Cardiovasc

Question 1

A 47-year-old woman with a history of tobacco abuse and ulcerative colitis is evaluated for
intermittent palpitations. She reports that for the last 6 months, every 2–4 days she notes a
sensation of her heart “flip-flopping” in her chest for approximately 5 minutes. She has not noted any
precipitating factors and has not felt light headed or had chest pains with these episodes. Her
physical examination is normal. A resting ECG reveals sinus rhythm and no abnormalities. Aside
from checking serum electrolytes, which of the following is the most appropriate testing?

Answer 1

b. Event monitor;

Question 2

A mediastinal mass is found incidentally on the chest radiograph of a 65-year-old female
non-smoker who is otherwise healthy, with no significant past medical history. Which option would
you recommend to this patient at this time?

Answer 2

4. CT scan of the chest;

Question 3

A 22-year-old male involved in a motorcycle accident presents to A&E with a fractured femur and,
following fixation, is noted to have become disorientated with several areas of petechial
haemorrhage. Choose and match the correct diagnosis causing the above-mentioned changes:

Answer 3

2. Fat embolism;

Question 4

A 75-year-old man presents to your emergency department appearing quite ill. His family says he
has not had his normal energy for the last 6 months, and they noted he was confused and lethargic
for the last day or two. As you take a history from the family, you palpate the patient’s radial pulse
and notice a regular beat-to-beat variability of pulse amplitude, although his rhythm is regular.
Indeed, as you later take his blood pressure, you note that only every other phase I (systolic)
Korotkoff sound is audible as the cuff pressure is slowly lowered and that this is independent of the
respiratory cycle. Based on this, you suspect this patient has which of the following?
Select one:

Answer 4

a. Severe left ventricular dysfunction;

Question 5

Which of the following statements are true?

Answer 5

4. Intermittent claudication distance is usually inconsistent on a day-to-day basis for a given patient;

Question 6

You are caring for a 45-year-old man in the cardiac intensive care unit. He presented with chest pain
and initially was thought to have the acute coronary syndrome, prompting initiation of antiplatelet
agents and IV heparin. After complete assessment and the return of negative serial cardiac
enzymes, it became clear that he instead had acute pericarditis. Shortly after admission to the
cardiac intensive care unit, he becomes hypotensive with elevated neck veins. His lungs are clear to
auscultation. His extremities are cool, and you note that his brachial pulse is only palpable during
expiration. What is the most likely diagnosis?

Answer 6

2. Cardiac tamponade;

Question 7

What is a modern method to identify bronchiectasis

Answer 7

2. CT scan;

Question 8

Which of the following statements is false?

Answer 8

2. The left lung has more lobes and segments than the right lung;

Question 9

You are caring for a 42-year-old woman with a prior history of rheumatic fever and resultant mitral
stenosis. Her valvular disease is currently moderate. You know that mitral stenosis causes an
elevation in left atrial pressure, which over time can cause cardiogenic pulmonary edema and
pulmonary hypertension. All of the following will result in an elevation of left atrial pressure and
potential worsening of lung function EXCEPT:

Answer 9

3. Metoprolol

Question 10

Which of the following regarding amputations is true?

Answer 10

Select one:
1. Toe amputations usually heal well in diabetics;

Question 11

A 65-year-old former factory worker with a past medical history of rheumatoid arthritis presents to
your primary care clinic complaining of fatigue. She also states that she has the following symptoms:
constipation, constantly feeling cold even when the thermostat is set at 80°F, brittle hair, and some
lower extremity swelling. You expeditiously measure her thyroid-stimulating hormone, which is
greatly elevated at 79.4 mIU/L. Regarding the present condition of her cardiovascular system, you
expect a decrease in all of the following measurements EXCEPT:

Answer 11

4. QT interval

Question 12

Which of the following statements regarding the restoration of sinus rhythm after atrial fibrillation is
true?

Answer 12

2. In patients who are treated with pharmacotherapy and are found to be in sinus rhythm, a
   prolonged Holter monitor should be worn to determine if anticoagulation can be safely stopped.

Question 13

Which of the following statements regarding blood pressure measurements is true?

Answer 13

1. Systolic pressure increases and diastolic pressure decreases when measured in more distal
   arteries.

Question 14

Initial treatment of spontaneous unspecified pneumothorax is

Answer 14

pleural puncture and one time aspiration of air

Question 15

Mr. Hoffman, an 82-year-old former tightrope performer, presents to your office for complaints of
syncope. He states that twice in the past week, he has spontaneously passed out with no warning
symptoms. Once, he struck his face, and you note that he has periorbital ecchymosis on exam.
Other than this, you find nothing abnormal on examination. You request an ECG and step out of the
room to begin your documentation. Shortly thereafter, your medical assistant requests your urgent
presence in Mr. Hoffman’s clinic room. He had another “spell” during the ECG and lost
consciousness. Serendipitously, the medical assistant captured the spell on ECG, pictured in Figure
below. What type of AV block is present and is matched to the appropriate treatment or diagnostic
test?

