CVS Week 1 to 11 Quiz 2nd

Question 1

One of the modifiable risk factors for atherosclerosis is hyperlipidaemia. What type of drug is given toreduce plasma lipids?
a.
Clopidogrel
b.
Diuretics
c.
Aspirin
d.
β-blockers
e.
Statins

Answer 1

The correct answer is: Statins

Raised cholesterol levels can be reduced by the statin family of drugs which areHMG CoA reductase inhibitors

Question 2

A 46-year-old obese man on an antihypertensive drug visits a clinic to get his routine health checkupdone. Blood investigation revealed high cholesterol levels more than 200 mg/dl.
Which of the following drugs recommended for the lowering of blood cholesterol inhibits the synthesisof cholesterol by blocking 3-hydroxy-3-methylglutaryl–coenzyme A (HMG-CoA) reductase?
a.
Nicotinic acid
b.
Clofibrate
c.
Atorvastatin
d.
Gemfibrozil
e.
Ezetimibe

Answer 2

The correct answer is: Atorvastatin

Atorvastatin mechanism of action – Statins exert their major effect—reduction of LDL levels—through a mevalonic acid–like moiety thatcompetitively inhibits HMG-CoA reductase

Question 3

When blood flow to the myocardium is compromised, ischaemia occurs, causing pain. Which of thefollowing is likely to cause ischaemic symptoms of the heart?
a.
Severe pulmonary artery stenosis
b.
Vertebro-basilar artery spasm
c.
Pericarditis
d.
Carotid artery thrombi
e.
Stenosis ofthecoronaryartery

Answer 3

The correct answer is: Stenosis of the coronary artery

Most ischaemic symptoms of the heart are caused by atherosclerosis,either via stenosis of the coronary artery or atherosclerosis withsuperimposed thrombi

Question 4

A 25-year-old man presents to the ER with complaints of chest pain radiating to the left arm and jaw.He gives a history of consuming cocaine 3 hours back. On examination his heart rate is 110/min,respiratory rate is 24/min and his ECG shows wide QRS complex and ST segment elevation. Whichserum cardiac enzyme is the most reliable in this condition?
a.
CKMB
b.
TroponinI
Troponin I is highly specific to cardiac muscle, and its levels in the bloodincrease within hours of myocardial damage and remain elevated for anextended period. This makes it the most reliable marker for myocardialinfarction
c.
Troponin T
d.
Myoglobin
e.
Troponin C

Answer 4

Troponin I

Troponin I is highly specific to cardiac muscle, and its levels in the bloodincrease within hours of myocardial damage and remain elevated for anextended period. This makes it the most reliable marker for myocardialinfarction

Question 5

A 62-year-old man was admitted to the coronary care unit for an evaluation of a recent episode of chestpain. Three days prior to admission, he had woken up in the middle of the night with a tight precordialpain which was intense and lasted 20 minutes. The pain radiated to the left upper limb and wasaccompanied by dyspnoea, which led him to seek medical attention. His troponin levels were notincreased, and the ECG was not suggestive of acute myocardial ischemia. He was then diagnosed withvariant angina associated with superimposed arteriosclerotic coronary artery disease. Which of thefollowing drug is most likely to be avoided in this presentation?
a.
Glyceryl trinitrate
b.
Amlodipine
c.
Verapamil
d.
Nifedipine
e.
Propranolol

Answer 5

Propranolol

β Blockers are not useful for vasospastic angina and, if used in isolation,may worsen that condition because of the unopposed action by alphareceptor mediated vasoconstriction by endogenous catecholamines

Question 6

Endothelial damage to arteries precipitates plaque development in arteriosclerosis. Excess low-densitylipoprotein (LDL) leaks into the extracellular space and becomes oxidised. Oxidised LDL is toxic toendothelial cells, and promotes inflammation and the laying down of fatty streaks. What is acharacteristic of very low-density lipoprotein (VLDL)?
a.
Produced from intermediate-density lipoprotein
b.
Carries dietary lipids
c.
Transports cholesterol from peripheral tissues to the liver
d.
Transports cholesterol from the liver to peripheral tissues
e.
Produced in the liver from endogenous lipids

Answer 6

The correct answer is: Produced in the liver from endogenous lipids

Question 7

Inadequate blood flow to the cardiac muscle as a result of abnormalities in the coronary circulationgives rise to the clinical symptom of chest pain: angina. What is true of Prinzmetal’s angina?
a.
Coronary artery spasm caused by intense sympathetic stimulation
b.
Occurs as a result of the transient blockage of a coronary artery by a thrombus that has formedat the site of an atheromatous plaque
c.
Rare condition inwhich vasospasms ofthe coronary arteryoccur at rest, often inthe early hours of themorning
d.
Occurs consistently with exercise and subsides after 3–10 min of rest
e.
Related to valvular heart disease

Answer 7

c.
Rare condition inwhich vasospasms ofthe coronary arteryoccur at rest, often inthe early hours of themorning

Variant angina, also known as Prinzmetal’s angina, is a rarecondition in which vasospasm of the coronary arteries occurs atrest, often in the early hours of the morning. It is thought to becaused by an exaggerated response to vasoconstrictors such asadrenaline and 5-HT

Question 8

The main disease process underlying cardiovascular disease is atherosclerosis. Which of the following isa risk factor for coronary artery disease?
a.
Age < 30 years
b.
Female sex
c.
Family history of arrhythmia
d.
Poordiet

e.
Previous DVT episodes

Answer 8

Poordiet

A poor diet can indirectly influence the development of cardiovascular disease byincreasing obesity and associated risk factors such as hypertension,hypertryglyceridaemia or type 2 diabetes. A diet containing high levels ofsaturated fats can increase the risk of coronary artery disease

Question 9

A 34-year-old businessman experienced crushing retrosternal chest pain during a business meeting. Hewas brought to the emergency room of the nearest hospital where an ECG helped diagnosed amyocardial infarction involving the apex and majority of the interventricular septum of the heart. Whatis the most probable coronary artery involved?
a.
Left marginal artery
b.
Atrioventricular nodal branch
c.
Left anteriordescendingartery
d.
Right marginal branch
e.
Circumflex branch of the left coronary artery

Answer 9

c.
Left anteriordescendingartery

The left anterior descending artery (LAD) supplies blood to the front ofthe left ventricle, the interventricular septum, and the apex of the heart

Question 10

Atherosclerosis is ‘hardening’ of arteries. Which of the following is a feature of atherosclerosis?
a.
It predisposes to coarctation of the aorta
b.
It is associated with moderate alcohol consumption
c.
It is a majorpredisposingfactor forischaemicheartdisease
d.
It mainly affects arterioles
e.
It is associated with a Mediterranean diet

Answer 10

c.
It is a majorpredisposingfactor forischaemicheartdisease

Atherosclerosis affects large and medium-sized arteries. Lesions oftenbegin as fatty streaks. In those who are predisposed to arteriosclerosis,lesions may progress to fibrolipid plaques. Haemorrhage and thrombi mayoccur in the plaques. This may lead to total occlusion of the blood supplyto important organs such as the coronary arteries

Question 11

SAQ: There is a 62-year-old man who presents with a chest pain that is classic for an acute myocardialischemia, including precordial discomfort radiating to the arm and neck that started 30 minutes agowhile he was watching television. He has risk factors for coronary artery disease, including elevatedcholesterol, high blood pressure, and an extensive smoking history. He has a carotid bruit on exam thatsuggests significant underlying atherosclerosis. An acute surge of catecholamines is responsible for thepatient’s tachycardia, elevated blood pressure, and diaphoresis. His ECG is diagnostic:
1. What is the most likely diagnosis?
2. What are some important features of his presenting history
3. What is the most important initial therapeutic maneuver?
4. Discuss the pathophysiology of a STEMI
5. Discuss the differential diagnosis of a STEMI\n

Answer 11

1. What is the most likely diagnosis?
   Answer = Anterior ST segment elevation myocardial infarction
2. What are some important features of his presenting history?
   Answer = acute onset of pain that radiates to the arm and neck, has a history of coronary artery disease,has a history of smoking and high blood pressure
3. What is the most important initial therapeutic maneuver?
   Answer = Prompt coronary revascularization
   ST elevation myocardial infarction is a true medical emergency that requires immediate recognition andprompt treatment. Time is the most important factor to consider at presentation because survival ofmyocardial tissue (as well as the patient) depends on prompt and early coronary revascularization.
   “Time is muscle” is a commonly used expression in emergency departments and catheterizationlaboratories around the world for good reason; the faster we recognize and treat STEMI, the more liveswe save.
4. Discuss the pathophysiology of a STEMI
   Answer = An ST segment elevation myocardial infarction (STEMI) is most commonly the result ofatherosclerotic plaque rupture with subsequent acute thrombus formation and completion occlusion ofthe arterial lumen. Rupture of the fibrous cap reveals the highly thrombogenic extracellular lipid core,initiating platelet activation and aggregation as well as thrombin activation.
5. Discuss the differential diagnosis of a STEMI
   Answer = The differential diagnosis for STEMI is extensive and includes other cardiovascular disorders,pulmonary pathology, and gastrointestinal (GI) disease. Perhaps the most important diagnosis to ruleout is the presence of an aortic dissection. This is critical as fibrinolytics and anticoagulants arecontraindicated in aortic dissection. One should suspect dissection in a patient with risk factors fordissection, including a history of uncontrolled blood pressure or Marfan’s disease.

