QUESTIONS
DIRECTIONS: Choose the one best response to each question.
V-1. A 35-year-old woman is seen in clinic for evaluation of dyspnea. Which of the following physical findings would fit the diagnosis of idiopathic pulmonary arterial hypertension?
A. Elevated neck veins, normal S1 and S2, II/VI diastolic blowing murmur heard at the right upper sternal border
B. Elevated neck veins; singular, loud S2; II/VI systolic murmur left lower sternal border
C. Elevated neck veins; loud, fixed, split S2; III/VI systolic murmur left lower sternal border
D. Elevated neck veins, expiratory splitting of S2, II/VI harsh systolic murmur left upper sternal border
E. Elevated neck veins, barrel chest, prolonged expiratory phase
V-2. A 75-year-old woman with widely metastatic non–small cell lung cancer is admitted to the intensive care unit with a systolic blood pressure of 73/25 mmHg. She presented complaining of fatigue and worsening dyspnea over the last 3–5 days. Her physical examination shows elevated neck veins. Chest radiograph shows a massive, water bottle–shaped heart shadow and no new pulmonary infiltrates. Which of the following additional findings is most likely present on physical examination?
A. Fall in systolic blood pressure greater than 10 mmHg with inspiration
B. Lack of fall of the jugular venous pressure with inspiration
C. Late diastolic murmur with opening snap
D. Pulsus parvus et tardus
E. Slow y-descent of jugular venous pressure tracing
V-3. A 78-year-old man is admitted to the intensive care unit with decompensated heart failure. He has long-standing ischemic cardiomyopathy. Electrocardiogram (ECG) shows atrial fibrillation and left bundle branch block. Chest radiograph shows cardiomegaly and bilateral alveolar infiltrates with Kerley’s B-lines. Which of the following is least likely to be present on physical examination?
A. Fourth heart sound
B. Irregular heart rate
C. Pulsus alternans
D. Reversed splitting of the second heart sound
E. Third heart sound
V-4. A 45-year-old man is admitted to the intensive care unit with symptoms of congestive heart failure. He is addicted to heroin and cocaine and uses both drugs daily via injection. His blood cultures have yielded methicillin-sensitive Staphylococcus aureus in four of four bottles within 12 hours. His vital signs show a blood pressure of 110/40 mmHg and a heart rate of 132 beats/min. There is a IV/VI diastolic murmur heard along the left sternal border. A schematic representation of the carotid pulsation is shown in Figure V-4A. What is the most likely cause of the patient’s murmur?
FIGURE V-4A
A. Aortic regurgitation
B. Aortic stenosis
C. Mitral stenosis
D. Mitral regurgitation
E. Tricuspid regurgitation
V-5. A 72-year-old man seeks evaluation for leg pain with ambulation. He describes the pain as an aching to crampy pain in the muscles of his thighs. The pain subsides within minutes of resting. On rare occasions, he has noted numbness of his right foot at rest, and pain in his right leg has woken him at night. He has a history of hypertension and cerebrovascular disease. Four years previously had a transient ischemic attack and underwent right carotid endarterectomy. He currently takes aspirin, irbesartan, hydrochlorothiazide, and atenolol on a daily basis. On examination, he is noted to have diminished dorsalis pedis and posterior tibial pulses bilaterally. The right dorsal pedis pulse is faint. There is loss of hair in the distal extremities. Capillary refill is approximately 5 seconds in the right foot and 3 seconds in the left foot. Which of the following findings would be suggestive of critical ischemia of the right foot?
A. Ankle-brachial index less than 0.3
B. Ankle-brachial index less than 0.9
C. Ankle-brachial index greater than 1.2
D. Lack of palpable dorsalis pedis pulse
E. Presence of pitting edema of the extremities
V-6. A 24-year-old man is referred to cardiology after an episode of syncope while playing basketball. He has no recollection of the event, but he was told that he collapsed while running. He awakened lying on the ground and suffered multiple contusions as a result of the fall. He has always been an active individual but recently has developed some chest pain with exertion that has caused him to restrict his activity. His father died at age 44 while rock climbing. He believes his father’s cause of death was sudden cardiac death and recalls being told his father had an enlarged heart. On examination, the patient has a III/VI midsystolic crescendo-decrescendo murmur. His electrocardiogram shows evidence of left ventricular hypertrophy. You suspect hypertrophic cardiomyopathy as the cause of the patient’s heart disease. Which of the following maneuvers would be expected to cause an increase in the loudness of the murmur?
A. Handgrip exercise
B. Squatting
C. Standing
D. Valsalva maneuver
E. A and B
F. C and D
V-7. Left bundle branch block is indicative of which of the following sets of conditions?
A. Atrial septal defect, coronary heart disease, aortic valve disease
B. Coronary heart disease, aortic valve disease, hypertensive heart disease
C. Coronary heart disease, aortic valve disease, pulmonary hypertension
D. Pulmonary embolism, cardiomyopathy, hypertensive heart disease
E. Pulmonary hypertension, pulmonary embolism, mitral stenosis
V-8. A 57-year-old man with long-standing ischemic cardiomyopathy is seen in the clinic for a routine visit. He reports good compliance with his diuretic regimen, but has seen his weight fall about 2 kg since his last visit. Routine chemistries are drawn and show a potassium value of 2.0 meq/L. The patient is referred to the emergency department for repletion of potassium. Which of the following is likely to be found on ECG before administration of potassium?
A. Diminution of P wave amplitude
B. Osborne waves
C. Prolongation of QT interval
D. Prominent U waves
E. Scooped ST segments
V-9. A 55-year-old woman from El Salvador is seen in the emergency department because of gradual onset of dyspnea on exertion. She denies chest pain, cough, wheezing, sputum, or fever. Her chest radiograph is notable for large pulmonary arteries and left atrial enlargement, but no parenchymal infiltrate. ECG shows a tall R in lead V1 and right axis deviation. Which of the following is most likely to be found on her echocardiography?
A. Aortic regurgitation
B. Aortic stenosis
C. Low left ventricular ejection fraction
D. Mitral stenosis
E. Tricuspid stenosis
V-10. A 29-year-old woman is in the intensive care unit with rhabdomyolysis due to compartment syndrome of the lower extremities after a car accident. Her clinical course has been complicated by acute renal failure and severe pain. She has undergone fasciotomies and is admitted to the intensive care unit. An ECG is obtained (shown in Figure V-10). What is the most appropriate course of action at this point?
