Crazy Heart
Question 114
A 72-year-old woman is evaluated during a follow-up visit. She has a 3-year history of heart failure with a left ventricular ejection fraction of 25% and New York Heart Association functional class III symptoms. She has an implantable cardioverter-defibrillator. She reports manageable lightheadedness with standing. Medications are lisinopril, carvedilol, and spironolactone at maximally tolerated doses.
On physical examination, the patient is afebrile, blood pressure is 98/64 mm Hg, and pulse rate is 68/min. The estimated central venous pressure is 6 cm H2O. An S3 is present. The lungs are clear to auscultation. There is no lower extremity edema.
Which of the following is the most appropriate management?
A Add ivabradine
B Add valsartan-sacubitril
C Discontinue carvedilol and start ivabradine
D Discontinue lisinopril and start valsartan-sacubitril
EContinue current medications
E
A 45-year-old man is evaluated for a 3-day history of fever, myalgia, headache, and nonproductive cough. He works as a large-animal veterinarian. Medical history is unremarkable, and he takes no medications.
On physical examination, vital signs are normal except for a temperature of 38.2 °C (100.8 °F). Oxygen saturation is 94% breathing ambient air. The examination is otherwise unremarkable.
A chest radiograph shows a patchy right lower lobe interstitial infiltrate.
Which of the following is the most likely cause of his illness?
A Bacillus anthracis
B Coxiella burnetii
C Chlamydia psittaci
D Francisella tularensis
E Yersinia pestis
Many zoonotic organisms have the potential to cause pulmonary infection, but they can be differentiated based on the severity of illness and animal reservoir; relatively mild infection coupled with exposure to livestock indicates likely Coxiella burnetii infection
A 79-year-old woman is brought into the emergency department after she was found unconscious in her apartment by a neighbor. She had been using a propane-fueled heater to heat her small apartment. No other medical history is available.
On physical examination, blood pressure is 100/64 mm Hg, pulse rate is 70/min, and respiration rate is 16/min. Pulse oximetry shows 100% oxygen saturation on mechanical ventilation using 50% oxygen. She is unresponsive to pain or voice but has intact normal deep tendon and brainstem reflexes.
Co-oximetry shows a carboxyhemoglobin level of 50%. CT scan of the head shows no acute changes.
Which of the following is the most appropriate treatment?
A Continue current management
B Decrease oxygen to 30%
C Hydroxocobalamin administration
D Hyperbaric oxygen therapy
Cited indications for hyperbaric oxygen therapy include loss of consciousness, ischemic cardiac changes, neurological deficits, significant metabolic acidosis, or carboxyhemoglobin level greater than 25%.
A 72-year-old man is evaluated in the hospital after developing acute kidney injury 2 days following coronary artery bypass grafting. He is currently on mechanical ventilation and requires vasopressors for hypotension. He underwent coronary angiography 12 hours prior to surgery. The serum creatinine has increased from 0.8 mg/dL (70.7 µmol/L) at baseline to 2.2 mg/dL (194.5 µmol/L), and urine output has decreased to 350 mL/24 h. History is significant for type 2 diabetes mellitus and coronary artery disease. Current medications are intravenous furosemide, insulin, propofol, fentanyl, and norepinephrine.
On physical examination, the patient is intubated and mechanically ventilated. A urinary catheter is in place. Temperature is 37.9 °C (100.2 °F), blood pressure is 98/60 mm Hg, pulse rate is 105/min, respiration rate is 28/min, and oxygen saturation is 96% on 30% FIO2. There is no rash. Decreased breath sounds are heard in the lung bases. The remainder of the examination is noncontributory.
Which of the following is the most appropriate test to perform next?
