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Primary Care FNP TEST BANK Review 1250 Terms . All Questions with Accurate Answers, 100% proven pass rate. ======================================================= Cardiovascular Board Review Questions 01 ================================================ ======= You see a 23 -year -old gravida 1 para 0 for her prenatal checkup at 38 weeks gestation. She complains of severe headaches and epigastric pain. She has had an uneventful pregnancy to date and had a normal prenatal examination 2 weeks ago. Her blood pressure is 140/100 mm Hg. A urinalysis shows 2+ protein; she has gained 5 lb in the last week, and has 2+ pitting edema of her legs. The most appropriate management at this point would be: (check one) A. Strict bed rest at home and reexamination within 48 hours B. Admitting the patient to the hospital for bed rest and frequent monitoring of blood pressure, weight, and proteinuria C. Admitting the patient to the hospital for bed rest and monitoring, and beginning hydralazine (Apresoline) to maintain blood pressure below 140/90 mm Hg D. Admitting the patient to the hospital, treating with parenteral magnesium sulfate, and planning prompt delivery either vaginally or by cesarean section - ✔✔D. Admitting the patient to the hospital, treating with parenteral magnesium s ulfate, and planning prompt delivery either vaginally or by cesarean section. This patient manifests a rapid onset of preeclampsia at term. The symptoms of epigastric pain and headache categorize her preeclampsia as severe. These symptoms indicate that the process is well advanced and that convulsions are imminent. Treatment should focus on rapid control of symptoms and delivery of the infant. Which one of the following is the most common cause of hypertension in children under 6 years of age? (check one) A. Essential hypertension B. Pheochromocytoma C. Renal parenchymal disease D. Hyperthyroidism E. Excessive caffeine use - ✔✔C. Renal parenchymal disease. Although essential hypertension is most common in adolescents and adults, it is rarely found in child ren less than 10 years old and should be a diagnosis of exclusion. The most common cause of hypertension is renal parenchymal disease, and a urinalysis, urine culture, and renal ultrasonography should be ordered for all children presenting with hypertensio n. Other secondary causes, such as pheochromocytoma, hyperthyroidism, and excessive caffeine use, are less common, and further testing and/or investigation should be ordered as clinically indicated. A 70 -year -old male with a history of hypertension and ty pe 2 diabetes mellitus presents with a 2 -month history of increasing paroxysmal nocturnal dyspnea and shortness of breath with minimal exertion. An echocardiogram shows an ejection fraction of 25%. Which one of the patients current medications should be di scontinued? (check one) A. Lisinopril (Zestril) B. Pioglitazone (Actos) C. Glipizide (Glucotrol) D. Metoprolol (Toprol -XL) E. Repaglinide (Prandin) - ✔✔B. Pioglitazone (Actos). According to the American Diabetes Association guidelines, thiazolidinediones (TZDs) are associated with fluid retention, and their use can be complicated by the development of heart failure. Caution is necessary when prescribing TZDs in patients with known heart failure or other heart diseases, those with preexisting edema, and tho se on concurrent insulin therapy (SOR C). Older patients can be treated with the same drug regimens as younger patients, but special care is required when prescribing and monitoring drug therapy. Metformin is often contraindicated because of renal insuffic iency or heart failure. Sulfonylureas and other insulin secretagogues can cause hypoglycemia. Insulin can also cause hypoglycemia, and injecting it requires good visual and motor skills and cognitive ability on the part of the patient or a caregiver. TZDs should not be used in patients with New York Heart Association class III or IV heart failure. A 72 -year -old African -American male with New York Heart Association Class III heart failure sees you for follow -up. He has shortness of breath with minimal exert ion. The patient is adherent to his medication regimen. His current medications include lisinopril (Prinivil, Zestril), 40 mg twice daily; carvedilol (Coreg), 25 mg twice daily; and furosemide (Lasix), 80 mg daily. His blood pressure is 100/60 mm Hg, and h is pulse rate is 68 beats/min and regular. Findings include a few scattered bibasilar rales on examination of the lungs, an S3 gallop on examination of the