packrat cardio questions

8/19/2019 Packrat Cardio Questions

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1. History & Physical/Cardiology

Which of the following conditions would cause a positive

Kussmaul's sign on physical examination?

Answers

A. Left ventricular failure

B. Pulmonary edema

C. Coarctation of the aortaD. Constrictive pericarditis

Explanations

(u) A. Left ventricular failure results in the back-up of blood int

the left atrium and then the pulmonary system so it would not

be associated with Kussmaul's sign.

(u) B. Pulmonary edema primarily results in increased

pulmonary pressures rather than having effects on the venou

inflow into the heart.(u) C. Coarctation of the aorta primarily affects outflow from th

heart du e to the stenosis resulting in d elayed and decreased

femoral pulses; it has no effect on causing Kussmaul's sign.

(c) D. Kussmaul's sign is an increase rather than the normal

decrease in the CVP during inspiration. It is most often caused

by severe right-sided heart failure; it is a frequent finding in

patients with constrictive pericarditis or right ventricular

infarction.


Anginal chest pain is most commonly described as which of the

following?

AnswersA. Pain changing with position or respiration

B. A sensation of discomfort

C. Tearing pain radiating to the back

D. Pain lasting for several hours

Explanations

(u) A. Pain changing with position or respiration is suggestive o

pericarditis.

(c) B. Myocardial ischemia is often experienced as a sensation odiscomfort lasting 5-15 minutes, described as dull, aching or

pressure.

(u) C. Tearing pain with radiation to the back represents aortic

dissection.

(u) D. Chest pain lasting for several hours is more suggestive fo

myocardial infarction.


Eliciting a history from a patient presenting with dyspnea due to

early heart failure the severity of the dyspnea should be

quantified by

Answers

A. amount of activity that precipitates it.B. how many pillows they sleep on at night.

C. how long it takes the dyspnea to resolve.

D. any associated comorbidities.

Explanations

(c) A. The amount of activity that precipitates dyspnea should

be quantified in the history.

(u) B. Orthopnea or paroxysmal nocturnal dyspnea can be

quantified by how many pillows a patient needs to sleep on to

be comfortable.(u) C. How long dyspnea takes to resolve or associated

comorbidities has no bearing on quantifying the severity of

dyspnea.

(u) D. See answer C above.


A 25 year-old female presents with a three-day history of chest

pain aggravated by coughing and relieved by sitting. She is febrile

and a CBC with differential reveals leukocytosis. Which of the

following physical exam signs is characteristic of her problem?

Answers

A. Pulsus paradoxus

B. Localized crackles

C. Pericardial friction rub

D. Wheezing

Explanations

(u) A. Pulsus paradoxus is a classic finding for cardiac

tamponade.

(u) B. Localized crackles are associated with pneumonia and

consolidation, not pericarditis.

(c) C. Pericardial friction rub is characteristic of an inflammator

pericarditis.

(u) D. Wheezing is characteristic for pulmonary disorders, such

as asthma.

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A 65 year-old white female presents with dilated tortuous veins on

the medial aspect of her lower extremities. Which of the following

would be the most common initial complaint?

Answers

A. Pain in the calf with ambulation

B. Dull aching heaviness brought on by periods of standing

C. Brownish pigmentation above the ankle

D. Edema in the lower extremities

Explanations

(u) A. Patients with deep venous thrombosis (DVT) may

present with complaints of pain in the calf with ambulation.

Secondary varicosities may result from DVT's.

(c) B. Dull aching heaviness or a feeling of fatigue brought on

by periods of standing is the most common complaint of

patients presenting initially with varicosities.

(u) C. Stasis Dermatitis and edema are most suggestive of

chronic venous insufficiency.(u) D. See C for explanation.


A 22 year-old male received a stab wound in the chest an hour ago.

The diagnosis of pericardial tamponade is strongly supported by

the presence of

Answers

A. pulmonary edema.

B. wide pulse pressure.

C. distended neck veins.

D. an early diastolic murmur.

Explanations

(u) A. Pulmonary edema may result with low output states as

seen with myocardial contusions, but it is not strongly

suggestive of tamponade.

(u) B. Wide pulse pressure is seen in conditions of high stroke

volume such as aortic insufficiency or hy perthyroidism.

Narrow pu lse pressure is seen with cardiac tamponade.

(c) C. Cardiac compression will manifest with distended neck

veins and cold clammy skin.

(u) D. The onset of diastolic murmur is suggestive of valvular

disease, not tamponade.

7. Diagnostic Studies/Cardiology

Cardiac nuclear scanning is done to detect

Answers

A. electrical conduction abnormalities.

B. valvular abnormalities.

C. ventricular wall dysfunction.

D. coronary artery patency/occlusion.

Explanations

(u) A. An EKG is used to determine electrical conduction

abnormalities.

(u) B. An echocardiogram is a non-invasive test used to

determine valvular abnormalities and wall motion.

(c) C. Visualization of the cardiac wall can be done with cardiac

nuclear scanning. This is done to determine hypokinetic area

from akinetic areas.

(u) D. Patency or occlusion is assessed with cardiac

catheterization (invasive).


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A 72 year-old male with a new diagnosis of congestive heart

failure and atrial fibrillation, develops episodes of

hemodynamic compromise secondary to increased

ventricular rate. A decision to perform elective

cardioversion is made and the patient is anticoagulated

with heparin. Which test should be ordered to assess for

atrial or ventricular mural thrombi?

A. Electrocardiogram

B. Chest x-ray

C. Transesophageal Echocardiogram

D. C-reactive protein

(u) A. Electrical conduction will not assess for mural thrombi.

(u) B. A chest x-ray will not visualize the left atria and ventricles to

assess for mural thrombi.

(c) C. Transesophageal echocardiography allows for determination o

mural thrombi that may have resulted from atrial fibrillation.

(u) D. C-reactive protein is not going to give you any information

regarding thrombi. This test is used to identify the presence of

inflammation.


A 64 year-old patient with known history of type 1 diabetes

mellitus for 50 years has developed pain radiating from the

right buttock to the calf. Patient states that the pain is

made worse with walking and climbing stairs. Based upon

this history which of the following would be the most

appropriate test to order?

Answers

A. Venogram

B. Arterial duplex scanning

C. X-ray of the right hip and L/S spine

D. Venous Doppler ultrasound

Explanations

(u) A. See B for explanation.

(c) B. Given the patient's long h istory of type 1 diabetes mellitus the

patient most likely has vascular occlusive disease. Evaluation of arter

blood flow is assessed using the du plex scanner. X-ray of the L/S spi

and r ight hip while not harmful may give information regarding bon

structures. Venous Doppler u ltrasound will not give information of

arterial perfusion.

(u) C. See B for explanation.

(u) D. See B for explanation.


A 36 year-old male complains of occasional episodes of

"heart fluttering". The patient describes these episodes as

frequent, short-lived and episodic. He denies any

associated chest pain. Based on this information, which

one of the following tests would be the most appropriate

to order?

Answers

A. Holter monitor

B. Cardiac catheterization

C. Stress testing

D. Cardiac nuclear scanning

Explanations

(c) A. Holter monitoring is a non-invasive test done to obtain a

continuous monitoring of the electrical activity of the heart. This can

help to detect cardiac rhythm disturb ances that can correlate with t

patient symptoms. Cardiac catheterization is an invasive p rocedure

done to assess coronary artery disease. Stress testing and cardiac

nuclear scanning are non-invasive testing maneuvers done to asses

coronary artery disease.

(u) B. See A for explanation.

(u) C. See A for explanation.

(u) D. See A for explanation.


A patient with a mitral valve replacement was placed post-

operatively on warfarin (Coumadin) for anticoagulation

prophylaxis. To monitor this drug for its effectiveness,

what test would be used?

Answers

A. PTT

B. PT-INR

C. Platelet aggregation

D. Bleeding time

Explanations

(u) A. PTT is a reflection of the intrinsic clotting system and is used to

monitor heparin administration.

(c) B. PT-INR is a reflection of the extrinsic and common pathway

clotting system. Coumadin interferes with Vitamin K synthesis which

needed in the manufacture of factors II, VII , IX, X which are part of th

extrinsic clotting pathway.

(u) C. Platelet aggregation tests are utilized to assess platelet

dysfunction.

(u) D. Bleeding time is used to assess platelet function.


