A 72-year-old man comes to a rural health clinic due to intermittent leg pain.  The patient reports a dull discomfort in his left lower calf with activity, causing him to stop and rest on the way to his mailbox, which is approximately 150 m (492 ft) from his house.  The pain improves with rest and does not occur at night when he is lying in bed.  Medical history is significant for hypertension and gout.  Current medications include lisinopril and allopurinol.  The patient has a 40-pack-year smoking history, but quit 5 years ago.  Family history is significant for a stroke in his father and breast cancer in his mother.  Blood pressure is 130/78 mm Hg and pulse is 75/min.  The patient’s left foot is shiny and devoid of hair, but there are no lower extremity ulcerations.  Strength and sensory examination of the left lower extremity is normal.  The ankle-brachial index is 0.76 on the left and 1.05 on the right (normal: 1.0-1.4).  Laboratory results are as follows:

Item 1 of 2

In addition to aspirin, which of the following medications is the most appropriate to add to this patient’s pharmacologic regimen?

Item 2 of 2

Following medication adjustment, the patient is sent for CT angiography that shows 90% stenosis of the left superficial femoral artery and 80% stenosis of the left popliteal artery.  Which of the following is the best additional recommendation for this patient?

A 3-week-old male infant with Down’s syndrome is brought by his parents to your office due to feeding difficulties.  According to the mother, the infant becomes short of breath and his face turns blue during feeding, and when he cries.  On chest auscultation, there is a harsh holosystolic murmur heard best over the lower left sternal border.  There are no rales or wheezing over the lung fields.

Item 1 of 2

Which of the following is the most useful test for diagnostic evaluation?

Item 2 of 2

In the long run, this infant is at increased risk of developing which of the following?

A 27-year-old woman is brought to the emergency department due to a 4-hour history of chest pain that is localized to the middle of the chest and the upper sternal area.  She describes it as “intense.”  The patient has never before experienced a similar pain.  She also describes some nausea and a mild occipital headache.  She has had no vomiting, abdominal pain, or shortness of breath.  A friend who accompanies her to the emergency department says that they attended a party and the patient smoked crack cocaine shortly prior to her episode of chest pain.  She did not consume alcohol.  The patient has a history of intravenous drug use.  She was treated with antibiotics for upper extremity cellulitis 6 months ago.  There is no family history of premature coronary artery disease.  The patient does not take any medications and has no known drug allergies.  On initial evaluation, temperature is 37.8 C (100 F), blood pressure is 204/102 mm Hg on the right arm and 210/104 mm Hg on the left arm, pulse is 102/min and regular, and respirations are 18/min.  Oxygen saturation is 99% on room air.  The patient appears thin, anxious, and agitated.  Heart sounds are normal and no murmurs are heard.  Lungs are clear to auscultation bilaterally.  The abdomen is soft and nontender.  Lower extremity pulses are full and symmetric.  There is no peripheral edema.  ECG shows sinus tachycardia but is otherwise unremarkable.  Portable chest x-ray reveals clear lung fields.  Finger-stick blood glucose level is 98 mg/dL.

Item 1 of 2

Which of the following is the most appropriate next step in management of this patient?

Item 2 of 2

After 2 hours in the emergency department, the patient develops weakness in her right arm.  Her chest pain is slightly improved, but still present at the middle and upper part of the sternum.  She has been treated with lorazepam, morphine, and nitroglycerin infusion.  Blood pressure is 133/80 mm Hg and pulse is 88/min and regular.  Neurologic examination shows mild muscle weakness affecting the right upper and right lower extremities.  Speech is normal.  Repeat ECG shows normal sinus rhythm with no significant abnormalities. Laboratory results are as follows:

Immediate noncontrast CT scan of the head reveals no evidence of bleeding.  Which of the following is the best next step in management of this patient?

