PANCE Blueprint Cardiology (13%)

The patient's presentation of severe abdominal pain, hypertension, and a large abdominal aortic aneurysm on ultrasound is highly suggestive of a ruptured or impending rupture of an abdominal aortic aneurysm. Immediate surgical repair is the most appropriate next step to prevent catastrophic hemorrhage and death. (Review PANRE Blueprint Topic: Aortic aneurysm and aortic dissection)

The patient's symptoms, elevated troponin levels, and ECG changes without ST-segment elevations are indicative of a Non-ST-Segment Elevation Myocardial Infarction (NSTEMI). Immediate medical management is required, including antiplatelet therapy and anticoagulation. (Review PANRE Blueprint Topic: Non-ST-Segment Elevation MI (NSTEMI))

The patient's ECG shows ST-segment elevations in leads II, III, and aVF, which are indicative of an inferior wall myocardial infarction. These myocardial infarctions arise due to right coronary artery insult. Immediate reperfusion therapy is required.

Given the patient's risk factors and acute onset of symptoms, an ECG should be immediately performed to rule out myocardial ischemia, which can present atypically without chest pain. (Review PANRE Blueprint Topic: Angina pectoris)

The patient's symptoms of sudden, severe pain, pallor, and absent pulses are highly suggestive of acute arterial embolism. In such a situation, rapid diagnosis and treatment are crucial to prevent irreversible tissue damage. Patients with viable or marginally threatened limbs are usually candidates for urgent vascular imaging (typically computed tomographic [CT] angiography, or catheter-based arteriography) to evaluate arterial anatomy and to potentially institute thrombolytic therapy. Patients with an immediately threatened extremity should preferentially undergo further evaluation and treatment in a surgical suite (Review PANRE Blueprint Topic: Arterial embolism/thrombosis)

Atrial fibrillation is characterized by an irregularly irregular rhythm and the absence of discernible P waves on ECG. It is a common arrhythmia, especially in patients with underlying heart conditions like hypertension and heart failure. The diagnosis is made based on ECG findings. Treatment includes rate control, rhythm control, and anticoagulation to prevent thromboembolic events.

This patient is allergic to penicillin, so ampicillin and amoxicillin are not appropriate antibiotic regimens for endocarditis prophylaxis. Clindamycin is the preferred antibiotic for patients with a penicillin allergy. Azithromycin and clarithromycin are also effective antibiotic regimens for patients with a penicillin allergy. (Review PANRE Blueprint Topic: Acute and subacute bacterial endocarditis)

This patient's presentation of bradycardia with symptoms of dizziness and fatigue suggests that his bradycardia is symptomatic. Given that he is on atenolol, a beta-blocker that can cause bradycardia, the most appropriate initial step is to discontinue the medication. (Review PANRE Blueprint Topic: Conduction Disorders)

The patient is in cardiogenic shock, indicated by hypotension, tachycardia, and signs of poor perfusion such as cold extremities and altered mental status. Norepinephrine is often used as a first-line vasopressor to improve perfusion in cardiogenic shock. (Review PANRE Blueprint Topic: Cardiogenic shock)

The patient's symptoms and ECG changes are suggestive of angina pectoris, a manifestation of coronary artery disease. An exercise stress test is the most appropriate next diagnostic step to assess the severity and to guide further management. (Review PANRE Blueprint Topic: Coronary Heart Disease)

The patient's clinical presentation and Doppler ultrasound findings are consistent with deep venous thrombosis (DVT). The most appropriate initial treatment for DVT is anticoagulation, and low molecular weight heparin (LMWH) is the preferred initial anticoagulant. It is administered subcutaneously and has a rapid onset of action. Typically, patients are initially given an injectable heparin (unfractionated or low molecular weight) for 5 to 7 days, followed by longer term treatment with an oral drug. For patients who are to start warfarin, warfarin is started within 24 to 48 hours after the start of the injectable heparin. For patients who are to start an oral factor Xa inhibitor (edoxaban) or dabigatran etexilate, the oral agent is started on the day after the 5 to 7 days of injectable heparin is completed. (Review PANRE Blueprint Topic: Venous thrombosis)

The patient's symptoms, along with the echocardiogram findings, are indicative of diastolic heart failure, also known as heart failure with preserved ejection fraction (HFpEF). The mainstay of treatment for diastolic heart failure is controlling hypertension and relieving symptoms. ACE inhibitors are effective in controlling blood pressure and have been shown to improve outcomes in heart failure. (Review PANRE Blueprint Topic: Heart Failure)

This patient has multiple risk factors for cardiovascular disease, including a family history of coronary artery disease, elevated LDL, low HDL, and type 2 diabetes. High-intensity statin therapy is recommended for PRIMARY PREVENTION for all individuals with diabetes who are between 40-75 years old and have an LDL level of 70-189 mg/dL, especially when they have multiple cardiovascular risk factors. (Review PANRE Blueprint Topic: Hypercholesterolemia )

The patient's newly elevated blood pressure, despite medication, along with elevated serum creatinine and potassium levels, raises the suspicion for secondary hypertension, possibly due to renal artery stenosis. A renal artery Doppler ultrasound is the most appropriate next step to evaluate this possibility. (Review PANRE Blueprint Topic: Hypertension )