A Examination of urine sediment
B Fractional excretion of sodium
C Kidney ultrasonographyDMeasurement of central venous pressure
The presence of granular casts and/or renal epithelial cells on urine microscopy has strong predictive value for acute tubular necrosis
A 43-year-old woman is evaluated during a follow-up visit. Six months ago, she was diagnosed with heart failure and pulmonary sarcoidosis. Cardiac magnetic resonance imaging suggested possible cardiac sarcoidosis. She is feeling better after initiation of therapy, but she still has exertional dyspnea when walking up one flight of stairs. An echocardiogram obtained 1 week ago showed a left ventricular ejection fraction of 30%. Medications are candesartan, carvedilol, and spironolactone. She has also been taking prednisone for cardiac sarcoidosis for the past 6 months.
On physical examination, temperature is normal, blood pressure is 98/60 mm Hg, and pulse rate is 58/min. There is no jugular venous distention. Lungs are clear to auscultation. Cardiac examination is normal. No edema is noted.
An electrocardiogram shows a QRS duration of 158 ms, left bundle branch block, and first-degree atrioventricular block.
Which of the following is the most appropriate management?
A Add furosemide
B Increase carvedilol
C Perform endomyocardial biopsy
D Refer for placement of an implantable cardioverter-defibrillator with cardiac resynchronization therapy
Cardiac resynchronization therapy (CRT), or biventricular pacing, involves traditional pacing of the right ventricular apex and pacing of the left ventricular lateral wall via a lead inserted through the coronary sinus into a lateral cardiac vein.
Cardiac resynchronization therapy is indicated in patients with an ejection fraction less than or equal to 35%, New York Heart Association functional class II to IV heart failure symptoms despite guideline-directed medical therapy, sinus rhythm, and left bundle branch block with a QRS duration of 150 ms or greater.
A 25-year-old woman is hospitalized with a 4-day history of fever and cough productive of brown sputum. She is at 14 weeks' gestation with her first pregnancy. Medical history is significant for mild persistent asthma. Medications are an albuterol inhaler, beclomethasone inhaler, and a prenatal vitamin.
On physical examination, temperature is 38.2 °C (100.8 °F), blood pressure is normal, pulse rate is 122/min, and respiration rate is 24/min. Oxygen saturation is 94% breathing ambient air. Crackles are heard at the left lung base on pulmonary auscultation.
Chest radiograph shows a left lower lobe infiltrate.
Which of the following is the most likely cause of pneumonia in this patient?
A Escherichia coli
B Klebsiella pneumoniae
C Listeria monocytogenes
D Staphylococcus aureus
E Streptococcus pneumoniae
The microbiology of community-acquired pneumonia in pregnancy is similar to that seen in the general population; among patients requiring hospitalization, the most common pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms, including Legionellaspecies, Chlamydia pneumoniae, and Mycoplasma pneumoniae.
A 60-year-old man is evaluated in the emergency department for headache, nausea, vomiting, and confusion lasting 4 hours. He ran out of his hypertensive medications a few days ago. Current medications are lisinopril, metoprolol succinate, hydrochlorothiazide, and aspirin.
On physical examination, blood pressure is 230/140 mm Hg and pulse rate is 100/min. All other vital signs are normal. He is too uncooperative to perform a mental status examination or funduscopic examination. The cardiovascular examination is positive for an S4 but otherwise normal.
Laboratory studies reveal normal electrolytes ; serum creatinine is 1.6 mg/dL (141.4 µmol/L). It was 1.2 mg/dL (106 µmol/L) at his last outpatient appointment.
Electrocardiogram shows left ventricular hypertrophy and sinus tachycardia. Chest radiograph is normal. CT scan of the brain shows no acute findings.
Which of the following is the most appropriate treatment?
A Intravenous hypertensive therapy to lower systolic blood pressure (SBP) to 160 mm Hg within the first 6 hours
B Intravenous hypertensive therapy to lower SBP to 120 mm Hg within the first hour
C Intravenous hypertensive therapy to lower SBP to 160 mm Hg within the first 48 hours
D Resume usual oral antihypertensive regimen and observe
Hypertensive emergency refers to elevation of SBP greater than 180 mm Hg, diastolic blood pressure (DBP) greater than 120 mm Hg, or both, that is associated with end-organ damage.