heart, and no edema on examination of the legs. An EKG reveals a left bundle branch block, and echoc ardiography reveals an ejection fraction of 25%, but no other abnormalities. Which one of the following would be most appropriate at this time? (check one) A. Increase the lisinopril dosage to 80 mg twice daily B. Increase the carvedilol dosage to 50 mg t wice daily C. Increase the furosemide dosage to 160 mg daily D. Refer for coronary angiography E. Refer for cardiac resynchronization therapy - ✔✔E. Refer for cardiac resynchronization therapy. This patient is already receiving maximal medical therapy. The 2002 joint guidelines of the American College of Cardiology, the American Heart Association (A HA), and the North American Society of Pacing and Electrophysiology endorse the use of cardiac resynchronization therapy (CRT) in patients with medically refractory, symptomatic, New York Heart Association (NYHA) class III or IV disease with a QRS interval of at least 130 msec, a left ventricular end -diastolic diameter of at least 55 mm, and a left ventricular ejection fraction (LVEF) ≤30%. Using a pacemaker -like device, CRT aims to get both ventricles contracting simultaneously, overcoming the delayed cont raction of the left ventricle caused by the left bundle -branch block. These guidelines were refined by an April 2005 AHA Science Advisory, which stated that optimal candidates for CRT have a dilated cardiomyopathy on an ischemic or nonischemic basis, an LVEF ≤0.35, a QRS complex ≥120 msec, and sinus rhythm, and are NYHA functional class III or IV despite maximal medical therapy for heart failure. Of the following dietary factors recommended for the prevention and treatment of cardiovascular disease, which one has been shown to decrease the rate of sudden death? (check one) A. Increased intake of plant protein B. Increased intake of omega -3 fats C. Increased intake of dietary fiber and whole grains D. Increased intake of monounsaturated oils E. Moderate alc ohol consumption (1 or 2 standard drinks per day) - ✔✔B. Increased intake of omega -3 fats. Omega -3 fats contribute to the production of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which inhibit the inflammatory immune response and platelet aggregation, are mild vasodilators, and may have antiarrhythmic properties. The American Heart Association guidelines state that omega -3 supplements may be recommended to patients with preexisting disease, a high risk of disease, or high triglyceride level s, as well as to patients who do not like or are allergic to fish. The Italian GISSI study found that the use of 850 mg of EPA and DHA daily resulted in decreased rates of mortality, nonfatal myocardial infarction, and stroke, with particular decreases in the rate of sudden death. A 75 -year -old male presents to the emergency department with a several -hour history of back pain in the interscapular region. His medical history includes a previous myocardial infarction (MI) several years ago, a history of ciga rette smoking until the time of the MI, and hypertension that is well controlled with hydrochlorothiazide and lisinopril (Prinivil, Zestril). The patient appears anxious, but all pulses are intact. His blood pressure is 170/110 mm Hg and his pulse rate is 110 beats/min. An EKG shows evidence of an old inferior wall MI but no acute changes. A chest radiograph shows a widened mediastinum and a normal aortic arch, and CT of the chest shows a dissecting aneurysm of the descending aorta that is distal to the pro ximal abdominal aorta but does not involve the renal arteries. Which one of the following would be the most appropriate next step in the management of this patient? (check one) A. Immediate surgical intervention B. Arteriography of the aorta C. Intravenou s nitroprusside (Nipride) D. A nitroglycerin drip E. Intravenous labetalol (Normodyne, Trandate) - ✔✔E. Intravenous labetalol (Normodyne, Trandate). Patients with thoracic aneurysms often present without symptoms. With dissecting aneurysms, however, the pr esenting symptom depends on the location of the aneurysm. Aneurysms can compress or distort nearby structures, resulting in branch vessel compression or embolization of peripheral arteries from a thrombus within the aneurysm. Leakage of the aneurysm will c ause pain, and rupture can occur with catastrophic results, including severe pain, hypotension, shock, and death. Aneurysms in the ascending aorta may present with acute heart failure brought about by aortic regurgitation from aortic root dilatation and di stortion of the annulus. Other presenting findings may include hoarseness, myocardial ischemia, paralysis of a hemidiaphragm, wheezing, coughing, hemoptysis, dyspnea, dysphagia, or superior vena cava syndrome. This diagnosis should be suspected in individu als in their sixties and seventies with the same risk factors as those for coronary artery disease, particularly smokers. A chest radiograph may show widening of the mediastinum, enlargement of the aortic knob, or tracheal displacement. Transesophageal ech ocardiography can be very useful when dissection is suspected. CT with intravenous contrast is very accurate for showing the size, extent of disease, pressure of leakage, and nearby pathology. Angiography is the preferred method for evaluation and is best for evaluation of branch vessel pathology. MR angiography provides noninvasive multiplanar image reconstruction, but does have limited availability and lower resolution than traditional contrast angiography. Acute dissection of the ascending aorta is a sur gical emergency, but dissections confined to the descending aorta are managed medically unless the patient demonstrates progression or continued hemorrhage into the retroperitoneal space or pleura. Initial management should reduce the systolic blood pressu re to 100 -120 mm Hg or to the lowest level tolerated. The use of a β -blocker such as propranolol or labetalol to get the heart rate below 60 beats/min should be first -line therapy. If the systolic blood pressure remains over 100 mm Hg, intravenous nitropru sside should be added. Without prior beta -blocade, vasodilation from the nitroprusside will induce reflex activation of the sympathetic nervous system, causing increased ventricular contraction and increased shear stress on the aorta. For descending dissec tions, surgery is indicated only for complications such as occlusion of a major aortic branch, continued extension or expansion of the dissection, or rupture (which may be manifested by persistent or recurrent pain). According to the U.S. Preventive Servi ces Task Force, which one of the following patients should be screened for an abdominal aortic aneurysm? (check one) A. A 52 -year -old male with type 2 diabetes mellitus B. An asymptomatic 67 -year -old male smoker with no chronic illness C. A 72 -year -old ma le with a history of chronic renal failure D. A 69 -year -old female with a history of coronary artery disease E. A 75 -year -old female with hypertension and hypothyroidism - ✔✔B. An asymptomatic 67 -year -old male smoker with no chronic illness. The U.S. Preve ntive Services Task Force has released a statement summarizing recommendations for screening for abdominal aortic aneurysm (AAA). The guideline recommends one -time screening with ultrasonography for AAA in men 65 -75 years of age who have ever smoked. No re commendation was made for or against screening women. Men with a strong family history of AAA should be counseled about the risks and benefits of screening as they approach 65 years of age. A 36 -year -old white female presents to the emergency department w ith palpitations. Her pulse rate is 180 beats/min. An EKG reveals a regular tachycardia with a narrow complex QRS and no apparent P waves. The patient fails to respond to carotid massage or to two doses of intravenous adenosine (Adenocard), 6 mg and 12 mg. The most appropriate next step would be to administer intravenous (check one) A. amiodarone (Cordarone) B. digoxin (Lanoxin) C. flecainide (Tambocor) D. propafenone (Rhythmol) E. verapamil (Calan) - ✔✔E. verapamil (Calan). If supraventricular tachycardia is refractory to adenosine or rapidly recurs, the tachycardia can usually be terminated by the administration of intravenous verapamil or a β-blocker. If that fails, intravenous propafenone or flecainide may be necessary. It is also important to look for and treat possible contributing causes such as hypovolemia, hypoxia, or electrolyte disturbances. Electrical cardioversion may be necessary if these measures fail to terminate th e tachyarrhythmia. A 60 -year -old African -American female has a history of hypertension that has been well controlled with hydrochlorothiazide. However, she has developed an allergy to the medication. Successful monotherapy for her hypertension would be mo st likely with which one of the following? (check one) A. Lisinopril (Prinivil, Zestril) B. Hydralazine (Apresoline) C. Clonidine (Catapres) D. Atenolol (Tenormin) E. Diltiazem (Cardizem) - ✔✔E. Diltiazem (Cardizem). Monotherapy for hypertension in Africa n- American patients is more likely to consist of diuretics