In hypertensive emergencies like this one, where the patient has end-organ damage (headache, blurred vision, chest pain), rapid reduction of blood pressure is crucial. Intravenous nitroprusside is the drug of choice for immediate BP control. (Review PANRE Blueprint Topic: Hypertensive emergencies)

Orthostatic hypotension, also known as postural hypotension, is a form of low blood pressure in which a person's blood pressure falls significantly when suddenly standing up or stretching. Clinically, it is defined as a fall in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg when a person assumes a standing position. The patient's symptoms of dizziness and fatigue, along with his medical history, low blood pressure, and lack of compensatory increase in HR suggest orthostatic hypotension with an autonomic cause. Given his age and medical history, a tilt-table test would be the most appropriate diagnostic test to evaluate for orthostatic hypotension, which is a common cause of hypotension in older adults and those on certain medications like beta-blockers. It is often treated by identifying and addressing the underlying cause, as well as by making lifestyle changes such as drinking more fluids and avoiding standing up too quickly. (Review PANRE Blueprint Topic: Orthostatic hypotension)

The patient's symptoms and ECG findings are consistent with Paroxysmal Supraventricular Tachycardia (PSVT). When vagal maneuvers fail, the next step is to administer IV adenosine, which is effective in terminating PSVT. (Review PANRE Blueprint Topic: Paroxysmal supraventricular tachycardia)

PAD is a condition that occurs when the arteries in the legs become narrowed or blocked. This can reduce blood flow to the legs and feet, which can cause pain, numbness, and other problems. PAD is a serious condition that can increase the risk of heart attack, stroke, and other health problems. The ABI test is a non-invasive way to measure blood flow to the legs. It is done by comparing the blood pressure in the ankles to the blood pressure in the arms. A normal ABI is between 0.9 and 1.4. An ABI below 0.9 is considered to be abnormal and may be a sign of peripheral artery disease (PAD). The ABI test is a sensitive and specific test for PAD. This means that it is very good at detecting PAD, even in people who do not have any symptoms. The ABI test is also a good way to monitor the progression of PAD and to see how well treatment is working. (Review PANRE Blueprint Topic: Peripheral artery disease)

The patient's symptoms of localized pain, erythema, and a palpable cord along the vein are suggestive of thrombophlebitis. The most appropriate next step is to perform a Doppler ultrasound to confirm the diagnosis and assess the extent of the thrombus. (Review PANRE Blueprint Topic: Phlebitis/thrombophlebitis)

This patient has hypertension with an elevated aldosterone level but suppressed renin, indicating primary aldosteronism. This pattern is classic for an aldosterone-producing adenoma and is among the most common forms of secondary hypertension. Chronic kidney disease would show normal or increased renin. Obstructive sleep apnea and atherosclerotic renal artery stenosis would not suppress renin. Pheochromocytoma would cause much higher blood pressures. Therefore, an aldosterone-producing adenoma is the most likely cause. (Review PANRE Blueprint Topic: Secondary hypertension)

NYHA class II includes patients with cardiac disease resulting in slight limitation of physical activity. Patients can walk more than one block and climb stairs, but perform ordinary physical activity with fatigue, palpitations, or dyspnea. This patient's ability to climb one flight of stairs slowly but not engage in strenuous activities is consistent with NYHA class II. Class I is no limitation, class III is marked limitation with activities like walking one block, class IV is inability to perform any activity without symptoms, and there is no class V. (Review PANRE Blueprint Topic: Heart Failure)

Beta-blockers like Metoprolol have been shown to improve mortality in patients with systolic heart failure by reducing the effects of the sympathetic nervous system on the heart. (Review PANRE Blueprint Topic: Heart Failure)

The patient's polymorphic ventricular tachycardia with QT prolongation is consistent with torsades de pointes. Torsades is caused by delayed repolarization and is treated with IV magnesium sulfate to stabilize the myocardial cells. Amiodarone and procainamide can worsen torsades. Atropine is not effective. Defibrillation would be indicated for sustained tachycardia with hemodynamic instability, but magnesium is the first-line treatment. (Review PANRE Blueprint Topic: Torsade de pointes)

Duplex ultrasound is the diagnostic modality of choice for evaluating the extent of venous insufficiency and planning treatment for varicose veins. (Review PANRE Blueprint Topic: Varicose veins)

Surgical debridement is often favored over nonsurgical methods, especially at the initial encounter, to remove necrotic tissue and bacterial burden. This is essential for promoting wound healing in VLUs. Anesthetic agents can be used to minimize pain during the procedure. (Review PANRE Blueprint Topic: Venous insufficiency)

In a pulseless patient with ventricular fibrillation, the most appropriate immediate intervention is defibrillation. This is the cornerstone of ACLS for ventricular fibrillation and has the highest likelihood of restoring a perfusing rhythm. (Review PANRE Blueprint Topic: Ventricular fibrillation)

In a hemodynamically stable patient with ventricular tachycardia, intravenous amiodarone is often the first-line treatment. It is effective for both supraventricular and ventricular arrhythmias and is generally well-tolerated. (Review PANRE Blueprint Topic: Ventricular tachycardia)