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A 43-year-old Caucasian man with a two-year history of diabetes mellitus presents to your office for a routine. He has no complaint His medications are metformin and aspirin. He works as a computer programmer and has a sedentary lifestyle. He drinks one to two cans of beer on weekends and smokes one pack of cigarettes per day. On physical examination, his blood pressure is 153/94 mm Hg and his heat rate is 82/min His BMI is 32.5 kg/m2. The remainder of the physical examination is unremarkable Laboratory studies reveal an HbA1c of 7.6%. At his check-up one month ago, his blood pressure was 149/92 mmHg. Which of the following interventions would be most effective for controlling his blood pressure?

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A 38-year-old woman presents to the emergency room complaining of chest pain for the past several hours She describes it as sharp, centrally located and non-radiation. The pain worsens somewhat with inspiration and movement. The patient denies having fevers, chills, dyspnea, swelling, or difficulty breathing at night. She says she first noticed the pain while exercising three weeks ago, but has experienced it at rest as well. She says that she has been exercising heavily in an attempt to lose weight. Her BMI is currently 34kg/m2. Her father had a myocardial infarction at age 60. Her medical history is significant for two normal vaginal deliveries. She smokes a half-pack of cigarettes daily. On physical examination, her blood pressure is 112/69 mm Hg and her heat rate is 72/min. Cardiac exam reveals a regular Sl and S2 without extra sounds or murmurs There is tenderness to palpation over the sternum. What is the most likely cause of her chest pain?

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A 63-year-old man presents to the ER with substernal chest pain and diaphoresis. The pain stated one hour ago and did not remit with antacids. He has a past medical history of asthma for which he uses inhaled fluticasone and peptic ulcer disease for which he takes omeprazole. His family history is significant for prostate cancer in his father and breast cancer in his mother. Physical examination reveals a blood pressure of 160/100 mmHg and a heat rate of 90/min. A bruit is heard over the right carotid artery and a mild systolic murmur is present at the cardiac apex Sublingual nitroglycerin and aspirin are administered in the. Within minutes, the patient reports decreased pain. Which of the following most likely accounts for this improvement in his symptoms?

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A 38-year-old female comes to your office complaining of occasional palpitations She describes feeling a fast and irregular heartbeat Over the past two months, she has had three such episodes, each lasting about two hours She denies any associated chest pain, shortness of breath cough or ankle swelling. She drinks alcohol on social occasions and does not smoke cigarettes She has no other medical problems and is not taking any medications On physical examination, her temperature is 37.1 C (98.9F), pulse is 80/min, blood pressure is 130/70mmHg, and respirations are 14/min. On auscultation of her heat the apical impulse is displaced and there is an S3. You also hear a pansystolic murmur, which is loudest at the apex and radiates to the axilla. Which of the following is the most likely cause of her symptoms?

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A 42-year-old woman is evaluated for depression, mood swings and poor. She also complains of mild headaches and muscle weakness. She has had two ER Visits for kidney stones over the past year. She denies any illicit drug use. Her blood pressure is 160/105 mmHg and her heat rate is 85/min. Her laboratory findings are shown below: Sodium 140mEq/L Potassium 3.6 mEq/L Chloride 101 mEq/L Bicarbonate 24 mEq/L BUN 13 mEq/L Creatinine 0.9 mEq/L Glucose 98 mEq/L Calcium 11.7 mg/dL Which of the following is the most likely cause of this patient's hypertension?

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A 60-year-old male is brought to ER by his son because he had an episode of syncope. He was watching TV in an arm-chair when suddenly lost his consciousness without any warning sign. He had several clonic jerks while unconscious He never had such an episode before. His past medical history is significant for acute myocardial infarction six months ago and well-controlled hypertension. His current medications include captopril metoprolol hydrochlorothiazide, clopidogrel and aspirin. His blood pressure is 130/85 mmHg and heat rate is 80/min with frequent ectopic beat. Physical examination revealed mild holosystolic apical murmur radiating to the axilla. Which of the following is the most probable pathophysiologic mechanism for his syncopal episode?

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A 45-year-old recently immigrated Mexican farmer comes to your office complaining of dyspnea, fatigue and abdominal distention for the past two months. On physical exam, his temperature is 37 C (98F), blood pressure is 126/80 mmHg, pulse is 80/min, and respirations are16/min. You note pedal edema, elevated jugular venous pressure with positive Kussmaul's sign, and increased abdominal girth with free fluid. Chest auscultation reveals decreased heart sound intensity at the apex and an early heart sound following S2 The jugular venous pressure tracing shows prominent 'x and 'y' descents. Which of the following is the most likely cause of this patient's symptoms?