or calcium channel blockers than β -blockers or ACE inhibitors. It has been suggested that hypertension in African -Americans is not as angiotensin II - dependent as it appears to be in Caucasians. A 60-year -old African -American male was recently diagnosed with an abdominal aortic aneurysm. A lipid profile performed a few months ago revealed an LDL level of 125 mg/dL. You would now advise him that his goal LDL level is: (check one) A. <100 mg/dL B. <1 30 mg/dL C. <150 mg/dL D. <160 mg/dL - ✔✔A. <100 mg/dL. Most physicians realize that the goal LDL level for patients with diabetes mellitus or coronary artery disease is <100 mg/dL. Many may not realize that this goal extends to people with CAD -equivalent diseases, including peripheral artery disease, symptomatic carotid artery disease, and abdominal aortic aneurysm. ======================================================= Cardiovascular Board Review Questions 02 ============================================ =========== An asymptomatic 3 -year -old male presents for a routine check -up. On examination you notice a systolic heart murmur. It is heard best in the lower precordium and has a low, short tone similar to a plucked string or kazoo. It does not radiate to the axillae or the back and seems to decrease with inspiration. The remainder of the examination is normal. Which one of the following is the most likely diagnosis? (check one) A. Eisenmenger's syndrome B. Mitral stenosis C. Peripheral pulmonic stenosis D. Still's murmur E. Venous hum - ✔✔D. Still's murmur. There are several benign murmurs of childhood that have no association with physiologic or anatomic abnormalities. Of these, Still's murmur best fits the murmur described. The cause of Still's murmur is unknown, but it may be due to vibrations in the chordae tendinae, semilunar valves, or ventricular wall. A venous hum consists of a continuous low -pitched murmur caused by the collapse of the jugular veins and their subsequent fluttering, and it worsens with inspiration o r diastole. The murmur of physiologic peripheral pulmonic stenosis (PPPS) is caused by physiologic changes in the newborns pulmonary vessels. PPPS is a systolic murmur heard loudest in the axillae bilaterally that usually disappears by 9 months of age. Mit ral stenosis causes a diastolic murmur, and Eisenmenger's syndrome involves multiple abnormalities of the heart that cause significant signs and symptoms, including shortness of breath, cyanosis, and organomegaly, which should become apparent from a routin e history and examination. A 57 -year -old male with severe renal disease presents with acute coronary syndrome. Which one of the following would most likely require a significant dosage adjustment from the standard protocol? (check one) A. Enoxaparin (Lov enox) B. Metoprolol (Lopressor, Toprol) C. Carvedilol (Coreg) D. Clopidogrel (Plavix) E. Tissue plasminogen activator (tPA) - ✔✔A. Enoxaparin (Lovenox). Enoxaparin is eliminated mostly by the kidneys. When it is used in patients with severe renal impairmen t the dosage must be significantly reduced. For some indications the dose normally given every 12 hours is given only every 24 hours. Although some β -blockers require a dosage adjustment, metoprolol and carvedilol are metabolized by the liver and do not re quire dosage adjustment in patients with renal failure. Clopidogrel is currently recommended at the standard dosage for patients with renal failure and acute coronary syndrome. Thrombolytics like tPA are given at the standard dosage in renal failure, altho ugh hemorrhagic complications are increased. A 55 -year -old male who has a long history of marginally -controlled hypertension presents with gradually increasing shortness of breath and reduced exercise tolerance. His physical examination is normal except f or a blood pressure of 140/90 mm Hg, bilateral basilar rales, and trace pitting edema. Which one of the following ancillary studies would be the preferred diagnostic tool for evaluating this patient? (check one) A. 12 -lead electrocardiography B. Posteroan terior and lateral chest radiographs C. 2-dimensional echocardiography with Doppler D. Radionuclide ventriculography E. Cardiac MRI - ✔✔C. 2-dimensional echocardiography with Doppler. The most useful diagnostic tool for evaluating patients with heart failu re is two -dimensional echocardiography with Doppler to assess left ventricular ejection fraction (LVEF), left ventricular size, ventricular compliance, wall thickness, and valve function. The test should be performed during the initial