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12. Diagnosis/Cardiology

A 64 year-old male, with a long history of COPD, presents with increasing fatigue over the last

three months. The patient has stopped playing golf and also complains of decreased appetite,

chronic cough and a bloated feeling. Physical examination reveals distant heart sounds,

questionable gallop, lungs with decreased breath sounds at lung bases and the abdomen reveals

RUQ tenderness with the liver two finger-breadths below the costal margin, the extremities show

2+/4+ pitting edema. Labs reveal the serum creatinine level 1.6 mg/dl, BUN 42 mg/dl, liver function

test's mildly elevated and the CBC to be normal. Which of the following is the most likely

diagnosis?Answers

A. Right ventricular failure

B. Pericarditis

C. Exacerbation of COPD

D. Cirrhosis

Explanations

(c) A. Signs of right

ventricular failure are fluid

retention i.e. edema,

hepatic congestion and

possibly ascites.

(u) B. See A for explanatio

(u) C. See A for explanatio

(u) D. See A for explanatio


A 56 year-old male with a known history of polycythemia suddenly complains of pain and

paresthesia in the left leg. Physical examination reveals the left leg is cool to the touch and the

toes are cyanotic. The popliteal pulse is absent by palpation and Doppler. The femoral pulse is

absent by palpation but weak with Doppler. The right leg and upper extremities has 2+/4+ pulses

throughout. Given these findings what is the most likely diagnosis?

Answers

A. Venous thrombosis

B. Arterial thrombosis

C. Thromboangiitis obliterans

D. Thrombophlebitis

Explanations

(u) A. See B for explanatio

(c) B. Arterial thrombosis

has occurred and is

evidenced b y the loss of th

popliteal and dorsalis ped

pulse. This is a surgical

emergency. Venous

occlusion and

thrombophlebitis do not

result in loss of arterial

pulse.

(u) C. See B for explanatio

(u) D. See B for explanatio


A 48 year-old male with a known history of hypertension is brought to the ED complaining of

headache, general malaise, nausea and vomiting. The patient currently takes nifedipine

(Procardia)90mg XL every day and atenolol (Tenormin) 50 mg every day. Vital signs reveal

temperature 98.6°F, pulse 72/minute, respiratory rate 20/minute, and the blood pressure is

168/120 mmHg. BP reading taken every 15 minutes from the time of admission reveal the systolic

to run from 176 to 186 mmHg and the diastolic to run from 135 to 150 mmHg. Physical

examination reveals papilledema bilaterally. There are no renal bruits noted. The EKG is normal.

Based upon this presentation, what is the most likely diagnosis?

Answers

A. Meningitis

B. Secondary hypertension

C. Pseudotumor cerebri

D. Malignant hypertension

Explanations

(u) A. See D for explanatio

(u) B. See D for explanatio

(u) C. Pseudotumor cereb

presents with p apilledema

but not hypertension and

more common in young

females.

(c) D. Malignant HTN is

characterized by diastolic

reading greater than 140

mm Hg with evidence of

target organ damage.


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A 55 year-old male is seen in follow-up for a complaint of chest pain. Patient states

that he has had this chest pain for about one year now. The patient further states that

the pain is retrosternal with radiation to the jaw. "It feels as though a tightness, or

heaviness is on and around my chest". This pain seems to come on with exertion

however, over the past two weeks he has noticed that he has episodes while at rest. If

the patient remains non- active the pain usually resolves in 15-20 minutes. Patient has

a 60-pack year smoking history and drinks a martini daily at lunch. Patient appears

overweight on inspection. Based upon this history what is the most likely diagnosis?Answers

A. Acute myocardial infarction

B. Prinzmetal variant angina

C. Stable angina

D. Unstable angina

Explanations

(u) A. Pain does not resolve in an acute

MI, it gradually gets worse.

(u) B. Pain typically occurs at rest is one o

the hallmarks of Prinzmetal variant

angina. This patient has just started to

develop pain at rest.

(u) C. Pain in stable angina is relieved

with rest and usually resolves within 10minutes. angina does not have pain at

rest.

(c) D. Pain in un stable angina is

precipitated by less effort than before o

occurs at rest.


Stable

A 60 year-old male is brought to the ED complaining of severe onset of chest pain and

intrascapular pain. The patient states that the pain feels as though "something is

ripping and tearing". The patient appears shocky; the skin is cool and clammy. The

patient has an impaired sensorium. Physical examination reveals a loud diastolic

murmur and variation in blood pressure between the right and left arm. Based upon

this presentation what is the most l ikely diagnosis?

Answers

A. Aortic dissection

B. Acute myocardial infarction

C. Cardiac tamponade

D. Pulmonary embolism

Explanations

(c) A. The scenario presented here is

typical of an ascending aortic dissection

In an acute myocardial infarction the

pain builds up gradually. Cardiac

tamponade may occur with a dissection

into the pericardial space; syncope is

usually seen with this occurrence.

Pulmonary embolism is usually associat

with dyspnea along with chest pain.





A 42 year-old male is brought into the ED with a complaint of chest pain. The pain

comes on suddenly without exertion and lasts anywhere from 10-20 minutes. The

patient has experienced this on three previous occasions. Today the patient

complains of lightheadedness with the chest pain lasting longer. Vital signs T-99.3°F

oral, P-106/minute and regular, R-22/minute, BP 146/86 mm Hg. EKG reveals sinus

rhythm with a rate of 100. Intervals are PR = 0.06 seconds, QRS = 0.12 seconds. A delta

wave is noted in many leads. Based upon this information what is the most likely

diagnosis?

Answers

A. Sinus tachycardia

B. Paroxysmal supraventricular tachycardia

C. Wolff-Parkinson-White syndrome

D. Ventricular tachycardia

Explanations

(u) A. See C for explanation.

(u) B. See C for explanation.

(c) C. Wolff-Parkinson-White syndrome

hallmarks on EKG include a shorten PR

interval, widened QRS, and delta waves

Sinus tachycardia has a normal PR

interval and no delta waves. PSVT usual

has a retrograde P wave or it may be

buried in the QRS complex.

(u) D. Ventricular tachycardia has a

widened QRS as it originates in the

ventricles.


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A 63 year-old male is admitted to the hospital with an exacerbation of

COPD. The electrocardiogram shows an irregularly, irregular rhythm at a

rate of 120/minute with at least three varying P wave morphologies. These

electrocardiogram findings are most suggestive of

Answers

A. atrial fibrillation.

B. multifocal atrial tachycardia.

C. atrioventricular junctional rhythm.D. third degree heart block.

Explanations

(u) A. Atrial fibrillation is an irregularly, irregular

rhythm with no definable P waves.

(c) B. Multifocal atrial tachycardia is seen most

commonly in patients with COPD. Electrocardiogram

findings include an irregularly, irregular rhythm

with a varying PR interval and various P wave

morphologies (Three or more foci).

(u) C. Atrioventricular junctional rhythm is an escaprhythm, because of depressed sinus node fun ction

with a ventricular rate between 40-60/minute.

(u) D. Third degree heart block presents with a wid

QRS at a rate less than 50/minute and blocked atria

impulses.

19. Health Maintenance/Cardiology

A 72 year-old female is being discharged from the hospital following an

acute anterolateral wall myocardial infarction. While in the hospital the

patient has not had any dysrhythmias or hemodynamic compromise.

Which of the following medications should be a part of her d/c meds?

A. Warfarin (Coumadin)

B. Captopril (Capoten)

C. Digoxin (Lanoxin)

D. Furosemide (Lasix)

Explanations

(u) A. Warfarin is not indicated since there is no role

for anticoagulation in this patient.

(c) B. ACE inhibitors have been shown to decrease

left ventricular hypertrophy and remodeling to allo

for a greater ejection fraction.

(u) C. The patient does not have any dysrhythmias

so Lanoxin is not indicated.

(u) D. The patient does not have any hemodynami

compromise or indicators of CHF.


A 44 year-old male with a known history of rheumatic fever at age 7 and

heart murmur is scheduled to undergo a routine dental cleaning. The

murmur is identified as an opening snap murmur. Patient has no known

drug allergies. What should this patient receive for antibiotic prophylaxis

prior to the dental cleaning?

Answers

A. This patient does not require antibiotic prophylaxis for a routine dental

cleaning.

B. This should receive Pen VK 250 mg p.o. QID for 10 days after the

procedure.

C. This patient should receive Amoxicillin 3.0 gms. p.o. 1 hour before the

procedure and then 1.5 gm. 6 hours after the procedure.

D. This patient should receive Erythromycin 250 mg QID for 1 day before

the procedure and then 10 days after the procedure.

Explanations

(h) A. See C for explanation.


(c) C. These are the current recommendations from

the American Heart Association if the patient is not

allergic to penicillin.

(u) D. See C for explanation.


A 36 year-old female presents for a refill of her oral contraceptives. She

admits to smoking one pack of cigarettes per day. She should be counseled

with regard to her risk of

Answers

A. venous thrombosis.

B. varicose veins.

C. atherosclerosis.

D. peripheral edema.

Explanations

(c) A. Women over age 35 who smoke are at

increased risk for the development of venous

thrombosis.