A. 18-lead ECG
B. Coronary catheterization
C. Hemodialysis
D. Intravenous fluids and a loop diuretic
E. Ventilation/perfusion imaging
FIGURE V-10
V-11. Acute hyperkalemia is associated with which of the following electrocardiographic changes?
A. Decrease in the PR interval
B. Prolongation of the ST segment
C. Prominent U waves
D. QRS widening
E. T-wave flattening
V-12. The ECG shown below (Figure V-12) was most likely obtained from which of the following patients?
A. A 33-year-old female with acute-onset severe headache, disorientation, and intraventricular blood on head CT scan
B. A 42-year-old male with sudden-onset chest pain while playing tennis
C. A 54-year-old female with a long history of smoking and 2 days of increasing shortness of breath and wheezing
D. A 64-year-old female with end-stage renal insufficiency who missed dialysis for the last 4 days
E. A 78-year-old male with syncope, delayed carotid upstrokes, and a harsh systolic murmur in the right second intercostal space
FIGURE V-12
V-13. You are evaluating a new patient in your clinic who has brought in the ECG shown below (Figure V-13) to the visit. The ECG was performed on the patient 2 weeks ago. What complaint do you expect to elicit from the patient?
A. Angina
B. Hemoptysis
C. Paroxysmal nocturnal dyspnea
D. Pleuritic chest pain
E. Tachypalpitations
FIGURE V-13
V-14. All the following ECG findings are suggestive of left ventricular hypertrophy EXCEPT:
A. (S in V1 + R in V5 or V6) greater than 35 mm
B. R in aVL greater than 11 mm
C. R in aVF greater than 20 mm
D. (R in I + S in III) greater than 25 mm
E. R in aVR greater than 8 mm
V-15. Based on the electrocardiogram below (Figure V-15), treating which condition might specifically improve this patient’s tachycardia?
A. Anemia
B. Chronic obstructive pulmonary disease (COPD)
C. Myocardial ischemia
D. Pain
FIGURE V-15
V-16. Doppler echocardiography is most useful for diagnosis of which of the following cardiac lesions?
A. Determination of cardiac mass in a patient with an audible “plop” on examination
B. Determination of left ventricular ejection fraction in a patient with a history of myocardial infarction
C. Diagnosis of myocardial ischemia in a patient with atypical chest pain
D. Diagnosis of pericardial effusion
E. Diastolic filling assessment in a patient with suspected heart failure with preserved ejection fraction
V-17. A 75-year-old man is undergoing routine cardiac catheterization for evaluation of stable angina that has not responded to medical therapy. He is inquiring about the risks associated with the procedure. Which of the following is the most common complication of cardiac catheterization and coronary angiography?
A. Acute renal failure
B. Bradyarrhythmias
C. Myocardial infarction
D. Tachyarrhythmias
E. Vascular access site bleeding
V-18. Which of the following patients is an appropriate candidate for right heart catheterization?
A. A 54-year-old woman with dyspnea of unclear etiology; a loud, fixed split second heart sound; normal chest radiograph; and evidence of bidirectional shunt across her interatrial septum
B. A 54-year-old man with an episode of sustained monomorphic ventricular tachycardia while at the casino terminated with bystander defibrillation. After arrival in the emergency department, the patient is hemodynamically stable.
C. A 63-year-old woman with a history of tobacco abuse, hypercholesterolemia, and Type 2 diabetes mellitus with chest pain at rest, a normal ECG, and mild elevation in serum troponin value
D. A 66-year-old man with a history of diabetes and hyper-cholesterolemia brought to the emergency department with 1 hour of substernal chest pain and shortness of breath. His blood pressure is 95/60 mmHg with a heart rate of 115 beats/min. An ECG shows a new left bundle branch block since his prior ECG 1 month ago.
E. A 79-year-old man seen in the cardiology clinic for evaluation of severe aortic stenosis found on echocardiography performed for evaluation of dyspnea
V-19. A 55-year-old woman is undergoing evaluation of dyspnea on exertion. She has a history of hypertension since age 32 and is also obese with a body mass index (BMI) of 44 kg/m2. Her pulmonary function tests show mild restrictive lung disease. An echocardiogram shows a thickened left-ventricular wall, left-ventricular ejection fraction of 70%, and findings suggestive of pulmonary hypertension with an estimated right-ventricular systolic pressure of 55 mmHg, but the echocardiogram is technically difficult and of poor quality. She undergoes a right heart catheterization that shows the following results:
What is the most likely cause of the patient’s dyspnea?
A. Chronic thromboembolic disease
B. Diastolic heart failure
C. Obstructive sleep apnea
D. Pulmonary arterial hypertension
E. Systolic heart failure
V-20. Which of the following is a risk factor for the development of thromboembolism in patients with the tachycardia-bradycardia variant of sick sinus syndrome?
A. Age greater than 50 years
B. Atrial enlargement
C. Diabetes mellitus
D. Prothrombin 20210 mutation
E. None of the above; there is no increased risk of thromboembolism with the tachycardia-bradycardia variant of sick sinus syndrome.
V-21. A 38-year-old man is evaluated for the recent onset of feeling fatigued. He is a busy executive and active triathlete. He competed a challenging course 1 week earlier without difficulty but feels tired at other times. Laboratory examination, including hematocrit and TSH, are unremarkable. Because his wife reports occasional snoring, a sleep study is recommended. There are no notable apneas, but ECG monitoring during the night shows sinus bradycardia. His heart rate varies between 42 and 56 while sleeping. His resting heart rate while awake is 65–72 beats/min. Which of the following is the most appropriate management for his bradycardia?
A. Carotid sinus massage
B. Intermittent nocturnal wakening
C. Measurement of free T4
D. No specific therapy
E. Referral for pacemaker placement
V-22. All of the following are reversible causes of sinoatrial node dysfunction EXCEPT:
A. Hypothermia
B. Hypothyroidism
C. Increased intracranial pressure
D. Lithium toxicity
E. Radiation therapy
V-23. A 58-year-old man is admitted to the hospital after experiencing 2 days of severe dyspnea. Three weeks ago he had an ST elevation myocardial infarction that was treated with thrombolytics. He reports excellent adherence to his medical regimen that includes atorvastatin, lisinopril, metoprolol, and aspirin. On examination, his heart rate is 44 beats/min, his blood pressure is 100/45 mmHg, his lungs have bilateral crackles, and his cardiac examination is notable for elevated neck veins, bradycardia, and 2+ bilateral leg edema. There are no gallops or new murmurs. ECG shows sinus bradycardia and evidence of the recent infarct, but no acute changes. Which of the following is the most appropriate next management step?