evaluation. Radionuc lide ventriculography can be used to assess LVEF and volumes, and MRI or CT also may provide information in selected patients. Chest radiography (posteroanterior and lateral) and 12 -lead electrocardiography should be performed in all patients presenting wi th heart failure, but should not be used as the primary basis for determining which abnormalities are responsible for the heart failure. A 23 -year -old female sees you with a complaint of intermittent irregular heartbeats that occur once every week or two, but do not cause her to feel lightheaded or fatigued. They last only a few seconds and resolve spontaneously. She has never passed out, had chest pain, or had difficulty with exertion. She is otherwise healthy, and a physical examination is normal. Which one of the following cardiac studies should be ordered initially? (check one) A. 24 -hour ambulatory EKG monitoring (Holter monitor) B. 30 -day continuous closed -loop event recording C. Echocardiography D. An EKG E. Electrophysiologic studies - ✔✔D. An EKG. The symptom of an increased or abnormal sensation of one's heartbeat is referred to as palpitations. This condition is common to primary care, but is often benign. Commonly, these sensations have their basis in anxiety or panic. However, about 50% of thos e who complain of palpitations will be found to have a diagnosable cardiac condition. It is recommended to start the evaluation for cardiac causes with an EKG, which will assess the baseline rhythm and screen for signs of chamber enlargement, previous myoc ardial infarction, conduction disturbances, and a prolonged QT interval. Which one of the following is most appropriate for the initial treatment of claudication? (check one) A. Regular exercise B. Chelation C. Vasodilating agents D. Warfarin (Coumadin) - ✔✔A. Regular exercise. Claudication is exercise -induced lower -extremity pain that is caused by ischemia and relieved by rest. It affects 10% of persons over 70 years of age. However, up to 90% of patients with peripheral vascular d isease are asymptomatic. Initial treatment should consist of vigorous risk factor modification and exercise. Patients who follow an exercise regimen can increase their walking time by 150%. A supervised program may produce better results. Risk factors include diabetes mellitus, hypertension, smoking, and hyperlipidemia. Unconventional treatments such as chelation have not been shown to be effective. Vasodilating agents are of no benefit. There is no evidence that anticoagulants such as aspirin have a role i n the treatment of claudication. In a patient who presents with symptoms of acute myocardial infarction, which one of the following would be an indication for thrombolytic therapy? (check one) A. New -onset ST -segment depression B. New -onset left bundle b ranch block C. New -onset first degree atrioventricular block D. New -onset Wenckebach second degree heart block E. Frequent unifocal ventricular ectopic beats - ✔✔B. New -onset left bundle branch block. In patients with ischemic chest pain, the EKG is import ant for determining the need for fibrinolytic therapy. Myocardial infarction is diagnosed by ST elevation ≥1 mm in two or more limb leads and ≥2 mm in two or more contiguous precordial leads. In a patient with an MI, new left bundle branch block suggests occlusion of the left anterior descending artery, placing a significant portion of the left ventricle in jeopardy. Thrombolytic therapy could be harmful in patients with ischemia but not infarction - they will show ST -segment depression only. Frequent unifo cal ventricular ectopy may warrant antiarrhythmic therapy, but not thrombolytic therapy. A 68 -year -old female has an average blood pressure of 150/70 mm Hg despite appropriate lifestyle modification efforts. Her only other medical problems are osteoporosi s and mild depression. The most appropriate treatment at this time would be (check one) A. lisinopril (Prinivil, Zestril) B. clonidine (Catapres) C. propranolol (Inderal) D. amlodipine (Norvasc) E. hydrochlorothiazide - ✔✔E. hydrochlorothiazide. Randomize d, placebo -controlled trials have shown that isolated systolic hypertension in the elderly responds best to diuretics and to a lesser extent, β - blockers. Diuretics are preferred, although long -acting dihydropyridine calcium channel blockers may also be use d. In the case described, β -blockers or clonidine may worsen the depression. Thiazide diuretics may also improve osteoporosis, and would be the most cost -effective and useful agent in this instance. A 31 -year -old