(u) B. Varicose veins are the result of pressure

overload on incompetent veins and not due to the

use of oral contraceptives.

(a) C. The defined risks of atherosclerosis includes

smoking, but does not include the use of oral

contraceptives.

(u) D. There is no relationship between the use of

oral contraceptives and the development of

peripheral edema.


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A 68 year-old female comes to the office for an annual physical examination. Her past

medical history is significant for a 40-pack year cigarette smoking history. She takes no

medications and has not been hospitalized for any surgery. Family medical history

reveals that her mother is living, age 87, in good health without medical problems. Her

father is deceased at age 45 from a motor vehicle crash. She has two siblings that are

alive and well. From this information, how many identifiable risk factors for

cardiovascular heart disease exist in this patient?

AnswersA. 0

B. 1

C. 2

D. 3

Explanations



(c) C. This patient has 2 identifiable ris

factors based upon the information

provided. These include her age 68 an

her history of cigarette smoking.


23. Clinical Intervention/Cardiology

Following an acute anterolateral myocardial wall infarction two days ago, a patient

suddenly develops hemodynamic deterioration without EKG changes occurring. What

complication can explain this scenario?

Answers

A. Free wall rupture

B. CVA

C. Atrial fibrillation

D. Sick sinus syndrome

Explanations

(c) A. Free wall rupture is a complicatio

that occurs within 72 hours of infarctio

It is seen mainly in Q wave transmural

and lateral wall infarctions.


(u) C. See A for explanation. Atrial

fibrillation would have EKG evidence o

irregularly, irregular rate and rhythm

(u) D. Sick sinus syndrome would have

EKG ev idence of decreased rate and

loss of P waves.


A 48 year-old male with a history of coronary artery disease and two myocardial

infarctions complains of shortness of breath at rest and 2-pillow orthopnea. His oxygen

saturation is 85% on room air. The patient denies any prior history of symptoms. The

patient denies smoking. Results of a beta-natriuretic peptide (BNP) are elevated. What

should be your next course of action for this patient?

Answers

A. Send him home on 20 mg furosemide (Lasix) p.o. every day and recheck in one week

B. Send him home on clarithromycin (Biaxin) 500 mg p.o. BID and recheck in 1 week

C. Admit to the hospital for work up of left ventricular dysfunction

D. Admit to the hospital for work up of pneumonia

Explanations

(h) A. See C for explanation.

(h) B. See C for explanation.

(c) C. An elevated BNP is seen in a

situation where there is increased

pressure in the ventricle during

diastole. This is representative of the le

ventricle being stretched excessively

when a patient has CHF. Sending a

patient home would be inappropriate

in this case.



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A 48 year-old male presents to the ED with complaints of chest pressure,

dyspnea on exertion, and diaphoresis that has been present for the last

one hour. Electrocardiogram reveals normal sinus rhythm at 92/minute

along with ST segment elevation in leads V3-V5. Initial cardiac enzymes

are normal. What is the next most appropriate step in the management

of this patient?

Answers

A. Coronary artery revascularizationB. Admission for medical management

C. Administer lidocaine

D. Administer nitrates

Explanations

(c) A. The standard of care for the management of acu

ST-segment elevation MI is coronary artery

revascularization. This patient is diagnosed with an ST

segment elevation MI based upon his history and EKG

findings. Cardiac enzymes are normal because of the

early p resentation of this patient.

(u) B. Although this patient will be admitted to the

hospital, this patient needs to have acute managemenof the myocardial infarction without delay.

(h) C. Prophylactic lidocaine has b een shown to increa

morbidity and mortality from acute MI when used in

this setting.

(u) D. Although pain control is a goal for patients with

acute MI, it is not the essential medication that will

impact this patient's care to the greatest degree.


An unresponsive patient is brought to the ED by ambulance. He is in

ventricular tachycardia with a heart rate of 210 beats/min and a blood

pressure of 70/40 mmHg. The first step in treatment is to

Answers

A. administer IV adenosine.

B. DC cardiovert.

C. administer IV lidocaine.

D. apply overdrive pacer.

Explanations

(u) A. Adenosine is used to treat PSVT.

(c) B. The first step in treatment of unstable ventricula

tachycardia with a pulse is to cardiovert using a 100 J

countershock.


(u) D. Overdrive pacing is indicated in Torsades de

Pointes.

27. Clinical Therapeutics/Cardiology

Which of the following antiarrhythmic drugs can be associated with

hyper- or hypothyroidism following long-term use?

Answers

A. Quinidine

B. Amiodarone

C. Digoxin

D. Verapamil

Explanations


(c) B. Amiodarone is structurally related to thyroxine

and contains iodine, which can induce a hyper- or

hyp othyroid state.




Which of the following hypertensive emergency drugs has the potential

for developing cyanide toxicity?

Answers

A. Sodium nitroprusside (Nipride)

B. Diazoxide (Hyperstat)

C. Labetalol (Normodyne)

D. Alpha-methyldopa (Aldomet)

Explanations

(c) A. Sodium nitroprusside metabolization results in

cyanide ion production. It can be treated with sodium

thiosulfite, which combines with the cyanide ion to form

thiocyanate, which is nontoxic.





Contraindications to beta blockade following an acute myocardial

infarction include which of the following?Answers

A. Third degree A-V block

B. Sinus tachycardia

C. Hypertension

D. Rapid ventricular response to Atrial fibrillation/flutter

Explanations

(c) A. Beta blockade is contraindicated in second and

third heart block.(u) B. Beta blockade has been proven to be beneficial

sinus tachycardia, hypertension and in atrial fib/flutte

with a rapid ventricular response.




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A 74 year-old male is diagnosed with pneumonia. The physician

assistant should ensure the patient is not on which of the following

before starting therapy with clarithromycin (Biaxin)?

Answers

A. Lisinopril (Zestril)

B. Furosemide (Lasix)

C. Simvastatin (Zocor)

D. Dipyridamole (Persantine)

Explanations



(c) C. Statins are known to interact with the macrolides as

they may cause prolonged QT interval, myopathy and

rhabdomyolysis.



According to the recent JNC VII guidelines, a 34 year-old male who has

type 1 diabetes mellitus and hypertension should be started on

which type of antihypertensive agent?

Answers

A. Beta-blocker

B. Loop diuretic

C. ACE inhibitor

D. Thiazide diuretic

Explanations

(u) A. Beta blockers could potentially be harmful in a

patient with diabetes mellitus. Use a cardioselective beta-

blocker to reduce the incidence of hypoglycemia.


(c) C. ACE inhibitors are effective in young patients. They

are capable of providing protection to the kidn ey

especially in diabetes mellitus.



Which of the following beta-adrenergic blocking agents hascardioselectivity for primarily blocking beta-1 receptors?

Answers

A. Propranolol (Inderal)

B. Timolol (Blocadren)

C. Metoprolol (Lopressor)

D. Pindolol (Visken)

Explanations

(u) A. Propranolol and timolol are nonselective beta-adrenergic antagonists.


(c) C. Metoprolol is selective for beta-1 antagonists

(u) D. Pindolol is an antagonist with partial agonist activity

33. Scientific Concepts/Cardiology

Which of the following is the mechanism of action of Class III

antiarrhythmic drugs?

Answers

A. Na+ channel blocker

B. K+ channel blockerC. Beta adrenoreceptor blocker

D. Ca++ channel blocker

Explanations

(u) A. Na+ channel blockers are Class I.

(c) B. K+ channel blockers are Class II I.

(u) C. Beta adrenoreceptor blockers are Class II.

(u) D. Ca++ channel blockers are Class VI.


In congestive heart failure the mechanism responsible for the

production of an S3 gallop is

Answers

A. contraction of atria in late diastole against a stiffened ventricle.

B. rapid ventricular filling during early diastole.

C. vibration of a partially closed mitral valve during mid to late

diastole.

D. secondary to closure of the mitral valve leaflets during systole.

Explanations

(u) A. Atrial contraction against a noncompliant ventricle i

the mechanism responsible for S4.

(c) B. Rapid ventricular filling during early diastole is the

mechanism responsible for the S3.

(u) C. Vibration of a partially closed mitral valve during m

to late diastole is the mechanism responsible for the

Austin-Flint murmur of aortic regurgitation.

(u) D. Closure of the mitral valve leaflets during systole is

the mechanism responsible for part of the S1 heart soun


What is the most likely mechanism responsible for retinal

hemorrhages and neurologic complications in a patient with

infective endocarditis?

Answers

A. Metabolic acidosis

B. Systemic arterial embolization of vegetations

C. Hypotension and tachycardia

D. Activation of the immune system

Explanations


(c) B. The vegetations that occur dur ing infective

endocarditis can become emboli and can be d ispersed

throughout the arterial system.


