A 22-year-old college wrestler comes for a sports physical examination. He tells you that he often feels excessively short of breath during practice and even has had chest pain that resolves with rest. He reports experiencing a syncopal episode 3 months ago while running a marathon. While taking the family history he tells you that his father died of ‘earlier-than-normal age’ sudden death. Later, you send the patient for an echocardiogram, which reveals a hypertrophic heart, a thickened interventricular septum and a functional left ventricular outflow obstruction durings systole. Which of the following would you expect as you auscultate his heart?

A 22-year-old college wrestler comes for a sports physical examination. He tells you that he often feels excessively short of breath during practice and even has had chest pain that resolves with rest. He reports experiencing a syncopal episode 3 months ago while running a marathon. While taking the family history he tells you that his father died of ‘earlier-than-normal age’ sudden death. You send the patient for an echocardiogram, which reveals a hypertrophic heart, a thickened interventricular septum and a functional left ventricular outflow obstruction durings systole. You suspected hypertrophic obstructive cardiomyopathy in this patient. You wanted to make sure that your auscultatory findings are consistent with your suspicions. Of the following which bedside maneuver increases the intensity of murmur of this disorder?

A 54-year-old male presents to the emergency room complaining of chest discomfort that started while he was landing the Boeing 747 plane in the airport this morning. He felt some lightheadedness as he taxied the plane. This is the fourth attack of chest discomfort in the last 6 months. It used to respond well to nitroglycerin but the effectiveness of nitroglycerin decreased over the weeks. Over the months, he has had several visits to the emergency department for this reason. A nuclear stress test performed last month gave an indeterminate result. Serum troponin was elevated once but not after every episode of chest discomfort. He is a commercial pilot for a major airline. He smokes one pack of cigarettes a day but drinks occasionally, in his words, ‘only on special occasions’. Of the following, what is the most important step in the management of this patient?

A 63-year-old woman comes to your office for her annual physical examination. In the review of systems, she denies any chest pains, shortness of breath on exertion, cough, fatigue and reports ‘just some joint pains here and there’. She has an estimated 10-year cardiovascular disease risk of 12%. She lives with her husband and children in a neighborhood near your medical center. According to the United States Preventive Services Task Force (USPSTF), of the following, what is recommended to this patient?

A 58-year-old woman presented to the emergency room complaining of severe, crushing, substernal chest pain that began while she was cooking a meal at a friend’s house this morning. She tells you that she experiences this type of pain when she walks fast or does something strenuous. An electrocardiogram demonstrates some signs of ischemia. Serial cardiac enzymes reveal elevated troponin. The cardiac catheterization reveals significant stenosis of the left anterior descending coronary artery and the patient has a bare-metal coronary stent placed. What is the primary recommendation for anticoagulation in this patient?

A 58-year-old woman presented to the emergency room complaining of severe, crushing, substernal chest pain that began while she was cooking a meal at a friend’s house this morning. She tells you that she experiences this type of pain when she walks fast or does something strenuous. An electrocardiogram demonstrates some signs of ischemia. Serial cardiac enzymes reveal elevated troponin. The cardiac catheterization reveals significant stenosis of the left anterior descending coronary artery and the patient has a bare-metal coronary stent placed. After stent placement, she is placed on clopidogrel, a medication that acts to prevent thrombosis at the stent site. Of the following, which explains the mechanism of action of clopidogrel?