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1. An 18-year-old woman is seen in clinic for symptoms of shortness of breath on exertion. Her

past health history is noncontributory except for an appendectomy at the age of 8. She reports of

no recent cough, sputum, wheeze, or chest discomfort.

On physical examination, she appears well. The blood pressure is 120/70 mm Hg, heart rate

is 80/min and regular, and respiratory rate is 12/min. Auscultation of the heart reveals an

increased intensity of the pulmonary component of the second heart sound. The lungs are clear

and the remaining physical is normal. Provide the

explanations is the most likely cause of her dyspnea?

2. A 22-year-old woman is evaluated in the emergency department because of symptoms of

prolonged palpitations. She complains of no associated chest discomfort, shortness of breath, or

lightheadedness. The palpitations have occurred twice before, but they always stopped

spontaneously after 5 minutes, and she cannot associate them with any triggers. The past health

history is negative and she is not on any medications.

On physical examination, the blood pressure is 110/70 mm Hg, heart rate is 160/min and

regular. The heart and lung examinations are normal, and the ECG is shown in Figure 1-2. The

heart rate abruptly changes to 72/min after applying carotid sinus pressure. provide

the most likely diagnosis?

3. A 73-year-old man is seen in the office for assessment of new-onset chest pain and shortness of

breath on exertion. The pain is described as retrosternal pressure and nonradiating. Medical

history includes hypertension, type 2 diabetes and dyslipidemia. His medications are atenolol,

metformin, glyburide, and simvastatin.

On examination, the blood pressure is 140/90 mm Hg, heart rate is 60/min and cardiac

auscultation reveals a murmur. On his ECG the rhythm is sinus and there is left axis deviation

with voltage enlargement consistent with left ventricular hypertrophy. He is sent for a coronary

angiogram and it reveals noncritical stenosis of the coronary arteries. This occurs most

frequently with which valvular heart diseases?

4. An 82-year-old woman presents to the emergency department with new-onset syncope. She was

walking at the time and reported no prodrome prior to the event. After a brief episode of

disorientation lasting less than a minute she was back to her baseline. Lately she has noticed

shortness of breath on exertion but no chest discomfort.

Physical examination reveals a blood pressure of 110/95 mm Hg, heart rate of 80/min, and a

harsh systolic ejection murmur heard best at the base of the heart and radiating to both carotids.

The carotid pulse is late in peaking and diminished in volume. Auscultation of the second

heart sound at the base might reveal which findings?

5. A 69-year-old woman is brought to the emergency department complaining of easy fatigue and

one episode of syncope. She was feeling well until the day of presentation and reports no chest

pain, fever, cough, or shortness of breath. Her past medical history is significant for angina,

hypertension, and dyslipidemia. Medications include metoprolol, amlodipine, and atorvastatin.

On physical examination, the blood pressure is 110/80 mm Hg, heart rate is regular at

56/min, and inspection of the jugular venous pressure (JVP) reveals irregular large a waves.

The ECG (see Figure 1-3) has fixed PP and RR intervals but varying PR intervals. Which

conditions is this most likely caused by?

6. A 57-year-old man presents to the emergency department with a 1-day history of chest pain and

shortness of breath. An ECG is diagnostic for an evolving anterior MI, and treatment is initiated

with aspirin, metoprolol, and heparin. His post MI course is complicated by the development of

heart failure. Nitroglycerinwould be a useful first medication under which circumstances?

7. A 28-year-old man presents to the hospital feeling unwell for weeks with new symptoms of

fever, chills, and night sweats. He reports no cough, sputum, or dysuria, and his past medical

history is negative for important co-morbidities. He is not taking any medications.

Pertinent findings on physical examination are a blood pressure of 120/70 mm Hg heart rate

of 100/min, and temperature of 38.5C. The heart sounds are normal but there is a 3/6 systolic

murmur. The lungs are clear, the abdomen is nontender, and his peripheral exam is normal. He

is admitted to the hospital for further investigations, and two days later the blood cultures are

positive for viridans group streptococci in multiple sets. Which cardiac

lesions has the highest risk of developing endocarditis?

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8. A 47-year-old woman presents to the emergency department with symptoms of new-onset

transient right arm weakness and word-finding difficulty lasting 3 hours. She is also

experiencing exertional dyspnea, and had a syncopal event 1 month ago. Her medical history is

only remarkable for 2 uneventful pregnancies, and she is not taking any medications.

Physical examination reveals normal vital signs, and no residual focal neurological deficits.

The ECG and CT brain are normal but an echocardiogram reveals a cardiac tumor in the left

atrium, it is pendunculated, and attached to the endocardium. What is the

most likely cause of this lesion?

9. A 72-year-old woman comes to the emergency department complaining of palpitations and

dyspnea. The symptoms started suddenly and there is no associated chest pain, fever, or lightheadedness. Her past medical history includes hypertension, dyslipidemia, and osteoarthritis.

Her medications are enalapril, hydrochlorothiazide, simvastatin, and acetaminophen.

Her ECG shows new-onset atrial flutter with a ventricular rate of 150/min. She is

hemodynamically stable with a blood pressure of 155/90 mm Hg, but is experiencing

palpitations. The jugular venous pressure and heart sounds are normal. There are no murmurs,

and the lungs are clear. Which of the following drugs is the best intravenous choice for

controlling the heart rate?

10. Several of the older patients in your practice intend to pursue exercise programs. They have no

cardiac symptoms, but some do have vascular risk factors such as diabetes or hypertension. In

these patients, which of the following best describes exercise electrocardiography?