(u) D. Glomerulonephr itis and arthritis result from

activation of the immune system.


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During an inferior wall myocardial infarction the signs and symptoms

of nausea and vomiting, weakness and sinus bradycardia are a result

of what mechanism?

Answers

A. Increased sympathetic tone

B. Increased vagal tone

C. Activation of the renin-angiotensin system

D. Activation of the inflammatory and complement cascade system

Explanations


(c) B. Increased vagal tone is common in inferior wall MI; i

the SA node is involved, bradycardia may develop.




Which of the following is the most common cause of secondary

hypertension?

A. Renal parenchymal disease

B. Primary aldosteronism

C. Oral contraceptive use

D. Cushing's syndrome

Explanations

(c) A. Renal parenchymal disease is the most common

cause of secondary hypertension.

(u) B. Primary aldosteronism can cause secondary

hypertension, but it is not the most common cause.

(u) C. Oral contraceptives can cause small increases in

blood p ressure but considerable increases are much less

common.

(u) D. Cushing's disease is a less common cause of

secondary hypertension.

38.

Clinical Therapeutics/CardiologyWhich of the following medication c lasses is the treatment of choice

in a patient with variant or Prinzmetal's angina?

A. Calcium channel blockers

B. ACE inhibitors

C. Beta blockers

D. Angiotensin II receptor blockers

Explanations(c) A. Calcium channel blockers are effective

prophylactically to treat coronary vasospasm associated

with variant or Prinzmetal's angina.

(u) B. ACE inhibitors are n ot a treatment for coronary

vasospasm.

(h) C. Beta blockers have been n oted to exacerbate

coronary vasospasm potentially leading to worsening

ischemia.

(u) D. Angiotensin II receptor blockers are not a treatmen

for coronary vasospasm.


11/63


A 63 year-old female with history of diabetes mellitus presents for blood

pressure follow-up. At her last two visits her blood pressure was 150/92

and 152/96. Today in the office her blood pressure is 146/92. Recent

blood work shows a Sodium 140 mEq/L, Potassium 4.2 mEq/L, BUN of 23

mg/dL, and Creatinine of 1.1 mg/dL. Which of the following is the most

appropriate initial medication in this patient?

A. Terazosin (Hytrin)

B. Atenolol (Tenormin)C. Lisinopril (Zestril)

D. Hydrochlorothiazide (HCTZ)

Explanations

(u) A. Alpha blockers are not the treatment of choice in

diabetic with hypertension.

(u) B. Patients with hypertension and d iabetes may

require a Beta blocker, but it should be added to an

ACE inhibitor

if the ACE inhibitor is ineffective on its own.

(c) C. ACE inhibitors should be part of the initial

treatment of hypertension in d iabetics because of beneficial effects in

diabetic nephropathy and is the most appropriate init

medication.

(u) D. Patients with hyp ertension and d iabetes mellitu

may require a diuretic, but it should be add ed to an

ACE

inhibitor if the ACE inhibitor is ineffective on its own.


What is the EKG manifestation of cardiac end-organ damage due to

hypertension?

A. Right bundle branch block

B. Left ventricular hypertrophy

C. Right ventricular hypertrophy

D. ST segment elevation in lateral precordial leads

Explanations

(u) A. Right bundle branch block is caused by a delay i

the conduction system in the right ventricle. It may be

caused by right ventricular hypertrophy or conditions

with higher pulmonic resistance such as cor pulmonal

Hypertension, however, is likely to cause changes in th

left ventricle rather than the right ventricle.

(c) B. Long-standing hypertension can lead to left

ventricular hypertrophy with characteristic changes

noted on EKG.

(u)C. See A for explanation.

(u) D. ST segment elevation is a sign of acute myocardia

infarction n ot hypertension.


Annual blood pressure determinations should be obtained beginning at

the age of

A. 3 years.

B. 5 years.

C. 12 years.

D. 18 years.

Explanations

(c) A. Periodic measurements of blood pressure should

be part of routine preventive health assessments

beginning at the age of 3 years.





Which of the following conditions would cause a positive Kussmaul's

sign on physical examination?

A. Left ventricular failure

B. Pulmonary edema

C. Coarctation of the aorta

D. Constrictive pericarditis

Explanations

(u) A. Left ventricular failure results in the back-up of

blood into the left atrium and then the pulmonary

system so it would not be associated with Kussmaul's

sign.

(u) B. Pulmonary edema primarily results in increased

pulmonary pressures rather than having effects on th

venous inflow into the heart.

(u) C. Coarctation of the aorta primarily affects outflow

from the heart du e to the stenosis resulting in delayed

and decreased femoral pulses; it has no effect on

causing Ku ssmaul's sign.

(c) D. Kussmaul's sign is an increase rather than the

normal decrease in the CVP during inspiration. It is mo

often caused by severe right-sided h eart failure; it is a

frequent finding in patients with constrictive pericardi

or right ventricular infarction.


12/63


Which of the following physical findings is suggestive of atrial septal defect?

A. Fixed split S2

B. Increased pulse pressure

C. Continuous mechanical murmur

D. Difference in blood pressure between the left and right arm

Explanations

(c) A. An atrial septal defect will cause a shun

of blood from the left to the right atrium. Th

will result in an equalization in the amount o

blood entering b oth the left and right

ventricles which effectively eliminates the

normally wide splitting that inspiration

typically causes in h earts without an atrial

septal defect.(u) B. Pulse pressures reflect the difference

aortic and left ventricular volumes that occu

during ventricular systole Increased pulse

pressures are seen in aortic regurgitation

which is a different entity than atrial septal

defect.

(u) C. Continuous mechanical murmurs are

noted in patients with patent ductus

arteriosus.

(u) D. Differences in blood pressure betwee

the left and r ight arms are seen in condition

such as coarctation of theaorta.


A 29 year-old male presents with complaint of substernal chest pain for 12 hours.

The patient states that the pain radiates to his shoulders and is relieved with

sitting forward. The patient admits to recent upper respiratory symptoms. On

examination vital signs are BP 126/68, HR 86, RR 20, temp 100.3 degrees F. There is

no JVD noted. Heart exam reveals regular rate and rhythm with no S3 or S4. There

is a friction rub noted. Lungs are clear to auscultation. EKG shows diffuse ST

segment elevation. What is the treatment of choice in this patient?

A. Pericardiocentesis

B. Nitroglycerin

C. Percutaneous coronary interventionD. Indomethacin (Indocin)

Explanations

(u) A. Pericardiocentesis is the treatment of

choice in a patient with a pericardial effusion

and cardiac tamponade, there is no evidenc

of either of these in this patient.

(u) B. Nitroglycerin is indicated in the

treatment of chest pain related to angina.

(u) C. Percutaneous coronory intervention i

the treatment of choice in a patient with an

acute myocardial infarction.

(c) D. Indomethacin, a nonsteroidal anti-inflammatory medication, is the treatment o

choice in a patient with acute

pericarditis.


A 24 year-old male presents for routine physical examination. On physical

examination, you find that the patient's upper extremity blood pressure is higher

than the blood pressure in the lower extremity. Heart exam reveals a late systolic

murmur heard best posteriorly. What is the most likely diagnosis in this patient?

A. Hypertrophic obstructive cardiomyopathy

B. Patent foramen ovale

C. Coarctation of the aorta

D. Patent ductus arteriosus

Explanations

(u) A. Patients with hypertrophic obstructive

cardiomyopathy do not present with

hypertension or weak femoral pulses.

(u) B. The murmur associated with patent

foramen ovale is a systolic ejection murmur

heard in the second and third intercostal

spaces and patients do not present with

hypertension.(c) C . Coarctation of the aorta commonly

presents with higher systolic pressures in th

upper extremities than the lower extremitie

and absent or weak femoral pulses.

(u) D. Patent ductus arteriosus is rare in

adults and patients are noted to have a

continuous rough, machinery murmur.


13/63


A 63 year-old female presents with a complaint of chest pressure for one

hour, noticed upon awakening. She admits to associated nausea,

vomiting, and shortness of breath. 12 lead EKG reveals ST segment

elevation in leads II, III, and AVF. Which of the following is the most likely

diagnosis?

A. Aortic dissection

B. Inferior wall myocardial infarction

C. Acute pericarditisD. Pulmonary embolus

Explanations

(u) A. A patient with aortic dissection will complain of

tearing, ripping pain. EKG is often normal, but may

reveal left ventricular strain pattern.

(c) B. Myocardial infarction often presents with ches

pressure and associated nausea and vomiting. ST

segment elevation in leads II, I II , and AVF are classic

findings seen in acute inferior wall myocardial

infarction.(u) C. Acute pericarditis presents with atypical chest

pain and d iffuse ST segment elevation.

