Question of the Week # 260

260 )  A 30 year old woman is evaluated  in your office during a routine antenatal visit. Her previous pregnancy 2 years was uneventful. She is now presenting at 12 week gestation. The patient has been compliant with antenatal vitamin supplements. She reports mild early morning nausea and vomiting. On physical examination, her vitals are with in normal limits. Cardiovascular examination reveal exaggerated heart sounds ( S1 and S2) and  a new systolic ejection murmur across the lower left sternal border. An S3 gallop is present.  A grade 1 diastolic murmur is heard at the left ventricular apex that increases in the left lateral decubitus position. Which of the following cardiovascular abnormalities would be best tolerated during an otherwise normal pregnancy?

A)     Mitral Stenosis with pulmonary hypertension

B)     Marfan syndrome with aortic valve involvement

C)     Peri-partum cardiomyopathy in prior pregnancy

D)     Atrial Septal Defect, Secundum type

E)    Bicuspid aortic valve with mean gradient 55mmHg.

Question of the Week # 259

259)  A 32 year old woman presents to your office after she discovered that she is pregnant based on a positive home pregnancy test. A repeat urine Beta-HCG is positive in the office. Her past medical history is significant for recurrent deep vein thromboses and homozygosity for  Factor V leiden mutation. She has been on coumadin for the past three years. Her physical examination is benign with out any clinical evidence of deep vein thromboses. You advice her to stop coumadin. You prescribe unfractionated heparin at a dose of 5000 IU twice daily  to be used through out her pregnancy . This patient is at risk for which of the follwing?

A) Hypokalemia

B) Fetal malformations

C) Vertebral fractures

D) Complete abortion

E) Thrombocytosis

Question of the Week # 258

258 )  A 32 year old woman is evaluated  in your office during a routine antenatal visit. She is a primigravida and is now presenting at 14 week gestation. The patient has been compliant with antenatal vitamin supplements. She reports mild early morning nausea and vomiting. On physical examination, her vitals are with in normal limits. Cardiovascular examination reveal exaggerated heart sounds ( S1 and S2) and  a new systolic ejection murmur across the lower left sternal border. An S3 gallop is present.  A grade 1 diastolic murmur is heard at the left ventricular apex that increases in the left lateral decubitus position. There is an exaggerated drop in systemic blood pressure by 16m Hg during inspiration ( Pulsus paradoxus). Which of the following physical examination findings in this patient is most likely to be pathological?

A)     New Systolic murmur

B)     Pulsus paradoxus

C)      S3 gallop

D)     Diastolic murmur

E)     Exaggerated heart sounds

Question of the Week # 257

257)  A 72 year old man with history of Diabetes Mellitus is rushed to the emergency room by the EMS 30 minutes after he collapsed at his home with severe left sided chest pain. Upon arrival, the patient was found to have very low blood pressure at 70/40 mm Hg.  Chest examination revealed diffuse coarse crepitations. An electrocardiogram showed ST elevations in the anterior leads with reciprocal depressions. The patient was immediately started on Aspirin, GP IIb/IIIA inhibitors, Clopidogrel and Heparin. He is placed on 50% 02 by Venturi mask and his oxygen saturation on this supplemental oxygen is 92%. A diagnosis of cardiogenic shock and pulmonary edema is made and the patient is admitted to intensive care unit. The patient is placed on Intra-Aortic Balloon Counterpulsation Pump (IABP) and is rushed to cardiac catheterization lab. In which of the following situations, IABP confers more harm than benefit?

A) Acute Mycocardial Infarction (MI) with Cardiogenic Shock

B) Aortic dissection with aortic regurgitation

C) Severe left ventricular failure with pulmonary edema

D)  Post-MI Ventricular Septal Perforation

E) Post-MI Acute Mitral Regurgitation

Question of the Week # 256

256)  A 72 year old man with history of Diabetes Mellitus is rushed to the emergency room by the EMS 30 minutes after he collapsed at his home with severe left sided chest pain. Upon arrival, the patient was found to have very low blood pressure at 70/40 mm Hg.  Chest examination revealed diffuse coarse crepitations. An electrocardiogram showed ST elevations in the anterior leads with reciprocal depressions. The patient was immediately started on Aspirin, GP IIb/IIIA inhibitors, Clopidogrel and Heparin. He is placed on 50% 02 by Venturi mask and his oxygen saturation on this supplemental oxygen is 92%. A diagnosis of cardiogenic shock and pulmonary edema is made and the patient is admitted to intensive care unit. If performed immediately, which of the following interventions would most likely reduce his risk of death?

A)     Thrombolytic therapy

B)     Dopamine infusion

C)      Intra-Aortic Balloon Pump (IABP)

D)     Percutaneous Coronary Intervention

E)     Left Ventricular Assist Device (LVAD)

Note : SHOCK TRIAL

Question of the Week # 255

A 16 year old woman is brought to your office by her mother for medical evaluation. Her mother has been out of country on a long business trip for 8 months and upon her return, she was shocked to notice that her daughter looked much skinnier than she was 8 months ago. The patient has lost about 30 lbs weight in the past 8 months and reports irregular menstruation. She is fearful of gaining weight and has been exercising excessively.  Physical examination reveals a very thin woman with a Body Mass Index (BMI) of 16. She has fine, downy dark hair all over her body. Which of the following findings are frequently seen in association with this condition?

A)     Diarrhea

B)     Tachycardia

C)      Hyperkalemia

D)     Decreased Bone mineral density

E)     Metabolic Acidosis

Question of the Week # 254

254 )  A 72 year old man with history of metastatic prostate cancer is admitted with severe weakness and lethargy. He has been having vomiting and abdominal pain for the past two weeks.  He also reports intermittent diarrhea alternating with constipation over the past 2 months. Three months ago, he was noted to have progressive prostate cancer despite therapy with bicalutamide and leuprolide. His PSA at that time was 300ng/ml. He was started on Ketoconozole at that time and he is compliant with it. His most recent visit to the outpatient clinic was 4 weeks ago at which time his PSA was 60ng/ml. On examination, his temperature is 98F, Heart rate is 130/min, Respiratory rate 20/min and Blood pressure 70/40 mm Hg. Chest is clear to auscultation and abdominal examination is benign. A CT scan of the adbomen reveals enlarged prostate and osteoblastic bone metastases in pelvis but no evidence of bowel obstruction. Urinalysis and Chest x-ray are benign. The patient is started on intravenous isotonic saline. Which of the following is the most appropriate next step in managing this patient?

A) Start Chemotherapy

B) Refer to Hospice

C) Intravenous Hydrocortisone

D) Start Norepinephrine drip

E) Intravenous Biphosphonates

 

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