Question 12

Which of the following is included in the major Jones criteria for the diagnosis of acute rheumatic fever?
a.
Erythema marginatum
b.
Elevated acute phase reactants
c.
Fever
d.
Arthralgia
e.
History of streptococcal infection

Answer 12

a.
Erythemamarginatum

Erythema marginatum is one of the major Jones criteria for thediagnosis of acute rheumatic fever

Question 13

A 42-year-old woman presents with a febrile illness and embolic phenomena suggestive of infectiveendocarditis. She had been otherwise fit and healthy, with no past medical or surgical history. Thepresenting illness is mild and has been progressive. What is the most likely responsible pathogen?
a.
Viridansstreptococci
b.
Coxiella burnetii
c.
Chlamydia psittaci
d.
Staphylococcus aureus
e.
Streptococcus bovis

Answer 13

a.
Viridansstreptococci

Viridans streptococci are the most common cause of subacute infectiousendocarditis, which is characterized by a mild progressive illness

Question 14

A 34-year-old male with a history of intravenous drug use presents with fever, night sweats,unintentional weight loss and vomiting. His physical exam uncovers a new cardiac murmur as well asconjunctival and palmar pallor. Echocardiography shows involvement of his tricuspid heart valve.
Which of the following microbes is the most likely source of infection?
a.
Staphylococcus epidermidis
b.
Staphylococcusaureus
c.
Viridans Streptococci
d.
Candida species
e.
Pseudomonas spp.

Answer 14

b.
Staphylococcusaureus

Staphylococcus aureus is the most common cause of infectiveendocarditis in intravenous drug abusers accounting for 50% cases andis thus the most correct answer

Question 15

An 8-year-old girl presented to the emergency department with fevers, chest pain and painful joints.Her physical exam shows small painless nodules beneath the skin and a new cardiac murmur. Her throatswab performed in the last month shows isolation of group A streptococci. You tentatively diagnoseacute rheumatic fever. Which of the following investigations should you order for further confirmationof the diagnosis?
a.
Christie, Atkins and Munch-Peterson (CAMP) reaction
b.
Blood Cultures
c.
C-reactive protein
d.
Antistreptolysin O(ASO) test
e.
Culture of throat swab

Answer 15

d.
Antistreptolysin O(ASO) test

An ASO test with significant titre of 1:200 is an indicator of priorgroup A streptococcal infection

Question 16

Which of the following statements correctly describes an aspect of myocarditis?
a.
Myocarditis only presents with heart failure symptoms
b.
Myocarditis always results in bradycardia
c.
Myocarditis is mainly caused by bacterial infections
d.
Viral invasion causes cellnecrosis and inflammationin myocarditis
e.
Autoimmune reactions are not involved in myocarditis

Answer 16

d.
Viral invasion causes cellnecrosis and inflammationin myocarditis

Viral myocarditis typically involves direct viral invasion ofcardiomyocytes, leading to cell damage and aninflammatory response

Question 17

Which antibodies are useful to monitor myocarditis in the active stage?
a.
Anti-actin
b.
Anti-formin
c.
Anti-myosin
d.
Anti-troponin
e.
Anti-phospholipid

Answer 17

c.
Anti-myosin

Anti-myosin antibodies are useful in monitoring myocarditis in the active stage,as they are directed against cardiac myosin and can indicate ongoing cardiacinflammation

Question 18

Colchicine used in the treatment of acute pericarditis acts by inhibiting the chemotaxis and phagocyticfunction of which white blood cells?
a.
Basophils
b.
Monocytes
c.
Lymphocytes
d.
Eosinophils
e.
Neutrophils

Answer 18

Neutrophils

Colchicine inhibits the chemotaxis and phagocytic function of neutrophils,reducing inflammation in conditions such as acute pericarditis

Question 19

An 8-year-old girl presents to the paediatric emergency department with symptoms of fever, painfuland tender joints and chest pain. Physical examination shows small painless nodules beneath the skin aswell as a new cardiac murmur. Radiological, microbiological and serological investigations confirm thediagnosis of acute rheumatic fever. Which of the following pathogenic mechanisms underlies thiscondition?
a.
None of the answers
b.
Direct cytotoxic effect by streptococcal toxins and enzymes
c.
Autoimmuneresponse tocross-reacting orsharedantigens
d.
Autoimmune response to hidden or sequestered antigen
e.
Hypersensitivity to streptococcal components

Answer 19

c.
Autoimmuneresponse tocross-reacting orsharedantigens

Autoimmune response occurs due to cross-reacting of antibodies, orshared antigens, between group A streptococci and myocardial cells.Antibodies produced against group A streptococci cross-react withhuman heart and joint tissue antigens and produce injury

Question 20

A 54-year-old woman presents with a history of intermittent shortness of breath, palpitations, andrecent onset of dizziness. On physical examination, a diastolic murmur is noted. An echocardiogramreveals a mass in the left atrium. Which of the following is the most likely diagnosis?
a.
Pulmonary embolism
b.
Mitral valve prolapse
c.
Endocarditis
d.
Atrial septal defect
e.
Atrialmyxoma

Answer 20

e.
Atrialmyxoma

Atrial myxoma is the most likely diagnosis given the presence of a mass in theleft atrium on echocardiogram, along with symptoms like shortness of breath,palpitations, dizziness, and a diastolic murmu

Question 21

Autopsy is conducted for a 15-year-old girl who died in a road traffic accident. Microphotograph of asection from the heart displays granulomatous nodules with central fibrinoid necrosis surrounded bychronic inflammatory cells. The findings are suggestive of which of the following diseases?
a.
Cardiac myxoma
b.
Rheumaticheartdisease
c.
Infective endocarditis
d.
Myocarditis
e.
Hypertrophic cardiomyopathy

Answer 21

b.
Rheumaticheartdisease

Rheumatic heart disease often shows Aschoff bodies, which aregranulomatous nodules with central fibrinoid necrosis surrounded by chronicinflammatory cells. These histopathological features are indicative ofrheumatic fever affecting the heart

Question 22

SAQ: A 27-year-old IV drug user is presenting with fevers, chills, night sweats, cough, and chest pain for2 weeks. He has a murmur on exam and evidence of septic pulmonary emboli on chest x-ray. He is ill-appearing, febrile, and tachycardic. His murmur is consistent with tricuspid regurgitation. He hasabnormal breath sounds over multiple lung fields. His skin exam reveals Janeway lesions on his rightpalm. His white blood cell count is 19,000 cells/mm3 with 78% neutrophils and 11% bands. His ECGshows sinus tachycardia with no evidence of atrioventricular conduction delay.
What is the most likely diagnosis?
What is the most likely next diagnostic step?
What other diagnostic tests may be considered?