(u) D. Pulmonary embolism often presents with eith

no EKG changes or sinus tachycardia. Classically

described,

rarely seen findings include a large S wave in lead I,

Q wave with T wave inversion in lead I II , ST segmen

depression in lead II , T wave inversion in leads V1-V

and a transient right bundle branch block.


A 12 month-old child with tetralogy of Fallot is most likely to have which

of the following cl inical features?

A. Chest pain

B. Cyanosis

C. Convulsions

D. Palpitations

Explanations

(u) A. Chest pain is not a feature of tetralogy of Fallo

(c) B. Cyanosis is very common in tetralogy of Fallot.

(u) C. Convulsions are occasionally seen as p art of

severe hypoxic spells in infancy rather than a featu

of tetralogy

of Fallot.

(u) D. Palpitations are uncommon in tetralogy of

Fallot.


A 23 year-old male presents with syncope. On physical examination you

note a medium-pitched, mid-systolic murmur that decreases with

squatting and increases with straining. Which of the following is the most

likely diagnosis?

A. Hypertrophic cardiomyopathy

B. Aortic stenosis

C. Mitral regurgitation

D. Pulmonic stenosis

Explanations

(c) A. Hypertrophic cardiomyopathy is characterized

by a medium- pitched, mid-systolic murmur that

decreases with squatting and increases with

straining.

(u) B. Straining decreases the intensity of the

murmur associated with aortic stenosis and squattin

increases the intensity.

(u) C. Mitral regurgitation is characterized by a

blowing systolic murmur that radiates to the axilla, it

not often associated with syncope.

(u) D. Pulmonic stenosis is a harsh systolic murmur

with a widely split S2, and no change with

maneuvers.


14/63


A patient with which of the following is at highest risk for

coronary artery disease?

A. Congenital heart disease

B. Polycystic ovary syndrome

C. Acute renal failure

D. Diabetes mellitus

Explanations

(u) A. Congenital heart disease is not an established r isk factor for


(u) B. While patients with polycystic ovary syndrome have

hyperinsulimemia, they do not have the same poor

prognosis for coronary artery disease as patients with diabetes

mellitus.

(u) C. Patients with acute renal failure are not at risk for coronary

artery disease, although patients with d iabetes andchronic renal disease do have this risk.

(c) D. Patients with diabetes mellitus are in the same risk category for

coronary artery disease as those patients with

established atherosclerotic disease.


Acute rebound hypertensive episodes have been reported

to occur with the sudden withdrawal of

A. verapamil (Calan).

B. l isinopril (Prinivil).

C. clonidine (Catapres).

D. hydrochlorothiazide (HCTZ)

Explanations

(u) A. Verapamil is a calcium channel blocker and there is no

associated rebound hyp ertension after withdrawal.

(u) B. Lisinopril is an ACE inhibitor, which is not associated with

rebound hypertension.

(c) C. Clonidine (Catapres) is a central alpha agonist and abrupt

withdrawal may produce a rebound hypertensive

crisis.

(u) D. Hydrochlorothiazide is a thiazide diuretic, which is not

associated with rebound hypertension.


15/63


A 38 year-old female with history of coarctation of the aorta repair at the age of two presents with fevers

for four weeks. The patient states that she has felt fatigued and achy during this time. Maximum

temperature has been 102.1 degrees F. She denies cough, congestion, or other associated symptoms.

Physical examination reveals a pale tired appearing female in no acute distress. Heart reveals a new grade

III-IV/VI systolic ejection border at the apex, and a II/VI diastolic murmur at the right sternal border.

What is the most likely diagnosis?

A. Acute myocardial infarction

B. Bacterial endocarditisC. Acute pericarditis

D. Restrictive cardiomyopathy

Explanations

(u) A. Acute MI

presents with

complaint of chest

pain, SOB, not with

fever and myalgias

(c) B. Bacterial

endocarditis

presents as febrileillness lasting sever

days to weeks,

commonly with

nonspecific

symptoms,

echocardiogram

often reveals

vegetations on

affected valves.

(u) C. Pericarditis

does not present

with systolic ordiastolic murmur o

vegetation, more

commonly

pericardial friction

rub would be note

(u) D. Restrictive

cardiomyopathy w

show impaired

diastolic filling on

echocardiogram an

is not associated wi

fever.


16/63


A 23 year-old female with history of palpitations presents for evaluation. She

admits to acute onset of rapid heart beating lasting seconds to minutes with

associated shortness of breath and chest pain. The patient states she can

relieve her symptoms with valsalva. Which of the following is the most

appropriate diagnostic study to establish a definitive diagnosis in this patient?

A. Cardiac catheterization

B. Cardiac MRI

C. Chest CT scanD. Electrophysiology study

Explanations

(u) A. Card iac catheterization evaluates coronar

arteries but has no role in the diagnosis of

supraventricular tachycardia.

(u) B. Cardiac MRI cannot diagnose and define

pathway of supraventricular tachycardia.

(u) C. Chest CT scan will not establish definitive

diagnosis of supraventricular tachycardia.

(c) D . Electrophysiology study is useful inestablishing the diagnosis and pathway of

complex arrh ythmias such as



Which of the following is the chief adverse effect of thiazide diuretics?

A. Hypokalemia

B. Hypernatremia

C. Hypocalcemia

D. Hypermagnesemia

Explanations

(c) A. Thiazide diuretics can induce electrolyte

changes. Principle among those is hypokalemia

(u) B. Hyponatremia, not hypernatremia may b

a complication of thiazide diuretics.

(u) C. Thiazide diuretics cause the retention of

calcium and would not cause hypocalcemia.

(u) D. Thiazide diuretics cause the retention of

calcium and do not readily affect magnesium

levels.


A 25 year-old male with history of syncope presents for evaluation. The patient

admits to intermittent episodes of rapid heart beating that resolve

spontaneously. 12 Lead EKG shows delta waves and a short PR interval. Which

of the following is the treatment of choice in this patient?

A. Radiofrequency catheter ablation

B. Verapamil (Calan)

C. Percutaneous coronary intervention

D. Digoxin (Lanoxin)

Explanations

(c) A. Radiofrequency catheter ablation is the

treatment of choice on patients with accessory

pathways, such as Wolff-Parkinson-White

Syndrome.

(h) B. Calcium channel blockers such as

verapamil decrease refractoriness of the

accessory pathway or increase that of the AV

node leading to faster ventricular rates,

therefore calcium channel blockers should be

avoided in patients with WPW.

(u) C. Percutaneous coronary intervention is

indicated in the treatment of coronary artery

disease, not preexcitation syndromes.

(h) D. Digoxin decreases refractoriness of the

accessory pathway and increases that of the AV

node leading to faster ventricular rates. It shou

therefore be avoided in patients with WPW.


A patient presents for a follow-up visit for chronic hypertension. Which of the

following findings may be noted on the fundoscopic examination of this

patient?

A. cherry-red fovea

B. boxcar segmentation of retinal veins

C. papilledema

D. arteriovenous nicking

Explanations

(u) A. Cherry-red fovea and boxcar

segmentation of the retinal veins are findings

seen in central retinal artery occlusion.

(u) B. See letter A for explanation.

(u) C. Papilledema is noted in conditions causing

increased intracranial pressure.

(c) D . Arteriovenous nicking is common in chron

hypertension.


17/63


Which of the following diagnostic tests should be ordered initially to evaluate for

suspected deep venous thrombosis of the leg?

A. Venogram

B. Arteriogram

C. Duplex ultrasound

D. Impedance plethysmography

Explanations

(u) A. Venogram has been replaced by

noninvasive tests due to discomfort, co

technical difficulties, and complications

such as phlebitis.

56

(h) B. Thrombophlebitis is a venous

problem, not an arterial one. Any

unnecessary invasive procedure ispotentially harmful.

(c) C. Ultrasound is the technique of

choice to detect deep venous thrombos

in the leg.

(a) D. Impedance plethysmography is

equivalent to ultrasound in detecting

thrombi of the femoral and popliteal

veins,

but it may miss early, nonocclusive

thrombi.


A 36 year-old patient with cardiomyopathy secondary to viral myocarditis develops

fatigue, increasing dyspnea, and lower extremity edema over the past 3 days. He

denies fever. A chest x-ray shows no significant increase in heart size, but reveals

prominence of the superior pulmonary vessels. Based on these clinical findings, which

of the following is the most likely diagnosis?

A. Heart failure

B. Subacute bacterial endocarditis

C. Pulmonary embolus

D. Pneumonia

Explanations

(c) A. Given the presence of

cardiomyopathy, the patient's heart ha

decreased functional reserve. The

symptoms and chest x-ray findings are

typical of congestive heart failure.

