A 55 year-old man comes to your office with complaints of gradual breast enlargement over the past 3 months. He has mild tenderness in both breasts, more pronounced on the left side. He also describes psychological discomfort about his appearance, explaining the feelings of embarrassment. His medical history is significant for hypertension, chronic heart failure (NYHA Class II), and type 2 diabetes mellitus. His current medications include spironolactone, metoprolol, metformin, furosemide and aspirin. He does not consume alcohol excessively and denies use of anabolic steroids or recreational drugs. He has no family history of breast cancer or hormonal disorders. On physical examination, you notice a well-appearing male. His blood pressure is 128/80 mm Hg and heart rate is 72 bpm. He has enlarged breasts, but no discharge or lumps. There is mild tenderness on palpation of both breasts. There is no nipple retraction or discharge. Which of his current medications most likely caused his breast condition?

A 58-year-old man presents to your office with progressive dyspnea over the last three months. Previously, he had been able to work in his farm and take care of his cows, but now he feels short of breath after walking only 50 feet. He does not have chest pain at rest but has experienced retrosternal chest pressure with strenuous work. His sleep is also not ‘peaceful’ because he wakes up at night feeling short of breath, which is relieved within minutes by sitting upright in bed. On physical examination, he is afebrile, with a heart rate of 88 beats per minute (bpm), blood pressure of 145/92 mm Hg, and respiratory rate of 18 breaths per minute. On cardiac examination, his heart rhythm is regular with a normal S1 and S2 with a systolic murmur loudest over the second right intercostal space. He also has elevated jugular venous pressure (JVP), pedal edema and bilateral crackles in lungs. Echocardiogram reveals an ejection fraction of 30% and aortic stenosis. Which of the following medications is shown to improve long-term survival in this patient?

A 72-year-old man comes to your office complaining of vision change, nausea, vomiting, and diarrhea. His past medical history is significant for gout, hypertension, diabetes, and congestive heart failure. He takes all his prescribed medications regularly. Upon further questioning, he informs you that, he also has a blurry vision and, his vision has a yellow hue to it. An electrocardiogram demonstrates bradycardia, a prolonged PR interval, a shortened QT interval, ST-segment scooping, and T-wave inversion. Of the following, what would be the most frequent electrolyte abnormality you would expect in this patient?

A 72-year-old man comes to your office complaining of vision change, nausea, vomiting, and diarrhea. His past medical history is significant for gout, hypertension, diabetes, and congestive heart failure. He takes all his prescribed medications regularly. Upon further questioning, he informs you that, he also has a blurry vision and, his vision has a yellow hue to it. An electrocardiogram demonstrates bradycardia, a prolonged PR interval, a shortened QT interval, ST-segment scooping, and T-wave inversion. Of the following, which is the most likely culprit causing distress to this patient?

A 74-year-old man presents to the emergency room complaining of shortness of breath. He has markedly reduced his ordinary activities because he is no longer able to perform them without losing his breath. He stopped going to Penn State football games because he is concerned about climbing stairs in the Beaver Stadium. Even simple things like taking a bath, wearing his clothes and cooking a meal make him distressful. However, he reports no symptoms at rest. He prefers to sit on his couch most of the time. What is his NYHA Functional Classification for heart failure?

A 74-year-old male presents to the cardiology clinic reporting lightheadedness, near fainting, fatigue, chest discomfort, and shortness of breath. He had a medical history of myocardial infarction a month ago, treated with right coronary artery stenting in a local hospital. His current symptoms started two days after his discharge from the hospital. His temperature is 99 °F (37.2 °C), heart rate is 36 beats/min, blood pressure is 88/58 mm Hg, respirations are 19 breaths/min, and oxygen saturation is 92% on room air. A cardiac event monitor, which the patient carries with him, has been showing consistent bradycardia with an average heart rate of 36 beats per minute. Of the following, which is most likely to treat his symptoms for long-term management?

A 44-year-old woman presents to the clinic feeling tired and fatigued all the time. She gained 30 pounds of weight despite dieting. She has also noticed an increasing problem with constipation despite adequate fiber intake.She is frequently cold when others are hot. Her menses have become irregular and heavy. Her current medications include lisinopril, amiodarone, atorvastatin, ibuprofen and claritin. On physical examination, her vitals reveal BP 165/98 mm Hg, P 55 bpm, R 20, and T 37°C. She is in no acute distress and appears in good health. She has a slightly enlarged, nontender thyroid noted on her neck. She has proximal muscle weakness. Her reflexes are diminished. The skin is cool, dry, and rough. The heart sounds are quiet. The rectal and pelvic examinations show no abnormalities, and the stool is negative for occult blood. You check her thyroid function, and her TSH is elevated and free T4 is low. What is the most likely cause of this patient’s condition?