Answer 22

What is the most likely diagnosis?
Answer = Infective endocarditis
What is the most likely next diagnostic step?
Answer =Blood cultures
What other diagnostic tests may be considered?
Answer =Echocardiogram, ECG

Question 23

What is the definitive treatment of patient diagnosed with constrictive pericarditis with worseningbreathlessness and leg edema?
a.
Pericardiocentesis
b.
Pericardiectomy
c.
Non-steroidal anti-inflammatories
d.
Corticosteroids
e.
Cardiac transplantation

Answer 23

b.
Pericardiectomy 
Pericardiectomy, the surgical removal of the fibrous layer of thepericardium, is the definitive treatment for constrictive pericarditis. Thisprocedure is aimed at relieving the heart from the restrictive andnoncompliant pericardium, which is impeding normal cardiac filling andfunction, thereby addressing the direct cause of symptoms likebreathlessness and edema

Question 24

A 17-year-old girl who is playing volleyball collapses and requires cardiopulmonary resuscitation. Shehad been healthy except for occasional episodes of chest pain while playing. Her cardiac biopsy is likelyto show which of the following findings?
a.
Foci of myocardial necrosis and inflammation
b.
Haphazardlyarrangedhypertrophiedmyocytes
c.
Extensive myocardial hemosiderin deposition
d.
Large, friable vegetations with destruction of aortic valve cusps

Answer 24

b.
Haphazardlyarrangedhypertrophiedmyocytes

The description of hypertrophied, disorganized myocytes is characteristicof hypertrophic cardiomyopathy (HCM), a common cause of suddencardiac death in young athletes. HCM often presents with symptoms likechest pain during physical activity and can lead to fatal arrhythmiasduring intense exercise

Question 25

A 32-year-old man is brought to the emergency department 10 minutes after he sustained a stabwound to the left chest just below the clavicle. On arrival, he is hypotensive with rapid and shallowbreathing and appears anxious and agitated. He is intubated and mechanically ventilated. Infusion of0.9% saline has begun. Five minutes later, his pulse is 137/min and blood pressure is 84/47 mm Hg. Examination shows a 3-cm single stab wound to the left chest at the 4th intercostal space at themidclavicular line without active external bleeding. Cardiovascular examination shows muffled heartsounds and jugular venous distention. Breath sounds are normal bilaterally. Further evaluation of thispatient is most likely to show which of the following findings? a. A 15 mmHgdecreasein systolicpressureduringinspiration b. Holosystolic blowing murmur best heard at the apex c. Opening snap and mid-systolic murmur loudest at the apex d. Irregularly irregular pulse with displaced cardiac apex

Answer 25

a. A 15 mmHgdecreasein systolicpressureduringinspiration  This is indicative of pulsus paradoxus, a sign commonly associated withcardiac tamponade. This condition occurs when fluid accumulation in thepericardium (blood, in this case) compresses the heart and impairs its abilityto pump effectively, leading to the described clinical findings includinghypotension, tachycardia, and muffled heart sounds

Question 26

Which of the following is the least common type of cardiomyopathy? a. Restrictive cardiomyopathy b. Dilated cardiomyopathy c. Arrhythmogenicright ventricularcardiomyopathy d. Hypertrophic cardiomyopathy

Answer 26

c. Arrhythmogenicright ventricularcardiomyopathy  ARVC is also relatively rare. It is primarily noted for affecting the rightventricle and being a significant cause of sudden cardiac death in theyoung and athletes. However, it is more common than restrictivecardiomyopathy but less common than dilated or hypertrophiccardiomyopathies

Question 27

Which of the following is a heart muscle disorder characterized by impaired systolic function of the leftventricle or both the ventricles, in the absence of coronary artery disease, valvular abnormality orpericardial disease? a. Arrhythmogenic right ventricular cardiomyopathy b. Dilatedcardiomyopathy c. Restrictive cardiomyopathy d. Hypertrophic cardiomyopathy

Answer 27

b. Dilatedcardiomyopathy  Dilated cardiomyopathy (DCM) is characterized by dilation andimpaired contraction of one or both ventricles and is typically notassociated with coronary artery disease, significant valvular disease, orpericardial disease. This condition fits the description of havingimpaired systolic function of the ventricles in the absence of otherheart diseases

Question 28

Which of the following is included in the triad of histological features of hypertrophic cardiomyopathy? a. Hypertrophiccardiomyocytes,myocardialdisarray, andfibrosis b. Normal cardiomyocytes, granulomas and fibrosis c. Hypertrophic cardiomyocytes, myocardial necrosis and fibrosis d. Hypertrophic cardiomyocytes, deposition of amyloid and fibrosis

Answer 28

a. Hypertrophiccardiomyocytes,myocardialdisarray, andfibrosis  Hypertrophic cardiomyopathy is characterized by hypertrophiedcardiomyocytes, often irregularly arranged, leading to myocardialdisarray. Additionally, there is usually some degree of fibrosis withinthe myocardium. These features together contribute to the impairedcardiac function seen in HCM

Question 29

In dilated cardiomyopathy, a section from the heart will show which of the following? a. Mild increase in collagen b. Fibroadiposetissue replacingthecardiomyocytes c. Dense fibrosis with disarray of cardiomyocytes d. Hypertrophic cardiomyocytes

Answer 29

b. Fibroadiposetissue replacingthecardiomyocytes  Replacement of cardiomyocytes by fibroadipose tissue ischaracteristic of arrhythmogenic right ventricular cardiomyopathy,particularly affecting the right ventricle

Question 30

Epsilon (ε) wave in ECG is a characteristic feature of which of the following? a. Restrictive cardiomyopathy b. Arrhythmogenicright ventricularcardiomyopathy c. Dilated cardiomyopathy d. Hypertrophic cardiomyopathy

Answer 30

b. Arrhythmogenicright ventricularcardiomyopathy  The Epsilon wave is a distinct finding in the ECG that is indicative ofArrhythmogenic Right Ventricular Cardiomyopathy (ARVC). Itrepresents localized delayed conduction in the right ventricle due tothe fibrofatty replacement of the myocardium that is characteristic ofARVC. The presence of this wave on the ECG, particularly in V1-V3leads, is highly suggestive of ARVC and is used as part of thediagnostic criteria for the disease

Question 31

A 54-year-old who recently immigrated to the US from India presents with progressively worseningfatigue, breathlessness on lying flat and swelling of his legs. For the past one year, he has hadintermittent fever, night sweats and cough. His pulse is 110/min and blood pressure 125/65 mmHg. Chest x-ray of the patient is shown. Furtherevaluation is most likely to show which of the following findings? a. Jugularvenousdistensiononinspiration b. Opening snap and mid-systolic murmur c. Head bobbing in synchrony with the heart beat d. Harsh ejection systolic murmur loudest in the aortic area

Answer 31

a. Jugularvenousdistensiononinspiration  The symptoms of fatigue, breathlessness while lying flat, and swelling of thelegs suggest right-sided heart failure or increased central venous pressure,which could be related to conditions like constrictive pericarditis or rightheart failure. Jugular venous distension (JVD), especially notable oninspiration (known as Kussmaul's sign), is indicative of these issues andaligns with the patient's presentation

Question 32

A 25-year-old man who suffers a sudden cardiac arrest is resuscitated. ECHO shows marked thinningwith dilation of the right ventricle with a normal left ventricle. MR imaging of his chest shows fibrofattyreplacement of the myocardium. The above features are diagnostic of which one of the following? a. Ischemic cardiomyopathy b. Arrhythmogenicright ventricularcardiomyopathy c. Restricted cardiomyopathy d. Hypertrophic cardiomyopathy e. Dilated cardiomyopathy

Answer 32

b. Arrhythmogenicright ventricularcardiomyopathy  ARVC is characterized by progressive fibrofatty replacement of theright ventricular myocardium. This condition often leads to ventriculararrhythmias and sudden cardiac arrest, particularly in youngindividuals. The described ECHO and MRI findings of right ventricularthinning and dilation along with fibrofatty replacement are classic forARVC

Question 33

SAQ: A 21-year-old healthy man with no active complaints but with a history of unexplained syncope isfound to have brisk carotid upstrokes, a grade 2/6 early systolic murmur along the left lower sternalborder whose intensity increases on a Valsalva maneuver and decreases when the patient moves from astanding position to a squatting position, performing a passive leg lift while recumbent and performingisometric handgrip exercises. An S4 gallop is also noted. Electrocardiogram (ECG) shows sinusbradycardia and left ventricular hypertrophy (LVH) by voltage. His review of systems and family historyraises concern for an increased risk for sudden cardiac death. A. What is the most likely diagnosis? B. What is considered the best diagnostic step? C. What is considered one of the best therapies?

