Preparing for the American Board of Internal Medicine Maintenance of Certification
The following questions can assist candidates for the Maintenance of Certification Exam in Cardiovascular Disease prepare for this test. We hope you find this helpful and welcome your feedback.
Questions 1-3 refer to the following clinical scenario.
A 57-year-old man presents to your office with intermittent palpitations. They last between 30 seconds and 10 minutes and have occurred several times per week over the past year. No associated symptoms (ie, dyspnea, chest pain, or diaphoresis) are present. His medical history is otherwise unremarkable and he takes no medications. His exam is remarkable only for a regular pulse. The electrocardiogram is essentially normal.
1. Appropriate investigation would include:
2. A 24-hour Holter monitor discloses one 30-second run of atrial fibrillation that was asymptomatic. Appropriate management would include:
3. Echocardiography demonstrates essentially normal findings. Appropriate management would now include:
4. Which of the following statements is incorrect regarding peripartum cardiomyopathy?
5.Which statement is correct regarding patent foramen ovale (PFO)?
Questions 6-10 refer to the following clinical scenario.
A 63-year-old woman with a history of hypothyroidism and hypertension is brought into the hospital emergency department by her family for the evaluation of mental status changes. The patient has been on antihypertensive medications, including metoprolol succinate 25 mg extended release (Toprol XL) daily and Lasix 40 mg PO twice a day. She is also taking thyroid supplements, but is not aware of the type of medication or dosage in this case. There is a strong suspicion that the patient has been noncompliant with prescribed medications.
On physical exam the patient's blood pressure is 128/64 mm Hg and her heart rate is 88 beats per minute (BPM). The patient is moderately obese (5'4", 210 lbs), appears lethargic but in no distress, and denies shortness of breath or chest pain. Physical exam demonstrates decreased breath sounds but no crackles. Sounds are distant but there are no murmurs or gallops. Her abdomen is slightly obese but not tender. There is bilateral trace edema on examination of the extremities.
Laboratory values include an elevated TSH level of 120 µ/dL. The white count is slightly elevated with a normal differential. The patient has normal oxygenation on room air. Electrocardiogram (ECG) reveals sinus rhythm and low QRS voltage (ie, < 0.7 mV in amplitude).
Echocardiography is ordered as part of the patients' workup. This study reveals moderate left ventricular dysfunction with an ejection fraction of 35%. There is a large circumferential pericardial effusion noted with a minimal degree of right-heart chamber compromise.
6. Based on the electrocardiography findings, the differential diagnosis for this patient could be:
7. The echocardiographic findings of a pericardial effusion in this patient are most likely due to:
The patient is admitted to the hospital and started on intravenous (IV) thyroid replacement. The next day, she is clinically unchanged. A cardiology consult is requested due to the echocardiographic findings.
8. Based on the findings of a large effusion with a minimal degree of right chamber collapse in a hemodynamically stable patient, pericardiocentesis would be required.
On the third hospital day the patient develops a low-grade temperature of 101.1° F. A physical exam reveals a slightly elevated respiratory rate of 23 breaths per minute. Repeat echocardiography is unchanged. The patient's heart rate now is 105 BPM and the blood pressure is 90/60 mm Hg.
9. Pericardiocentesis should be considered at this point.
The patient is sent for a pericardiocentesis on the 4th hospital day, and 1.5 liters of a yellowish colored fluid is removed successfully from the pericardial space. The drain is left overnight and removed only when drainage is less than 30 mL/24 hours. The patient's heart rate remains elevated at 110 BPM, but after treatment with IV vancomycin and ceftriaxone her heart rate normalizes. Repeat echocardiography is obtained 3 days later.
10. Findings on repeat echocardiography would likely include: