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Question 1 |
A 67-year-old man with a history of hypertension and smoking comes to the emergency department complaining of severe, tearing abdominal pain radiating to his back. He is diaphoretic and appears anxious. His blood pressure is 160/90 mm Hg, and his pulse is 110/min. Abdominal ultrasound reveals a 7 cm abdominal aortic aneurysm. What is the most appropriate next step in the management of this patient?
Immediate surgical repair | |
Administer antihypertensive medication and observe Hint: While antihypertensive medication is important for managing hypertension, it is not sufficient in this acute setting. | |
Schedule elective surgery within the next month Hint: This is not an elective situation; immediate intervention is required. | |
Initiate anticoagulant therapy Hint: Anticoagulants would exacerbate the risk of rupture and hemorrhage. | |
Perform CT angiography Hint: While useful for diagnosis, it would delay the necessary immediate surgical intervention. |
Question 1 Explanation:
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)
Question 2 |
A 52-year-old woman with a history of hypertension and diabetes presents to the emergency department with chest pain that started 3 hours ago. The pain is described as a "heavy" feeling in the center of her chest. She also reports nausea and shortness of breath. Her ECG shows T-wave inversions but no ST-segment elevations. Troponin levels are elevated. What is the most likely diagnosis?
Unstable Angina Hint: This condition would not show elevated troponin levels. | |
Stable Angina Hint: This is unlikely given the acute presentation and elevated troponin. | |
NSTEMI | |
STEMI Hint: ST-segment elevations would be present on ECG. | |
Pericarditis Hint: This would typically present with different ECG changes and would not elevate troponin levels. |
Question 2 Explanation:
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))
Question 3 |
A 60-year-old man with no significant past medical history presents to the emergency department with severe chest pain radiating to his left arm. He is diaphoretic and nauseated. His ECG shows ST-segment elevations in leads II, III, and aVF. What part of the heart is most likely affected?
Anterior Wall Hint: On the 12 contiguous leads of an ECG, an anterior wall myocardial infarction can affect multiple leads. It shows maximal ST-segment elevation at the anterior leads, V3 and V4. Anterior wall myocardial infarctions result from occlusion of the left anterior descending artery (LAD), which is also known as the "widow maker." | |
Posterior Wall Hint: A posterior wall myocardial infarction (MI) appears on a standard 12-lead ECG as ST depressions in leads V1-V4. The depressions are usually deepest in leads V2-V4. This occurs because the ECG leads are placed anteriorly, but the myocardial injury is posterior. | |
Inferior Wall | |
Lateral Wall Hint: Lateral wall myocardial infarctions are characterized by acute ST-segment changes in leads I, aVL, V5 and V6. This ECG distribution is usually associated with an acute left circumflex artery lesion. | |
Septal Wall Hint: In a the 12 contiguous leads of an ECG, the septal leads are V1 and V2. Thus, with a septal wall myocardial infarction, we see ST-segment changes and elevation in leads V1 and V2. Septal infarcts stem from insult to the left anterior-descending coronary artery (LAD). |
Question 3 Explanation:
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.
Question 4 |
A 65-year-old man comes to the emergency department with acute onset of pain in his upper back. The pain started 45 minutes ago while he was lifting some heavy boxes. He feels lightheaded and has broken out in a cold sweat. He denies any chest pain or difficulty breathing. His medical history includes hypertension, hyperlipidemia, and osteoarthritis. His temperature is 36.8°C (98.2°F), pulse is 90/min, respirations are 20/min, and blood pressure is 150/90 mmHg. The patient appears anxious and diaphoretic. Physical examination reveals normal heart and lung sounds. Abdominal examination is unremarkable. What investigation should be immediately performed in this patient?
Abdominal Ultrasound Hint: Not indicated as the abdomen is non-tender. | |
Chest X-ray Hint: Less urgent than ECG in this scenario. | |
Electrocardiogram (ECG) | |
Upper Endoscopy Hint: Not indicated as there are no gastrointestinal symptoms. | |
MRI of the Spine Hint: Not appropriate for acute evaluation. |
Question 4 Explanation:
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)
Question 5 |
A 72-year-old man with a history of smoking and peripheral artery disease complains of sudden, severe pain in his left leg. The pain started while he was walking his dog and has not improved with rest. The leg appears pale and is cold to the touch. Pulses are absent below the knee. Based on this history, which of the following would be the most appropriate test to order?
