Chest Pain and Cardiac Dysrhythmias

Questions

1. A 59-year-old man presents to the emergency department (ED) complaining
   of new onset chest pain that radiates to his left arm. He has a history
   of hypertension, hypercholesterolemia, and a 20-pack-year smoking
   history. His electrocardiogram (ECG) is remarkable for T-wave inversions
   in the lateral leads. Which of the following is the most appropriate next
   step in management?
   a. Give the patient two nitroglycerin tablets sublingually and observe if his chest
   pain resolves.
   b. Place the patient on a cardiac monitor, administer oxygen, and give aspirin.
   c. Call the cardiac catheterization laboratory for immediate percutaneous intervention
   (PCI).
   d. Order a chest x-ray; administer aspirin, clopidogrel, and heparin.
   e. Start a β-blocker immediately.

2. A 36-year-old woman presents to the ED with sudden onset of leftsided
   chest pain and mild shortness of breath that began the night before.
   She was able to fall asleep without difficulty but woke up in the morning
   with persistent pain that is worsened upon taking a deep breath. She
   walked up the stairs at home and became very short of breath, which made
   her come to the ED. Two weeks ago, she took a 7-hour flight from Europe
   and since then has left-sided calf pain and swelling. What is the most common
   ECG finding for this patient’s presentation?
   a. S1Q3T3 pattern
   b. Atrial fibrillation
   c. Right-axis deviation
   d. Right-atrial enlargement
   e. Tachycardia or nonspecific ST-T–wave changes

3. A 51-year-old man with a long history of hypertension presents to the
   ED complaining of intermittent chest palpitations lasting for a week. He
   denies chest pain, shortness of breath, nausea, and vomiting. He recalls
   feeling similar episodes of palpitations a few months ago but they resolved.
   His blood pressure (BP) is 130/75 mm Hg, heart rate (HR) is 130 beats per
   minute, respiratory rate (RR) is 16 breaths per minute, and oxygen saturation
   is 99% on room air. An ECG is seen below. Which of the following is
   the most appropriate next step in management?
   2 Emergency Medicine
   a. Sedate patient for immediate synchronized cardioversion with 100 Joules
   b. Prepare patient for the cardiac catheterization laboratory
   c. Administer Coumadin
   d. Administer amiodarone
   e. Administer diltiazem

4. A 54-year-old woman presents to the ED because of a change in behavior
   at home. For the past 3 years she has end-stage renal disease requiring
   dialysis. Her daughter states that the patient has been increasingly tired and
   occasionally confused for the past 3 days and has not been eating her usual
   diet. On examination, the patient is alert and oriented to person only. The
   remainder of her examination is normal. An initial 12-lead ECG is performed
   as seen below. Which of the following electrolyte abnormalities best
   explains these findings?

a. Hypokalemia
b. Hyperkalemia
c. Hypocalcemia
d. Hypercalcemia
e. Hyponatremia

5. A 29-year-old tall, thin man presents to the ED after feeling short of breath
   for 2 days. In the ED, he is in no acute distress. His BP is 115/70 mm Hg, HR
   is 81 beats per minute, RR is 16 breaths per minute, and oxygen saturation is
   98% on room air. Cardiac, lung, and abdominal examinations are normal. An
   ECG reveals sinus rhythm at a rate of 79. A chest radiograph shows a small
   right-sided (less than 10% of the hemithorax) spontaneous pneumothorax.
   A repeat chest x-ray 6 hours later reveals a decreased pneumothorax. Which
   of the following is the most appropriate next step in management?
   a. Discharge the patient with follow-up in 24 hours
   b. Perform needle decompression in the second intercostal space, midclavicular
   line
   c. Insert a 20F chest tube into right hemithorax
   d. Observe for another 6 hours
   e. Admit for pleurodesis

6. A 42-year-old man found vomiting in the street is brought to the ED by
   emergency medical services (EMS). He has a known history of alcohol abuse
   with multiple presentations for intoxication. Today, the patient complains of
   acute onset, persistent chest pain associated with dysphagia, and pain upon
   flexing his neck. His BP is 115/70 mm Hg, HR is 101 beats per minute, RR is
   18 breaths per minute, and oxygen saturation is 97% on room air. As you
   listen to his heart, you hear a crunching sound. His abdomen is soft with
   mild epigastric tenderness. The ECG is sinus tachycardia without ST-T–wave
   abnormalities. On chest x-ray, you note lateral displacement of the left mediastinal
   pleural. What is the most likely diagnosis?
   a. Aspiration pneumonia
   b. Acute pancreatitis
   c. Pericarditis
   d. Esophageal perforation
   e. Aortic dissection