(u) B. Endocarditis occurs as a result of

infection that primarily occurs in the

blood stream. Endocarditis would

present with signs of infection or seedin

rather than signs of heart failure.

(u) C. Pulmonary embolus usually

presents with an acute onset of chest

pain, severe dyspnea, and anxiety.(u) D. Pneumonia is less likely since the

is no fever and edema is not usually

associated with pneumonia.


Which of the following is first-line treatment for symptomatic bradyarrhythmias due

to sick sinus syndrome (SSS)?

A. Permanent pacemaker

B. Radiofrequency ablation

C. Antiarrhythmics

D. Anticoagulation therapy

Explanations

(c) A. Permanent pacemakers are the

therapy of choice in patients with

symptomatic bradyarrhythmias in sick

sinus syndrome.

(u) B. Radiofrequency ablation is used

for the treatment of accessory pathway

in the heart. (u) C. See A for explanatio



18/63


What type of chest pain is most commonly associated with a dissecting aortic aneurysm?

A. Squeezing

B. Dull, aching

C. Ripping, tearing

D. Burning

Explanations

(u) A. Squeezing pain is more

characteristic of angina or

esophageal pain.

(u) B. Dull, aching pain is more

characteristic of chest wall pain,

possibly angina, or anxiety.

(c) C. A dissecting aortic aneurysm

often presents with a very severeripping, tearing-like pain.

(u) D. Burning pain is more

characteristic of esophageal reflux

esophagitis, or tracheobronchitis.


A 52 year-old obese female with a history of hypertension, tobacco abuse, and

hyperlipidemia presents for routine follow-up. Which of her risk factors for coronary

atherosclerosis is not modifiable?

A. Age

B. High LDL

C. Hypertension

D. Obesity

Explanations

(c) A. Age is a non modifiable risk

factor, as is family h istory of

premature coronary heart disease

(u) B. High LDL is a modifiable risk

factor, as is Hypertension, low HD

obesity, tobacco abuse, physical

inactivity




An 8 year-old boy is brought to a health care provider complaining of dyspnea and fatigue.

On physical examination, a continuous machinery murmur is heard best in the second left

intercostal space and is widely transmitted over the precordium. The most likely diagnosis

is

A. ventricular septal defect.

B. atrial septal defect.

C. congenital aortic stenosis.

D. patent ductus arteriosus.

Explanations

(u) A. Ventricular septal defect

causes a holosystolic murmur

rather than a continuous

machinery-like murmur.

(u) B. Atrial septal defect causes a

fixed split S2 rather than a

continuous systolic heart murmur

(u) C. Congenital aortic stenosis

causes a crescendo-decrescendo

systolic murmur heard best in the

second

intercostal space.

(c) D. Patent ductus arteriosus is

classically described in children as

continuous machinery-type

murmur that is

widely transmitted across the

precordium.


19/63


20/63


Which of the following medications used in the treatment of

supraventricular tachycardia is able to cause sinus arrest and

asystole for a few seconds while it breaks the paroxysmal

supraventricular tachycardia?

A. Digoxin (Lanoxin)

B. Adenosine (Adenocard)

C. Verapamil (Calan)

D. Quinidine (Quinaglute)

Explanations

(u) A. Digoxin is not used for the acute termination of


(c) B. Adenosine is an endogenous nucleoside that results in

profound (although transient) slowing of the AV

conduction and sinus node discharge rate. This agent has a very

short half-life of 6 seconds.

(u) C. Although verapamil may be used for the termination of

acute supraventricular tachycardia, it does not lead tosinus arrest in therapeutic doses.

(u) D. Quinidine is rarely used today and is not indicated for the

termination of supraventricular tachycardia.


An elderly female presents for evaluation of exertional

syncope, dyspnea, and angina. She admits that previous to

these symptoms she had insidious progression of fatigue that

caused her to curtail her activities. Which of the following is

the most likely diagnosis?

A. Aortic stenosis

B. Aortic regurgitation

C. Mitral stenosis

D. Mitral valve prolapse

Explanations

(c) A. The major symptoms of aortic stenosis are exertional syncop

dyspnea, and angina. Symptoms do not become apparent for a

number of years and usually are not present until the valve is

narrowed to less than 0.5 cm to 2 cm of valve surface area.

(u) B. Patients with aortic regurgitation are likely to complain of an

uncomfortable awareness of their heart, especially when lying

down. These patients develop sinus tachycardia with exertion an

complain of palpitations and head pounding with activity.

(u) C. The symptoms related to mitral stenosis are related to

increased pulmonary pressure after the left atrium can no longe

overcome the outflow obstruction.

(u) D. Patients with mitral valve prolapse are typ ically

asymptomatic throughout their lives, although a wide range of

symptoms is possible. When symptoms do occur, p alpitations from

arrhythmias are most common along with lightheadedness.

Syncope is not part of this disease process.


Which of the following would you expect on physical

examination in a patient with mitral valve stenosis?

A. Systolic blowing murmur

B. Opening snap

C. Mid-systolic click

D. Paradoxically split S2

Explanations

(u) A. Mitral stenosis is a diastolic, not a systolic murmur.

(c) B. Mitral stenosis is characterized by a mid-diastolic opening

snap.

(u) C. Mid-systolic clicks are noted in mitral valve prolapse, not

mitral stenosis.

(u) D. Paradoxical splitting of S2 occurs in aortic stenosis not mitra

stenosis.


Which of the following is the most common cause for acute

myocardial infarction?

A. Occlusion caused by coronary microemboli

B. Thrombus development at a site of vascular injury

C. Congenital abnormalities

D. Severe coronary artery spasm

Explanations

(u) A. Coronary microemboli occlusion is a rare cause of acute

myocardial infarction.

(c) B. Acute myocardial infarction occurs when a coronary artery

thrombus develops rapidly at a site of vascular

injury. In most cases, infarction occurs when an atherosclerotic

plaque fissures, ruptures, or ulcerates and when conditions favo

thrombogenesis, so that a mural thrombus forms at the site of

rupture and leads to coronary artery occlusion.

(u) C. Congenital abnormalities are rare causes of acute MI.

(u) D. Severe coronary artery spasm is more likely to result in

Prinzmetal's angina rather than true infarction.


21/63


A 78 year-old male with history of coronary artery disease status post CABG and ischemic cardiomyopathy

presents with complaint of progressive dyspnea and orthopnea. He also complains of lower extremity

edema. The patient denies fever, chest pain, or cough. On physical examination, vital signs are BP 120/68,

HR 75 and regular, RR 22, afebrile. You note the patient to have an S3 heart sound, jugular venous

distention, and 2+ lower extremity edema. The patient is admitted and treated. Upon discharge from the

hospital, the patient should be educated to monitor which of the following at home?

A. Daily weights

B. Daily spirometryC. Daily blood glucose

D. Daily fat intake

Explanations

(c) A. Home

monitoring of dail

weights can alert

the health care

provider to the

early recognition o

worsening heart

failure.(u) B. Spirometry

monitoring is

important in a

patient with

asthma, not heart

failure.

(u) C. Daily blood

glucose monitorin

is important in a

patient with

diabetes, not hea

failure.(u) D. Daily fat

intake is importan

but will not impro

his heart failure

management.


Which of the following is the most common cause of arterial embolization?

A. Rheumatic heart disease

B. Myxoma

C. Atrial fibrillation

D. Venous thrombosis

Explanations

(u) A. Rheumatic

heart disease is a

rare cause of

embolization

(u) B. Myxoma is a

rare cause of embolization.

(c) C. Atrial

fibrillation is

present in 60-70%

of patients with

arterial emboli an

is associated with

left atrial

appendage

thrombus.

(u) D. Venous

thrombosis may ba cause of

embolization

paradoxically, bu t

uncommon.


22/63


The most common arrhythmia encountered in patients with mitral stenosis is

A. atrial flutter.

B. atrial fibrillation.

C. paroxysmal atrial tachycardia.

D. atrio-ventricular dissociation.

Explanations


(c) B. Mitral stenosis leads to enlargement of

the left atrium, which is the major

predisposing risk factor for the

development of atrial fibrillation.




Long term use of which of the following drugs may cause a drug-induced lupus-

type eruption?

A. prednisone

B. tetracycline

C. procainamide

D. oral contraceptives

Explanations

(u) A. Prednisone is not implicated in drug-

induced skin reactions.

(u) B. Tetracycline and sulfonamides are

known to cause a photosensitive rash on su

exposed areas of the skin.

(c) C. Procainamide and hydralazine are the

most common drugs that may cause a lupu

like eruption.

(u) D. Oral contraceptives may induce

erythema nodosum.