Doppler ultrasound of the leg Hint: Doppler ultrasound of the leg: While Doppler ultrasound can assess blood flow, it is not as definitive or as rapid as CT angiography for diagnosing arterial embolism. | |
Magnetic Resonance Angiography (MRA) Hint: Magnetic Resonance Angiography (MRA): MRA can provide detailed images of blood vessels but is generally slower than CT angiography and may not be readily available in all settings, making it less ideal for emergent situations. | |
Computed Tomographic (CT) Angiography | |
Ankle-Brachial Index (ABI)
Hint: ABI is useful for assessing the severity of chronic peripheral artery disease but is not appropriate for diagnosing acute arterial embolism. | |
X-ray of the leg Hint: An X-ray would not provide information on blood vessels and is not useful in diagnosing arterial embolism. |
Question 5 Explanation:
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)
Question 6 |
A 68-year-old female with a history of hypertension and heart failure is brought to the emergency department due to worsening shortness of breath. Her ECG reveals an irregularly irregular rhythm with a rate of 135/minute and no discernible P waves. What is the most likely diagnosis based on these ECG findings?
Atrial flutter Hint: This condition is characterized by regular atrial contractions and usually presents with a "sawtooth" pattern on ECG. | |
Atrial fibrillation | |
Ventricular tachycardia Hint: This is a life-threatening condition characterized by a rapid heart rate originating from the ventricles. It usually presents with wide QRS complexes on ECG. | |
Sinus tachycardia Hint: This is a regular rhythm originating from the sinus node, usually in response to stress or other stimuli. P waves are present and regular. | |
First-degree heart block Hint: This condition involves a prolonged PR interval but maintains a regular rhythm. P waves are present and regular. |
Question 6 Explanation:
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.
Question 7 |
A 55-year-old man with a history of aortic stenosis repaired with a prosthetic valve is scheduled to have a dental procedure. He is allergic to penicillin. Which of the following antibiotic regimens is the most appropriate for endocarditis prophylaxis?
Amoxicillin 2 g orally 1 hour before the procedure Hint: This patient is allergic to penicillin, so ampicillin and amoxicillin are not appropriate antibiotic regimens for endocarditis prophylaxis. | |
Ampicillin 2 g IM or IV 30 minutes before the procedure
Hint: This patient is allergic to penicillin, so ampicillin and amoxicillin are not appropriate antibiotic regimens for endocarditis prophylaxis. | |
Clindamycin 600 mg orally 1 hour before the procedure | |
Azithromycin 500 mg orally 24 hours before the procedure Hint: Azithromycin 500 mg is an option in penicillin allergic patients but should be given 30-60 minutes before the procedure. | |
Cefazolin 1 g IM or IV 30 minutes before the procedure Hint: This would be appropriate in a patient allergic to penicillin and unable to take oral medication |
Question 7 Explanation:
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)
Question 8 |
A 68-year-old man with a history of hypertension and hyperlipidemia presents to the emergency department with complaints of dizziness and fatigue for the past 2 days. He denies chest pain, shortness of breath, or syncope. His medications include atenolol and simvastatin. Vital signs reveal a heart rate of 42/min, blood pressure of 110/70 mmHg, respiratory rate of 16/min, and oxygen saturation of 98% on room air. The ECG shows sinus bradycardia with no other abnormalities. Which of the following is the most appropriate initial management for this patient?
Atropine 0.5 mg IV Hint: Generally used for symptomatic bradycardia, but in this case, the cause is likely medication-induced. | |
Discontinue atenolol | |
Transcutaneous pacing Hint: Indicated for more severe cases with hemodynamic instability. | |
Adenosine 6 mg IV Hint: Used for supraventricular tachycardia, not bradycardia. | |
Isoproterenol infusion Hint: Used for refractory cases and not as a first-line treatment. |
Question 8 Explanation:
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)
Question 9 |
A 72-year-old man with a history of ischemic heart disease is admitted to the ICU for worsening dyspnea and fatigue. His blood pressure is 75/40 mmHg, heart rate is 115 bpm, and oxygen saturation is 90% on room air. His extremities are cold to touch, and he appears lethargic. ECG shows ST-segment depression in leads II, III, and aVF. What is the most appropriate next step in management?
Administer IV fluids Hint: IV fluids may exacerbate heart failure. | |
Initiate norepinephrine infusion | |
Administer nitroglycerin IV Hint: Nitroglycerin can worsen hypotension. | |
Perform coronary angiography Hint: Coronary angiography is not the immediate priority. | |
Administer aspirin and heparin Hint: Aspirin and heparin are not the immediate treatment in this scenario. |
Question 9 Explanation:
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)
Question 10 |
A 58-year-old woman presents to her primary care provider for a routine check-up. She has a history of hypertension and hyperlipidemia. She mentions experiencing occasional chest tightness during her morning walks, which resolves with rest. Her ECG shows T-wave inversions in leads V1-V4. What is the most appropriate diagnostic test to confirm the suspected diagnosis?
Exercise stress test | |
Coronary angiography Hint: Coronary angiography is usually reserved for high-risk or unclear cases. | |
Cardiac MRI Hint: Cardiac MRI is not the first-line diagnostic tool for CAD. | |
Echocardiogram Hint: Echocardiogram is useful but not specific for CAD. | |
24-hour Holter monitor Hint: 24-hour Holter monitor is not indicated for diagnosing CAD. |
Question 10 Explanation:
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)
Question 11 |
A 55-year-old man presents to the emergency department with a 2-day history of increasing pain and swelling in his left calf. He recently had a hip replacement surgery and has been mostly bedridden. On physical examination, the left calf is swollen, erythematous, and tender to touch. Doppler ultrasound confirms the presence of a thrombus in the left popliteal vein. Which of the following is the most appropriate initial treatment for this patient?
Aspirin 325 mg orally | |
Warfarin with a target INR of 2-3 | |
Low molecular weight heparin (LMWH) | |
Surgical thrombectomy | |
Compression stockings |
Question 11 Explanation:
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)
Question 12 |
A 72-year-old woman with a history of hypertension and type 2 diabetes presents to the clinic complaining of increasing shortness of breath and fatigue over the past month. She denies chest pain but reports difficulty lying flat at night. On examination, her blood pressure is 140/90 mm Hg, and she has bilateral lower extremity edema. An echocardiogram shows a preserved ejection fraction but impaired relaxation of the left ventricle. Which of the following is the most appropriate treatment for this patient's condition?
ACE inhibitors | |
Beta-blockers Hint: Beta-blockers are generally not first-line for diastolic heart failure. | |
Diuretics Hint: Diuretics may relieve symptoms but do not address the underlying issue. | |
Calcium channel blockers Hint: Calcium channel blockers are less effective in treating heart failure. | |
Digoxin Hint: Digoxin is not recommended for diastolic heart failure. |
Question 12 Explanation:
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)
Question 13 |
A 55-year-old man with a family history of coronary artery disease and a personal history of type 2 diabetes comes to the clinic for a follow-up. His lipid panel reveals a total cholesterol of 260 mg/dL, LDL of 180 mg/dL, HDL of 35 mg/dL, and triglycerides of 200 mg/dL. He is currently on metformin for his diabetes. He has no history of cardiovascular events but is concerned about his elevated cholesterol levels. Given this patient's comorbidities and lipid profile, which of the following medications would provide the most benefit in terms of cardiovascular risk reduction?
Niacin Hint: Niacin is generally not first-line due to side effects. | |
Fibrates Hint: Fibrates are more effective for lowering triglycerides. | |
High-intensity statin therapy | |
Ezetimibe Hint: Ezetimibe is usually added to statin therapy if needed. | |
Omega-3 fatty acids Hint: Omega-3 fatty acids have limited efficacy in lowering LDL. |
Question 13 Explanation:
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 )
Question 14 |
A 48-year-old woman with a history of essential hypertension, controlled on hydrochlorothiazide and amlodipine, comes to the clinic for a routine follow-up. She mentions that she has been experiencing frequent headaches and palpitations for the past two weeks. Her blood pressure today is 160/100 mm Hg. Lab tests reveal elevated serum creatinine and potassium levels. She denies any recent changes in diet, medication, or lifestyle. Given the new symptoms and lab findings, which of the following is the most appropriate next step in the management of this patient's hypertension?
