QUESTION 103
A 57-year-old male with a past history of treated hypertension for 15 years, diabetes mellitus type II, and a 20 pack-year smoking history presented to an acute care clinic complaining that over the past 6 months when climbing from the 1st floor to the 3rd floor at work by the stairwell, that he had developed a pressure-like sensation in his chest. Each episode lasted for about 5 minutes, and resolved shortly after he stopped climbing the stairs. Of the following, what is the most likely diagnosis?
A. Aortic dissection
B. Metastatic lung carcinoma
C. Stable angina
D. Unstable angina
E. Acute myocardial infarct
Answer for Question 103
Answer: C (stable angina)
Explanation: the man has multiple risk factors for atherosclerosis (age, sex, hypertension, diabetes mellitus, and smoking history). Given the chronicity of the symptoms (i.e., occurring over a 6 month time period), aortic dissection, unstable angina, and acute myocardial infarct are all unlikely, as these are acute events. The symptoms are characteristic for stable angina, which is caused by coronary artery atherosclerosis. When the plaque reaches a critical degree of stenosis (70-75%), during exercise an adequate amount of blood to oxygenate the myocardium can no longer reach the heart, and chest pain occurs. While metastatic lung carcinoma, given the smoking history, is possible, compared to stable angina, would be a rare cause of such a clinical presentation.
QUESTION 104
A 52-year-old male with a past history of treated hypertension for 20 years, diabetes mellitus type II, and a 30 pack-year smoking history presented to an acute care clinic complaining that over the past 4 months when climbing from the 1st floor to the 4th floor at work by the stairwell, that he had developed a pressure-like sensation in his chest. Each episode lasted for about 5 minutes, and resolved shortly after he stopped climbing the stairs. Given that his heart is the source of his symptoms, of the following list of possible lesions of a coronary artery, what was the most likely source of the symptoms?
A. An atheroma producing 25% stenosis
B. An atheroma producing 50% stenosis
C. An atheroma producing 75% stenosis
D. A non-occlusive thromboembolus
E. A partial coronary artery dissection
Answer for Question 104
Answer: C (an atheroma producing 75% stenosis)
Explanation: the symptoms, a pressure-like chest pain occurring during exertion and resolving at rest, in an older male with hypertension, diabetes mellitus, and a history of smoking, are consistent with stable angina. Stable angina is caused by a significantly stenotic atherosclerotic plaque. A 70-75% stenosis is considered significant; with less stenosis than this most often being asymptomatic. While a non-occlusive thromboembolus, such as from a mural thrombus after a myocardial infarct, or associated with a dilated cardiomyopathy could cause angina, it should present acutely, and be a sudden change. Coronary artery dissections are rare, and, while a partial dissection could cause stable angina (i.e., if the dissection occurred, then stopped, then resolved), it would be a very rare compared to atherosclerosis as a cause.
QUESTION 105
A 49-year-old male with a 40 pack-year smoking history presented to an acute care clinic complaining that over the past 6 months each time he has mowed the lawn that he developed a pressure-like sensation in his chest that occasionally was associated with some nausea. Each episode lasted for about 5 to 10 minutes, and resolved shortly after he stopped pushing the mower. His wife finally convinced him to see a doctor although he believes it was just bad heartburn. Given that his heart was the source of his symptoms, of the following, which was the initiating step in his disease process?
A. Necrosis of smooth muscle cells
B. Rupture of elastic lamina
C. Generation of reactive oxygen species
D. Endothelial dysfunction
E. Constriction of vaso vasorum
Answer for Question 105
Answer: D (endothelial dysfunction)
Explanation: give a cardiac origin, the symptoms, a pressure-like chest pain occurring during exertion and resolving at rest, in an older male with hypertension, diabetes mellitus, and a history of smoking, are consistent with stable angina. The most common cause of stable angina is coronary artery atherosclerosis. The initiating step in coronary artery atherosclerosis is endothelial dysfunction, which can be induced by a variety of factors (i.e., cardiac risk factors). Once the endothelium becomes dysfunctional, it will promote thrombosis and allow attachment of white blood cells when it should not. White blood cells in the intima release reactive oxygen species and lead to oxidation of LDL, which accumulates in macrophages.