For adults with a hypertensive emergency and without a compelling condition (such as aortic dissection) systolic blood pressure should be reduced by no more than 25% within the first hour; then, if stable, to 160 mm Hg within the next 2 to 6 hours; and then cautiously to normal during the following 24 to 48 hours.
A 32-year-old woman is brought to the emergency department by her boyfriend after she was found unresponsive and lying on the ground. She was last seen more than 24 hours ago. History is significant for substance use disorder. She has no other medical problems and takes no prescription drugs.
On physical examination, the patient is intubated and on mechanical ventilation. She is minimally responsive. Blood pressure is 120/75 mm Hg, and pulse rate is 110/min. The remainder of the vital signs and the cardiac, pulmonary, and abdominal examinations are unremarkable. The neurologic examination is nonfocal. Urine output has been <20 mL/h for the past 2 hours.
Laboratory studies:
Calcium
6.9 mg/dL (1.7 mmol/L)
Creatine kinase
40,000 U/L
Creatinine
2.8 mg/dL (247.5 µmol/L)
Electrolytes :
Sodium
150 mEq/L (150 mmol/L)
Potassium
5.5 mEq/L (5.5 mmol/L)
Chloride
110 mEq/L (110 mmol/L)
Bicarbonate
16 mEq/L (16 mmol/L)
Phosphorus
5.9 mg/dL (1.9 mmol/L)
Fractional excretion of sodium
<1%
Urine myoglobin
300 mg/mL
Urinalysis
Reddish brown urine; pH 5.2; 4+ blood; 2+ protein; granular casts
Toxicology screen
Positive for cocaine and opiates
Which of the following is the most appropriate treatment?
A Hemodialysis
B Intravenous 0.9% saline
C Intravenous 5% dextrose
D Intravenous calcium gluconate infusion
E Intravenous isotonic sodium bicarbonate in 5% dextrose
Initial management of rhabdomyolysis-induced acute kidney injury includes aggressive fluid resuscitation with normal saline aimed at maintaining a urine output of 200 to 300 mL/h.
A 51-year-old man is evaluated in the emergency department for an abrupt loss of consciousness while sitting in a restaurant. The event was witnessed, and the patient was noted to shake for several seconds before he regained consciousness. No prodromal symptoms occurred before the episode. After the event, he had no confusion or altered sensorium. Medical history is significant for nonischemic cardiomyopathy. He is slightly limited by shortness of breath during exercise. He has been taking metoprolol succinate and lisinopril for 9 months.
On physical examination, temperature is normal, blood pressure is 134/78 mm Hg, pulse rate is 72/min, and respiration rate is 15/min. Cardiac examination reveals a regular rhythm with intermittent ectopy. The chest is clear to auscultation. The estimated central venous pressure is normal. No edema is present. Carotid massage produces no bradycardia.
Laboratory findings are notable for a negative result on a serum troponin test.
Telemetry in the emergency department demonstrates short runs of nonsustained ventricular tachycardia. A 12-lead electrocardiogram shows premature ventricular contractions. An echocardiogram demonstrates a left ventricular ejection fraction of 25%.
Which of the following is the most appropriate management?
A Electroencephalography
B Exercise treadmill stress testing
C Implantable cardioverter-defibrillator placement
D PET of the mediastinum2%
E Tilt-table test
Implantable cardioverter-defibrillator (ICD) therapy is indicated in patients with nonischemic cardiomyopathy who have a left ventricular ejection fraction less than or equal to 35% and who have New York Heart Association functional class II or III symptoms; ICD implantation is also reasonable for patients with nonischemic cardiomyopathy and unexplained syncope and significant left ventricular dysfunction.