Answer 15

a. Second-degree Mobitz type II AV node block – Permanent pacemaker implantation

Question 16

After reading the information booklet about his proposed procedure, an anxious 45-year-old female patient has consented for a procedure is worried about the post-procedural complications of pain and possible rib fractures. What procedure is this patient planned to have?

Answer 16

1. Thoracotomy;

Question 17

You are asked to evaluate a 27-year-old internal medicine resident reporting 1 week of cough,
coryza, and a low-grade fever. Today, he has developed rapidly escalating chest discomfort while in
clinic. He notes that the pain becomes more intense when he takes a deep breath. You perform a
standard 12-lead ECG (see Figure). On examination, his blood pressure is normal, he is afebrile,
and his jugular venous pulse is not elevated. However, he appears mildly uncomfortable from the
chest pain. The next most appropriate step would be which of the following?

Answer 17

d. Prescribe ibuprofen and colchicine;

Question 18

Which one of these statements is false?

Answer 18

4. Stanford types A and B aortic dissection require emergency repair;

Question 19

A 40-year-old IV drug abuser presents with fevers, breathlessness and pain in his right buttock. His
temperature is 38oC and examination reveals marked mottling over the right gluteal area and thigh.
He has a grade V aortic murmur. Choose and match the correct diagnosis causing the
above-mentioned changes:

Answer 19

3. Mycotic embolism;

Question 20

Which of the following is not indicative for major amputation?

Answer 20

3. Neurofibroma

Question 21

An 18-year-old man with no prior past medical history presents for his required medical assessment
before beginning his freshman year at the local university. His history and examination uncover no
concerning symptoms or signs. However, his ECG shows an irregular rhythm and is pictured in
Figure below. What is the most appropriate next step?

Answer 21

Reassurance;

Question 22

You are taking care of a patient with cor pulmonale in the medical intensive care unit. Unfortunately,
he suffered a respiratory arrest at home and requires intubation and mechanical ventilation.
Currently, with a tidal volume of 500 mL, FiO2 of 0.4, positive end-expiratory pressure of 20
mmHg, and respiratory rate of 20, his pH is 7.40, PCO2 is 40 mmHg, and oxygen saturation is
86%. You are concerned about the afterload experienced by his right ventricle. All of the
following are likely to increase his right ventricular afterload EXCEPT:

Answer 22

1. Increasing FiO2 to increase arterial oxygen saturation to 95%;

Question 23

Which of the following statements is false?

Answer 23

2. ABPI means ‘ankle-brachial pulsatility index;

Question 24

You are taking care of a 77-year-old patient with severe aortic stenosis in the cardiac intensive care
unit. Surgical aortic valve replacement is planned for tomorrow. However, suddenly, he becomes
severely short of breath and manifests signs of acute pulmonary edema. On auscultation, you
can now appreciate a soft, short apical systolic murmur (in addition to his previously appreciated
murmur of aortic stenosis) that was not present previously. You suspect that he has suffered a
ruptured mitral valve chordae and now has severe, acute mitral regurgitation. Which of the
following parameters will likely increase due to his new severe mitral regurgitation?

Answer 24

Ejection fraction

Question 25

From a pathophysiologic perspective, all of the following are upregulated in heart failure with reduced ejection fraction EXCEPT:

Answer 25

Calcium uptake into the sarcoplasmic reticulum;

Question 26

A 22-year-old college student with no past medical history was seen in the urgent care clinic 3 days ago for coryza, myalgias, cough, and fever, which was typical of the viral upper respiratory illness making its way through the campus. He was given a cough suppressant and antipyretics and advised to remain hydrated. Today, he presents to the emergency department with lethargy and fatigue. He is obtunded with a heart rate of 120 bpm and blood pressure of 78/62 mmHg. His extremities are cool, and the jugular venous pulse is elevated nearly to the mandible. Precordial auscultation reveals very quiet heart sounds, an S3 gallop, and a soft murmur of mitral regurgitation. An emergent transthoracic echocardiogram shows no pericardial effusion, a non-dilated left ventricle with an ejection fraction of 30%, and mild mitral regurgitation. Endomyocardial biopsy shows lymphocytic myocarditis. Which of the following statements regarding this patient's prognosis and implications for therapy are true?