Add a beta-blocker to her current regimen Hint: Adding a beta-blocker would not address the underlying issue. | |
Switch to a loop diuretic Hint: Switching to a loop diuretic is not indicated with these lab findings. | |
Initiate ACE inhibitor therapy Hint: Initiating an ACE inhibitor could worsen renal function. | |
Refer for renal artery Doppler ultrasound | |
Increase the dose of amlodipine Hint: Increasing the dose of amlodipine would not address the underlying issue. |
Question 14 Explanation:
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 )
Question 15 |
A 55-year-old man with a history of poorly controlled hypertension presents to the emergency department with severe headache, blurred vision, and chest pain. His blood pressure is measured at 220/130 mm Hg. An EKG shows signs of left ventricular hypertrophy but no acute ischemic changes. Which of the following is the most appropriate initial treatment for this patient's hypertensive emergency?
Oral hydrochlorothiazide Hint: Oral hydrochlorothiazide is too slow-acting for a hypertensive emergency. | |
Sublingual nifedipine Hint: Sublingual nifedipine can cause an unpredictable drop in BP and is not recommended.
| |
Intravenous nitroprusside | |
Oral amlodipine Hint: Oral amlodipine is also too slow-acting for immediate control. | |
Intravenous furosemide Hint: Intravenous furosemide is not the first-line treatment for hypertensive emergencies and could exacerbate volume depletion. |
Question 15 Explanation:
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)
Question 16 |
A 67-year-old man with a history of type 2 diabetes and coronary artery disease comes to the clinic complaining of faintness, lightheadedness, dizziness, confusion, and blurred vision that occur within seconds to a few minutes of standing and resolve rapidly on lying down. His resting blood pressure today is 90/60 mm Hg and you note a drop of 22 mm Hg systolic three minutes after a change from supine to standing. He has little compensatory increase in heart rate with the drop in blood pressure. He is currently on metformin, aspirin, and a beta-blocker. Which of the following is the most appropriate diagnostic test to evaluate the cause of this patient's hypotension?
24-hour urine collection for catecholamines Hint: 24-hour urine collection for catecholamines is used to diagnose pheochromocytoma, which usually presents with hypertension, not hypotension. | |
Echocardiogram Hint: Echocardiogram is useful for evaluating cardiac function but is not the first-line test for diagnosing the cause of hypotension in this case. | |
Tilt-table test | |
Serum cortisol levels Hint: Serum cortisol levels would be appropriate if adrenal insufficiency were suspected, but this patient's presentation doesn't strongly suggest that. | |
Renal function tests Hint: Renal function tests are important but would not directly diagnose the cause of this patient's hypotension. |
Question 16 Explanation:
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)
Question 17 |
A 52-year-old woman presents to the emergency department with palpitations and a feeling of "racing heart" that started suddenly while she was watching TV. She denies chest pain, shortness of breath, or dizziness. Her ECG shows a narrow complex tachycardia with a rate of 180 beats per minute. Vagal maneuvers have been unsuccessful in terminating the tachycardia. Which of the following is the most appropriate next step in the management of this patient?
Administer IV adenosine | |
Perform synchronized cardioversion Hint: Synchronized cardioversion is reserved for unstable patients or those who do not respond to medical therapy. | |
Administer IV metoprolol Hint: IV metoprolol is not the first-line treatment for PSVT and is generally used for rate control in atrial fibrillation or flutter. | |
Administer IV amiodarone Hint: IV amiodarone is generally reserved for ventricular tachycardias or refractory PSVT. | |
Insert a temporary pacemaker Hint: A temporary pacemaker is not indicated in this scenario as the patient is stable and the tachycardia is likely to respond to simpler measures. |
Question 17 Explanation:
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)
Question 18 |
A 60-year-old woman with a history of type 2 diabetes and hypertension presents to the clinic with complaints of intermittent claudication. She reports that the pain occurs in her right calf after walking about three blocks and is relieved by rest. On physical examination, her right dorsalis pedis and posterior tibial pulses are diminished. Which of the following ABI values would most likely confirm the diagnosis of PAD in this patient?