Answer 33

A. What is the most likely diagnosis? Answer = Hypertrophic cardiomyopathy (HCM) B. What is considered the best diagnostic step? Answer = Transthoracic echocardiogram (TTE) C. What is considered one of the best therapies? Answer = Implantable cardioverter defibrillator (ICD)

Question 34

Chronic venous insufficiency is characterized by ambulatory venous hypertension of the lower limbwhich is due to which of the following? a. Lymphatic obstruction of the lower limb b. Valvularincompetenceof thesuperficialveins c. Frequent movement of the lower limb d. Increased muscle tone of the lower limb

Answer 34

b. Valvularincompetenceof thesuperficialveins  Valvular incompetence of the superficial veins leads to blood pooling andincreased venous pressure in the lower limbs. The failure of the valves tofunction properly allows blood to flow backward, causing ambulatoryvenous hypertension, which is a hallmark of chronic venous insufficiency

Question 35

A 56-year-old male who is a known case of Marfan syndrome and history of long-standinghypertension complains of sudden onset chest pain and back pain. He died on the way to the hospital.Autopsy reveals blood in the pericardial sac. What will the wall of the aorta in this patient show? a. Fibrosis b. Cystic medial degeneration c. Aggregates of foamy macrophages d. Granulomatousreaction

Answer 35

d. Granulomatousreaction  This type of inflammatory response is not associated with Marfansyndrome. Granulomatous inflammation is seen in conditions such astuberculosis or certain vasculitides, which are not related to theconnective tissue abnormalities seen in Marfan syndrome

Question 36

A 35-year-old women, 4 weeks post childbirth has come to visit you in the GP practice. She has nosignificant past medical history and is a non-smoker. She has trialled compressions stockings, however,would like more definitive management given the appearance of her varicose veins. Prior to referringthis patient, you decide you must perform an investigation before referring. What is the gold standardfor investigating a patient with varicose veins? a. Lower limb XR b. Venous MRI c. CT lower limb d. Venousduplexultrasound

Answer 36

d. Venousduplexultrasound  Venous duplex ultrasound is the gold standard for investigating varicoseveins. It combines traditional ultrasound and Doppler ultrasound to visualizethe veins and measure blood flow, allowing for accurate assessment ofvenous reflux and valve function

Question 37

All the following are risk factors for peripheral vascular disease EXCEPT a. Hypertension b. Ischemicheart disease c. Diabetes mellitus d. Low levels of homocysteine

Answer 37

b. Ischemicheart disease  This condition shares many risk factors with PVD, such as atherosclerosis,which can affect multiple vascular beds

Question 38

for several years. She reports that these veins do not cause her any pain or discomfort. Onexamination, there are visible varicose veins, but there are no signs of ulceration or venous eczema. Thepatient has palpable lower limb pulses and her Ankle-Brachial Index (ABI) is 1.0. Which of the followingdo not warrant treatment of varicose veins? a. No signs of ulceration or venous eczema b. Both "there arepalpable lowerlimb pulses"and "no signs ofulceration orvenous eczema" c. There are palpable lower limb pulses d. ABI < 0.6

Answer 38

b. Both "there arepalpable lowerlimb pulses"and "no signs ofulceration orvenous eczema"  Varicose veins typically do not require treatment if there are no signsof severe complications such as ulceration or venous eczema, and ifthe arterial supply, indicated by palpable pulses, is adequate. Thiscombination suggests that the varicose veins are more of a cosmeticconcern rather than a medical necessity for treatment

Question 39

All of the followings are examples of small vessels vasculitis associated with ANCA Except: a. Microscopicpolyangiitis b. Churg-Strauss syndrome c. Goodpasture disease d. Granulomatosis with polyangiitis

Answer 39

The correct answer is: Goodpasture disease

Question 40

The triad of ruptured abdominal aortic aneurysm include all the following EXCEPT a. Pulsusparadoxus b. Pulsatile abdominal mass c. Hypotension d. Abdominal pain

Answer 40

a. Pulsusparadoxus  Pulsus paradoxus, which is an abnormal decrease in systolic blood pressureduring inspiration, is not associated with a ruptured AAA but is morecommonly linked with conditions such as cardiac tamponade, constrictivepericarditis, and severe asthma or COPD exacerbations

Question 41

The main clinical manifestations of Kawasaki disease are all the following Except: a. Heart failure b. Conjunctivitis c. Cervicallymphadenopathy d. Peeling of the skin of fingers

Answer 41

The correct answer is: Heart failure

Question 42

A 27-year-old woman presents to the ED with complaints of sudden onset severe chest pain at 28thweek of pregnancy. On examination, pulse: 100/min and BP in the right arm is 150/88 mm of Hg andleft arm is 120/80 mm Hg. CT scan shows intimal flap and widening of the aorta with double lumen. Allthe following genetic conditions are associated with this condition EXCEPT a. Turner syndrome b. Ehler Danlos syndrome c. Marfan syndrome d. Achondroplasia

Answer 42

d. Achondroplasia  This condition primarily affects bone growth, leading to dwarfism, andis not associated with an increased risk of aortic dissection

Question 43

A 80-year -old female, presented a small left leg ulcer over the medial malleolus. She is fully activeproviding care for her husband. The skin around the ulcer is erythematous, crusted and appearingdarker than the with atrophie blanche, the ankle is slightly edematous and you could feel the posteriortibial artery pulsation with ABI of 0.95. The ulcer itself is filled with yellow-green slough and is notpainful but towards the end of the day her left leg gets sore, but the pain goes away when she is in bed.She has a history of varicose veins 10 years ago treated by vein stripping. What is the most appropriatenext step? a. Empirical oral antibiotics b. Steroidapplicationto theulcer c. Below knee compression stocking d. Vein sclerotherapy

Answer 43

The correct answer is: Below knee compression stocking

Question 44

It is a busy day in your rural emergency department. You pick up a patient, a 45 year old female whosepresenting complaint is that of a aching leg. She has no past medical history, and is a non smoker. Ontaking a more detailed history, you notice as a part of her medication history that she has been on theoral contraceptive pill for the past 15 years. Which of the following reflects the pathogenesis of DVT? a. Decreased platelet count, increased fibrinolysis, and hyperviscosity b. Vasodilation, increased capillary permeability, and decreased blood pressure c. Increased cardiac output, arterial hypertension, and venous distension d. Hypercoagulability,stasis, andendothelial injury

Answer 44

d. Hypercoagulability,stasis, andendothelial injury  These three factors constitute Virchow's triad, which describes theprimary mechanisms that lead to the development of DVT. The useof oral contraceptive pills can contribute to hypercoagulability,increasing the risk of thrombosis

Question 45

When describing the general phases of the cardiac myocyte action potential, which phase has rapiddepolarisation due to a transient increase of Na conductance into the cell? a. Phase0 b. Phase 2 c. Phase 3 d. Phase 4 e. Phase 1

Answer 45

a. Phase0 upstroke phase that causes rapid depolarisation due to transient increase of Naconductance into the cell

Question 46

Are you able to describe the proper electrical conductance (in the correct order ) through the heart? a. SA node -> AV node -> Bundle if his -> Purkinje fibers -> Bundle branches -> b. SA node -> AV node -> Bundle if his ->Bundle branches -> Purkinje fibers c. SA node -> AV node -> Bundle branches -> Bundle if his -> Purkinje fibers d. AV node -> SA node -> Bundle if his -> Bundle branches -> Purkinje fibers

Answer 46

b. SA node -> AV node -> Bundle if his ->Bundle branches -> Purkinje fibers This is the correct order of electrical conductance through the heart

Question 47

Closure of the aortic and pulmonary valves produces which heart sound? a. S1 b. S2 S2 is due to closure of semilunar valves c. S4 d. S3

Answer 47

b. S2 S2 is due to closure of semilunar valves

Question 48

Which of the following regarding anatomy of the heart is true? a. The right atrium is posterior to the left atrium b. The apex is formed by the right ventricle c. The right coronary artery suppliespart of left ventricle d. The ascending aorta is entirely outside the pericardial sac e. The left coronary artery supplies right atrium