A. Begin dopamine
B. Hold metoprolol
C. Measure TSH
D. Refer for pacemaker placement
E. Refer for urgent coronary angiography
V-24. A 23-year-old college student home for the summer is evaluated in the emergency department for dizziness that began within the last 3 days. He reports a rash on his right leg that looked like a target several days ago, but is otherwise healthy. Physical examination shows bradycardia at 40 beats/min and blood pressure of 88/42 mmHg; oxygen saturation is normal. His examination is otherwise unremarkable except for a bulls-eye rash over the right upper thigh. ECG shows third-degree AV block. Which of the following laboratory studies is most likely to reveal the etiology of his signs and symptoms?
A. ANA
B. HLA B27 testing
C. Borrelia burgdorferi ELISA
D. RPR
E. SCL-70
V-25. In the tracing below (Figure V-25), what type of conduction abnormality is present and where in the conduction pathway is the block usually found?
A. First-degree AV block; intranodal
B. Second-degree AV block type 1; intranodal
C. Second-degree AV block type 2; infranodal
D. Second-degree AV block type 2; intranodal
FIGURE V-25
V-26. A 47-year-old woman with a history of tobacco abuse and ulcerative colitis is evaluated for intermittent palpitations. She reports that for the last 6 months every 2–4 days she notes a sensation of her heart “flip-flopping” in her chest for approximately 5 minutes. She has not noted any precipitating factors and has not felt lightheaded or had chest pains with these episodes. Her physical examination is normal. A resting ECG reveals sinus rhythm and no abnormalities. Aside from checking serum electrolytes, which of the following is the most appropriate testing?
A. Abdominal CT with oral and IV contrast
B. Event monitor
C. Holter monitor
D. Reassurance with no further testing needed
E. Referral for EP study
V-27. After further testing, the patient in question V-26 is found to have several episodes of atrial premature contractions. Which of the following statements regarding the dysrhythmia in this patient is true?
A. Atrial premature contractions are less common than ventricular premature contractions on extended ECG monitoring.
B. Echocardiography is indicated to determine if structural heart disease is present.
C. Metoprolol should be initiated for symptom control.
D. The patient should be reassured that this is not a dangerous condition and does not require further evaluation.
E. The patient should undergo a stress test to determine if ischemia is present.
V-28. A 55-year-old man with end-stage COPD is admitted to the intensive care unit with an exacerbation of his obstructive lung disease. Because of hypercarbic respiratory failure, he is intubated and placed on assist-control mechanical ventilation. Despite aggressive sedation, his ventilator alarms several times that peak inspiratory pressures are high. The physician is called to the bedside to evaluate tachycardia. Examination is notable for a blood pressure of 112/68 mmHg and heart rate of 180 beats/min. Cardiac examination shows a regular rhythm, but no other abnormality. Breath sounds are decreased on the right. ECG shows narrow complex tachycardia. With carotid sinus massage, the heart rate transiently drops to 130 beats/min, but then returns to 180 beats/min. Which of the following is the most appropriate next step in management?
A. Adenosine 25-mg IV push
B. Amiodarone 200-mg IV push
C. Chest radiograph
D. Metoprolol 5-mg IV push
E. Sedation followed by cardioversion
V-29. All of the following are risk factors for stroke in a patient with atrial fibrillation EXCEPT:
A. Diabetes mellitus
B. History of congestive heart failure
C. History of stroke
D. Hypertension
E. Left atrial size greater than 4.0 cm
V-30. Which of the following statements regarding restoration of sinus rhythm after atrial fibrillation is true?
A. Dofetilide may be safely started on an outpatient basis.
B. In patients who are treated with pharmacotherapy and are found to be in sinus rhythm, a prolonged Holter monitor should be worn to determine if anticoagulation could be safely stopped.
C. Patients who have pharmacologically maintained sinus rhythm after atrial fibrillation have improved survival compared with patients who are treated with rate control and anticoagulation.
D. Recurrence of atrial fibrillation is uncommon when pharmacotherapy is used to maintain sinus rhythm.
V-31. A 57-year-old woman with a history of a surgically corrected atrial septal defect in childhood presents to the emergency department with palpitations for 3 days. She is found to have a heart rate of 153 beats/min and blood pressure of 128/75 mmHg, and an ECG shows atrial flutter. An echocardiogram demonstrates moderate right and left atrial dilation, postoperative changes from her surgery, and normal left and right ventricular function. Which of the following is true?
A. Anticoagulation with dabigatran should be initiated.
B. If a transesophageal echocardiogram does not demonstrate left atrial thrombus, she may be cardioverted without anticoagulation.
C. Intravenous heparin should be started immediately.
D. She should be immediately cardioverted.
E. Transthoracic echocardiogram is adequate to rule out the presence of left atrial thrombus.
V-32. A patient presents with palpitations and shortness of breath for 6 hours. In the emergency department waiting room an ECG is performed (shown in Figure V-32). Which of the following is most likely to be found on physical examination?
A. Diffuse abdominal tenderness with guarding
B. Diffuse expiratory polyphonic wheezing with poor air movement and hyperinflation
C. Left ventricular heave and third heart sound
D. Supraclavicular lymphadenopathy
E. Vesicular rash over right T5 dermatome
FIGURE V-32
V-33. A 43-year-old woman is seen in the emergency department after sudden onset of palpitations 30 minutes prior to her visit. She was seated at her work computer when the symptoms began. Aside from low back pain, she is otherwise healthy. In triage, her heart rate is 178 beats/min, and blood pressure is 98/56 mmHg with normal oxygen saturation. On physical examination, she has a “frog sign” in her neck and tachycardia, but is otherwise normal. ECG shows a narrow complex tachycardia without identifiable P waves. Which of the following is the most appropriate first step to manage her tachycardia?
A. 5 mg metoprolol IV
B. 6 mg adenosine IV
C. 10 mg verapamil IV
D. Carotid sinus massage
E. DC cardioversion using 100 J
V-34. A 37-year-old man who is healthy aside from a prior knee surgery is evaluated in the emergency department for palpitations that developed suddenly while eating dinner. He is found to have a heart rate of 193 beats/min, blood pressure of 92/52 mmHg, and normal oxygen saturation. His physical examination is normal aside from tachycardia and mild diaphoresis. An ECG obtained before his knee surgery shows delta waves in the early precordial leads. His current ECG shows wide complex tachycardia. Which of the following therapies is contraindicated for treatment of his tachyarrhythmia?