0.5 | |
0.9 Hint: An ABI of 0.9 is at the lower limit of the normal range (0.9-1.3) and would not confirm PAD. | |
1.3 Hint: An ABI of 1.3 is within the normal range and would not indicate PAD. | |
1.5 Hint: An ABI of 1.5 is above the normal range and could indicate vessel stiffness but is not diagnostic for PAD. | |
2.0 Hint: An ABI of 2.0 is significantly above the normal range and could indicate non-compressible arteries, often seen in severe calcification, but is not diagnostic for PAD. |
Question 18 Explanation:
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)
Question 19 |
A 45-year-old man presents to the emergency department with a 2-day history of increasing pain, redness, and warmth over his left antecubital fossa. He reports that he had a peripheral IV line placed in that area for antibiotics during a recent hospitalization for pneumonia. On examination, the skin over the antecubital fossa is erythematous, warm, and tender to touch. There is a palpable cord along the course of the vein. Which of the following is the most appropriate next step in the management of this patient?
Initiate anticoagulation therapy Hint: Anticoagulation therapy is generally not initiated without confirming the diagnosis and extent of the thrombus. | |
Perform Doppler ultrasound | |
Administer IV antibiotics Hint: IV antibiotics are not indicated unless there is evidence of bacterial infection, which is not the case here. | |
Surgical excision of the affected vein Hint: Surgical excision is reserved for severe cases and is not the first-line treatment. | |
Apply warm compresses and elevate the limb Hint: Warm compresses and limb elevation are supportive measures but do not replace the need for diagnostic confirmation. |
Question 19 Explanation:
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)
Question 20 |
A 32-year-old woman is found to have a blood pressure of 158/102 mm Hg. Laboratory studies reveal a plasma aldosterone level of 32 ng/dL (normal 4-31 ng/dL) and plasma renin activity of 0.2 ng/mL/hr (normal 0.5-1.9 ng/mL/hr). Which of the following is the most likely cause of her hypertension?
Chronic kidney disease Hint: Chronic kidney disease would show normal or increased renin. | |
Obstructive sleep apnea Hint: Obstructive sleep apnea and atherosclerotic renal artery stenosis would not suppress renin. | |
Aldosterone-producing adenoma | |
Atherosclerotic renal artery stenosis Hint: Obstructive sleep apnea and atherosclerotic renal artery stenosis would not suppress renin. | |
Pheochromocytoma Hint: Pheochromocytoma would cause much higher blood pressures. |
Question 20 Explanation:
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)
Question 21 |
A 52-year-old man with dilated cardiomyopathy presents with fatigue and shortness of breath. He reports being able to walk up one flight of stairs slowly but then needing to rest. He is unable to engage in strenuous physical activities. Which NYHA functional class best describes his level of cardiovascular disability?
Class I Hint: Patients without limitation of physical activity. | |
Class II | |
Class III Hint: Patients with marked limitation of physical activity, in which less than ordinary activity results in fatigue, palpitation, dyspnea, or anginal pain; they are comfortable at rest. | |
Class IV Hint: Patients who are not only unable to carry on any physical activity without discomfort but who also have symptoms of heart failure or the anginal syndrome even at rest; the patient's discomfort increases if any physical activity is undertaken. | |
Class V Hint: There is no class V. |
Question 21 Explanation:
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)
Question 22 |
A 67-year-old man with a history of coronary artery disease and diabetes mellitus comes to his provider's office complaining of increasing shortness of breath and fatigue over the past month. He also reports swelling in his ankles. On examination, he has jugular venous distension, bilateral crackles on lung auscultation, and 2+ pitting edema in both ankles. An echocardiogram reveals a left ventricular ejection fraction of 30%. Which of the following medications is most likely to improve this patient's mortality?
Digoxin Hint: Digoxin is used for symptom control but has not been shown to improve mortality. | |
Furosemide Hint: Furosemide is a diuretic used for symptom relief but does not improve mortality. | |
Metoprolol | |
Nifedipine Hint: Nifedipine is a calcium channel blocker and is generally not recommended in systolic heart failure. | |
Hydralazine Hint: Hydralazine is used in combination with nitrates for symptom relief but does not improve mortality alone. |
Question 22 Explanation:
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)
Question 23 |
A 65-year-old woman is admitted to the hospital for community-acquired pneumonia. She is started on IV erythromycin. The next day she develops a prolonged QT interval on ECG and then a run of polymorphic ventricular tachycardia. Which of the following is the best management for this arrhythmia?