Answer 48

c. The right coronary artery suppliespart of left ventricle The right coronary artery supplies part of leftventricle (diaphragmatic surface)

Question 49

In terms of anatomical relations, which of the following is correct? a. The lung is inferior to the heart b. The diaphragm is superior to the mediastinum c. The apex of the heartis anterior to its base d. The aorta is superficial to the sternum e. Sternum is superior to the heart

Answer 49

c. The apex of the heartis anterior to its base The apex is anterior and part of the left ventricle while the base isthe posterior surface formed mainly by left atrium

Question 50

In which structure of the nervous system would damage cause increased parasympathetic activity? a. Nucleus solitarius b. Cardiac decelerator centre c. Dorsal motor nucleus of the vagus d. Rostral ventrolateralmedulla (RVLM)

Answer 50

d. Rostral ventrolateralmedulla (RVLM) Damage to RVLM will decrease sympathetic

Question 51

When the left ventricular stroke volume is 40 ml/beat and the heart rate is 80 beats/minutes, thecardiac output is? Select one: a. 4.5 Litres/minute b. 6 Litres/minute c. 3.2 Litres/minute d. 5 Litres/minute e. 2 Litres/minute

Answer 51

c. 3.2 Litres/minute Cardiac output= SV X HR. 40 x 80= 3.2 L/min

Question 52

During your Emergency Medicine rotation, you see a patient where physical examination reveals ananxious, diaphoretic patient with unstable vital signs and hypoxemia. He denies any medical problemsbut admits to daily use of cocaine, including intranasal cocaine approximately 30 minutes ago. Thinkingabout some of the effects of cocaine use on the body, which of the following is true? a. QRS prolongation b. heart failure as a main issue c. decreased binding to Na channels d. increased Phase 0 depolarization

Answer 52

a. QRS prolongation

Question 53

The T wave of the electrocardiogram occurs during which phase of the cardiac cycle? a. Isovolumetric relaxation b. Rapid ventricular ejection c. Isovolumetric contraction d. Reduced ventricular ejection e. Atrial systole

Answer 53

Reduced ventricular ejection Ventricles relaxed, not associated with ECG waves

Question 54

Which of the following structures separates the diaphragmatic surface of the heart from the base? a. Thecoronarysulcus b. The left atrium c. The posterior interventricular groove d. The anterior interventricular groove e. The right ventricle

Answer 54

a. Thecoronarysulcus The coronary sulcus (atrioventricular sulcus) separates the diaphragmaticsurface of the heart from the base

Question 55

Which of the following is true when differentiating between the pacemaker (SA, AV node) and non-pacemaker (cardiac muscle) AP? a. AP SA Node has no automaticity b. AP Cardiac muscle has three phases c. AP Cardiac muscle can occur in cardiac muscles other than SA & AV d. AP Cardiac muscle driven by funny current Na channels

Answer 55

c. AP Cardiac muscle can occur in cardiac muscles other than SA & AV See chart below to help with differentiating: AP SA Node AP Cardiac muscle Occur in pacemaker cells Occur in cardiac muscles other than SA and AV Driven by funny current Na channels Driven by stimulus, no funny current Unstable RMP (-50 to -90 mV) Stable RMP -90 mV Only 3 phases 4 phases Automaticity is possible No automaticity

Question 56

Which of the following best describes the histological structure of the atrioventricular valves? a. Characterized by a thin layer of endothelial cells overlying a thick myocardial layer b. Contains a fibrous skeleton that provides attachment sites for cardiac muscle c. Composed mainly of dense connective tissue with a central core of endocardium d. Predominantly made of cardiac muscle tissue for enhanced contractility e. Composed of three parts:collagen with some elasticfibres leaflets; fine, strongfibrous ligaments andpapillary muscles

Answer 56

e. Composed of three parts:collagen with some elasticfibres leaflets; fine, strongfibrous ligaments andpapillary muscles The atrioventricular valves are indeed composed of threeparts: cusps- collagen with some elastic fibres leaflets;chordae tendineae- fine, strong fibrous ligaments that arisefrom the powerful papillary muscles of the respectiveventricles

Question 57

All cardiac valves are normally closed during which of the following phases of cardiac cycle? a. Atrial contraction b. Systolic ejection c. Ventricular filling d. Isovolumetricrelaxation

Answer 57

d. Isovolumetricrelaxation Semilunar valves close after ejection and atrioventricular valves are stillclosed from the end of previous diastole

Question 58

The repolarization phase of the cardiac action potential depends upon which type of channels? a. Both fast sodium channels and slow calcium channels b. Potassiumchannels c. Fast sodium channels d. Sodium potassium pumps e. Slow calcium channels

Answer 58

b. Potassiumchannels Opening of these channels results in potassium exiting cardiac muscle celland hence repolarization both during phase 1 (initial repolarization- rapidpotassium channels) and phase 3 (rapid repolarization- slow potassiumchannels)

Question 59

Which of the following best describes the structure of the myocardium? a. Striated muscle tissuearranged in abranching pattern b. Smooth muscle tissue that contracts involuntarily c. Connective tissue providing elasticity to the heart chambers d. A single layer of epithelial cells lining the heart chambers

Answer 59

a. Striated muscle tissuearranged in abranching pattern The myocardium is composed of striated muscle tissue arrangedin a branching pattern, allowing for the coordinated contractionof the heart

Question 60

Regarding hormonal control of the cardiovascular system, which of the following statements is correct? a. Adrenaline/epinephrine causes vasodilatation in skeletal muscle by acting on β 1 receptors. b. Angiotensin-converting enzyme is predominately found in the vascular bed of thegastrointestinal tract. c. Antidiuretic hormone is released when arise in osmolarity is detected. d. Renin is converted to angiotensin I by angiotensinogen. e. Adrenaline is secreted from the adrenal cortex.

Answer 60

c. Antidiuretic hormone is released when arise in osmolarity is detected.

Question 61

Which of the following is true of the baroreceptor reflex? a. Baroreceptors in the carotid body are innervated by the glossopharyngeal nerve. b. Decreased loading of baroreceptors increases venous tone by reducing parasympatheticactivity. c. It is central to the long-term regulation of blood pressure d. Constriction of cutaneous arteriolesbrought about by the baroreceptorreflex can be overcome bythermoregulatory changes in vasculartone. e. Increased stretch in the arterial wall causes a decrease in baroreceptor firing.

Answer 61

d. Constriction of cutaneous arteriolesbrought about by the baroreceptorreflex can be overcome bythermoregulatory changes in vasculartone.  The baroreceptor reflex is important in thecutaneous circulation if the temperature isneutral but can be overcome if there is peripheralvasodilation due to high temperature

Question 62

Which of the following best describes the anatomical feature that distinguishes arteries from veins? a. Veins possess semilunar valves throughout their length to facilitate blood flow to the tissues b. Veins are responsible for the oxygenation of blood, which is why they have thinner wallscompared to arteries c. Arteries typically have higher bloodpressure, necessitating thicker, moreelastic walls than veins d. Arteries have thinner walls than veins, allowing for higher rates of gas exchange e. Arteries contain a single layer of smooth muscle, whereas veins are composed of multiplelayers, including a thick tunica adventitia

Answer 62

c. Arteries typically have higher bloodpressure, necessitating thicker, moreelastic walls than veins  Arteries have thicker, more elastic walls thanveins to handle the higher pressure of bloodflow

Question 63

A 40-year-old female has a blood pressure of 300/200 mmHg. Without further information, what is theclinical classification? a. Secondary hypertension b. Surgical hypertension c. Benign hypertension d. Essential hypertension e. Emergencyhypertension  Acute, severe elevation of blood pressure (>220/130) most likelyassociated with objective findings of acute end-organ damage

Answer 63

e. Emergencyhypertension

Question 64

thecommonly used antihypertensive agents. Below is a list of adverse effects seen with different classes ofantihypertensive agents, together with some important properties of selected agents. Which of thebelow antihypertensive agents would you be cautious about using if your hospitalized patient is havinga hard time regulating their electrolytes? a. Thiazide diuretics —hypercholesterolaemia, hyperglycaemia, thrombocytopenia and gout b. Angiotensin II receptor blockers —similar to ACE inhibitors but cough is less common c. Calcium channel blockers —headaches, sweating, palpitations and ankle oedema d. Beta-blockers —bradycardia, postural hypotension, depression and cold peripheries e. ACE inhibitors —angio-oedema, cough, postural hypotension, hyperkalaemia, progression ofrenal failure and first-dose hypotension