A 74-year-old homeless woman is evaluated for hospital discharge. She was admitted 6 days ago with a diagnosis of community-acquired pneumonia, and empiric ceftriaxone and azithromycin were begun. Her fever resolved within 48 hours of admission; however, hospital discharge was delayed because of difficulty arranging posthospitalization placement. Medical history is otherwise noncontributory. She takes no other medications.
On physical examination, vital signs are normal. Oxygen saturation is 96% breathing ambient air. The remainder of the examination is unremarkable.
Sputum culture obtained at admission is growing Streptococcus pneumoniae sensitive to penicillin, ceftriaxone, levofloxacin, and vancomycin and resistant to erythromycin. Blood cultures obtained at admission show no growth.
The patient has been accepted into a group home and is ready for hospital discharge.
Which of the following is the most appropriate management at discharge?
A Continue only azithromycin
B Continue only ceftriaxone
C Stop all antibiotics
D Stop ceftriaxone and azithromycin and switch to amoxicillin
E Stop ceftriaxone and azithromycin and switch to levofloxacin
In patients with uncomplicated community-acquired pneumonia not requiring ICU admission, a short course of antibiotic therapy (5-7 days) is sufficient.
A 64-year-old woman is evaluated in the emergency department 45 minutes after sudden onset of right-sided weakness and the loss of the ability to speak. An emergent noncontrast CT of the head shows no hemorrhage or early signs of infarct. The patient also has hypertension and atrial fibrillation. Medications are hydrochlorothiazide and warfarin.
On physical examination, blood pressure is 158/78 mm Hg, and pulse rate is 72/min and irregularly irregular. Global aphasia, left-gaze preference, right hemiparesis, and loss of pain sensation on the right side are noted.
Results of laboratory studies show an INR of 1.3.
The patient receives intravenous recombinant tissue plasminogen activator (alteplase) 1 hour after symptom onset. Blood pressure is now 168/86 mm Hg, but other vital signs are unchanged, as are results of repeat neurologic examination.
Which of the following is the most appropriate next step in management?
A Aspirin administration
B CT angiography of the head
C Intravenous labetalol administration
D MRI of the brain
This patient should have CT angiography of the head. She has an acute ischemic stroke and was appropriately treated within 3 hours of symptom onset with intravenous recombinant tissue plasminogen activator (alteplase). The neurologic examination was consistent with an acute occlusion of the left intracranial internal carotid artery or middle cerebral artery. The patient's atrial fibrillation and subtherapeutic INR make a cardioembolic stroke subtype likely. Patients with an ischemic stroke and large-vessel occlusion have low recanalization rates with intravenous thrombolysis, and recently completed clinical trials have shown a clinical benefit from the addition of endovascular therapy, such as embolectomy, among carefully selected patients. The first step in patient selection requires the presence of a large vessel occlusion on vessel imaging, which is most quickly seen with CT angiography.
A 72-year-old man is hospitalized for a 1-week history of worsening shortness of breath; he also has worsening lower extremity edema despite an increase in his furosemide dose 2 days ago. History is significant for hypertension, stage G3a chronic kidney disease, and heart failure with a preserved ejection fraction. Outpatient medications are amlodipine, lisinopril, furosemide, and low-dose aspirin.
On physical examination, blood pressure is 112/60 mm Hg, and pulse rate is 97/min. BMI is 28. Cardiac examination reveals an elevated jugular venous pressure and an S4. Breath sounds are diminished at the lung bases. There is 2+ pitting edema of the lower legs.
Laboratory studies:
Blood urea nitrogen
64 mg/dL (22.8 mmol/L); 2 weeks ago, 40 mg/dL (14.3 mmol/L)
Creatinine
2.3 mg/dL (203.3 µmol/L); 2 weeks ago, 1.9 mg/dL (168 µmol/L)
Sodium
130 mEq/L (130 mmol/L); 2 weeks ago, 133 mEq/L (133 mmol/L)
Urinalysis
Specific gravity 1.009; 1+ protein; few hyaline casts
Chest radiograph shows bibasilar effusions and vascular congestion.
Which of the following is the most appropriate treatment?