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A 25-year-old G2, PI at 28 weeks gestation is brought to the emergency department by her boyfriend, who found her lying on her bed in a pool of blood She is very drowsy, but denies any pain or uterine contractione Her temperature is 38 C (100.4 F) and respirations are 18/min Physical examination is suggestive of a transverse lie Inspection of the perineum reveals gross blood and active bleeding per vagina. Which of the following set of parameters would most likely be seen in this patient? CO PCWP SVR BP HR Set A Decreased Increased Increased Decreased Increased set B Decreased Decreased Increased Decreased Decreased Set C Decreased Decreased Increased Decreased Increased set D Decreased Decreased Decreased Decreased Increased set E Increased Decreased Increased Decreased Increased

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A 54 year-old male comes to the physician because of abdominal distention He thinks his big belly is making it hard for him to breathe He received radiation therapy for Hodgkin lymphoma several years ago and was told that he is cured He drinks alcohol on a regular basis His temperature is 36.7C (98F), blood pressure is 120/76 mm Hg, pulse is 80/min and respirations are 20/min Examination shows a jugular venous pressure7 cm above the sternal angle Dullness to percussion and decreased breath sounds are noted in the right lung base The abdomen is quite distended with an obvious fluid wave Mild hepatomegaly is present Extremities have 2 lower extremity edema. Initial laboratory studies are shown below: Serum creatinine 08 mg/dL Alburnin 4.0 mg/dL Total bihrubin 1.0 mg/dl Prothrombin time 11 sec Urinalysis is within normal limits. Which of the following is the most likely cause of his condition?

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A 32-year-old woman presents with progressively worsening dyspnea on exertion one month after returning from a vacation in Texas. She says that her symptoms have progressed to the point that she now wakes during the night with a choking sensation that improves only with sitting up. Recently her shortness of breath has required her to significantly limit her physical activity. She denies having associated chest pain, skin rash or joint pain She has no significant past medical history. Family history is significant for thyroid cancer in her aunt and lung cancer in her father, a heavy smoker. On physical examination, her temperature is 37.20C (99 F), pulse is g6/min, blood pressure is 110/70 mmHg, and respirations are 14/min. Bilateral pitting ankle edema is present. Her liver is enlarged 2 cm below the right costal marginal. Lung auscultation reveals decreased breath sounds at the bilateral bases. Cardiac exam reveals the presence of a third heat sound. Chest x ray shows an enlarged cardiac silhouette and small bilateral pleural effusion. EKG is unremarkable. Which of the following is the most likely cause of her symptoms?

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A 45-year-old mildly overweight male recovering from an anterior wall myocardial infarction develops sudden onset of sharp pain in the left side of his chest He presented five days earlier with substernal chest pain and diaphoresis. He has had no dyspnea, extremity swelling or palpitations since admission. His past medical history is significant for diabetes mellitus type 2. He seems mildly restless, especially in the supine position. The pain improves when sitting up and leaning forward. His breathing is fast and shallow due to the pain. His lungs are clear on auscultation. His blood pressure is 120/78 mmHg and his heart rate is 60/min There is no change in blood pressure upon deep inspiration. ECG shows sinus rhythm with new diffuse ST segment elevation. Which of the following is the most likely diagnosis?

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An 88-year-old female nursing home resident is brought to the hospital with a one-week history of moaning, decreased oral intake and decreased ambulation. Physical examination reveals a very thin female who is moaning and appears to be in pain. She opens her eyes spontaneously but does not respond to questions. Her blood pressure is 75/43 mmHg, pulse is 105/min, temperature is 35.5°C (96°F), and respirations are 22/min. Oxygen saturation (pulse oximetry) is 97% on room air. Her skin and oral mucosa are dry and her neck veins are flat. There is no lymphadenopathy. On chest auscultation, there are crackles in the right upper lung lobe. Abdomen is soft and non-distended. There is 2 pitting presacral and lower extremity edema, and a deep pressure ulcer in the sacral area. Laboratory analysis reveals the following: Sodium 155mEq/L Potassium 5.3 mEq/L Glucose 88mg/dL Bicarbonate 14mEq/L BUN 151mg/dL Creatinine 3.1mg/dl Which of the following is the most likely cause of her lower extremity edema?

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