Answer 26

His chance of survival is <10% without cardiac transplantation. Emergent transplant listing is warranted;

Question 27

A 59-year-old male presents to A&E with paralysis and paraesthesia of his lower limbs. On examination, there are no femoral pulses and he has mottling of the skin of the lower abdomen. Choose and match the correct diagnosis causing the above-mentioned changes:

Answer 27

Acute aortic thrombosis;

Question 28

All of the following clinical conditions are associated with orthopnea EXCEPT:

Answer 28

Hepatopulmonary syndrome;

Question 29

You are following a 57-year-old man who suffered a large anterior myocardial infarction 8 months ago. Despite a late presentation to medical care (>5 hours after chest pain onset), he underwent primary coronary intervention with the excellent angiographic result. After that stay in the hospital, he has been followed by you regularly and maintains excellent medication compliance. Today, his heart rate is 65 bpm, and blood pressure is 104/82 mmHg. He looks quite well and reports absolutely no symptoms, even during a recent elk hunting trip requiring long days of hiking up and downhills. His medications are aspirin, clopidogrel, atorvastatin, carvedilol, and valsartan. His ECG shows sinus rhythm, with a right bundle branch block and QRS duration of 135 msec. Echocardiography today shows an ejection fraction of 25% with a large area of anterior dyskinesis consistent with an aneurysm. Which of the following therapies is indicated to reduce this patient's mortality?

Answer 29

1. Implantable cardioverter-defibrillator

Question 30

Which of the following medications has been shown to reduce mortality in heart failure with reduced ejection fraction?

Answer 30

3. Metoprolol succinate;

Question 31

Which of the following is not a cause of gangrene?

Answer 31

Deep vein thrombosis insufficiency;

Question 32

A 35-year-old woman is admitted to the hospital with malaise, weight gain, increasing abdominal girth, and oedema. The symptoms began about 3 months ago and gradually progressed. The patient reports an increase in waist size of ~15 cm. The swelling in her legs has gotten increasingly worse such that she now feels her thighs are swollen as well. She has dyspnea on exertion and two-pillow orthopnea. She has a history of Hodgkin disease diagnosed at age 18. She was treated at that time with chemotherapy and mediastinal irradiation. On physical examination, she has temporal wasting and appears chronically ill. Her current weight is 96 kg, an increase of 11 kg over the past 3 months. Her vital signs are normal. Her jugular venous pressure is ~16 cm, and the neck veins do not collapse on inspiration. Heart sounds are distant. There is a third heart sound heard shortly after aortic valve closure. The sound is short and abrupt and is heard best at the apex. The liver is enlarged and pulsatile. Ascites is present. There is pitting oedema extending throughout the lower extremities and onto the abdominal wall. An echocardiogram shows pericardial thickening, dilatation of the inferior vena cava and hepatic veins, and abrupt cessation of ventricular filling in early diastole. Ejection fraction is 65%. What is the best approach for the treatment of this patient?

Answer 32

Pericardial resection;

Question 33

The main complications after radical lung surgery are:

Answer 33

All correct;

Question 34

Which of the following statements regarding ruptured abdominal aortic aneurysms is true?

Answer 34

Most patients die following ruptured AAA;

Question 35

Pleurodesis treatment against malignant pleural effusions can be complicated by:

Answer 35

All correct;

Question 36

Lung cancer assumed as central when the disease affects: 1. The main bronchus 2. The lobular bronchus 3. The segmental bronchus 4. The subsegmental bronchus 5. Bronchi of the fifth range

Answer 36

1, 2, 3 are correct;

Question 37

Initial treatment of spontaneous unspecified pneumothorax

Answer 37

Pleural puncture and one-time aspiration of the air;

Question 38

A false statement

Answer 38

Left lung has more lobes than the right lung

Question 39

What statement regarding angiography is false?

Answer 39

Compared with conventional angiography, the digital subtraction angiograms require increased contrast load for reliable images

Question 40

Q2. You are working in a rural health clinic in Northern India. You evaluate an 8-year-old boy who has never seen a physician. His mother tells you that he is unable to keep up with his peers in terms of physical activity. On your initial examination of his skin, you notice clubbing and cyanosis in his feet, but his hands appear normal. Without any further examination, you suspect that he has which of the following congenital abnormalities?