A. Adenosine
B. Carotid sinus massage
C. DC cardioversion
D. Digoxin
E. Metoprolol
V-35. In an ECG with wide complex tachycardia, which of the following clues most strongly supports the diagnosis of ventricular tachycardia?
A. Atrial-ventricular dissociation
B. Classic right bundle branch block pattern
C. Irregularly irregular rhythm with changing QRS complexes
D. QRS duration greater than 120 milliseconds
E. Slowing of rate with carotid sinus massage
V-36. A 40-year-old male with diabetes and schizophrenia is started on antibiotic therapy for chronic osteomyelitis in the hospital. His osteomyelitis has developed just under an ulcer where he has been injecting heroin. He is found suddenly unresponsive by the nursing staff. His electrocardiogram is shown in Figure V-36. The most likely cause of this rhythm is which of the following substances?
A. Furosemide
B. Metronidazole
C. Droperidol
D. Metformin
E. Heroin
FIGURE V-36
V-37. Normal sinus rhythm is restored with electrical cardioversion in the patient in question V-36. A 12-lead electrocardiogram is notable for a prolonged QT interval. Besides stopping the offending drug, the most appropriate management for this rhythm disturbance should include intravenous administration of which of the following?
A. Amiodarone
B. Lidocaine
C. Magnesium
D. Metoprolol
E. Potassium
V-38. You are caring for a patient with heart rate–related angina. With minor elevations in heart rate, the patient has anginal symptoms that impact his quality of life. On review of a 24-hour Holter monitor, it appears that the patient has sinus tachycardia at the time of his symptoms. What is the mechanism for this patient’s arrhythmia?
A. Delayed afterdepolarizations
B. Early afterdepolarizations
C. Increased automaticity
D. Reentry pathway
V-39. Where are the most common drivers of atrial fibrillation anatomically located?
A. Left atrial appendage
B. Mitral annulus
C. Pulmonary vein orifice
D. Sinus venosus
E. Sinus node
V-40. Symptoms of atrial fibrillation vary dramatically from patient to patient. A patient with which of the following clinical conditions will likely be the most symptomatic (e.g., short of breath) if the patient develops atrial fibrillation?
A. Acute alcohol intoxication
B. Hypertrophic cardiomyopathy
C. Hyperthyroidism
D. Hypothermia
E. Postoperative after thoracotomy
V-41. A 47-year-old postmenopausal woman is seen for onset of severe dyspnea over the last few weeks. She reports no preceding chest pain, cough, sputum, or fever, though she does report leg swelling. Physical examination is notable for a blood pressure of 145/78 mmHg and heart rate of 123 beats/min. Exophthalmos is present as well as bilateral inspiratory crackles occupying approximately one-third of the lower chest; neck vein distention; normal cardiac rhythm, though tachycardia is present; and a third heart sound with no murmur. Bilateral lower extremity edema and a fine hand tremor are also present. Which of the following is the most likely pathophysiologic explanation for her heart failure?
A. Anemia with high-output state
B. Chronic systemic hypertension with resultant left ventricular hypertrophy and nonsystolic heart failure
C. Hemochromatosis with subsequent restrictive cardiomyopathy
D. Myocardial infarction with depressed left ventricular systolic function
E. Thyrotoxicosis with high-output state
V-42. Which of the following statements is true regarding measurement of plasma BNP to diagnose heart failure?
A. An elevated plasma BNP in a dyspneic patient confirms the diagnosis of left heart failure.
B. In the presence of renal failure, BNP levels are suppressed even when heart failure is present.
C. Plasma BNP levels may be falsely low in patients with obesity and heart failure.
D. Serial measurement of BNP in the therapy of decompensated heart failure should be used to guide therapy.
E. All of the above are true.
V-43. A 64-year-old man with an ischemic cardiomyopathy, ejection fraction 35%, and stage C heart failure is seen in the cardiology clinic for evaluation of his disease status. The patient reports a regular exercise regimen of walking on the treadmill several times weekly and occasional exacerbations of his leg edema that he manages with an extra dose of furosemide. He has never been hospitalized for heart failure. His current medical regimen includes lisinopril, aspirin, furosemide, atorvastatin, digoxin, spironolactone, and metoprolol. He is interested in stopping medications because of their expense. Which of the following statements is true regarding his medical regimen?
A. ACE inhibition therapy has not been shown to improve heart failure symptoms.
B. Beta blocker therapy in this patient may be exacerbating his occasional need for extra furosemide and therefore should be stopped.
C. He should be switched from spironolactone to eplerenone for improved efficacy, as seen in patients with EF less than 35%.
D. If digoxin is withdrawn, he will likely have worsening symptoms.
E. If he is intolerant to lisinopril because of cough, it would be reasonable to switch him to an angiotensin-receptor blocker.
V-44. A 78-year-old slender woman is seen in the emergency department after several weeks of dyspnea on exertion that progressed to dyspnea at rest following a summer cookout where she consumed multiple pickled vegetables. She also complains of leg swelling, orthopnea, and occasionally awakening at night with dyspnea. Her past medical history is notable for long-standing systemic hypertension, uterine prolapse, and an anxiety disorder. Examination confirms the presence of heart failure with a laterally displaced and sustained point of maximum impulse and a fourth heart sound. She is admitted to the hospital and given diuretics, and an echocardiogram is obtained. Echocardiography reveals severe left ventricular hypertrophy with an ejection fraction of 70%, but there are no focal wall motion abnormalities, and aortic and mitral valvular function is intact. Her right ventricular systolic pressure is estimated to be 45 mmHg. After resolution of her heart failure symptoms with diuresis, the patient is ready for discharge. Which of the following medications have been shown to improve mortality in patients with heart failure with preserved ejection fraction and should be included in this patient’s regimen?
A. Digoxin
B. Lisinopril
C. Metoprolol
D. Sildenafil
E. None of the above
V-45. A 68-year-old man with a history of myocardial infarction and congestive heart failure is comfortable at rest. However, when walking to his car he develops dyspnea, fatigue, and sometimes palpitations. He must rest for several minutes before these symptoms resolve. His New York Heart Association classification is which of the following?
A. Class I
B. Class II
C. Class III
D. Class IV
V-46. The husband of a 68-year-old woman with congestive heart failure is concerned because his wife appears to stop breathing for periods of time when she sleeps. He has noticed that she stops breathing for approximately 10 seconds and then follows this with a similar period of hyperventilation. This does not wake her from sleep. She does not snore. She feels well rested in the morning but is very dyspneic with even mild activity. What is your next step in management?