73.

Scientific Concepts/CardiologyWhich of the following is a cause of high output heart failure?

A. myocardial ischemia

B. complete heart block

C. aortic stenosis

D. thyrotoxicosis

Explanations(u) A. Low output heart failure occurs

secondary to ischemic heart disease,

hypertension, dilated cardiomyopathy,

valvular and pericardial disease, and

arrhythmia.



(c) D. High output heart failure occurs in

patients with reduced systemic vascular

resistance. Examples include: thyrotoxicosis

anemia, pregnancy, beriberi and Paget's

disease. Patients with high output heart

failure usually have normal pump function

but it is not adequate to meet the high

metabolic demands.


A 46 year-old male with no past medical history presents complaining of chest

pain for four hours. The patient admits to feeling very poorly over the past two

weeks with fever and upper respiratory symptoms. The patient denies shortness

of breath or diaphoresis. On examination the patient appears fatigued. Vital signs

reveal a BP of 130/80, HR 90 and regular, RR 14. The patient is afebrile. Labs reveal a

Troponin I of 10.33 ug/L (0-0.4ug/L). Cardiac catheterization shows normal

coronary arteries and an ejection fraction of 40% with global hypokinesis. Which

of the following is the most likely diagnosis?

A. myocarditis

B. pericarditis

C. hypertrophic cardiomyopathy

D. coronary artery disease

Explanations

(c) A. Myocarditis often occurs secondary to

acute viral illness and causes cardiac

dysfunction. Patients will commonly have a

history of a recent febrile illness. Chest pain

may mimic that of a myocardial infarction an

Troponin I levels maybe elevated in one-

third of patients. Contractile dysfunction is

seen on catheterization and/or

echocardiogram.

(u) B. Pericarditis does not typically cause

ventricular dysfunction and cardiac enzym

are usually n ormal.

(u) C. Hypertrophic cardiomyopathy is

associated with ventricular hypercontractili

(u) D. This patient had normal coronary

arteries on cardiac catheterization, no signs



23/63


Which of the following antihypertensive agents is considered to have both

alpha- and beta-blocker activities?

A. carvedilol (Coreg)

B. hydralazine (Apresoline)

C. minoxidil (Loniten)

D. spironolactone (Aldactone)

Explanations

(c) A. Carvedilol has both alpha- and b eta-

blocker activities.

(u) B. Hydralazine and minoxidil are

considered vasodilators.


(u) D. Spironolactone is a potassium-sparing

diuretic.


A 12 year-old boy presents to the office with pain in his legs with activity

gradually becoming worse over the past month. He is unable to ride a bicycle

with his friends due to the pain in his legs. Examination of the heart reveals an

ejection click and accentuation of the second heart sound. Femoral pulses are

weak and delayed compared to the brachial pulses. Blood pressure obtained in

both arms is elevated. Chest x-ray reveals rib notching. Which of the following is

the most likely diagnosis?

A. abdominal aortic aneurysm

B. pheochromocytoma

C. coarctation of the aorta

D. thoracic outlet syndrome

Explanations

(u) A. Abdominal aortic aneurysm is usually

asymptomatic until the patient has dissection

or rupture. I t is uncommon in a child.

(u) B. Pheochromocytoma classically causes

paroxysms of hyp ertension due to

catecholamine release from the adrenal

medulla, but does not cause variations in bloo

pressure in the upper and lower extremities.

(c) C. Coarctation is a discrete or long segment

of narrowing adjacent to the left subclavian

artery. As a result of the coarctation, systemic

collaterals develop. X-ray findings occur from

the d ilated and pulsatile intercostal arteries

and the "3" is due to the coarctation site with

proximal and distal dilations.

(u) D. Thoracic outlet syndrome occurs when

the brachial plexus, subclavian artery , or

subclavian vein becomes compressed in the

region of the thoracic outlet. It is the most

common cause of acute arterial occlusion in th

upper extremity of adults under 40 years old


According to the recent JNC VII guidelines, a 34 year-old male who has type 1

diabetes mellitus and hypertension should be started on which type of

antihypertensive agent?

A. beta-blocker

B. loop diuretic

C. ACE inhibitor

D. thiazide diuretic

Explanations

(u) A. Beta blockers could potentially be

harmful in a patient with diabetes mellitus. Us

a cardioselective beta- blocker to reduce the

incidence of hypoglycemia.


(c) C. ACE inhibitors are effective in young

patients. They are capable of providing

protection to the kidney especially in diabete

mellitus.



24/63


A patient presents with moderate mitral stenosis. Which of the

following complications is associated with an increased risk of

systemic embolization in this patient?

A. atrial fibrillation

B. pulmonary hypertension

C. increased left atrial pressure

D. left ventricular dilatation

Explanations

(c) A. 50-80% of patients with mitral stenosis will develop

paroxysmal or chronic atrial fibrillation; 20-30% of patients with

atrial fibrillation will hav e systemic embolization.

(u) B. Pulmonary hypertension can occur in patients with sever

mitral stenosis with symptoms of low cardiac output and right

sided heart failure. Pulmonary hypertension does not cause

systemic embolization.

(u) C. Patients with mitral stenosis can have increased left atrialpressures relative to the left ventricular diastolic pressures; this

does not usually cause systemic embolization.

(u) D. Left ventricular dilatation is more common in aortic valve

disease than mitral valve disease.


A 19 year-old female presents with complaint of palpitations.

On examination you note the patient to have particularly long

arms and fingers and a pectus excavatum. She has a history of

joint dislocation and a recent ophthalmologic examination

revealed ectopic lentis. Which of the following echocardiogram

findings would be most consistent with this patient's physical

features?

A. right atrial enlargement B. aortic root dilation

C. pulmonic stenosis

D. ventricular septal defect

Explanations

(u) A. Patients with Marfan's syndrome commonly have mitral

valve p rolapse and possibly aortic regurgitation. Right atrial

enlargement, pulmonic stenosis and ventricular septal defect a

not commonly seen.

(c) B. This patient has the signs and symptoms consistent with

Marfan's syndrome. Ectopia lentis, aortic root dilation and aortic

dissection are major criteria for the diagnosis of the disease.

(u) C. See A for explanation. (u) D. See A for explanation.


A patient presents with chest pain. ECG done in the emergency

department reveals ST segment elevation in leads II, III, and

AVF. This is most consistent with a myocardial infarction in

which of the following areas?

A. anterior wall

B. inferior wall

C. posterior wall

D. lateral wall

Explanations

(u) A. Anterior wall myocardial infarction is characterized by ST

segment elevation in 1 or more of the precordial (V1- V6) leads.

(c) B. Inferior wall myocardial infarction is characterized by ST

segment elevation in leads II , III , and AVF.

(u) C. Posterior wall myocardial infarction is characterized by ST

segment depression in leads V1-V3 and a large R wave in leads

V1-V3.

(u) D. Lateral wall myocardial infarction is characterized by ST

segment elevation in leads I and AVL.


Which of the following is an absolute contraindication to

thrombolytic therapy in a patient with an acute ST segment

elevation myocardial infarction?

A. history of severe hypertension presently controlled B.

current use of anticoagulation therapy

C. previous hemorrhagic stroke

D. active peptic ulcer disease

Explanations



(c) C . Absolute contraindications to thrombolytic therapy includ

a previous hemorrhagic stroke, a stroke within one year, a

known intracranial neoplasm, active internal bleeding, and a

suspected aortic dissection. Severe, but controlled hypertensio

use of anticoagulation, and active peptic ulcer disease are relati

contraindications in which the risk/benefit ratio must be weighe

in each patient.



A postmenopausal woman is at greatest risk of death from

which of the following?

A. stroke

B. heart disease

C. ovarian cancer

D. breast cancer

Explanations


(c) B. Although women tend to be concerned about dy ing from

breast cancer, heart disease is the number one k iller of

postmenopausal women.




25/63


A 46 year-old female is being evaluated for a new-onset hypertension that was

discovered on screening at her workplace. The patient had several readings

revealing systolic and diastolic hypertension. Patient is currently on no

medications. Physical examination is unremarkable. A complete laboratory

evaluation revealed hypokalemia as the only abnormality. Which of the

following is the most likely diagnosis for this patient?

A. pheochromocytoma

B. renal artery stenosisC. coarctation of the aorta

D. primary aldosteronism

Explanations

(u) A. Pheochromocytoma will result in an

increase in the production and release of

catecholamines, which results in an increase in

urinary metanephrines on testing.

(u) B. Renal artery stenosis is identified by an

abnormal radionuclide uptake on the affected

kidney.

(u) C. Coarctation of the aorta is identified bydelayed and weakened femoral pulses along

with a blood pressure in the lower extremities

significantly lower than in the upper extremitie

(c) D. Primary aldosteronism has an increased

aldosterone secretion, which causes the

retention of sodium and the loss of potassium.