A Add conivaptan
B Add dobutamine infusion
C Increase furosemide
D Start ultrafiltration
CRS is a disorder of the heart and kidneys in which acute or long-term dysfunction in one organ induces acute or long-term dysfunction in the other. CRS is characterized by the triad of concomitant decreased kidney function, diuretic-resistant heart failure with congestion, and worsening kidney function during heart failure therapy.
In cardiorenal syndrome type 1, loop diuretics are first-line therapy for managing volume overload in patients with decompensated heart failure with evidence of peripheral and/or pulmonary edema.
A 75-year-old woman is hospitalized for a 3-week history of progressive exertional dyspnea, increasing peripheral edema, and mental status changes. For the past 4 nights, she has been sleeping in a recliner instead of her bed. She reports no chest pain. She has a 6-year history of ischemic cardiomyopathy, for which she takes low-dose aspirin, furosemide, carvedilol, lisinopril, digoxin, spironolactone, and as-needed metolazone.
On physical examination, the patient is afebrile, blood pressure is 84/52 mm Hg, pulse rate is 118/min, and respiration rate is 28/min. Oxygen saturation is 95% breathing ambient air. She is confused. Jugular venous distention is present. Cardiac examination reveals an S3. There is ascites on abdominal examination. The extremities are cool, and there is lower extremity edema to the knees.
Laboratory studies:
Alanine aminotransferase
172 U/L
Aspartate aminotransferase
163 U/L
Creatinine
2.9 mg/dL (256.4 µmol/L) (baseline, 1.2 mg/dL [106.1 µmol/L])
Potassium
4.7 mEq/L (4.7 mmol/L)
Sodium
132 mEq/L (132 mmol/L) (baseline, 140 mEq/L [140 mmol/L])
Digoxin
0.3 ng/mL (0.38 nmol/L) (normal range, 0.5-2.0 ng/mL [0.64-2.56 nmol/L])
An electrocardiogram shows no acute changes. An echocardiogram shows a left ventricular ejection fraction of 20%.
Which of the following is the most appropriate initial treatment?
A Increase carvedilol
B Increase digoxin
C Increase lisinopril
D Start dobutamine
In patients with cardiogenic shock, inotropes such as dobutamine or milrinone may be considered to improve cardiac function.
A 25-year-old man is evaluated in the emergency department for left hand pain at the site of injection drug use. All of his immunizations are up to date. He takes no medications.
On physical examination, temperature is 39.3 °C (102.7 °F), blood pressure is 88/50 mm Hg, pulse rate is 110/min, and respiration rate is 26/min. A violaceous, swollen, indurated area is noted on the dorsum of the left hand at the site of recent injection drug use; it is warm to the touch and tender.
Laboratory studies:
Hematocrit
36%
Leukocyte count
25,000/µL (25 × 109/L)
Platelet count
100,000/µL (100 × 109/L)
Alanine aminotransferase
65 U/L
Aspartate aminotransferase
105 U/L
Creatinine
2.5 mg/dL (221 µmol/L)
Empiric treatment with vancomycin and piperacillin-tazobactam is initiated and he undergoes surgical debridement. Intraoperative findings confirm necrotizing fasciitis, and tissue and blood cultures grow group A Streptococcus.
Which of the following is the most appropriate antibiotic treatment?
A Continue vancomycin and piperacillin-tazobactam
B Change to doxycycline and ceftazidime
C Change to linezolid and imipenem
D Change to penicillin and clindamycin
In patients with necrotizing fasciitis caused by group A Streptococcus, the combination of penicillin and clindamycin is indicated for antimicrobial therapy after surgical debridement.
A 49-year-old woman is evaluated in the emergency department for a 12-hour history of new-onset right-sided visual loss. The patient has type 2 diabetes mellitus treated with metformin.
On physical examination, blood pressure is 138/72 mm Hg, and pulse rate is 102/min and irregularly irregular. Cardiac auscultation reveals no carotid bruits or cardiac murmurs. A visual field deficit is present on the right side of both eyes. No weakness or sensory loss is noted.