Answer 64

e. ACE inhibitors —angio-oedema, cough, postural hypotension, hyperkalaemia, progression ofrenal failure and first-dose hypotension

Question 65

A 55-year-old female presents to your clinic complaining of a headache. During a physical examinationshe is found to have an arterial blood pressure of 190/120 mmHg. What would direct the attention tothe diagnosis of malignant hypertension in this case? a. There is positive family history of ischemic heart disease b. She does not exercise c. Her diastolic blood pressure is recorded more than 100 mmHg on the next visit d. There is a history of smoking for more than 3 years e. There is evidence of rapidly progressive end organ damage

Answer 65

e. There is evidence of rapidlyprogressive end organ damage  Malignant hypertension is often associated with acuteend-organ damage, including the eyes

Question 66

After a mild hemorrhage, compensatory responses initiated by the baroreceptor reflex keeps bloodpressure at or close to its normal value. Which one of the following values is less after compensationthan it was before the hemorrhage? a. Ventricular contractility b. Coronary blood flow c. Venouscompliance d. Heart rate e. Total peripheral resistance

Answer 66

c. Venouscompliance  Baroreceptor reflex after bleeding will lead to sympathetic stimulationresulting in venous constriction as a result of decreased venous complianceto allow for increased venous return

Question 67

A 41-year-old female with long standing hypertension presents to your clinic. She has been onAngiotensin converting enzyme (ACE) Inhibitors for two years. This medication works by inhibitingwhich one of the following steps? a. Angiotensin I + Renin to Angiotensinogen b. Renin to Angiotensinogen c. Angiotensinogen to Angiotensin II d. Angiotensinogen to Angiotensin I e. Angiotensin I toAngiotensin II

Answer 67

e. Angiotensin I toAngiotensin II  ACE inhibitors stop action of ACE to convert Angiotensin I toangiotensin II

Question 68

It is important to have a commanding knowledge of the properties and adverse effects of thecommonly used antihypertensive agents. Below is a list of adverse effects seen with different classes ofantihypertensive agents, together with some important properties of selected agents. Which of thebelow antihypertensive agents would you be cautious about in a patient that has uncontrolleddiabetes? a. ACE inhibitors —angio-oedema, cough, postural hypotension, hyperkalaemia, progression ofrenal failure and first-dose hypotension. b. Calcium channel blockers —headaches, sweating, palpitations and ankle oedema c. Angiotensin II receptor blockers —similar to ACE inhibitors but cough is less common d. Beta-blockers —bradycardia, postural hypotension, depression and cold peripheries e. Thiazide diuretics —hypercholesterolaemia,hyperglycaemia,thrombocytopenia and gout

Answer 68

e. Thiazide diuretics —hypercholesterolaemia,hyperglycaemia,thrombocytopenia and gout  Your concern is the risk factor of hyperglycaemia from athiazide diuretic with a patient who already hadhyperglycaemia from uncontrolled diabetes

Question 69

Blood flow through an organ would be increased by decreasing which of the following parameters? a. Number of open arteries b. Arterial pressure c. Diameter of veins d. Hematocrit e. Diameter of artery

Answer 69

d. Hematocrit  Hematocrit reflect blood viscosity, if it decreases resistance is decreased andallow to increase blood flow to the organ

Question 70

Systemic arteriolar constriction may result from an increase in local concentration of which of thefollowing compounds? a. Nitric oxide b. Beta agonist c. Angiotensin II d. Arial natriuretic peptide (ANP) e. Hydrogen ion

Answer 70

c. Angiotensin II  Angiotensin II is a potent vasoconstrictor

Question 71

Which type of vessel or location has the lowest velocity of flow in the systemic (peripheral) circuit? a. Arterioles b. Large arteries c. Aorta d. Capillaries e. Veins

Answer 71

d. Capillaries  The capillaries have the lowest velocity of flow in the systemic circuit. Thisreduced flow rate is essential for allowing sufficient time for the exchange ofgases, nutrients, and waste products between blood and tissues

Question 72

You have just diagnosed a 45-year-old man with essential hypertension. Which of the following is amodifiable risk factor for hypertension? a. Age b. Ethnicity c. Gender d. Family size e. Obesity

Answer 72

e. Obesity  Obesity is a modifiable risk factor for hypertension

Question 73

Thinking about the positive inotropic effects of sympathetic stimulation on the heart and how theyincrease cardiac output, which of the following is correct? a. leads to a decrease in intracellular calcium levels and increased contractility b. deactivates the cyclic AMP (cAMP) second messenger system c. decreases heart rate, which also decreases cardiac output d. decreases the release of norepinephrine e. binds to β1-adrenergicreceptors on cardiacmyocytes

Answer 73

e. binds to β1-adrenergicreceptors on cardiacmyocytes  this is one of the responses to positive inotropic effects ofsympathetic stimulation on the heart and how it increasescardiac output

Question 74

What is the mechanism of action of angiotensin II? a. Increases bradykinin secretion and increases potassium serum levels b. Increases aldosterone secretion andincreases vasoconstriction c. Increases stroke volume and heart rate d. Increases bradykinin secretion and decreases potassium serum levels e. Decreases aldosterone secretion and increases vasoconstriction

Answer 74

b. Increases aldosterone secretion andincreases vasoconstriction  It is a powerful vasoconstrictor and stimulatesadrenal glands to produce aldosterone

Question 75

A patient presents to the emergency department and examination reveals elevated jugular venouspressure, muffled heart sounds and worsening hypotension. Which of the following best describes thetype of circulatory shock? a. Cardiogenic shock b. Distributive shock c. Obstructiveshock d. Hypovolaemic shock e. Anaphylactic shock

Answer 75

c. Obstructiveshock  This patient has cardiac tamponade (Beck’s triad- reveals elevated jugularvenous pressure, muffled heart sounds and worsening hypotension) whichis an obstructive shock

Question 76

A 55-year-old man presents to your office with worsening heart failure. You notice symptoms and signsof congestion and low perfusion. Which of the following is a SIGN of LOW PERFUSION? a. Cool extremities b. Elevated jugular venous pressure c. Fatigue d. Hyperthermia e. Lower extremity edema

Answer 76

a. Cool extremities  Cool extremities is a sign of low perfusion

Question 77

Activation of the sympathetic system and release of catecholamines from adrenal medulla maintains theblood pressure and cardiac output in which of the following phases of shock? a. Progressive phase b. Irreversible phase c. Non-progressivephase

Answer 77

c. Non-progressivephase  In this phase activation of the sympathetic system and release ofcatecholamines from adrenal medulla leading to widespreadvasoconstriction to maintain BP and cardiac output

Question 78

Cardiac (heart) failure occurs when the heart is unable to maintain the necessary cardiac output. Whichof the following statements would you associate with cardiac failure? a. Cardiac failure often results in ventricular atrophy b. Cardiac failure may becompensated for in the earlystages by increasedventricular end-diastolicvolume c. Cardiac failure may be associated with a decrease in cardiac output with exercise d. Cardiac failure cannot occur if the cardiac output is over 5 litres per minute. e. Cardiac failure may be precipitated by polycythaemia vera

Answer 78

b. Cardiac failure may becompensated for in the earlystages by increasedventricular end-diastolicvolume  In the early stages of heart failure, the heart may pumpsufficient blood by its compensating mechanisms (e.g.by increasing ventricular end-diastolic volume,according to Starling’s law)

Question 79

A 72-year-old woman attends the clinic with isolated ankle swelling over the past 3 months. She is nottroubled by breathlessness. She has a history of hypertension, indigestion and migraine. She has beenstarted on a number of medicines recently. She has a normal echocardiogram that day. Whichmedication is most likely to blame? a. Amlodipine b. Lansoprazole c. Furosemide d. Bendroflumethiazide e. Propranolol

Answer 79

a. Amlodipine  Calcium channel blockers of the dihydropyridine class (amlodipine,nifedipine, etc.) commonly cause ankle swelling as a side effect. This mayseem like a picky question but it is just to help you practice yourpharmacology and consider the side effects of certain drugs. Also to remindyou that some antihypertensive drugs can also cause vasodilation hence theresulting ankle swelling in your patient

Question 80

A 74-year-old man is admitted with shortness of breath. On examination, crepitations are heard up tothe mid-zones. A diagnosis of acute left ventricular failure is made. Which of the following treatmentswould be started first? a. β-Blockers b. Diuretics c. Oxygen d. Continuous positive airway pressure (CPAP) e. Morphine

Answer 80

b. Diuretics Why is this the most correct answer? In acute left ventricular failure (LVF), the primary issue is pulmonary congestion due to fluid overload. Diuretics, such as intravenous furosemide, are the first-line treatment because they rapidly reduce preload (the volume of blood returning to the heart) by promoting diuresis. This alleviates pulmonary congestion and improves symptoms like shortness of breath.

