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Case #1
A 68 year old man is brought to the emergency department by
ambulance after having a syncopal episode while jogging. He states
that he was running when he suddenly passed out. He denies any
palpitations, chest pain, or dizziness preceding this event. He does
report that for the past few weeks, he has had some substernal chest
pain when exercising, but that has been relieved with rest. He denies
any shortness of breath, leg swelling, or orthopnea. He denies any
significant past medical history but has not been to a doctor in over 10
years because he has felt overall well during this time. He denies any
significant family history for cardiovascular disease. He also denies
any tobacco, drug, or alcohol use. On physical examination, his
temperature is 37 degrees Celsius, blood pressure is 158/98, HR 96
bpm, respiratory rate 15 /min, and oxygen saturation is 98% on room
air. Physical examination findings are significant for pulsus parvus and
tardus on neck exam, laterally displaced PMI, normal S1 but diminished
S2, 3/6 midsystolic murmur, loudest at the base and radiating to the
neck. S4 is also audible. Lungs are clear to auscultation, abdominal
examination is soft, nontender, and non-distended. There is no lower
extremity edema.
1. The mechanism for syncope in this case is most likely:
A. impaired cardiac output from fixed stenotic valve orifice
B. impaired cardiac output due to atrial tachyarrhythmia
C. impaired cardiac output due to low forward flow of blood from valve
regurgitation
D. impaired cardiac output due to low preload
Case #2
A 65 year old woman presents to the emergency room after calling 911
with a 30 minute history of chest pain. She has never had chest pain
before, but developed symptoms this morning right after eating
breakfast. She describes the pain as tightness in her epigastrium
and also moving up to the middle of her chest. She reports associated
nausea and diaphoresis but no vomiting. Her pain is 8/10 in severity.
She feels mildly short of breath, but that was improved in the
Emergency room when she received oxygen. She denies any recent
1
1. Based on the above information, the best treatment plan for this
patient is:
A. intravenous fluids
B. aspirin, nitrate, and beta blocker
C. aspirin, nitrate, beta blocker, and unfractionated heparin
D. aspirin, nitrate, beta blocker, unfractionated heparin, and primary
percutaneous coronary intervention
An EKG taken in the doctors office shows normal rate and rhythm with
no ST segment changes.
1. The mechanism for chest pain in this case is most likely:
A. increased myocardial oxygen demand due to a hypertrophied left
ventricle
B. increased myocardial oxygen demand due to chronically elevated
heart rate
C. decreased myocardial oxygen supply due to fixed, obstructive
atherosclerotic plaques in his coronary arteries
D. decreased myocardial oxygen supply due to decreased coronary
perfusion pressure