A 72-year-old man comes to the emergency department due to progressive shortness of breath and cough productive of yellowish sputum.  The patient says, “I have been feeling breathless for the past several months while mowing the lawn or walking around the house, but it has been worse over the last 3 days.”  He has had no chest pain or leg swelling but notes that his heart “has been racing.”  The patient has a history of hypertension, peptic ulcer disease, and osteoarthritis.  He was hospitalized for pneumonia a year ago and required intravenous antibiotics.  Six months ago, the patient underwent a cardiac stress test for chest discomfort, which was unremarkable.  The patient has smoked a pack of cigarettes daily for 45 years.  Blood pressure is 160/90 mm Hg, pulse is 148/min, and respirations are 26/min.  He is speaking in partial sentences and using accessory muscles of respiration but is alert and cooperative.  There is no jugular venous distension or heart murmurs, rub, or gallops, but the heart sounds are irregular.  Lung auscultation reveals bilateral rhonchi and expiratory wheezes.  Arterial blood gases while breathing 2 L of oxygen via nasal cannula reveal PO₂ of 66 mm Hg, PCO₂ of 52 mm Hg, and pH 7.33.  ECG shows narrow QRS complexes with distinct P waves of different morphologies and variable PR segments and R-R intervals.  Chest x-ray reveals no pulmonary infiltrates or consolidation.  Inhaled bronchodilators and systemic glucocorticoids are administered.

Item 1 of 2

Which of the following is the most appropriate additional step in management of this patient’s arrhythmia?

Item 2 of 2

The patient’s dyspnea has improved after initial treatment in the emergency department, but he continues to have palpitations.  Pulse is 125/min and irregular.  Blood pressure is 140/88 mm Hg and respirations are 16/min.  Oxygen saturation is 92% on 2 L oxygen via nasal cannula.  ECG findings are unchanged from the time of admission.  Laboratory results are as follows:

Which of the following is the most appropriate next step in management of this patient?

A 56-year-old man comes to the physician for an initial evaluation.  He reports tiredness and decreased exercise tolerance over the past few weeks.  He feels “out of breath” when he goes ballroom dancing with his wife, which has been a regular activity for them.  He has not had any cough, orthopnea, wheezing, and lower extremity edema.  The patient’s other medical problems include gastroesophageal reflux disease.  Approximately a month ago he had a particularly severe episode of burning in the upper abdomen and chest, but he has not noted any dark stools or blood in the stool.  He takes famotidine intermittently and uses ibuprofen periodically for pain in his left knee but is not taking any regular medications.  He has a 30-pack-year smoking history and drinks 1-2 beers per night.  The patient’s mother had diabetes mellitus and died of a stroke.  His father died of colon cancer.  His blood pressure is 144/89 mm Hg and pulse is 94/min and regular.  BMI is 32 kg/m².  Examination shows normal jugular venous pressure and clear lungs.  First and second heart sounds are normal.  Deep palpation in the epigastric region elicits mild tenderness.  Laboratory results are as follows:

ECG is shown in the exhibit.  Which of the following is the most appropriate next step in pharmacotherapy?

A 55-year-old man comes to the emergency department due to sudden onset of retrosternal chest pain.  The pain began 10 hours ago and has been mostly constant, although he describes it as “being bad and then getting a little better.”  The patient has had no lightheadedness, syncope, or shortness of breath.  ECG shows normal sinus rhythm with 2-mm ST-segment elevation in leads V2 to V5.  He is taken emergently for cardiac catheterization and undergoes percutaneous coronary intervention with stent placement to the left anterior descending artery.  After the procedure, the ST-segment changes improve and he has complete resolution of the chest pain.  On the third night, just prior to discharge, he calls for the nurse due to the sudden onset of sharp, retrosternal chest pain.  The patient first noticed the pain while turning around in bed; it worsens with deep breathing.  Temperature is 37.8 C (100 F), blood pressure is 134/80 mm Hg, heart rate is 108/min, and respirations are 22/min.  Physical examination reveals regular heart sounds and clear lung fields.  There is a scratchy sound heard during ventricular systole along the left sternal border.  Abdominal palpation reveals no localized tenderness.  ECG shows sinus tachycardia with Q waves and T-wave inversion in leads V2 to V5.

Item 1 of 2

Which of the following is the most likely cause of this patient’s recurrent symptoms?

Item 2 of 2

Which of the following is the most appropriate next step in management of this patient?