IBC 2 P1

A 43-year-old man comes to the physician because of a 1-month history of increasing shortness of breath. He has been using two pillows at night but frequently wakes up feeling as if he is choking. Five months ago, he underwent surgery for the creation of an arteriovenous fistula in his left upper arm. He has hypertension and chronic kidney disease due to reflux nephropathy. He receives hemodialysis three times a week. His current medications are enalapril, vitamin D3, erythropoietin, sevelamer, and atorvastatin. His temperature is 37.1°C (98.8°F), pulse is 103/min and bounding, respirations are 22/min, and blood pressure is 106/58 mm Hg. Physical examination shows bilateral pitting pedal edema. There is jugular venous distention. A prominent bruit is heard over the brachiocephalic arteriovenous fistula. There are crackles heard at both lung bases. Cardiac examination shows an S3 gallop. The abdomen is soft and nontender. Which of the following is the most likely cause of this patient's symptoms?

A 65-year-old man comes to the physician for the evaluation of a 2-month history of worsening fatigue and shortness of breath on exertion. While he used to be able to walk 4–5 blocks at a time, he now has to pause every 2 blocks. He also reports waking up from having to urinate at least once every night for the past 5 months. Recently, he has started using two pillows to avoid waking up coughing with acute shortness of breath at night. He has a history of hypertension and benign prostatic hyperplasia. His medications include daily amlodipine and prazosin, but he reports having trouble adhering to his medication regimen. His pulse is 72/min, respirations are 20/min, and blood pressure is 145/90 mm Hg. Physical examination shows 2+ bilateral pitting edema of the lower extremities. Auscultation shows an S4 gallop and fine bibasilar rales. Further evaluation is most likely to show which of the following pathophysiologic changes in this patient?

A 65-year-old man is brought to the emergency department because of a 1-week history of worsening shortness of breath. The symptoms occur when he climbs the stairs to his apartment on the third floor and when he goes to bed. He gained 2.3 kg (5 lbs) in the past 5 days. He has a history of hypertension, hyperlipidemia, alcoholic steatosis, and osteoarthritis. He underwent surgical repair of a ventricular septal defect at the age of 4 months. He started taking ibuprofen and simvastatin one week ago. He drinks two to three beers daily after work. His temperature is 37.0°C (98.6°F), his pulse is 114/min, and his blood pressure is 130/90 mm Hg. Physical examination shows jugular venous distention and 2+ pitting edema in his lower extremities. Crackles are heard over the lower lung fields bilaterally. On cardiac examination, a late-diastolic heart sound is heard. Echocardiography shows concentric hypertrophy of the left ventricle. Which of the following is the most likely cause of this patient's condition?

A 72-year-old man comes to the physician because of progressively worsening shortness of breath. The symptoms most commonly occur when lying flat at night. He also reports shortness of breath when walking up the two flights of stairs to his apartment. He reports no chest pain. Medical history is remarkable for myocardial infarction 2 years ago. The patient has smoked one pack of cigarettes daily for 40 years. He does not exercise. His medications include aspirin, lisinopril, bisoprolol, and atorvastatin. Pulse is 85/min and blood pressure is 124/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Examination shows an extra heart sound during early diastole on auscultation. Faint crackles are heard at both lung bases. There is 1+ ankle edema bilaterally. Cardiac ultrasonography shows a left ventricular ejection fraction of 0.35. Which of the following hemodynamic changes are most likely present in this patient?

