The Challenge Cardiology. Week 2

A 75-year-old female presents to the hospital complaining of shortness of breath and requiring 3-4 pillow to be able to sleep at night, which has been progressively worsening over the last week. She has a past medical history of hypertension and cancer. She states that he was recently started on a new chemotherapy agent one month ago for a newly diagnosed lymphoma. Which of the following agents was this patient most likely started on by his care provider?

Which of the following is the most appropriate initial antihypertensive medication for use in patients with severely elevated blood pressure and acute cardiac ischemia?

Your ED is extremely busy, with an average 5-hour wait when ZT, a 26yo male (61kg) with a past medical history of sickle cell disease presents reporting 10/10 pain. He says this feels like his previous episodes of pain crisis. He has taken 2 doses of his home 10mg oxycodone tablets, but with no relief. The triage nurse asks what the most appropriate course of action is, as she doesn’t want to “waste a room” since ZT seems fine and is on FaceTime with a friend. Which is the most appropriate response to the triage nurse?

A 62-year-old male with a history of chronic kidney disease (CKD), depression, and recently diagnosed squamous cell carcinoma presents to the emergency department with with fatigue, weakness, and constipation. His presenting vital signs include BP 110/62 mm Hg, HR 110 beats/min, RR 26 breaths/min, and temperature 38.9 C. His lab test results include Na 145mEq/L, K+ 5.1 mEq/L, Cl 101 mEq/L, CO2 18 mEq/L, SCr 1.2 mg/dL (baseline 1.0 mg/dL), BUN 15 mg/dL, calcium 13.4 mg/dl, and glucose 126 mg/dL. The patient was started on 0.9% sodium chloride infusion and the team with requesting on how to treat this patient hypercalcemia of malignancy. Which is the best therapy to add next for this patient’s hypercalcemia?

65-year-old male presenting to the emergency department (ED) via emergency medical services (EMS) transport from home for shortness of breath and chest pain. The past medical history includes diabetes mellitus, and a recent NSTEMI and placement of a drug-eluting stent 3 days ago. Current medications include aspirin 81 mg PO daily, Clopidogrel 75 mg PO daily, atorvastatin 80 mg daily, Metoprolol tartrate 50 mg BID. The patient’s vital signs revealed a heart rate of 114 beats/min, blood pressure of 144/90 mm Hg (mean arterial pressure [MAP] 108 mm Hg), respiratory rate of 14 breaths/min, and oxygen saturation of 98%. His lab test results include Na 149 mEq/L, K+ 4.1 mEq/L, Cl 101 mEq/L, CO2 22 mEq/L, SCr 1.1 mg/dL (baseline 1.0 mg/dL), BUN 15 mg/dL, glucose 126 mg/dL, a VerifyNow P2Y12 platelet function result of 285 (Reference range 180-376 PRU). PM is 5’8” tall and weighs 150 lb. Which of the following is the most appropriate intervention for this patient?

72 yo F PMHx significant for HTN, atrial fibrillation (on apixaban), HF (EF 30%), presents to the ED after a motor vehicle collision (car vs. pole). In the trauma bay she is mentating well and her vitals are as follows: HR 90, BP 88/62, RR 20, 95% O2 saturation on room air. FAST exam positive for intraperitoneal fluid, concerning for hemorrhage secondary to a blunt injury.  Which intervention should be prioritized for this patient?

A 42-year-old man with von Willebrand disease presents to the emergency department with a fall to his side with and open fracture to his elbow. Vital signs include a heart rate of 90 bpm and a blood pressure of 115/75 mm Hg. Laboratory workup is notable for a hemoglobin of 12.0 g/dL, platelets of 150,000/microliter, and an international normalized ratio of 1.0. The trauma team consults orthopedics, and they will not have to take him to the OR. What is the most appropriate treatment to address this patient’s bleeding?

What is the recommended dose for Selexipag?

A 45 year old woman, B.L., is brought in by ambulance to the ED. She is in cardiac arrest and her rhythm is asystole. Her sister states they were walking around the neighborhood when she suddenly collapsed and went unresponsive. She recently had surgery on her foot about a month ago and this was the first day she felt well enough to take a short walk. The nurses are unable to get any vital signs on the patient and CPR is started. The ED physician is concerned for a pulmonary embolism and wants to give a dose of alteplase. The patient is 70 kg. Which of the following is the correct dose of alteplase to give?