This should be the primary consideration for th

patient.


A 54 year-old female who has diabetes presents with rubor, absence of hair,

and brittle nails of her left foot. She complains of leg pain that awakens her at

night. Examination reveals a femoral bruit with diminished popliteal and

pedal pulses on the left side. The most appropriate therapy would be

A. vasodilator therapy.

B. bypass surgery.

C. exercise program.

D. embolectomy.

Explanations

(u) A. Vasodilator therapy is not indicated.

(c) B. Bypass surgery is indicated in the presen

of rest pain and provides relief of symptoms in

80 to 90% of patients.

(u) C. While an exercise program is appropriate

with claudication, rest pain is a surgical

indication.

(u) D. Embolectomy is used for acute arterial

occlusion.


Which electrolyte abnormality is associated with an increase in the risk for

digoxin toxicity?]

A. hypercalcemia

B. hypokalemia

C. hypermagnesemia

D. hyponatremia

Explanations


(c) B. Decreased concentration of potassium

results in the increased activity of cardiac

glycosides by increasing tissue b inding and

decreasing renal excretion of digoxin. Potassiu

loss is the only significant electrolyte abnormali

that significantly affects digoxin metabolism.




A 56 year-old male, status post myocardial infarction, is noted to have left

ventricular hypertrophy and an ejection fraction of 38%. Which of the

following medications should be prescribed to prevent the development of

heart failure symptoms?

A. amlodipine (Norvasc)

B. furosemide (Lasix)

C. hydrochlorothiazide (HCTZ)

D. lisinopril (Zestril)

Explanations

(u) A. See D for explanation.

(u) B. See D for explanation.

(u) C. See D for explanation.

(c) D. ACE inhibitors have been shown to

markedly improve survival and are also

recommended for prevention of symptoms in

patients at risk for heart failure.


26/63


A 74 year-old patient presents with signs and symptoms of heart failure. EKG shows the

patient to be in atrial fibrillation at a rate of 80 bpm. Blood pressure is 120/76. The

patient denies complaint of palpitations, chest pain, or syncope. Which of the

following is the most important long term therapy in this patient?

A. verapamil (Calan)

B. amiodarone (Cordarone)

C. furosemide (Lasix)

D. warfarin (Coumadin)

Explanations

(u) A. Calcium channel blockers are

utilized in rate control of atrial

fibrillation. This patient's rate is

controlled at 80bpm presently.

(u) B. Antiarrhythmic therapy may be

considered in patients with atrial

fibrillation; however anticoagulation

therapy must occur first.(u) C. Diuretics may be indicated in th

acute treatment of heart failure;

however they may not be needed lon

term.

(c) D . Patients with atrial fibrillation ha

an increased r isk for stroke, therefore

these patients need anticoagulation

with warfarin to an INR of 2.0-3.0.


Which of the following ECG findings is consistent with hyperkalemia?

A. prolonged QT interval

B. delta wave

C. peaked T waves

D. prominent U waves

Explanations

(u) A. Prolonged QT interval is seen in

hypocalcemia.

(u) B. Delta wave is a sign of ventricula

preexcitation seen in Wolf-Parkinson-

White (WPW) Syndrome.

(c) C. Narrowing and peaking of T

waves are the beginning EKG change

associated with hyperkalemia.

(u) D. Prominent U waves are a sign of

prolonged ventricular repolarization

seen in hypokalemia.


A 58 year-old male presents with chest pain. Vital signs include blood pressure of

210/175, pulse 80, RR 20. Which of the following would you expect to find on physical

examination?

A. papilledema

B. carotid bruit

C. diastolic murmur

D. absent peripheral pulses

Explanations

(c) A. Malignant hypertension is

characterized by marked blood

pressure elevation with papilledema,

often with encephalopathy or

nephropathy.

(u) B. Carotid bruits are associated wit

carotid artery stenosis.

(u) C. Diastolic murmurs are associated

with valvular heart disease such as

aortic regurgitation and mitral stenosi

(u) D. Peripheral pulses are absent in

acute arterial occlusion or severe

periph eral arterial disease.


27/63


A 55 year-old diabetic female presents for a 3 month blood pressure follow-

up. At the last visit the BP was 160/90 for the third consecutive visit. She was

placed on an ACE inhibitor and educated regarding lifestyle modifications. At

today's visit the patient complains of persistent annoying dry cough that has

been going on since the last visit. BP today is 120/70. What is the best

recommendation to control her BP?

A. add a diuretic

B. stop the ACE inhibitor and continue lifestyle modificationsC. switch patient to an Angiotensin II Receptor Blocker (ARB)

D. do nothing and recheck BP in 3 months

Explanations

(u) A. This patient's blood pressure is controlled;

there is no indication at this time to add an

additional drug.

(u) B. This patient's chronic dry cough is likely

secondary to the ACE inhibitor, the medication

should be stopped, however the patient needs

something for blood pressure control.

(c) C. This patient's chronic dry cough is likelysecondary to the ACE inhibitor, the medication

should be stopped. Angiotensin II Receptor

Blockers (ARBs) are similar to ACE inhibitors for B

control, but do not cause cough.

(u) D. This patient's chronic dry cough is likely

secondary to the ACE inhibitor, the medication

should be stopped to encourage compliance.


A newborn is seen for an initial two week visit. Physical examination reveals a

thrill and a continuous machinery murmur in the left second intercostal

space. Which of the following is the most likely diagnosis?

A. patent ductus arteriosus

B. ventricular septal defect

C. tetralogy of Fallot

D. coarctation of the aorta

Explanations

(c) A. Patent ductus arteriosus is characterized by

a classic harsh, machinery-like murmur that is

continuous through systole and diastole. This is

heard best at the left second interspace and is

commonly associated with a thrill.

(u) B. Ventricular septal defect is characterized by

a holosystolic murmur at the lower left sternal

border.

(u) C. Tetralogy of Fallot is characterized by a

systolic thrill at the left sternal border with a

systolic ejection murmur that may or may not ha

an associated systolic click.

(u) D. Coarctation of the aorta is associated with a

systolic ejection click or a short systolic murmur a

the left sternal border.


A patient had an acute inferior, transmural myocardial infarction 4 days ago.

A new murmur raises the suspicion of mitral regurgitation due to papillary

muscle rupture. Which of the following murmur descriptions describes this

condition?

A. A grade III/VI diastolic murmur heard best at the apex without radiation.

B. A grade IV/VI systolic ejection murmur heard best at the base with

radiation to the left clavicle.

C. A grade II/VI systolic murmur heard best at the apex preceded by a click

and without radiation.

D. A grade IV/VI systolic murmur heard best at the apex with radiation to the

left axilla.

Explanations

(u) A. This is a classic description of mitral stenosi

(u) B. This is a classic description for pulmonic

stenosis.

(u) C. This is a classic description for mitral valve

prolapse.

(c) D. This is a classic description of mitral

regurgitation. The papillary muscle rupture is a

complication of an acute inferior transmural

myocardial infarction, and results in a failure of

the mitral valve leaflets to close. The direction of

regurgitant flow of blood is toward the left axilla.


A 58 year-old male who is otherwise healthy presents with chest pain and is

found to have left main coronary artery stenosis of 75%. The most important

aspect of his management now is

A. daily aspirin to prevent MI.

B. nitrate therapy for the angina.

C. aggressive risk factor reduction.

D. referral for coronary artery revascularization.

Explanations

(u) A. See D for explanation.

(u) B. See D for explanation.

(u) C. See D for explanation.

(c) D. Although medical therapy is important,

revascularization is indicated when stenosis of th

left main coronary artery is greater than 50%.


28/63


A 17 year-old woman presents to the office with recurrent episodes of

palpitations and near syncope. Initial ECG was normal. She is concerned about

these episodes since they can occur at any time. Which of the following is the

most appropriate step to pursue in her evaluation?

A. cardiac catheterization

B. tilt table testing

C. echocardiogram

D. Holter monitoring

Explanations

(u) A. A cardiac catheterization will not be

useful since the patient is at low risk for actua


(u) B. Tilt table testing is useful only in trying t

determine vasodepressor syncope that is

related to position.

(u) C. An echocardiogram shows valves and le

ventricle function, not pathways of conductio(c) D. Holter monitoring will identify the heart

rhythm; an event recorder may also be usefu

in this setting if the Holter monitor is not

diagnostic.


A 37 year-old female with history of Turner's syndrome and coarctation of the

aorta repaired at the age of 3 presents for routine examination. The patient is

without complaints of chest pain, dyspnea, palpitations, or syncope. On

exam

packrat cardio questions

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