USMLE Step Two

A 42-year-old male with a history of hypertension has been experiencing dyspnea on exertion. He denies any chest pain. His blood pressure is 140/40 mm Hg, heart rate 90 bpm and respirations 18 breaths per minute. Physical examination reveals elevated jugular venous pressure and an early systolic ejection sound is heard. A III/IV early diastolic decrescendo murmur heard best at the right upper sternal border is present along with a I/IV diastolic rumble at the apex. Also noted is a II/VI systolic ejection murmur at the right upper sternal border. What other physical exam finding might you expect?

A 58-year-old male with a history of diabetes, hypertension and a renal transplant presents to the emergency department after being found unresponsive at home. His temperature is 37.3 C, blood pressure is 70/30 mm Hg, heart rate 120 bpm, respirations 24 breaths per minute and oxygen saturation 70% on room air. Physical examination reveals bilateral pulmonary rales, an S4 heart sound is present and no murmurs could be auscultated. He is intubated for airway protection. ECG reveals sinus tachycardia with a left bundle branch block. A Swan-Ganz catheter is inserted and the values are: right atrial pressure - 8 mm Hg; right ventricular pressure - 38/8 mm Hg; pulmonary artery pressure - 42/22 mm Hg; pulmonary capillary wedge pressure - 26 mm Hg; cardiac output - 4.0 L/min; cardiac index - 2.0 L/min. Which of the following is the most likely diagnosis?

A 29-year-old female with a history of hypertension presents for a routine clinic visit without any physical complaints. Her blood pressure is 180/100 mm Hg, which she admits it has been at home as well. Physical examination reveals normal lung sounds, a regular rhythm with a hyperdynamic apical impulse and an S4 heart sound, an abdominal bruit is heard, no lower-extremity edema. Her pulses are 2+ in upper and lower extremities. Her blood pressure medications include lisinopril, amlodipine, atenolol, hydrochlorothiazide, hydralazine and clonidine, which she states she takes regularly. Screening for secondary causes of hypertension thus far has been negative which has included electrolytes, a complete blood count, creatinine, urinary and serum catecholamines, morning cortisol levels, renin/aldosterone levels, thyroid-stimulating hormone levels and a dexamethasone suppression test. Which of the following tests should be ordered next?