QUESTION 106
A 52-year-old male with a 30 pack-year smoking history and poorly-controlled hypertension presented to an acute care clinic complaining that over the past 3 months each time he has walked his dog at night that after 5 blocks, he developed a pressure-like sensation in his chest that occasionally was associated with some nausea. Each episode lasted for about 5 to 10 minutes, and resolved shortly after he stopped walking. Given that his heart was the source of his symptoms, of the following, which laboratory test is more likely to be elevated?
A. Troponin I
B. CK-MM
C. Erythrocyte sedimentation rate
D. ASO titer
E. Alanine aminotransferase
Answer for Question 106
Answer: C (erythrocyte sedimentation rate)
Explanation: given a cardiac origin, the symptoms, a pressure-like chest pain occurring during exertion and resolving at rest, in an older male with hypertension and a history of smoking, are consistent with stable angina. The most common cause of stable angina is coronary artery atherosclerosis. In stable angina, there is no irreversible injury to cardiac myocytes, so troponin I and CK-MM (and CK-MB) should be within normal range. ASO titer (anti-streptolysin-O) is indicative of a previous Group A streptococcal infection, which is possible, but is not directly related to his disease process. Erythrocyte sedimentation rate is elevated in a variety of diseases, including coronary artery atherosclerosis. As a component of atherosclerosis is inflammation, and as ESR can be a marker for inflammation, ESR can be elevated; however, it is non-specific as a screening method for coronary artery disease.
QUESTION 107
A 54-year-old male with a past history of hypertension, diabetes mellitus type II and elevated cholesterol, presented to an acute care clinic complaining that over the past 6 months when taking the stairs to his 4th floor office, that he had developed a pressure-like sensation in his chest. Each episode lasted for about 5 minutes, and resolved shortly after he stopped climbing the stairs. Sometimes, the pain was associated with nausea, occasionally with some shortness of breath, and once, the pain radiated into his left arm. Of the following, which test would confirm the diagnosis?
A. CT scan of the chest
B. Echocardiogram
C. MRI of the back
D. Coronary artery angiogram
E. Lumbar puncture with culture
Answer for Question 107
Answer: D (Coronary artery angiogram)
Explanation: the patient has several risk factors for coronary artery atherosclerosis, including age, sex, hypertension, diabetes mellitus, and hypercholesterolemia. The symptoms, given they occur with exertion and resolve within a few minutes, and can be associated with nausea, dyspnea, and radiation into the arm, are consistent with angina. A coronary artery angiogram would confirm the diagnosis.
QUESTION 108
A 58-year-old male presented to an acute care clinic complaining that he had developed a pressure-like sensation in his chest while playing basketball at the gym today with friends. The episode lasted for about 10 minutes, and was associated with some nausea and shortness of breath. The primary care physician determines that the patient’s heart is the source of the condition. Of the following, which condition would most likely be a risk factor for the patient’s disease process?
A. Chronic alcoholism
B. Metastatic tumor
C. High concentrations of HDL
D. Diabetes mellitus
E. Recurrent sinus infections
Answer for Question 108
Answer: D (Diabetes mellitus)
Explanation: the symptoms are consistent with angina. The main cause of angina is coronary artery atherosclerosis. Major risk factors for coronary artery atherosclerosis include age >55 years in males, diabetes mellitus, hypertension, tobacco use, and hypercholesterolemia. Chronic alcoholism, metastatic tumor, high concentrations of HDL and recurrent sinus infections are not associated with coronary artery atherosclerosis. Low concentrations of HDL are a risk factor for atherosclerosis.
