QUESTION 113
A 67-year-old male with a past medical history of hypertension, hyperlipidemia, and a 30 pack-year smoking history is brought to the emergency room by ambulance, following an episode of chest pain occurring while golfing with friends, which started 6 hours ago. He describes the chest pain as though someone were standing on his chest and he clenches his fist in front of his chest when he does so. In addition to the pain, he is short of breath, nauseous, and sweating. He says that the pain extends to his left and right arm and jaw. His vital signs are BP of 164/96, heart rate of 104 bpm, and respiratory rate of 23 breaths per minute. Laboratory testing reveals an elevated troponin I upon admission. Of the following, which finding is most likely to be identified via physical examination?
A. A pleural rub
B. A pericardial friction rub
C. A systolic murmur
D. A diastolic murmur
E. Asymmetric pulses
Answer for Question 113
Answer: C (a systolic murmur)
Explanation: the symptoms are consistent with an acute coronary syndrome (i.e., pressure sensation in the chest associated with sweating, nausea, and shortness of breath, and with the pain extending to the left arm, right arm, and jaw). The elevated troponin I indicates damage to the cardiac myocytes, which would be consistent with an acute myocardial infarct. With injury to the myocardium, papillary muscle dysfunction can occur, resulting in mitral insufficiency, which would be a systolic murmur. While a pericardial friction rub can occur in association with pericarditis due to an acute myocardial infarct, normally this requires at least around 1 day before it develops and would not be present at 6 hours.
QUESTION 114
A 51-year-old male with a past medical history of poorly-controlled hypertension for 10 years presents to the emergency room with complaints of a sharp tearing pain in his chest that radiates to his back. The blood pressure in his right and left arm are 151/91 and 149/90 respectively. Physical examination reveals no murmur. A chest x-ray reveals a widened mediastinum. He is told he needs emergent surgery; however, he refuses and leaves against medical advice. Given that he survives without surgery, of the following, which is most likely to develop as a result of his presenting condition?
A. Coarctation of the aorta
B. False aneurysm
C. A dilated left ventricle of the heart
D. Berry aneurysm
E. True aneurysm
Answer for Question 114
Answer: B (False aneurysm)
Explanation: the clinical scenario is consistent with an aortic dissection, which most commonly occur in the background of hypertension. The absence of a murmur indicates that the dissection did not extend to the heart, as if it had done so, it would most likely have caused aortic insufficiency. Given that he survived, the aortic dissection was contained, but would have, on image, appeared as a bulge in the wall of the vessel–therefore, it would be a false aneurysm. As the intima and most of the media are on the lumen side of the hemorrhage, a true aneurysm would not develop. An aortic dissection does not normally cause coarctation of the aorta, and, with no aortic insufficiency, if would not cause a dilated left ventricle of the heart. A berry aneurysm occurs in the brain, and hypertension will contribute to its development, but berry aneurysms are not associated otherwise with aortic dissection.
QUESTION 115
A 63-year-old male comes to the emergency room complaining of abdominal pain. He says that over the past 2 months, he has had abdominal pain which occurs 1-2 hours after eating, and then dissipates. Because of this pain, he has not wanted to eat, and has lost 15 lbs in that time frame. He has a 30 pack-year smoking history and hypertension. Of the following, what other disease process is most likely to be identified?
A. Metastatic lung carcinoma
B. Berry aneurysm
C. Pheochromocytoma
D. Peripheral vascular disease
E. Early onset Alzheimer’s disease
Answer for Question 115
Answer: D (peripheral vascular disease)
Explanation: the history of abdominal pain occurring after eating a meal is characteristic of mesenteric ischemia. Because the disease process has been going on for some time, the best diagnosis would be chronic mesenteric ischemia. Chronic mesenteric ischemia is most commonly due to atherosclerosis of the celiac artery, superior mesenteric artery or both. As atherosclerosis is a systemic disorder, in patients with one form of atherosclerosis, another form can often be found; thus, in a person with chronic mesenteric ischemia, of the choices, peripheral vascular disease, which is also most commonly due to atherosclerosis, would be the one most likely to be identified.