A CT scan of the head shows a hypodensity in the left occipital lobe, and a carotid duplex ultrasound shows less than 60% stenosis of both internal carotid arteries with normal vertebral artery flow. An electrocardiogram shows atrial fibrillation.
Which of the following medications should be administered now?
A Apixaban
B Aspirin
C Clopidogrel
D Intravenous heparin
In the absence of thrombolytic therapy for cardioembolic stroke, short-term therapy with aspirin reduces the risk of stroke at 2 weeks.
A 69-year-old man is evaluated after a recent hospitalization for heart failure. On hospital admission, he was appropriately treated, and an echocardiogram showed a left ventricular ejection fraction of 30% and left ventricular hypertrophy. He is currently asymptomatic. Medical history is otherwise significant for hypertension and hyperlipidemia. Medications are enalapril, furosemide, low-dose aspirin, and atorvastatin.
On physical examination, vital signs are normal. There is no jugular venous distention. Cardiac examination is normal. No edema is noted.
Which of the following is the most appropriate treatment?
A Add bisoprolol
B Add diltiazem
C Add spironolactone
D Discontinue enalapril and add losartan
E No additional therapy
In patients with heart failure with reduced ejection fraction, β-blockers improve remodeling, increase ejection fraction, and reduce hospitalization and mortality when added to ACE inhibitor and diuretic therapy.
A 47-year-old man is hospitalized with a 1-month history of increasingly severe low back pain and a 3-day history of fever and chills. He reports injection drug use (last injected 1 week ago). Medical history is otherwise unremarkable, and he takes no medications.
On physical examination, temperature is 38 °C (100.4 °F), blood pressure is 110/76 mm Hg, pulse rate is 88/min, and respiration rate is 16/min. Neurologic examination reveals no deficits, and no murmur is heard on cardiac auscultation. Palpation of the spine elicits point tenderness over L2-L4.
Laboratory studies show an erythrocyte sedimentation rate of 98 mm/h and a leukocyte count of 18,300/µL (18.3 × 109/L).
MRI is positive for spondylodiskitis at L3-L4.
Blood samples were obtained, and empiric vancomycin was initiated.
Two sets of blood cultures are positive for methicillin-resistant Staphylococcus aureus, with a vancomycin minimum inhibitory concentration of 1.5 µg/mL; repeat blood cultures are pending. The vancomycin trough level is 19 µg/mL.
Transesophageal echocardiography shows no valvular vegetations.
Which of the following is the most appropriate treatment?
A Add gentamicin to vancomycin
B Add rifampin to vancomycin
C Change vancomycin to daptomycin
D Continue vancomycin
When treating methicillin-resistant Staphylococcus aureus bacteremia, vancomycin should be used only if the minimum inhibitory concentration is 2 µg/mL or less.
A 56-year-old man is evaluated in the emergency department for altered mental status of 18 hours' duration. He has a history of cirrhosis due to hepatitis C viral infection and also has anxiety. He has not changed his diet recently, and he has no symptoms suggestive of gastrointestinal bleeding. His bowel movements have been regular and unchanged. His only medication is alprazolam started 2 weeks earlier, after a visit to an urgent care center.
On physical examination, vital signs are normal. Oxygen saturation is 96% breathing ambient air. Abdominal examination is unremarkable; there is no evidence of ascites. Psychomotor slowing and asterixis are noted. There are no focal neurologic findings. The remainder of the examination is unremarkable.
Complete blood count, serum electrolytes and creatinine, and blood glucose are normal.
In addition to starting lactulose, which of the following is the most appropriate next step in management?
A CT of the head
B Initiate a protein-restricted diet
C Initiate rifaximin
D Withdraw alprazolam
Up to 80% of patients with hepatic encephalopathy have a precipitating factor, most commonly infection or gastrointestinal bleeding