Question 81

Heart failure occurs when the heart is unable to maintain necessary cardiac output despite normalvenous pressures. Which of the following events occurs in congestive cardiac failure? a. Glomerular filtration rate is increased b. Reabsorption of sodium in renal tubules is reduced c. The parasympathetic nervous system is stimulated d. Totalbodysodiumisincreased e. Aldosterone secretion is reduced

Answer 81

d. Totalbodysodiumisincreased  Cardiac failure typically stems from reduced myocardial contractility,prompting compensatory activation of the sympathetic nervous system andthe renin-angiotensin system. This response decreases renal blood flow andfiltration, increases sodium and water reabsorption, and reduces their urinaryexcretion, ultimately causing edema

Question 82

65-year-old man develops worsening ankle swelling and is found to have right ventricular failure.Which other clinical sign is most likely to be elicited on examination? a. Wheeze b. Hepatomegaly c. Bilateral basal crepitations d. Hypertension e. Mid-diastolic murmur

Answer 82

b. Hepatomegaly  Hepatomegaly occurs in right ventricular failure due to hepaticcongestion.

Question 83

A 68-year-old man was admitted to intensive care unit with the complaints of breathlessness and pedaledema. He was diagnosed with congestive heart failure. Angiotensin converting enzyme has known todelay the progression of heart failure by various beneficial effects. Which of the following effect ofAngiotensin converting enzyme would help in reducing the incidence of sudden death? a. ACE inhibitors decrease cardiac output and increases afterload b. ACE inhibitor reduces arterial compliance by potentiating Angiotensin II activity c. ACE inhibitors increase preload and increases ventricular dilation d. ACE inhibitors increase venous tone by augmenting Angiotensin II activity e. ACE inhibitors reverseventricular remodelling byattenuating cardiacfibrosis induced byAngiotensin II

Answer 83

e. ACE inhibitors reverseventricular remodelling byattenuating cardiacfibrosis induced byAngiotensin II  ACE inhibitors may reverse ventricular remodelling viachanges in preload/afterload by preventing the growtheffects of Angiotensin II on myocytes and by attenuatingcardiac fibrosis induced by Angiotensin II

Question 84

A 65-year-old man in congestive heart failure (CHF) is unable to climb a flight of stairs withoutexperiencing shortness of breath. Digoxin is administered to improve cardiac muscle contractility. Innext two weeks, he has a marked improvement in his symptoms. What cellular action of digoxin inrelieving symptoms of congestive heart failure? a. Inhibition of β-adrenergic stimulation b. Inhibition of adenosine triphosphate (ATP) degradation c. Inhibition of the sodium (Na+) pump d. Inhibition of mitochondrial calcium (Ca2+) release e. Inhibition of cyclic adenosine 5′-monophosphate (cAMP) synthesis

Answer 84

c. Inhibition of the sodium (Na+) pump  Digoxin acts by inhibiting sodium (Na+) pump

Question 85

Which of the following treatments should be used first in a patient presenting to their generalpractitioner with signs of heart failure but no evidence of pulmonary oedema? a. Spironolactone (potassium sparing diuretic) b. Ramipril(ACEinhibitor) c. Furosemide (loop diuretic) d. Losartan (ARB) e. Atenolol (Beta- blocker)

Answer 85

b. Ramipril(ACEinhibitor)  Angiotensin-converting enzyme inhibitors (ACEI) should be part of thefirst line therapy for anyone with heart failure

Question 86

A 65-year-old man complains of increasing dyspnea on exertion and orthopnea. His physicalexamination reveals an S3 heart sound, pulmonary rales, jugular venous distension, and lower extremityedema. He is normotensive, and his extremities are warm to touch. An echocardiogram confirms anejection fraction of 25% and a dilated left ventricle. What is the most appropriate next step inmanagement? a. Sublingual nitroglycerin b. Oral beta blocker c. NSAID d. Oral furosemide e. Intravenousfurosemide

Answer 86

e. Intravenousfurosemide  Intravenous furosemide is indicated in this patient with warm/wetprofile decompensated heart failure

Question 87

In terms of capillary haemodynamics, which of the following describes hypoalbuminaemia? a. Decreases plasma oncoticpressure b. Decreases plasma hydrostatic pressure c. Decreases interstitial fluid hydrostatic pressure d. Increases plasma oncotic pressure e. Increases interstitial fluid hydrostatic pressure

Answer 87

a. Decreases plasma oncoticpressure  This describes low plasma proteins(hypoalbuminaemia)

Question 88

A 58-year-old woman presents to the emergency department with pulmonary edema, hypoxia, elevatedjugular venous pressures, and tachycardia. Her heart rate is 165 beats per minute, her blood pressure is100/60, and oxygen is 84% on room air, improving to 92% on 6 liters per minute of oxygen by nasalcannula. Before treating her for congestion, you want to clarify the cause of her heart failure andtachycardia. Which test is the MOST likely to provide an answer in this case? a. Troponin level b. ECG c. Chest radiograph d. Thyroid stimulating hormone e. Electrolyte levels

Answer 88

b. ECG  ECG can help diagnose wide range of abnormalities and possible causes of heartfailure such as ischemia, arrhythmia, conduction disorder or ventricular hypertrophy

Question 89

SAQ: A 54-year-old woman presents to the ED with progressive respiratory distress, exertional dyspnea,orthopnea, and paroxysmal nocturnal dyspnea in the setting of heavy nonsteroidal anti-inflammatorydrug (NSAID) use. She is tachycardiac, hypertensive, and hypoxemic. Her physical exam is notable for elevated jugularvenous pressure, an audible S3, bilateral rales, a pulsatile liver, and lower extremity edema. Laboratory evaluation reveals acute kidney injury and elevated brain natriuretic peptide. Arterial bloodgas reveals hypoxia and hypercapnia. A chest x-ray shows cardiomegaly, diffuse bilateral infiltrates, andsmall bilateral pleural effusions. What is the most likely diagnosis?

Answer 89

acute decompensated heart failure (ADHF)

Question 90

Calcium channel blockers target the gating mechanism of voltage-gated Ca2+ ion channels. Which ofthe following drugs is not a calcium channel blocker? a. Amlodipine b. Amiodarone c. Verapamil d. Lercanidipine e. Diltiazem

Answer 90

b. Amiodarone  Amiodarone is not a calcium channel blocker. It is an antiarrhythmic whichworks by prolonging the action potential duration, prolonging therefractory period by acting at potassium channels, and affecting the flow ofions across the membrane.