A. Electroencephalography
B. Maximize heart failure management
C. Nasal continuous positive airway pressure (CPAP) during sleep
D. Obtain a sleep study
E. Prescribe bronchodilators
V-47. A 53-year-old man undergoes cardiac transplantation for end-stage ischemic cardiomyopathy due to an underlying familial hypercholesterolemic disorder. His donor was a 23-year-old motor vehicle accident victim. The patient does well for the first 3 years after transplantation with only a single episode of acute rejection. He shows good compliance with his immunosuppression regimen, which includes prednisone and sirolimus. He is evaluated at a routine follow-up visit and reports that he has developed dyspnea on exertion. His pulmonary function tests are unchanged and a chest radiograph is normal. He undergoes right and left heart catheterization with biopsy of the transplanted heart. Severe, diffuse, concentric, and longitudinal coronary artery disease is found on coronary angiography, and histology shows no evidence of acute rejection. Which of the following statements is true regarding the coronary atherosclerosis found in this patient?
A. No immunosuppressive regimen has been shown to have a lower incidence of coronary atherosclerosis after cardiac transplantation.
B. The coronary atherosclerosis is most likely immunologic injury of the vascular endothelium in the transplanted organ.
C. The current coronary atherosclerosis after cardiac transplant is likely due to atherosclerosis present prior to transplantation.
D. The patient’s underlying cholesterol disorder did not predispose him to recurrent coronary atherosclerosis after cardiac transplantation.
E. Therapy with statins has not been associated with a reduced incidence of this complication of transplantation.
V-48. Which of the following is a known complication of ventricular assist device placement in patients with end-stage heart failure?
A. Cerebrovascular accident
B. Infection of insertion site
C. Mechanical device failure
D. Thromboembolism
E. All of the above
V-49. All of the following are potential complications of an atrial septal defect in adults EXCEPT:
A. Air embolism from a central venous catheter
B. Arterial oxygen desaturation with exertion
C. Embolic cerebrovascular accident
D. Pulmonary arterial hypertension
E. Unstable angina
V-50. A 32-year-old woman is seen by her primary care physician clinic for routine follow-up of her hypothyroidism. She also has a history of complex congenital heart disease with a partially corrected VSD with predominantly right to left shunt across her patch. She is doing well and is able to work in janitorial services without severe dyspnea. She denies any heart failure or neurologic symptoms, but does have a peripheral oxygen saturation of 78%. A routine CBC is drawn and shows a hematocrit of 65%. Which of the following is the most appropriate management of her elevated hematocrit?
A. Begin oxygen therapy
B. Check co-oximetry on arterial blood gas sample
C. Check serum erythropoietin level
D. Expectant waiting
E. Refer to hematology for phlebotomy
V-51. A 43-year-old man recently was found to have an asymptomatic atrial septal defect that was closed using a percutaneous patch 1 month ago without complication. He is undergoing a root canal at the dentist next week and calls his primary care office to determine if antibiotic prophylaxis is indicated. Which of the following statements is true regarding antibiotic prophylaxis in this patient?
A. Because he had only simple congenital heart disease, no prophylaxis is indicated.
B. Because the lesion is corrected, no prophylaxis is indicated.
C. He should avoid potentially bacteremic dental procedures unless no other alternative is available.
D. Routine antibiotic prophylaxis is indicated for bacteremic dental procedures, particularly if the patch is less than 6 months old.
E. Routine antibiotic prophylaxis is indicated for bacteremic dental procedures whenever foreign material is present.
V-52. A 20-year-old man undergoes a physical examination with chest radiograph for enrollment in the military. He has had a normal childhood without any major illness. There is no history of sinusitis, pneumonia, or chronic respiratory disease. Chest radiograph shows dextrocardia. On closer physical examination, a spleen tip is palpable on the right of the abdomen and the liver can be percussed on the left. Which of the following is true regarding his condition?
A. He is likely to have aortic stenosis.
B. He is likely to have aspermia.
C. He is likely to have an atrial septal defect.
D. He is likely to have a ventriculoseptal defect.
E. He is likely to otherwise be normal.
V-53. A 24-year-old male seeks medical attention for the recent onset of headaches. The headaches are described as “pounding” and occur during the day and night. He has had minimal relief with acetaminophen. Physical examination is notable for a blood pressure of 185/115 mmHg in the right arm, a heart rate of 70 beats/min, arterioventricular (AV) nicking on funduscopic examination, normal jugular veins and carotid arteries, a pressure-loaded PMI with an apical S4, no abdominal bruits, and reduced pulses in both lower extremities. Review of symptoms is positive only for leg fatigue with exertion. Additional measurement of blood pressure reveals the following:
Which of the following diagnostic studies is most likely to demonstrate the cause of the headaches?
A. MRI of the head
B. MRI of the kidney
C. MRI of the thorax
D. 24-hour urinary 5-HIAA
E. 24-hour urinary free cortisol
V-54. The patient described in question V-53 is most likely to have which of the following associated cardiac abnormalities?
A. Bicuspid aortic valve
B. Mitral stenosis
C. Preexcitation syndrome
D. Right bundle branch block
E. Tricuspid atresia
V-55. Mitral stenosis is frequently complicated by pulmonary hypertension. Which of the following is a cause of pulmonary hypertension in mitral stenosis?
A. Interstitial edema in the walls of small pulmonary vessels
B. Passive transmission of elevated left atrial pressure
C. Obliterative changes in the pulmonary vascular bed
D. Pulmonary arteriolar constriction
E. All of the above
V-56. A 58-year-old man with a history of systemic hypertension, hyperlipidemia, and tobacco abuse is admitted to the intensive care unit with crushing chest pain associated with ST-segment elevation and small precordial Q waves. Because his symptoms have been present for 36 hours, he is not a candidate for thrombolytics. On admission to the ICU, his systemic blood pressure is 123/67 mmHg, heart rate is 67 beats/min after beta blockade, and his oxygenation saturation is 93% on 2L nasal cannula. The remainder of the physical examination is normal. He is treated with lisinopril, aspirin, heparin, and metoprolol. Before transfer can be arranged to a tertiary center, the patient reports extreme dyspnea. He is found to be diaphoretic and to have a heart rate of 80 beats/min, blood pressure of 84/56 mmHg, and oxygen saturation of 93% on 100% non-rebreather. His lungs have bilateral crackles throughout, and neck veins are moderately elevated. ECG is unchanged. Chest radiograph shows new alveolar infiltrates in the right lung greater than the left. Which of the following is a likely finding on physical examination?
