrioventricular block; a standby external pacemaker should be available

Category: Cardiology--->Pulmonary Hypertension And Pericardium
Page: 7 of 8