healthy female is admitted to the hospital from the emergency department after presenting with aching in her right shoulder and swelling in the ipsilateral forearm and hand. The only precipitating event that she can recall is digging strenuously in the back yard to put in a new garden. Ultrasonogr aphy is remarkable for a thrombus in the axillosubclavian vein. She has no prior history of clotting, takes no medications, and has no previous history of medical or surgical procedures involving this extremity. The most likely etiology for this patient's condition is (check one) A. a hypercoagulable state B. a compressive anomaly in the thoracic outlet C. use of injection drugs D. Budd -Chiari syndrome - ✔✔B. a compressive anomaly in the thoracic outlet. Thrombosis of the upper extremity accounts for about 10% of all venous thromboembolism (VTE) cases. However, axillosubclavian vein thrombosis (ASVT) is becoming more frequent with the increased use of indwelling subclavian vein catheters. Spontaneous ASVT (not catheter related) is seen most commonly in youn g, healthy individuals. The most common associated etiologic factor is the presence of a compressive anomaly in the thoracic outlet. These anomalies are often bilateral, and the other upper extremity at similar risk for thrombosis. While a hypercoagulable state also may contribute to the thrombosis, it is much less common. Budd -Chiari syndrome refers to thrombosis in the intrahepatic, suprahepatic, or hepatic veins. It is not commonly associated with spontaneous upper -extremity thrombosis. A 56 -year -old wh ite male presents with a 2 -week history of intermittent pain in his left leg. The pain usually occurs while he is walking and is primarily in the calf muscle or Achilles region. Sometimes he will awaken at night with cramps in the affected leg. He has no k nown risk factors for atherosclerosis. Which one of the following would be the best initial test for peripheral vascular occlusive disease? (check one) A. Ankle -brachial index B. Arterial Doppler ultrasonography C. Arteriography D. Magnetic resonance angiography (MRA) E. Venous ultrasonography - ✔✔A. Ankle -brachial index. The ankle -brachial index (ABI) is an inexpensive, sensitive screening tool and is the most appropriate first test for peripheral vascular occlusive disease (PVOD ) in this patient. The ABI is the ratio of systolic blood pressure measured in the ankle to systolic pressure using the standard brachial measurement. A ratio of 0.9 -1.2 is considered normal. Severe disease is defined as a ratio <0.50. More invasive and ex pensive testing using Doppler ultrasonography, arteriography, or magnetic resonance angiography may be useful if the ABI suggests an abnormality. Venous ultrasonography would not detect PVOD, but it could rule out deep venous thrombosis, which is another c ommon etiology for calf pain. A 69 -year -old male has a 4 -day history of swelling in his left leg. He has no history of trauma, recent surgery, prolonged immobilization, weight loss, or malaise. His examination is unremarkable except for a diffusely swolle n left leg. A CBC, chemistry profile, prostate -specific antigen level, chest radiograph, and EKG are all normal; however, compression ultrasonography of the extremity reveals a clot in the proximal femoral vein. He has no past history of venous thromboembo lic disease. In addition to initiating therapy with low molecular weight heparin, the American College of Chest Physicians recommends that warfarin (Coumadin) be instituted now and continued for at least (check one) A. 1 month B. 3 months C. 6 months D. 12 months - ✔✔B. 3 months. For patients with a first episode of unprovoked deep venous thrombosis, evidence supports treatment with a vitamin K antagonist for at least 3 months (SOR A). The American College of Chest Physicians recommends that patients be ev aluated at that point for the potential risks and benefits of long -term therapy (SOR C). ======================================================= Cardiovascular Board Review Questions 03 ======================================================= A 35 -year -old African -American female has just returned home from a vacation in Hawaii. She presents to your office with a swollen left lower extremity. She has no previous history of similar problems. Homan's sign is positive, and ultrasonography reveals a noncompress ible vein in the left popliteal fossa extending distally. Which one of the following is true in this situation? (check one) A. Monotherapy with an initial 10 -mg loading dose of warfarin (Coumadin) would be appropriate B. Enoxaparin (Lovenox) should be adm inistered at a dosage of 1 mg/kg subcutaneously twice a day C. The incidence of thrombocytopenia is the same with low -molecular -weight heparin as with unfractionated heparin D. The dosage of warfarin should be adjusted to maintain the INR at 2.5 -3.5 E. Ant icoagulant therapy should be started as soon as possible and maintained for 1 year to prevent deep vein thrombosis (DVT) recurrence - ✔✔B. Enoxaparin (Lovenox) should be administered at a dosage of 1 mg/kg subcutaneously twice a day. The use of low -molecul ar-weight heparin allows patients with acute deep vein thrombosis (DVT) to be managed as outpatients. The dosage is 1 mg/kg subcutaneously twice daily. Patients chosen for outpatient care should have good cardiopulmonary reserve, normal renal function, and no risk for excessive bleeding. Oral anticoagulation with warfarin can be initiated on the first day of treatment after heparin loading is completed. Monotherapy with warfarin is inappropriate. The incidence of thrombocytopenia with low -molecular -weight h eparin is lower than with conventional heparin. The INR should be maintained at 2.0 -3.0 in this patient. The 2.5 -3.5 range is used for patients with mechanical heart valves. The therapeutic INR should be maintained for 3 -6 months in a patient with a first DVT related to travel. Which one of the following historical features is most suggestive of congestive heart failure in a 6 - month -old white male presenting with tachypnea? (check one) A. Diaphoresis with feeding B. Fever C. Nasal congestion D. Noisy respiration or wheezing E. Staccato cough - ✔✔A. Diaphoresis with feeding. Symptoms of congestive heart failure in infants are often related to feedings. Only small feedings may be tolerated, and dyspnea may develop with feedings. Profuse perspira tion with feedings, is characteristic, and related to adrenergic drive. Older children may have symptoms more similar to adults, but the infant's greatest exertion is related to feeding. Fever and nasal congestion are more suggestive of infectious problems . Noisy respiration or wheezing does not distinguish between congestive heart failure, asthma, and infectious processes. A staccato cough is more suggestive of an infectious process, including pertussis. Which one of the following procedures carries the h ighest risk for postoperative deep venous thrombosis? (check one) A. Abdominal hysterectomy B. Coronary artery bypass graft C. Transurethral prostatectomy D. Lumbar laminectomy E. Total knee replacement - ✔✔E. Total knee replacement. Neurosurgical procedu res, particularly those with penetration of the brain or meninges, and orthopedic surgeries, especially those of the hip, have been linked with the highest incidence of venous thromboembolic events. The risk is due to immobilization, venous injury and stas is, and impairment of natural anticoagulants. For total knee replacement, hip fracture surgery, and total hip replacement, the prevalence of DVT is 40% -80%, and the prevalence of pulmonary embolism is 2% -30%. Other orthopedic procedures, such as elective s pine procedures, have a much lower rate, approximately 5%. The prevalence of DVT after a coronary artery bypass graft is approximately 5%, after transurethral prostatectomy <5%, and after abdominal hysterectomy approximately 16%. A 13 -year -old male is fou nd to have hypertrophic cardiomyopathy. His father also had hypertrophic cardiomyopathy, and died suddenly at age 38 following a game of tennis. The boy's mother asks you for advice regarding his condition. What advice should you give her? (check one) A. He may participate in noncontact sports B. He should receive lifelong treatment with beta -blockers C. His condition usually decreases lifespan D. His hypertrophy will regress with age E. His siblings should undergo echocardiography - ✔✔E. His siblings shou ld undergo echocardiography. Hypertrophic cardiomyopathy is an autosomal dominant condition and close relatives of affected individuals should be screened. The hypertrophy usually stays the same or worsens with age. This patient should not participate in s trenuous sports, even those considered noncontact. Beta -blockers have not been shown to alter the progress of the disease. The mortality rate is believed to be about 1%, with some series estimating 5%. Thus, in most cases lifespan is normal. A 70 -year -old white male has a slowly enlarging, asymptomatic abdominal aortic aneurysm. You should usually recommend surgical intervention when the diameter of the aneurysm