IV amiodarone Hint: Can worsen torsades | |
IV magnesium sulfate | |
Atropine Hint: Not effective for torsades | |
Defibrillation Hint: Second-line if magnesium fails | |
IV procainamide Hint: Can worsen torsades |
Question 23 Explanation:
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)
Question 24 |
A 55-year-old woman comes to the provider's office complaining of aching pain and heaviness in her legs that worsens as the day progresses. She is a cashier and stands for long periods. On examination, you notice dilated, tortuous veins in her lower extremities. She has tried compression stockings with minimal relief. What is the most appropriate next step in the management of this patient's condition?
Sclerotherapy Hint: Sclerotherapy is a treatment option but should be considered after confirming the diagnosis and extent with duplex ultrasound. | |
Endovenous laser treatment Hint: Endovenous laser treatment is a treatment option but should be considered after diagnostic confirmation. | |
Surgical ligation and stripping Hint: Surgical ligation and stripping are usually reserved for severe cases and after diagnostic confirmation. | |
Duplex ultrasound | |
Continue compression stockings Hint: The patient has already tried compression stockings with minimal relief, indicating the need for further diagnostic evaluation. |
Question 24 Explanation:
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)
Question 25 |
A 62-year-old man with a history of chronic venous insufficiency presents to the provider with a venous leg ulcer (VLU) on his right lower leg. The ulcer has been present for six weeks and shows minimal signs of healing despite the use of compression therapy and elevation. On examination, the ulcer has a significant amount of exudate and some necrotic tissue. The patient reports moderate pain at the site. What is the most appropriate next step in the management of this patient's VLU?
Apply a hydrogel dressing with silver Hint: Hydrogel dressing with silver is generally used for managing bioburden or residual necrotic tissue but would not be as effective as surgical debridement in this case. | |
Initiate oral antibiotics Hint: Oral antibiotics are not indicated unless there is evidence of bacterial infection. | |
Perform sharp surgical debridement | |
Prescribe enzymatic debridement agents Hint: Enzymatic debridement is generally reserved for situations when preferred methods are not available. | |
Refer for larval therapy Hint: Larval therapy, also known as maggot therapy, is a type of biotherapy. It involves applying live, sterile maggots to a wound to help it heal. Larval therapy is an alternative to surgical debridement but is not the first-line choice. |
Question 25 Explanation:
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)
Question 26 |
A 56-year-old man collapses at a family gathering and is found to be unresponsive. A family member starts CPR while another calls 911. When EMS arrives, they find the patient pulseless and initiate advanced cardiac life support (ACLS). The initial rhythm on the monitor shows ventricular fibrillation. Which of the following is the most appropriate immediate intervention for this patient?
Administer intravenous amiodarone Hint: Amiodarone is used for refractory ventricular fibrillation but is not the first-line treatment. | |
Perform synchronized cardioversion Hint: Synchronized cardioversion is not appropriate for pulseless ventricular fibrillation. | |
Administer intravenous epinephrine Hint: Epinephrine is used in the ACLS algorithm but is not the immediate first step in a pulseless ventricular fibrillation. | |
Initiate immediate defibrillation | |
Administer intravenous atropine Hint: Atropine is not used in the management of ventricular fibrillation. |
Question 26 Explanation:
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)
Question 27 |
A 62-year-old woman with a history of ischemic heart disease is brought to the emergency department with palpitations and lightheadedness. Her vital signs are stable, and she is alert and oriented. The ECG shows a wide-complex tachycardia with a rate of 160 beats per minute. Which of the following is the most appropriate initial treatment for this patient?
Administer intravenous adenosine Hint: Adenosine is generally not effective for ventricular tachycardia and is primarily used for supraventricular tachycardia. | |
Perform synchronized cardioversion Hint: Synchronized cardioversion is reserved for hemodynamically unstable patients. | |
Administer intravenous amiodarone | |
Initiate immediate defibrillation Hint: Immediate defibrillation is indicated for pulseless ventricular tachycardia, not for a stable patient. | |
Administer intravenous metoprolol Hint: Metoprolol is not the first-line treatment for ventricular tachycardia and could potentially worsen the condition. |
Question 27 Explanation:
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)
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