A 71-year-old woman comes to the physician because of progressive shortness of breath and swollen legs for the past 4 weeks. She has tried sleeping in a raised position using 2 pillows but still wakes up occasionally from a choking sensation. She has type 2 diabetes mellitus, arterial hypertension, and gastroesophageal reflux disease. Her sister has polymyalgia rheumatica. Her current medications include insulin, enalapril, and omeprazole. She has smoked one half-pack of cigarettes daily for 45 years. Her temperature is 37.0°C (98.6°F), pulse is 112/min, respirations are 22/min, and blood pressure is 119/76 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 90%. Examination shows an enlarged tongue, pitting edema below the knees, and jugular venous distention. Crackles are heard at both lung bases. Her hemoglobin concentration is 9.0 g/dL, leukocyte count is 6100/mm3, erythrocyte sedimentation rate is 62 mm/h, and serum creatinine is 2.1 mg/dL. An ECG shows sinus rhythm and low-voltage QRS complexes. Echocardiography shows symmetrical left ventricular hypertrophy, reduced diastolic filling, and an ejection fraction of 55%. Which of the following is the most likely cause of this patient's symptoms?

A 75-year-old man is brought to the emergency department because of a 5-day history of worsening shortness of breath when lying down and lower leg swelling. He has a history of hypertension, hyperlipidemia, nonalcoholic fatty liver disease, and myocardial infarction that developed 10 years ago. Current medications include metoprolol, lisinopril, ethacrynic acid, eplerenone, and aspirin. He drinks one beer daily. He has a 30-pack-year smoking history. He is allergic to sulfonamides. Temperature is 37.0°C (98.6°F), pulse is 120/min, and blood pressure is 120/80 mm Hg. Physical examination shows jugular venous distention and 3+ pitting edema of the lower extremities. Crackles are heard over the lower lung fields bilaterally. The point of maximal impulse is palpated 2 cm to the left of the midclavicular line at the 6th intercostal space. Which of the following additional findings is most strongly associated with increased mortality?

A 69-year-old man comes to the physician with a 9-month history of worsening shortness of breath on exertion and the need to urinate at night. He occasionally has palpitations but does not have chest pain. The patient had a transient ischemic attack 5 years ago for which he underwent right-sided carotid endarterectomy. He has hypertension and type 2 diabetes mellitus. Current medications include metformin, lisinopril, aspirin, and simvastatin. He appears fatigued. His pulse is 61/min, respirations are 25/min, and blood pressure is 120/75 mm Hg. Pulse oximetry shows an oxygen saturation of 96%. Examination shows cold extremities. There are no murmurs or rubs on cardiac auscultation. Fine, bilateral crackles are heard at the lung bases. There is 2+ lower extremity edema. An ECG shows sinus rhythm and T wave inversions in leads V1 to V4. Which of the following agents is most likely to improve the patient's long-term survival?

A 68-year-old man comes to the emergency department because of a 1-week history of worsening bouts of shortness of breath at night. He has had a cough for 1 month occasionally productive of frothy sputum. He has type 2 diabetes mellitus and long-standing hypertension. Two years ago, he was diagnosed with Paget disease of bone during a routine health maintenance examination. He has smoked a pack of cigarettes daily for 20 years. His temperature is 37.0°C (98.6°F), pulse is 110/min, respirations are 25/min, and blood pressure is 145/98 mm Hg. Current medications include metformin, alendronate, hydrochlorothiazide, and enalapril. Physical examination shows bibasilar crackles. Cardiac examination shows a dull, low-pitched sound during late diastole that is best heard at the apex. There is no jugular venous distention or peripheral edema. Arterial blood gas analysis on room air shows:

pH 7.46
PCO2 29 mm Hg
PO2 83 mm Hg
HCO3- 20 mEq/L
Echocardiography shows a left ventricular ejection fraction of 55%. Which of the following is the most likely underlying cause of this patient’s current condition?

A 66-year-old man comes to the physician because of a 3-week history of shortness of breath with exertion. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. Current medications include aspirin, losartan, simvastatin, and insulin. His temperature is 37.1°C (98.8°F), pulse is 74/min, and blood pressure is 150/84 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Cardiac examination is shown. Further evaluation of this patient is most likely to show which of the following?