approaches: (check one) A. 3.5 cm B. 4.5 cm C. 5.5 cm D. 6.5 cm E. 7.5 cm - ✔✔C. 5.5 cm. Based on recent clinical trials, the most common recommendation for surgical repair is when the aneurysm approaches 5.5 cm in diameter. Two large studies, the Aneurysm Detection and Management (ADAM) Veteran Affairs Cooperative Study, and the United Kingdom Sma ll Aneurysm Trial, failed to show any benefit from early surgery for men with aneurysms less than 5.5 cm in diameter. The risks of aneurysm rupture were 1% or less in both studies, with 6 -year cumulative survivals of 74% and 64%, respectively. Interestingl y, the risk for aneurysm rupture was four times greater in women, indicating that 5.5 cm may be too high, but a new evidence -based threshold has not yet been defined. Which one of the following drug classes is preferred for treating hypertension in patien ts who also have diabetes mellitus? (check one) A. Centrally -acting sympatholytics B. Alpha -blocking agents C. Beta -blocking agents D. ACE inhibitors E. Calcium channel blockers - ✔✔D. ACE inhibitors. ACE inhibitors have proven beneficial in patients who have either early or established diabetic renal disease. They are the preferred therapy in patients with diabetes and hypertension, according to guidel ines from the American Diabetes Association, the National Kidney Foundation, the World Health Organization, and the JNC VII report. A 75 -year -old Hispanic male presents with dyspnea on exertion which has worsened over the last several months. He denies ch est pain and syncope, and was fairly active until the shortness of breath slowed him down recently. You hear a grade 3/6 systolic ejection murmur at the right upper sternal border which radiates into the neck. Echocardiography reveals aortic stenosis, with a mean transvalvular gradient of 55 mm Hg and a calculated valve area of 0.6 cm2. Left ventricular function is normal. Which one of the following is appropriate management for this patient? (check one) A. Aortic valve replacement B. Aortic balloon valvot omy C. Medical management with beta -blockers and nitrates D. Watchful waiting until the gradient is severe enough for treatment E. Deferring the decision pending results of an exercise stress test - ✔✔A. Aortic valve replacement. Since this patient's mean aortic -valve gradient exceeds 50 mm Hg and the aortic -valve area is not larger than 1 cm2, it is likely that his symptoms are due to aortic stenosis. As patients with symptomatic aortic stenosis have a dismal prognosis without treatment, prompt correction of his mechanical obstruction with aortic valve replacement is indicated. Medical management is not effective, and balloon valvotomy only temporarily relieves the symptoms and does not prolong survival. Patients who present with dyspnea have only a 50% cha nce of being alive in 2 years unless the valve is promptly replaced. Exercise testing is unwarranted and dangerous in patients with symptomatic aortic stenosis. Which one of the following is considered a contraindication to the use of beta -blockers for co ngestive heart failure? (check one) A. Mild asthma B. Symptomatic heart block C. New York Heart Association (NYHA) Class III heart failure D. NYHA Class I heart failure in a patient with a history of a previous myocardial infarction E. An ejection fractio n <30% - ✔✔B. Symptomatic heart block. According to several randomized, controlled trials, mortality rates are improved in patients with heart failure who receive beta -blockers in addition to diuretics, ACE inhibitors, and occasionally, digoxin. Contraindi cations to beta -blocker use include hemodynamic instability, heart block, bradycardia, and severe asthma. Beta -blockers may be tried in patients with mild asthma or COPD as long as they are monitored for potential exacerbations. Beta -blocker use has been s hown to be effective in patients with NYHA Class II or III heart failure. There is no absolute threshold ejection fraction. Beta -blockers have also been shown to decrease mortality in patients with a previous history of myocardial infarction, regardless of their NYHA classification. Which one of the following is the leading cause of death in women? (check one) A. Breast cancer B. Lung cancer C. Ovarian cancer D. Osteoporosis E. Cardiovascular disease - ✔✔E. Cardiovascular disease. Cardiovascular disease i s the leading cause of death among women. According to the CDC, 29.3% of deaths in females in the U.S. in 2001 were due to cardiovascular disease and 21.6% were due to cancer, with most resulting from lung cancer. Breast