A. A fourth heart sound, III/VI systolic murmur heard best at the apex with a “cooing” quality that radiates to the axilla
B. A right ventricular heave, loud second heart sound, III/VI murmur increasing with inspiration at the right lower sternal border
C. A third heart sound, III/VI crescendo-decrescendo murmur heard best at the right upper sternal border
D. Diffuse urticarial reaction, wheezing on pulmonary examination
E. Mucosal edema, finger swelling, stridor
V-57. Which of the following is the most appropriate next step in therapy for the patient in question V-56?
A. Aerosolized albuterol
B. Initiation of norepinephrine infusion
C. Intravenous infusion of nitroprusside
D. Intravenous methylprednisolone
E. Placement of intraaortic balloon pump
V-58. A 26-year-old healthy woman is seen for a pap smear at a routine office visit. She feels well and has no complaints and no significant past medical history. Her internist performs a full physical examination and a midsystolic click is heard. No murmur or gallop is present. She is concerned about this finding. Which of the following statements is true regarding her examination finding?
A. In most patients with this disorder, an underlying cause such as a heritable disorder of connective tissue is found.
B. Infective endocarditis prophylaxis is indicated for dental procedures potentially associated with bacteremia.
C. Most patients are asymptomatic from this lesion and will remain so their entire life.
D. She should begin therapy with aspirin 325 mg po daily.
E. This disorder cannot be visualized on echo-cardiography.
V-59. A 78-year-old man is evaluated for the onset of dyspnea on exertion. He has a long history of tobacco abuse, obesity, and diabetes mellitus. His current medications include metformin, aspirin, and occasional ibuprofen. On physical examination his peripheral pulses show a delayed peak and he has a prominent left ventricular heave. He is in a regular rhythm with a IV/VI midsystolic murmur that is loudest at the base of the heart and radiates to the carotid arteries. A fourth heart sound is present. Echocardiography confirms severe aortic stenosis without other valvular lesions. Which of the following most likely contributed to the development of his cardiac lesion?
A. Congenital bicuspid aortic valve
B. Diabetes mellitus
C. Occult rheumatic heart disease
D. Underlying connective tissue disease
E. None of the above
V-60. A 63-year-old man presents with new-onset exertional syncope and is found to have aortic stenosis. In counseling the patient, you tell him that your therapeutic recommendation is based on the observation that untreated patients with his presentation have a predicted average lifespan of:
A. 5 years
B. 4 years
C. 3 years
D. 2 years
E. 1 year
V-61. Which of the following physical examination findings suggests severe aortic regurgitation?
A. Corrigan’s pulse
B. Pulsus alternans
C. Pulsus bigeminus
D. Pulsus paradoxus
E. Pulsus parvus et tardus
V-62. A 41-year-old Somali woman is seen in clinic for onset of hemoptysis in the sixth month of her pregnancy. This is her fourth pregnancy and the others were uncomplicated, though she was 35 years old at the birth of her last child. Prior to this, she had been healthy. She reports mild dyspnea beginning at the fourth month of her pregnancy with onset of mild leg swelling shortly thereafter that she attributed to her pregnancy. The dyspnea has become severe, and she is now limited to walking around her house. She began to cough small amounts of bloody sputum 5 days ago. She had neither fever nor purulent sputum and has not responded to a course of antibiotics prescribed by her obstetrician. Physical examination is notable for a normal temperature, heart rate of 110 beats/min, blood pressure of 108/60 mmHg, and oxygen saturation of 91% on room air. No source of bleeding is seen in her nares or oropharynx. Her lungs have diffuse crackles, and cardiac examination shows moderately elevated neck veins, a regular heart rhythm, a loud second heart sound, and a low-pitched diastolic rumble heard best at the apex. The abdomen has a gravid uterus, and 1+ lower extremity edema is present. Which of the following is most likely to demonstrate the cause of her symptoms?
A. Bronchoscopy
B. Chest CT with contrast
C. Echocardiogram
D. Right heart catheterization
E. Upper airway inspection by an otolaryngologist
V-63. In the patient described in question V-62, which of the following should be prescribed at her visit to alleviate her symptoms?
A. Benazepril
B. Digoxin
C. Furosemide
D. Heparin
E. Levofloxacin
V-64. Which of the following patients with echocardiographic evidence of significant mitral regurgitation has the best indication for surgery with the most favorable likelihood of a positive outcome?
A. A 52-year-old man with an ejection fraction of 25%, NYHA class III symptoms, and a left-ventricular end-systolic dimension of 60 mm
B. A 54-year-old man with an ejection fraction of 30%, NYHA class II symptoms, and pulmonary hypertension
C. A 63-year-old man in sinus rhythm without symptoms, an ejection fraction of 65%, and a normal right heart catheterization
D. A 66-year-old man without symptoms, an ejection fraction of 50%, and left-ventricular end-systolic dimension of 45 mm
E. A 72-year-old asymptomatic woman with newly discovered atrial fibrillation, ejection fraction of 60%, and end-systolic dimension of 35 mm
V-65. All of the following are potential causes of tricuspid regurgitation EXCEPT:
A. Congenital heart disease
B. Infective endocarditis
C. Inferior wall myocardial infarction
D. Pulmonary arterial hypertension
E. Rheumatic heart disease
F. All of the above will cause tricuspid regurgitation.
V-66. All the following are true about cardiac valve replacement EXCEPT:
A. Bioprosthetic valve replacement is preferred to mechanical valve replacement in younger patients because of the superior durability of the valve.
B. Bioprosthetic valves have a low incidence of thromboembolic complications.
C. The risk of thrombosis with mechanical valve replacement is higher in the mitral position than in the aortic position.
D. Mechanical valves are relatively contraindicated in patients who wish to become pregnant.
E. Double-disk tilting mechanical prosthetic valves offer superior hemodynamic characteristics over single-disk tilting valves.
V-67. Which of the following infectious agents have been associated with the development of inflammatory myocarditis?