A 41-year-old man comes to the emergency department because of fatigue, worsening abdominal discomfort, and progressive swelling of his legs for 3 months. The swelling is worse in the evenings. His only medication is ibuprofen for occasional joint pain. The patient does not smoke and drinks 2–3 beers each weekend. His temperature is 36.0°C (96.8°F), pulse is 88/min, respirations are 18/min, and blood pressure is 130/80 mm Hg. Pulmonary examination shows no abnormalities. Abdominal examination shows a mildly distended abdomen with shifting dullness. The liver is palpated 2–3 cm below the right costal margin. When pressure is applied to the right upper quadrant, the patient's jugular veins become visibly distended for 15 seconds. The 2nd and 3rd metacarpophalangeal joints of both hands are tender to palpation. There is 2+ edema in the lower extremities. Which of the following is the most likely underlying cause of this patient's edema?

A 70-year-old man comes to the physician for evaluation of worsening nocturia, fatigue, and shortness of breath on exertion (ejercicio). While he used to be able to walk for 15 minutes at a time, he now has to pause every 5 minutes. Recently, he has started using two pillows to avoid waking up short of breath at night. He has a history of hypertension treated with daily amlodipine and prazosin; he has difficulty adhering to his medication regimen. His pulse is 75/min, and blood pressure is 150/90 mm Hg. Physical examination shows a laterally displaced apical heartbeat and 2+ bilateral pitting edema of the lower legs. Auscultation shows an S4 gallop and fine bibasilar rales. Further evaluation is most likely to show which of the following pathophysiologic changes in this patient?

A 38-year-old woman comes to the physician because of an 8-week history of shortness of breath and dull chest pain. She has a history of antiphospholipid syndrome. Physical examination shows jugular venous distention. Right heart catheterization shows a mean pulmonary arterial pressure of 30 mm Hg and a pulmonary capillary wedge pressure of 10 mm Hg. Further evaluation is most likely to show which of the following?

A 70-year-old man comes to the physician because of a 6-month history of worsening shortness of breath on exertion and bouts of coughing while sleeping. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. Current medications include lisinopril, simvastatin, and insulin. The patient appears tired but in no acute distress. His pulse is 70/min, blood pressure is 140/85 mm Hg, and respirations are 25/min. He has crackles over both lower lung fields and 2+ pitting edema of the lower extremities. An ECG shows T wave inversions in leads V1 to V4. Which of the following agents is most likely to improve the patient's long-term survival?

A 29-year-old man is brought to the emergency department 20 minutes after being stabbed in the left thigh. His pulse is 110/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. Examination shows a 2-cm wound overlying a pulsatile mass on the left anterior thigh, 4 cm below the inguinal crease. A thrill is palpated, and a bruit is heard over this area. Peripheral pulses are normal bilaterally. The patient is at greatest risk for which of the following?

A 72-year-old man with coronary artery disease comes to the emergency department because of chest pain and shortness of breath for the past 3 hours. Troponin levels are elevated and an ECG shows ST-elevations in the precordial leads. Revascularization with percutaneous coronary intervention is performed, and a stent is successfully placed in the left anterior descending artery. Two days later, he complains of worsening shortness of breath. Pulse oximetry on 3L of nasal cannula shows an oxygen saturation of 89%. An x-ray of the chest shows distended pulmonary veins, small horizontal lines at the lung bases, and blunting of the costophrenic angles bilaterally. Which of the following findings would be most likely on a ventilation-perfusion scan of this patient?

An investigator is studying patients with acute decompensated congestive heart failure. He takes measurements of a hormone released from atrial myocytes, as well as serial measurements of left atrial and left ventricular pressures. The investigator observes a positive correlation between left atrial pressures and the serum level of this hormone. Which of the following is most likely the mechanism of action of this hormone?

A 55-year-old woman is brought to the emergency department because of epigastric pain, sweating, and breathlessness for 45 minutes. She has hypertension treated with hydrochlorothiazide. She has smoked 1 pack of cigarettes daily for the past 30 years and drinks 1 glass of wine daily. Her pulse is 105/min and blood pressure is 100/70 mm Hg. Arterial blood gas analysis on room air shows:

pH 7.49
pCO2 32 mm Hg
pO2 57 mm Hg
An ECG shows ST elevations in leads V1–V6. Which of the following is the most likely cause of hypoxemia in this patient?

