A 43 year-old man presents to the emergency department complaining of weakness, feeling bad, and difficulty breathing for the last 4 days. His temperature is normal, heart rate is 160 beats per minute, blood pressure is 60/40 mm Hg, and oxygen saturation is 91% on 80% FiO2 by face mask.On physical examination, his trachea is not deviated. His lung sounds are normal. But his heart sounds are muffled, distant and faint. You noted swollen veins in the neck with pressure not changing with breathing. There is an abnormal drop in systolic blood pressure when he inhales and the disappearance of radial pulse on inspiration. ECG revealed a QRS complex height that varies from one heart beat to the next. On chest x-ray, the cardiac silhouette is rounded in its lower portion and tapers at the base of the heart resembling a plastic bag filled with water sitting on a table. Jugular venous pressure waveform is remarkable for prominent x descent and absent y descent. Laboratory tests revealed normal troponin levels. Echocardiogram revealed a small right ventricle and confirmed the suspected diagnosis. Which of the following is most likely to be diagnosed in this patient?
A 64-year-old man presents to your primary care office because his ‘pre-surgery clearance form’ needs to be filled by a doctor. Next month he is scheduled to undergo pancreatectomy for a malignant tumor of the pancreatic head. His medical history is significant for ischemic heart disease and diabetes mellitus requiring insulin. His most recent serum creatinine level was 2.1 mg/dL. Of the following which medication is considered the first-line therapy to reduce perioperative morbidity and mortality in this patient?
A 58 year-old woman comes to your office with a pre-surgery clearance form. She is going to have cataract surgery next month and her eye doctor wanted her to get a physical examination before the surgery. She reports no medical complaints. Her past medical history is significant for occasional acid reflux disorder. Her serum creatinine level was 1.2 mg/dL two weeks ago. She works as a teller in a local bank and exercises one hour a day in the local gym. Her temperature is 99 °F (37.2 °C), heart rate is 78 beats/min, blood pressure is 125/80 mm Hg, respirations are 19 breaths/min, and oxygen saturation is 98% on room air. Her physical examination is significant for cataracts in both eyes. Of the following, the next step in her management is
A 67-year-old male presents to the emergency room with severe chest pain. His ECG records ST segment elevation and development of new Q waves in precordial leads. Lab findings reveal elevated troponin. He is admitted for definitive treatment. Which of the following is true concerning ventricular remodeling after myocardial infarction?
A 68 year-old woman comes to your office for the first office visit after she was diagnosed with cardiac AL amyloidosis and right-sided heart failure. As you prepare to examine her, what clinical signs would you expect to find in her?
A 68-year-old woman presents to your office complaining of shortness of breath. She reports that over the last two months, she has become progressively short of breath with activity. She feels dizzy when she walks faster; her abdomen feels distended; and her legs feel swollen. Her temperature is 98 °F, heart rate is 56 beats/min, blood pressure is 110/84 mm Hg, respirations are 19 breaths/min, and oxygen saturation is 94% on room air. Physical examination is notable for bilateral crackles in the lung fields and pitting edema in bilateral lower extremities. You ordered an ECG, which shows the right bundle branch block with low voltage QRS complexes. Later your order an echocardiogram which revealed a concentric thickening of the left ventricle; relative apical-sparing or “cherry-on-top” pattern on a longitudinal strain bull’s eye display with bright myocardium. Laboratory tests revealed elevated troponin. Abdominal fat biopsy shows apple-green birefringence with Congo red staining. Of the following, which is the most likely diagnosis in this patient?
A 26-year old male comes to the emergency room complaining of syncope. He passed out while exercising in the gym. His father died of sudden cardiac death in his early 40s. Physical examination is significant for paradoxical splitting of second heart sound, S4 gallop, sustained apical impulse and a systolic ejection murmur at left lower sternal border. The murmur increased with the Valsalva maneuver. Patient was admitted for investigative studies. ECG revealed left ventricular hypertrophy with exaggerated septal Q waves. Echocardiogram showed asymmetrical thickening of the interventricular septum, resulting in dynamic obstruction of the LV outflow tract and abnormal systolic motion of the mitral valve. Which of the following medications should be avoided in this patient?
A 26-year old male comes to the emergency room complaining of syncope. He passed out while exercising in the gym. His father died of sudden cardiac death in his early 40s. Physical examination is significant for paradoxical splitting of second heart sound, S4 gallop, sustained apical impulse and a systolic ejection murmur at left lower sternal border. The murmur increased with the Valsalva maneuver. What is the next step in the management of this patient?