A. Coxsackie virus
B. Diphtheria
C. Q fever
D. Trypanosoma cruzi
E. All of the above
V-68. All of the following are risk factors for the development of peripartum cardiomyopathy EXCEPT:
A. Advanced maternal age
B. Malnutrition
C. Primiparity
D. Twin pregnancy
E. Use of tocolytics
V-69. A 67-year-old man with a long history of alcohol abuse presents with findings consistent with left ventricular failure including pulmonary edema and congestion. He undergoes right heart catheterization and left heart catheterization. No significant coronary artery disease is found. Which of the following right heart catheterization numbers (see Table V-69) would support a diagnosis of beriberi heart disease?
TABLE V-69
V-70. A 20-year-old basketball player is seen for evaluation prior to beginning another season of competitive sports. A harsh systolic murmur is heard at the left lower sternal border. Which of the following maneuvers will enhance this murmur if hypertrophic cardiomyopathy is the underlying cause?
A. Hand grip
B. Leaning forward while sitting
C. Lying left side down
D. Squatting
E. Valsalva maneuver
V-71. A 62-year-old woman presents to your office with dyspnea of 4 months duration. She has a history of monoclonal gammopathy of unclear significance (MGUS) and has been lost to follow-up for the past 5 years. She is able to do only minimal activity before she has to rest but has no symptoms at rest. She has developed orthopnea but denies paroxysmal nocturnal dyspnea. She complains of fatigue, lightheadedness, and lower extremity swelling. On examination, blood pressure is 110/90 mmHg and heart rate is 94 beats/min. Jugular venous pressure is elevated, and the jugular venous wave does not fall with inspiration. An S3 and S4 are present, as well as a mitral regurgitation murmur. The point of maximal impulse is not displaced. Abdominal examination is significant for ascites and a large, tender, pulsatile liver. Chest radiograph shows bilateral pulmonary edema. An electrocardiogram shows an old left bundle branch block. Which clinical features differentiate constrictive pericarditis from restrictive cardiomyopathy?
A. Elevated jugular venous pressure
B. Kussmaul’s sign
C. Narrow pulse pressure
D. Pulsatile liver
E. None of the above
V-72. You are evaluating a new patient in the clinic. The 25-year-old patient was diagnosed with “heart failure” in another state and has since relocated. He has New York Heart Association class II symptoms and denies angina. He presents for evaluation and management. The patient has been wheelchair bound for many years and has severe scoliosis. He has no family history of hyperlipidemia. His physical examination is notable for bilateral lung crackles, an S3, and no cyanosis. An electrocardiogram (ECG) is obtained in the clinic and shows tall R waves in V1 and V2 with deep Qs in V5 and V6. An echocardio-gram reports severe global left ventricular dysfunction with reduced ejection fraction. What is the most likely diagnosis?
A. Amyotrophic lateral sclerosis
B. Atrial septal defect
C. Chronic thromboembolic disease
D. Duchenne’s muscular dystrophy
E. Ischemic cardiomyopathy
V-73. A 35-year-old woman with a history of tobacco abuse presents to the emergency department because of severe chest pain radiating to both arms. The pain began 8 hours ago and is worse with inspiration. She has been unable to lie down as this markedly exacerbates the pain, but she feels better with sitting forward. Examination is notable for a heart rate of 96 beats/min, blood pressure of 145/78 mmHg, and oxygen saturation of 98%. Lungs are clear and a friction rub with three components is audible and is best heard at the left lower sternal border. Which of the following are most likely to be found on her ECG?
A. Diffusely inverted T waves in the precordial leads
B. PR elevation in leads II, III, and aVF
C. Sinus tachycardia
D. ST-segment elevation in I, aVL, and V2–V6 with upward concavity and reciprocal depressions in aVR
E. ST-segment elevation V1–V6 with convex curvature and reciprocal depressions in aVR
V-74. Which of the following statements is true regarding pulsus paradoxus?
A. It consists of a greater than 15 mmHg increase in systolic arterial pressure with inspiration.
B. It may be found in patients with severe obstructive lung disease.
C. It is the reversal of a normal phenomenon during inspiration.
D. It results from right ventricular distention during expiration resulting in compression of the left ventricular volume and subsequent reduction in systolic pulse pressure.
E. All of the above are true.
V-75. Which of the following are features of Beck’s triad in cardiac tamponade?
A. Hypotension, electrical alternans, prominent x-descent in neck veins
B. Hypotension, muffled heart sounds, electrical alternans
C. Hypotension, muffled heart sounds, jugular venous distention
D. Kussmaul’s sign, hypotension, muffled heart sounds
E. Muffled heart sounds, hypotension, friction rub
V-76. A 35-year-old woman is admitted to the hospital with malaise, weight gain, increasing abdominal girth, and edema. The symptoms began about 3 months ago and gradually progressed. The patient reports an increase in waist size of approximately 15 cm. The swelling in her legs has gotten increasingly worse such that she now feels her thighs are swollen as well. She has dyspnea on exertion and two-pillow orthopnea. She has a past history of Hodgkin’s disease diagnosed at age 18. She was treated at that time with chemotherapy and mediastinal irradiation. On physical examination, she has temporal wasting and appears chronically ill. Her current weight is 96 kg, which reflects an increase of 11 kg over the past 3 months. Her vital signs are normal. Her jugular venous pressure is approximately 16 cm, and the neck veins do not collapse on inspiration. Heart sounds are distant. There is a third heart sound heard shortly after aortic valve closure. The sound is short and abrupt and is heard best at the apex. The liver is enlarged and pulsatile. Ascites is present. There is pitting edema extending throughout the lower extremities and onto the abdominal wall. Echocardiogram shows pericardial thickening, dilatation of the inferior vena cava and hepatic veins, and abrupt cessation of ventricular filling in early diastole. Ejection fraction is 65%. What is the best approach for treatment of this patient?
A. Aggressive diuresis only
B. Cardiac transplantation
C. Mitral valve replacement
D. Pericardial resection
E. Pericardiocentesis
V-77. A 19-year-old previously healthy hockey player is defending the goal when he is hit in the left chest with a hockey puck. He immediately collapses to the ice. His coach runs to his side and finds him unresponsive and without a pulse. Which of the following is most likely responsible for this syndrome?
A. Aortic rupture
B. Cardiac tamponade
C. Commotio cordis
D. Hypertrophic cardiomyopathy
E. Tension pneumothorax
V-78. A 48-year-old white man is seen in the clinic for a routine physical examination. He reports no complaints. Examination shows a blood pressure of 134/82 mmHg with a normal heart rate. BMI is 31 kg/m2. The remainder of his physical examination is normal. Which of the following is true regarding lifestyle modification?
