An 80-year-old man was treated for ventricular arrhythmias. He presents 1 month later with joint pain. He also has an unusual mask-like rash over his face and body. Discontinuation of drug therapy causes the symptoms to abate. What drug was most likely administered to this patient? 1 Tocainide 2 Quinidine 3 Procainamide 4 Phenytoin 5 Propranolol Correct Answer Procainamide - often prescribed for long-term control of arrhythmias. May cause lupus like SE. A 62-year-old woman with a long-standing history of hypertension presents with severe headache; it started this morning and is rapidly worsening. During the interview, she suddenly collapses. Your brief examination shows that she responds with extensor posturing on external stimuli. Her deep tendon reflexes are 3, and you elicit Babinski bilaterally. You also notice that her breathing has a peculiar pattern: deep inspiration with a pause at full inspiration, followed by a brief insufficient release and the endinspiration pause. How do you best describe her respiratory pattern? Answer Choices 1 Cheyne-Stokes 2 Apneusis 3 Ataxic 4 Cluster 5 Central neurogenic hyperventilation Correct Answer Her breathing pattern is apneustic. Apneustic breathing pattern characterizes *deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release and the end-inspiration pause before expiration.* What is the mechanism of LMWH? Correct Answer Both unfractionated heparin and low molecular weight Heparin act by *forming a complex with antithrombin III.* A 5-day-old male infant has subtle, unusual facial features (i.e., a triangular face, hypertelorism, and down-slanting eyes). He also has a webbed neck and low-set ears. Suspecting a congenital disorder, you order a complete work-up, including a CBC, coagulation profile, cardiac evaluation, karyotyping, and mutation analysis. PTPN11 (protein-tyrosine phosphatase, nonreceptor-type 11) mutations are detected. Echocardiography detects a cardiac defect. What's most likely to be found on echo? Correct Answer This neonate most likely has Noonan syndrome (NS). Pulmonary stenosis is the most common cardiac defect in this condition. Noonan syndrome is a sporadic, or autosomal dominant, congenital disorder with typical phenotypical features that may not be visible to the casual onlooker. The most common facial features include hypertelorism and low-set, backward-rotated ears with a thick helix. The philtrum is deeply grooved in more than 90% of cases. Congenital cardiac defects, bleeding disorders, mental retardation, webbed neck, and a short stature are other features. A 35-year-old woman presents for follow-up. She has a 6-month past medical history of hypertension; it has responded poorly to lifestyle approaches. She denies using any medications; she does not smoke or use illicit drugs. Her review of systems is notable for muscular weakness, paresthesias, headaches, polyuria, and polydipsia. On physical exam, her blood pressure is 155/95 mm Hg. She has generalized muscular weakness that is measured in all 4 extremities. The remainder of her exam is unremarkable. Laboratory analysis reveals hypokalemia and a hemoglobin A1c level of 5.5. What dx test result is most likely? 1 Metabolic alkalosis 2 Low serum aldosterone to plasma renin activity ratio 3 Hyponatremia 4 Increased erythrocyte sedimentation rate 5 Hypoglycemia Correct Answer The correct response is metabolic alkalosis. This patient is demonstrating signs and symptoms consistent with primary hyperaldosteronism, which is most commonly caused by a unilateral adrenocortical adenoma (Conn's syndrome), but in a minority of patients, it is caused by adrenal hyperplasia. A 40-year-old man presents with atrial flutter with 2:1 atrioventricular (AV) conduction, giving him a pulse of 150 per minute, which is perfectly regular. His blood pressure is 70/40 mm Hg. He takes no medications regularly. You plan to provide him with urgent direct current cardioversion with conscious sedation. What would be an appropriate level of energy for cardioversion in order to restore sinus rhythm in this patient? 1. 10 Joules 2. 15 Joules 3. 50 Joules 4. 200 Joules 5. 300 Joules 6. 360 Joules Correct Answer Of all of the arrhythmias, both supraventricular and ventricular, atrial flutter is the easiest to cardiovert back to a regular sinus rhythm. Direct cardioversion is usually successful with low energy - 25 to 100 Joules. There is no need to apply especially high energies such as 200 Joules, 300 Joules, or 360 Joules as the initial energy for cardioversion in case of atrial flutter, as higher energies have a greater probability of causing burns or broken bones. On the other hand, 10 or 15 Joules is unlikely to result in a successful cardioversion. *50* A 48-year-old man is brought to the ER complaining of difficulty breathing, fatigue, and intermittent chest pain for the past month. On further questioning, he states that the breathing seems to worsen when lying down. On physical exam, you note elevated respiratory and heart rates and pale, sweaty skin. On auscultation, rales are noted as well as a 3rd heart sound. Which of the following is the most likely diagnosis? 1 Right Ventricular failure 2 Pulmonary Embolism 3 Mitral Valve Stenosis 4 Left Ventricular failure 5 Chronic Obstructive Pulmonary Disease (COPD) Correct Answer Left Ventricular failure