7. A 65-year-old man with a history of chronic hypertension presents to the
   ED with sudden-onset tearing chest pain that radiates to his jaw. His BP is
   205/110 mm Hg, HR is 90 beats per minute, RR is 20 breaths per minute,
   and oxygen saturation is 97% on room air. He appears apprehensive. On
   cardiac examination you hear a diastolic murmur at the right sternal border.
   A chest x-ray reveals a widened mediastinum. Which of the following is the
   preferred study of choice to diagnose this patient’s condition?
   a. Electrocardiogram (ECG)
   b. Transthoracic echocardiography (TTE)
   c. Transesophageal echocardiography (TEE)
   d. Computed tomography (CT) scan
   e. Magnetic resonance imaging (MRI)

8. A 47-year-old man with a history of hypertension presents to the ED
   complaining of continuous left-sided chest pain that began while snorting
   cocaine 1 hour ago. The patient states he never experienced chest pain in
   the past when using cocaine. His BP is 170/90 mm Hg, HR is 101 beats per
   minute, RR is 18 breaths per minute, and oxygen saturation is 98% on
   room air. The patient states that the only medication he takes is alprazolam
   to “calm his nerves.” Which of the following medications is contraindicated
   in this patient?
   a. Metoprolol
   b. Diltiazem
   c. Aspirin
   d. Lorazepam
   e. Nitroglycerin

9. A 32-year-old woman presents to the ED with a persistent fever of
   101°F over the last 3 days. The patient states that she used to work as a
   convenience store clerk but was fired 2 weeks ago. Since then, she has been
   using drugs intravenously daily. Cardiac examination reveals a heart murmur.
   Her abdomen is soft and nontender with an enlarged spleen. Chest radiograph
   reveals multiple patchy infiltrates in both lung fields. Laboratory results reveal
   white blood cells (WBC) 14,000/μL with 91% neutrophils, hematocrit 33%,
   and platelets 250/μL. An ECG reveals sinus rhythm with first-degree heart
   block. Which of the following is the most appropriate next step in management?
   a. Obtain four sets of blood cultures, order a transthoracic echocardiogram (TTE),
   and start antibiotic treatment.
   b. Order a monospot test and recommend that the patient refrain from vigorous
   activities for 1 month.
   c. Administer a nonsteroidal anti-inflammatory drug (NSAID) and inform the
   patient she has pericarditis.
   d. Administer isoniazid (INH) and report the patient to the Department of Health.
   e. Order a Lyme antibody and begin antibiotic therapy.

10. A 61-year-old woman was on her way to the grocery store when she
    started feeling chest pressure in the center of her chest. She became
    diaphoretic and felt short of breath. On arrival to the ED by EMS, her BP is
    130/70 mm Hg, HR is 76 beats per minute, and oxygen saturation is 98%
    on room air. The nurse gives her an aspirin and an ECG is performed as
    seen below. Which of the following best describes the location of this
    patient’s myocardial infarction (MI)?

a. Anteroseptal
b. Anterior
c. Lateral
d. Inferior
e. Posterior

13. A 55-year-old man presents to the ED with worsening weakness, muscle
    cramps, and paresthesias. His past medical history is significant for hypertension
    and diabetes. He smokes one pack of cigarettes per day. On examination,
    the patient is alert and oriented and diffusely weak. An ECG is seen below.
    Which of the following is the most important next step in management?

a. Administer calcium gluconate.
b. Administer insulin and dextrose.
c. Administer aspirin and call the catheterization laboratory.
d. Order an emergent head CT scan and get a neurology consult.
e. Collect a sample of his urine to test for ketones.