RK is a 59yo female (101kg) who is brought to the ED as a post-cardiac arrest patient. Paramedics report she has an extensive cardiac history with previous CABG. She was eating dinner with her family when she suddenly grabbed her chest and lost consciousness. Her daughter is in nursing school and immediately began performing CPR. Once EMS arrived, they noted the patient to be in ventricular fibrillation, and obtained ROSC after 1 shock. Their post-ROSC EKG shows a ST segment elevation in the lateral leads, with reciprocal changes in the septal leads, which is confirmed with in-house EKG prompting the ED physician to call a STEMI alert. Upon presentation RK looks visibly ill, she is pale and diaphoretic, HR 98, BP 104/52, RR 24, O₂ saturation 88% on 15L non-rebreather. The ED team is concerned that she may go into cardiac arrest again. Unfortunately, the cath lab calls back saying that they have cases ongoing in both of their rooms, so there will be a delay in taking RK up. Due to her critical presentation, the ED physician decides to proceed with alteplase administration due to the delay in catheterization. Which of the following is the most appropriate dosing of alteplase for RK?

A 45-year-old female presents to the Emergency Department with the complaint of sharp, substernal chest pain for the past 3 weeks which has slowly worsened in intensity. The pain increases with movement and is improved by sitting up. She is also complaining of fever and lethargy. On examination, a pericardial friction rub is auscultated and the diagnosis of pericarditis is confirmed with an ECG.

Which one of the following statements best describes the appropriate first-line treatment for this condition?

A 20-year-old man presents to the ED with several days of progressive chest pain, fatigue, myalgias, and exertional dyspnea. He states that he had the “flu” 1 week before. He denies any illicit drug use or family history of heart disease. Physical examination reveals temperature of 100.5°F, heart rate of 125, no murmurs on cardiac examination, and scattered bilateral crackles on lung examination. EKG demonstrates sinus tachycardia, chest x-ray reveals cardiomegaly and mild pulmonary edema, and laboratory reports are normal except for troponin I, which is elevated at 10 ng per mL. Which of the following is the most likely etiology?

47-year-old male presenting to the emergency department (ED) via emergency medical services (EMS) transport from home for altered mental status and new onset palpitations. The patient has a past medical history of hypertension taking amlodipine. Her presenting vital signs include BP 120/62 mm Hg, HR 161 beats/min, RR 21 breaths/min, and temperature 38.9oC.  A 12-lead ECG reveals a wide complex tachycardia with a irregular rhythm with prolonged QT internal that is identified as polyomorphic ventricular tachycardia. Which of the following interventions would be the best initial option for acute management in this patient?

What is the cutoff required for the diagnosis of early-onset neonatal sepsis?

What is the goal blood pressure after achieving adequate heart rate control for aortic dissection?

TH is a 62yo male who presents to the ED with a 3-day history of weakness, fever, and neck stiffness. He has a past medical history of hypertension for which he takes lisinopril and reports no allergies. In triage his temperature is 101.3°F, HR 102, RR 21, BP 114/72, O2 saturation 98% on room air. CBC and BMP are significant for a WBC of 11.8 and lactate of 3.7. The physician suspects meningitis and prepares for a lumbar puncture. Which of the following is the most appropriate recommendation for empiric therapy in TH?

1. Which of the following is the earliest electrocardiogram (EKG) finding in acute myocardial infarction (MI)?

1. The ED provider is deciding on which pharmacological agent to use for hypertensive emergency. She wants to know what is the maximum duration of clevidipine?

What intervention should be prioritized in patients presenting  aortic dissection with hypotension secondary to aortic rupture or pericardial tamponade?

A 47 -year-old man with a past medical history of hypertension presents to the emergency department (ED) with the chief complaints of fever, chills, and abdominal pain. Pertinent vital signs on admission are as follows: blood pressure 110/78 mm Hg, heart rate 115 beats/minute, respiratory rate 16 breaths/minute, temperature 100.3°F, and oxygen saturation of 97% on room air. The patient’s workup is suspicious for sepsis with moderate risk intra-abdominal infection and is currently being admitted to the medical wards. According to the patient’s medical record, he has not allergies and currently taking amlodipine 10 mg by mouth daily. Which of the following is the most appropriate antibiotic therapy for this patient?