A 58-year-old man comes to the physician because of a 5-day history of progressively worsening shortness of breath and fatigue. He has smoked one pack of cigarettes daily for 30 years. His pulse is 96/min, respirations are 26/min, and blood pressure is 100/60 mm Hg. An x-ray of the chest is shown. Which of the following is the most likely cause of this patient's findings?

A 72-year-old woman is admitted to the intensive care unit for shortness of breath and palpitations. A cardiac catheterization is performed and measurements of the left ventricular volume and pressure at different points in the cardiac cycle are obtained. The patient's pressure-volume loop (light gray) is shown with a normal pressure-volume loop (dark gray) for comparison. Which of the following is the most likely underlying cause of this patient's symptoms?

An investigator is studying early post-mortem changes in the lung. Autopsies are performed on patients who died following recent hospital admissions. Microscopic examination of the lungs at one of the autopsies shows numerous macrophages with brown intracytoplasmic inclusions. A Prussian blue stain causes these inclusions to turn purple. These findings are most consistent with a pathological process that would manifest with which of the following symptoms?

A 65-year-old woman comes to the physician because of a 1-month history of progressively worsening shortness of breath, dry cough, and fatigue. She has type 2 diabetes mellitus, hyperlipidemia, and coronary artery disease. Current medications include aspirin, metformin, and atorvastatin. Her temperature is 36°C (96.8°F), heart rate is 97/min, and blood pressure is 102/61 mm Hg. Cardiopulmonary examination shows an S3 gallop and coarse crackles at the lung bases. There is 1+ ankle edema bilaterally. Which of the following sets of hemodynamic changes is most likely in this patient?

A 51-year-old man comes to the physician because of progressive shortness of breath, exercise intolerance, and cough for the past 6 months. He is no longer able to climb a full flight of stairs without resting and uses 3 pillows to sleep at night. He has a history of using cocaine in his early 30s but has not used any illicit drugs for the past 20 years. His pulse is 99/min, respiratory rate is 21/min, and blood pressure is 95/60 mm Hg. Crackles are heard in both lower lung fields. An x-ray of the chest shows bilateral fluffy infiltrates and thickening of the interlobar fissures, and an enlarged cardiac silhouette. Which of the following findings is most likely in this patient?

A 67-year-old man is brought to the emergency department because of the sudden onset of severe substernal chest pain at rest. He has a history of hypertension, type 2 diabetes mellitus, and alcohol use disorder. He is diaphoretic and appears anxious. The lungs are clear to auscultation. An ECG shows ST-segment elevations in leads I, aVL, V5, and V6. One hour later, he develops dyspnea and a productive cough with frothy sputum. Which of the following best describes the most likely underlying pathophysiology of this patient's dyspnea?

A 67-year-old woman comes to the physician because of progressive swelling of her legs, shortness of breath on exertion, and abdominal discomfort for the past 3 months. She has also had nausea and decreased appetite, resulting in a 6-kg (13-lb) weight loss. She is being treated with paclitaxel for ovarian cancer and has had 2 episodes of pulmonary embolism during the past year. The patient has smoked one pack of cigarettes daily for 25 years and drinks two glasses of wine daily. She appears tired. The patient is 164 cm (5 ft 4 in) tall and weighs 54 kg (119 lb); BMI is 20 kg/m2. Temperature is 37.0°C (98.6°F), pulse is 115/min, respirations are 18/min, and blood pressure is 135/85 mm Hg. Examination shows conjunctival icterus, protuberant abdomen with a fluid wave and shifting dullness, and 2+ pitting edema of the lower extremities. Lungs are clear to auscultation. There is visible distention of the jugular veins. Which of the following is the most likely explanation for this patient's findings?