14. While eating dinner, a 55-year-old man suddenly feels a piece of steak
    “get stuck” in his stomach. In the ED, he complains of dysphagia, is drooling,
    and occasionally retches. On examination, his BP is 130/80 mm Hg,
    HR is 75 beats per minute, RR is 15 breaths per minute, and oxygen saturation
    is 99% on room air. He appears in no respiratory distress. Chest x-ray
    is negative for air under the diaphragm. Which of the following is the most
    appropriate next step in management?
    a. Administer 1-mg glucagon intravenously while arranging for endoscopy.
    b. Administer a meat tenderizer such as papain to soften the food bolus.
    c. Administer 10-mL syrup of ipecac to induce vomiting and dislodge the food
    bolus.
    d. Perform the Heimlich maneuver until the food dislodges.
    e. Call surgery consult to prepare for laparotomy.

15. A 59-year-old man presents to the ED with left-sided chest pain and
    shortness of breath that began 2 hours prior to arrival. He states the pain is
    pressure-like and radiates down his left arm. He is diaphoretic. His BP is
    160/80 mm Hg, HR 86 beats per minute, and RR 15 breaths per minute.
    ECG reveals 2-mm ST-segment elevation in leads I, aVL, V3 to V6. Which of
    the following is an absolute contraindication to receiving thrombolytic
    therapy?
    a. Systolic BP greater than 180 mm Hg
    b. Patient on Coumadin and aspirin
    c. Total hip replacement 3 months ago
    d. Peptic ulcer disease
    e. Previous hemorrhagic stroke

16. A 67-year-old woman is brought to the ED by paramedics complaining
    of dyspnea, fatigue, and palpitations. Her BP is 80/50 mm Hg, heart is
    139 beats per minute, and RR is 20 breaths per minute. Her skin is cool
    and she is diaphoretic. Her lung examination reveals bilateral crackles and
    she is beginning to have chest pain. Her ECG shows a narrow complex
    irregular rhythm with a rate in the 140s. Which of the following is the most
    appropriate immediate treatment for this patient?
    a. Diltiazem
    b. Metoprolol
    c. Digoxin
    d. Coumadin
    e. Synchronized cardioversion

17. A 61-year-old woman with a history of congestive heart failure (CHF)
    is at a family picnic when she starts complaining of shortness of breath. Her
    daughter brings her to the ED where she is found to have an oxygen saturation
    of 85% on room air with rales halfway up both of her lung fields.
    Her BP is 185/90 mm Hg and pulse rate is 101 beats per minute. On examination,
    her jugular venous pressure (JVP) is 6 cm above the sternal angle.
    There is lower extremity pitting edema. Which of the following is the most
    appropriate first-line medication to lower cardiac preload?
    a. Metoprolol
    b. Morphine sulfate
    c. Nitroprusside
    d. Nitroglycerin
    e. Oxygen

18. A 27-year-old man who is otherwise healthy presents to the ED with a
    laceration on his thumb that he sustained while cutting a bagel. You irrigate
    and repair the wound and are about to discharge the patient when he asks
    you if he can receive an ECG. It is not busy in the ED so you perform the
    ECG, as seen below. Which of the following is the most appropriate next
    step in management?

a. Admit the patient for placement of a pacemaker.
b. Admit the patient for a 24-hour observation period.
c. Administer aspirin and send cardiac biomarkers.
d. Repeat the ECG because of incorrect lead placement.
e. Discharge the patient home.

19. A 56-year-old woman with a history of ovarian cancer presents to the
    ED with acute onset of right-sided chest pain, shortness of breath, and
    dyspnea. Her BP is 131/75 mm Hg, HR is 101 beats per minute, respirations
    are 18 breaths per minute, and oxygen saturation is 97% on room
    air. You suspect this patient has a pulmonary embolism (PE). Which of the
    following tests is most likely to be abnormal?
    a. Arterial blood gas
    b. Oxygen saturation
    c. ECG
    d. Chest radiograph
    e. D-dimer

20. A 61-year-old woman with a history of diabetes and hypertension is
    brought to the ED by her daughter. The patient states that she started feeling
    short of breath approximately 12 hours ago and then noticed a tingling
    sensation in the middle of her chest and became diaphoretic. An ECG
    reveals ST-depression in leads II, III, and aVF. You believe that the patient
    had a non–ST-elevation MI. Which of the following cardiac markers begins
    to rise within 3 to 6 hours of chest pain onset, peaks at 12 to 24 hours, and
    returns to baseline in 7 to 10 days?
    a. Myoglobin
    b. Creatinine kinase (CK)
    c. Creatinine kinase-MB (CK-MB)
    d. Troponin I
    e. Lactic dehydrogenase (LDH)