1. What intervention should be prioritized in patients presenting aortic dissection with hypotension secondary to aortic rupture or pericardial tamponade?

An 82-year-old male with congestive cardiac failure experienced rapid decompensation of his clinical status, manifested by increasing shortness of breath, swelling, and increased fatiguability. Laboratory studies showed an elevation in his creatinine level. In order to manage this acute change, he was started on intravenous Dobutamine to improve his hemodynamic status. What effect does this drug have on the body?

1. A 42-year-old man is brought to the emergency room by ambulance after a syncopal episode. He doesn’t respond. A review of the patient’s medical records indicates that he was recently treated for a bacterial respiratory infection; however, the specific antibiotic was not noted. He has a complicated medical history characterized by severe diabetes mellitus and chronic kidney disease. On examination he is pale and sweating with a rapid but weak pulse. An electrocardiogram is obtained and the results displays torsades de pointes. A baseline metabolic panel is pending. Which of the following medications could patient been taking to precipitate torsades de pointes?

   

A 45-year-old man was the driver in a motor vehicle collision. The patient is unable to offer a medical history during the initial presentation. His temperature is 97.6°F (36.4°C), blood pressure is 104/74 mmHg, pulse is 150/min, respirations are 12/min, and oxygen saturation is 98% of room air. During the GCS exam, he does not open his eyes, contracts in pain and makes unintelligible noises. He has obvious signs of trauma to his chest and abdomen. His abdomen is distended and markedly tender to palpation. He also has an obvious open deformity of his left femur. What is the best initial step in management?

A 63-year-old man arrives at the ER with a 20-minute history of crushing pain under the sternum. He was found to be uncomfortable and sweating during his presentation, with ST segment elevations in leads V3-V5. He is given a sublingual nitroglycerin tablet, which significantly reduces his pain level. Which of the following is the most important mechanism by which this drug works in this patient?

1. A 60-year-old woman with a history of atrial arrhythmia comes to the emergency department with complaints of tinnitus, headache, visual disturbances, and severe diarrhea. The patient is given oxygen through a nasal cannula. ECG electrodes, a pulse oximeter and an automated blood pressure cuff are applied. The patient suddenly faints. Her ECG shows the presence of multifocal ventricular tachycardia with a smooth change in the QRS electrical axis. Which of the following medications is most likely responsible for this patient’s symptoms?

A 72 yo F with PMHx of atrial fibrillation (not on anticoagulation), hypertension is brought to the ED after sustaining a high speed (50-60 mph) MVC as the front passenger with airbag deployment. Initial exam yields a GCS of 5, concerning for severe TBI. The patient undergoes RSI with etomidate and succinylcholine and a bolt is placed for ICP monitoring. Current vitals are as follows: RR 18, HR 88 bpm, BP 110/76, ICP 19, temperature 37 degrees Celsius. Which intervention is inappropriate at this time?

A 78-year-old woman presents to the emergency department because of increasing chest pain for last 3 hours. She had a history of intracranial hemorrhage 2 weeks ago. Her temperature is 98.3°F (36.8°C), blood pressure is 110/80 mmHg, pulse is 94/min, respirations are 26/min, and O2 saturation is 89% on room air. ECG shows inferior wall MI. Which of the following is contraindicated in this patient?

A 22-year-old man presents to the ER from a community hospital where he was diagnosed with a C3-C4 fracture and incomplete spinal cord injury (SCi). The fracture has been reduced. Which is the most appropriate statement for initiating high-dose methylprednisolone therapy for this patient’s SCI?

A 62 year old male, C.W. is brought in by ambulance for complaints of chest pain and a feeling that his heart is racing. As he enters the ED he suddenly goes unresponsive. You pull up the patient’s chart and find he has a past medical history of hypertension, hyperlipidemia, and chronic kidney disease which he does to dialysis Mon/Wed/Fri. His wife arrives with him and states “he hasn’t been feeling well and has missed 2 dialysis sessions.” An EKG is completed and it has T wave inversions. Which of the following H’s and T’s could be causing the patient to be unresponsive?