Answer 40

C. Patent ductus arteriosus with secondary pulmonary hypertension

Question 41

15. A 56-year-old construction worker with hypertension and a prior history of tobacco abuse presents to the emergency department with 30 minutes of acute-onset nausea, dyspnea, and chest pressure. His initial ECG is presented in Figure V-15. All of the following are present in this ECG EXCEPT:

Answer 41

E. Ventricular tachycardia

Question 42

18. You are asked to evaluate a 27-year-old internal medicine resident reporting 1 week of cough, coryza, and a low-grade fever. Today, he has developed rapidly escalating chest discomfort while in clinic. He notes that the pain becomes more intense when he takes a deep breath. You perform a standard 12-lead ECG (see Figure V-18). On examination, his blood pressure is normal, he is afebrile, and his jugular venous pulse is not elevated. However, he appears mildly uncomfortable from the chest pain. The next most appropriate step would be which of the following?

Answer 42

D. Prescribe ibuprofen and colchicine.

Question 43

Q24. A 60-year-old man is undergoing an electrophysiology study for evaluation of syncope. After careful venous cannulation and placement of conductance and pacing catheters and after administration of 0.2 mg/kg of propranolol and 0.04 mg/kg of atropine, his heart rate is 65 bpm. After stopping the drugs and allowing adequate time for washout, his superior/lateral right atrium is paced 140 bpm. On cessation of this overdrive pacing, his next sinus beat occurs 1800 msec later. Based on these observations, this patient can be diagnosed with which of the following?

Answer 43

D. SA nodal disease. The answer is D. (Chap. 274) Determining the intrinsic heart rate (IHR) may distinguish SA node dysfunction from slow heart rates that result from high vagal tone. The normal IHR after administration of 0.2 mg/kg of propranolol and 0.04 mg/kg of atropine is 117.2 – (0.53 × age) in bpm; a low IHR is indicative of SA disease. For this patient, his IHR should be approximately 85 bpm. Electrophysiologic testing may play a role in the assessment of patients with presumed SA node dysfunction and in the evaluation of syncope, particularly in the setting of structural heart disease. In this circumstance, electrophysiologic testing is used to rule out more malignant etiologies of syncope, such as ventricular tachyarrhythmias and AV conduction block. There are several ways to assess SA node function invasively. They include the sinus node recovery time (SNRT), which is de!ned as the longest pause after cessation of overdrive pacing of the right atrium near the SA node (normal: <1500 msec

Question 44

All of the following are reversible causes of SA node dysfunction EXCEPT:

Answer 44

E. Radiation therapy Radiation therapy can result in permanent dysfunction of the node and therefore is an irreversible, or intrinsic, cause of SA node dysfunction. In symptomatic patients, pacemaker insertion may be indicated

Question 45

Which of the following is a risk factor for development of thromboembolism in patients with the tachycardia-bradycardia variant of sick sinus syndrome?

Answer 45

Atrial enlargement

Question 46

A 71-year-old woman with ischemic cardiomyopathy and a left ventricular ejection fraction of 38% has been hospitalized for the past week with acute decompensated heart failure. After diuresis and medication optimization, she is feeling immensely better. She is on the maximally tolerated doses of an angiotensin-converting enzyme (ACE) inhibitor, β-blocker, and appropriate diuretic dose. You are planning for discharge today. On rounds, the nurse notes that the patient had several short (5–10 beats) runs of nonsustained ventricular tachycardia (NSVT) and multiple premature ventricular contractions (PVCs) overnight, although she remained asymptomatic. A medical student on the team asks if the NSVT carries any prognostic signifcance and if any intervention is needed. What is the most appropriate response

Answer 46

“NSVT is associated with an increased mortality in patients with heart failure. However, suppression of PVCs and NSVT with antiarrhythmic drugs does not change this prognosis.

Question 47

. All of the following increase the risk for tracheal stenosis EXCEPT

Answer 47

Male gender

Question 48

Adenoid cystic carcinomas

Answer 48

Spread submucosally

Question 49

Which of the following is NOT a non-small-cell tumor of the lung

Answer 49

Carcinoid tumor

Question 50

The most common pattern of benign calcification in hamartomas is

Answer 50

Popcorn

Question 51

.For an adenocarcinoma that has pleural invasion, tumor necrosis, and has lymphovascular invasion the correct subtype is

Answer 51

Lepidic predominant adenocarcinoma (LPA)

Question 52

Excisional biopsy of a chest wall mass is allowed if

Answer 52

Imaging reveals classic appearance of a chondrosarcoma.

Question 53

Osteosarcoma of the rib

Answer 53

Is treated with adjuvant chemotherapy before resection

Question 54

A chylothorax is likely to be present in a patient whose pleural fluid analysis results show a triglyceride level of

Answer 54

130mg/100mL

Question 55

The primary site or male patients with malignant pleural efusions is

Answer 55

Lung

Question 56

The fungi associated with the highest mortality rate due to invasive mycoses in the United States is

Answer 56

Aspergillus