A. Brisk walking for as little as 10 minutes, 4 days per week will lower his blood pressure to within the normal range.
B. Dietary NaCl restriction of less than 6 g per day will reduce his blood pressure.
C. Lifestyle modification will have no effect on his blood pressure.
D. Reduction of alcohol consumption to three or fewer drinks per day will decrease his blood pressure.
E. Weight loss of approximately 9 kg can be expected to bring his blood pressure to within the normal limit.
V-79. A 46-year-old white female presents to your office with concerns about her diagnosis of hypertension 1 month previously. She asks you about her likelihood of developing complications of hypertension, including renal failure and stroke. She denies any past medical history other than hypertension and has no symptoms that suggest secondary causes. She currently is taking hydrochlorothiazide 25 mg/d. She smokes half a pack of cigarettes daily and drinks alcohol no more than once per week. Her family history is significant for hypertension in both parents. Her mother died of a cerebrovascular accident. Her father is alive but has coronary artery disease and is on hemodialysis. Her blood pressure is 138/90 mmHg. Body mass index is 23. She has no retinal exudates or other signs of hypertensive retinopathy. Her point of maximal cardiac impulse is not displaced but is sustained. Her rate and rhythm are regular and without gallops. She has good peripheral pulses. An electrocardiogram reveals an axis of –30 degrees with borderline voltage criteria for left ventricular hypertrophy. Creati-nine is 1.0 mg/dL. Which of the following items in her history and physical examination is a risk factor for a poor prognosis in a patient with hypertension?
A. Family history of renal failure and cerebrovascular disease
B. Persistent elevation in blood pressure after the initiation of therapy
C. Ongoing tobacco use
D. Ongoing use of alcohol
E. Presence of left ventricular hypertrophy on ECG
V-80. A 28-year-old female has hypertension that is difficult to control. She was diagnosed at age 26. Since that time she has been on increasing amounts of medication. Her current regimen consists of labetalol 1000 mg bid, lisinopril 40 mg qd, clonidine 0.1 mg bid, and amlodipine 5 mg qd. On physical examination she appears to be without distress. Blood pressure is 168/100 mmHg, and heart rate is 84 beats/min. Cardiac examination is unremarkable, without rubs, gallops, or murmurs. She has good peripheral pulses and has no edema. Her physical appearance does not reveal any hirsutism, fat maldistribution, or abnormalities of genitalia. Laboratory studies reveal a potassium of 2.8 meq/dL and a serum bicarbonate of 32 meq/dL. Fasting blood glucose is 114 mg/dL. What is the likely diagnosis?
A. Congenital adrenal hyperplasia
B. Fibromuscular dysplasia
C. Cushing’s syndrome
D. Conn’s syndrome
E. Pheochromocytoma
V-81. What is the best way to diagnose this disease in question V-80?
A. Renal vein renin levels
B. 24-hour urine collection for metanephrines
C. Magnetic resonance imaging of the renal arteries
D. 24-hour urine collection for cortisol
E. Plasma aldosterone/renin ratio
V-82. Which of the following patients with aortic dissection or hematoma is best managed without surgical therapy?
A. A 74-year-old male with a dissection involving the root of the aorta.
B. A 45-year-old female with a dissection involving the aorta distal to the great vessel origin but cephalad to the renal arteries.
C. A 58-year-old male with aortic dissection involving the distal aorta and the bilateral renal arteries.
D. A 69-year-old male with an intramural hematoma within the aortic root.
E. All of the above patients require surgical management of their aortic disease.
V-83. A 68-year-old male presents to your office for routine follow-up care. He reports that he is feeling well and has no complaints. His past medical history is significant for hypertension and hypercholesterolemia. He continues to smoke a pack of cigarettes daily. He is taking chlorthalidone 25 mg daily, atenolol 25 mg daily, and pravastatin 40 mg nightly. Blood pressure is 133/85 mmHg, and heart rate is 66 beats/min. Cardiac and pulmonary examinations are unremarkable. A pulsatile abdominal mass is felt just to the left of the umbilicus and measures approximately 4 cm. You confirm the diagnosis of abdominal aortic aneurysm by CT imaging. It is located infrarenally and measures 4.5 cm. All the following are true about the patient’s diagnosis EXCEPT:
A. The 5-year risk of rupture of an aneurysm of this size is 1–2%.
B. Surgical or endovascular intervention is warranted because of the size of the aneurysm.
C. Infrarenal endovascular stent placement is an option if the aneurysm experiences continued growth in light of the location of the aneurysm infrarenally.
D. Surgical or endovascular intervention is warranted if the patient develops symptoms of recurrent abdominal or back pain.
E. Surgical or endovascular intervention is warranted if the aneurysm expands beyond 5.5 cm.
V-84. A 32-year-old female is seen in the emergency department for acute shortness of breath. A helical CT shows no evidence of pulmonary embolus, but incidental note is made of dilatation of the ascending aorta to 4.3 cm. All the following are associated with this finding EXCEPT:
A. Syphilis
B. Takayasu’s arteritis
C. Giant cell arteritis
D. Rheumatoid arthritis
E. Systemic lupus erythematosus
V-85. A 68-year-old man with a history of coronary artery disease is seen in his primary care clinic for complaint of cough with sputum production. His care provider is concerned about pneumonia, so a chest radiograph is ordered. On the chest radiograph, the aorta appears tortuous with a widened mediastinum. A contrast-enhanced CT of the chest confirms the presence of a descending thoracic aortic aneurysm measuring 4 cm with no evidence of dissection. What is the most appropriate management of this patient?
A. Consult interventional radiology for placement of an endovascular stent.
B. Consult thoracic surgery for repair.
C. No further evaluation is needed.
D. Perform yearly contrast-enhanced chest CT and refer for surgical repair when the aneurysm size is greater than 4.5 cm.
E. Treat with beta blockers, perform yearly contrast-enhanced chest CT, and refer for surgical repair if the aneurysm grows more than 1 cm/year.
V-86. A 37-year-old woman with no significant past medical history except for a childhood murmur is evaluated for severe pain of sudden onset in her right lower extremity. Examination is notable for a young, uncomfortable woman with normal vital signs except for a heart rate of 110 beats/min. Right leg has pallor distal to the right knee and is cold to the touch, and the dorsalis pedis pulse is absent. Which of the following studies is likely to diagnose the underlying reason for the patient’s presentation?
A. Angiography of right lower extremity
B. Blood cultures
C. Echocardiogram with bubble study
D. Serum c-ANCA
E. Venous ultrasound of right upper extremity