Question 91

The electrical activity of heart muscle can be recorded on the surface of the body as anelectrocardiogram (ECG). What is the normal duration of the QRS interval? a. 0.06–0.10secs b. 0.12–0.20 secs c. 0.30 secs d. 0.11 secs e. Varies with the heart rate

Answer 91

a. 0.06–0.10secs  ventricular depolarization represented by QRS complex is normally 0.06-0.10 secs

Question 92

A 67-year-old man was found collapsed at home. The paramedic’s acquired an ECG. What is the mostlikely diagnosis from the list below? a. Atrial flutter b. Ventricularfibrillation c. Complete heart block d. Left ventricular hypertrophy e. Atrial fibrillation

Answer 92

b. Ventricularfibrillation  In ventricular fibrillation, the electrocardiogram is bizarre and ordinarilyshows no tendency toward a regular rhythm of any type

Question 93

The electrical activity of heart muscle can be recorded on the surface of the body as anelectrocardiogram (ECG). Which of the following does the S wave indicate on an ECG? a. Depolarization of the atria b. Depolarization of the interventricular septum from left to right c. Ventricular repolarization d. Depolarizationof the area ofthe heart nearthe base e. Depolarization of the main mass of the ventricles

Answer 93

d. Depolarizationof the area ofthe heart nearthe base  The QRS complex shows the depolarization of the ventricles, whichalso masks the repolarization of the atria. The S wave represents thedepolarization of the area of the heart near the base

Question 94

Atrial fibrillation is a condition in which the pulse rate is irregularly irregular. Which of the followingstatements about atrial fibrillation is true? a. The ventricular rate exceeds the atrial rate b. The ventricular rhythm is regular c. It is associated with tricuspid incompetence d. There are multiple P waves on the ECG e. It may bedue tomultiple re-entrantexcitationwaves in theatria

Answer 94

e. It may bedue tomultiple re-entrantexcitationwaves in theatria  Atrial fibrillation is due to multiple circulating re-entrant excitation in theatria. This results in an irregular and fast atrial rate (up to 500 per minute).Hence the AV node also discharges at an irregular, but slower rate (about90–150 beats per minutes). P waves cannot usually be detected on theECG

Question 95

What is the approximate heart rate, in beats/min, indicated by the ECG strip? a. 60 b. 150 c. 75 d. 100 e. 50

Answer 95

c. 75  Large square method: Divide 300 by the number of large squares between R-Rinterval

Question 96

Abnormal rhythms of the heart occur when the normal conduction is disrupted. What is first-degreeheart block? a. Conduction through theatrioventricular node takeslonger than normal,prolonging the PR interval b. Atria and ventricles are completely separated and beat independently c. Heart rate varies with occasional extra beats d. PR interval lengthens progressively until a ventricular beat is dropped e. Not all atrial impulses are conducted to the ventricles

Answer 96

a. Conduction through theatrioventricular node takeslonger than normal,prolonging the PR interval  First-degree atrioventricular (AV) block occurs whenconduction through the AV node takes longer thannormal. This prolongs the PR interval, slowing the heartrate

Question 97

To gather information about impulse conduction from the atria to the ventricles, which ECG componentwill provide this information? a. ST segment b. PRinterval c. P wave d. T wave

Answer 97

b. PRinterval  The PR interval is the time from the onset of the P wave to the start of the QRScomplex. It reflects conduction through the AV node

Question 98

Cardiac output is determined by stroke volume and heart rate. Which of the following options increasesheart rate in sinus rhythm? a. Atropine b. Digoxin c. Atenolol d. Propranolol e. Verapamil

Answer 98

a. Atropine  Atropine is a muscarinic receptor antagonist, producing an initial bradycardiabecause of central stimulation, followed by tachycardia (the vagus is blockedso that sympathetic effect is unopposed)

Question 99

Which term best describe the rhythm observed in the following ECG? a. Sinus bradycardia b. Normalsinusrhythm c. First degree heart block d. Sinus tachycardia e. Ventricular ectopic beats

Answer 99

b. Normalsinusrhythm  The above ECG contains all characteristics of normal sinus rhythm with a rate of75 bpm and p wave is preceding every QRS complex which is narrow. Normal pwave and PR intervals ≥0.12 seconds

Question 100

SAQ: A 54-year-old man with obesity, hypertension, obstructive sleep apnea, and excessive alcoholconsumption comes to the emergency room with a 3-day history of palpitations, fatigue, and shortnessof breath. He has had similar symptoms in the past, but these were always short-lived and he did notpreviously seek medical attention. On physical examination, his heart rate is 110 bpm irregularlyirregular, and blood pressure is 126/87 mmHg. Cardiopulmonary examination is normal apart from theirregular rhythm. What is the most likely diagnosis? What is the next diagnostic step? What is the next step in therapy?

Answer 100

What is the most likely diagnosis? Answer = Paroxysmal atrial fibrillation What is the next diagnostic step? Answer = Electrocardiogram What is the next step in therapy? Answer = Anticoagulation and rate control

Question 101

A 68-year-old male with a history of syphilis presents with generalized fatigue. He denies dyspnea,lower extremity edema or orthopnea. His BP is 170/90 mmHg and heart rate 80 beats/minute. A III-IVshort early diastolic murmur is heard at the right upper sternal border. Systolic pulsation of the uvulaand systolic capillary pulsations are seen upon light compression of the nail bed. Echo confirms severeaortic regurgitation from a dilated aortic root. The ejection fraction is 60%. The left ventricular endsystolic dimension is 5.7 cm and the left ventricular end diastolic dimension is 7.6 cm. Which of thefollowing is the most appropriate course of action? a. Start an ACE inhibitor and repeat an echocardiogram in 6 months b. Start nifedipine and repeat an echocardiogram in 6 months c. Surgicalaortic valvereplacement d. start a beta-blocker and repeat and echocardiogram in 6 months

Answer 101

c. Surgicalaortic valvereplacement  Given the patient's severe aortic regurgitation, significantly dilated leftventricular dimensions, and symptoms, suggests that the patient is at riskfor developing irreversible heart damage, making immediate surgery amore suitable option than medical management

Question 102

An electrocardiogram (ECG) of a patient with diagnosed mitral stenosis reveals a P mitrale pattern. ThisECG finding is typically indicative of changes within the atrial chambers of the heart. Which combinationof changes is most likely responsible for the presence of P mitrale in this patient? a. Left atrialenlargementand leftatrialhypertrophy b. Left ventricular enlargement and left ventricular hypertrophy c. Left atrial enlargement and left ventricular hypertrophy d. Right atrial enlargement and right atrial hypertrophy e. Right atrial enlargement and right ventricular hypertrophy

Answer 102

a. Left atrialenlargementand leftatrialhypertrophy  P mitrale is a characteristic finding in patients with mitral stenosis,representing left atrial enlargement and hypertrophy. The enlarged leftatrium can cause a broad, notched P wave in the ECG, especially in lead II,as well as a biphasic P wave in lead V1

Question 103

A 70-year-old man with known severe aortic stenosis experiences an episode of syncope while walkingup the stairs. Considering his cardiac history, which underlying mechanism or etiology is most likelyresponsible for his syncope? a. Orthostatic hypotension b. Decreased cerebralperfusion frominadequate cardiacoutput c. Bradyarrhythmias including advanced AV blocks d. Ventricular arrhythmia e. Vasovagal syncope

Answer 103

b. Decreased cerebralperfusion frominadequate cardiacoutput  Severe aortic stenosis can lead to decreased cardiac output,especially during exertion, resulting in insufficient cerebralperfusion and syncope

Question 104

25-year-old woman is brought to the emergency department following a motor vehicle accident. She has a heart rate of 120 bpm and a blood pressure of 85/55 mmHg. She is saturating 89% while breathing ambient air. A chest radiograph shows pulmonary edema, and an echocardiogram reveals severe mitral regurgitation. Which of the following would be contraindicated in this patient? a. Placement of an intraaortic balloon pump b. Initiation of dobutamine c. Initiation of sodium nitroprusside d. Initiation ofphenylephrine e. Immediate surgical evaluation

Answer 104

d. Initiation ofphenylephrine  Initiation of phenylephrine, a selective α1-adrenergic receptor agonist, would increase afterload and thereby worsen the MR. Although this doesnot exactly fit the TLO of outlining the management of MR, it doeshowever help you practice your pharmacology and logically think aboutcontraindications for certain meds and why. For example, you want tothink that a selective α1-adrenergic receptor agonist causesvasoconstriction which would then increase the afterload.

Question 105

A 60-year-old woman with a bicuspid aortic valve complicated by chronic aortic regurgitation is seeking a second opinion. Her most recent echocardiogram showed severe AR but normal LV function and size. Additionally, the ascending aorta was normal. She is quite active in her community and denies symptoms of congestive heart failure. She insists on being referred to a cardiac surgeon for replacement. What is the next step in therapy? a. Reassure the patient and tell her to return only when she develops symptoms b. Obtain serial echocardiograms to monitorfor the onset of LV dysfunction or dilatation c. Start an ACE inhibitor to slow the progression of disease d. Refer her to a cardiac surgeon for aortic valve repair e. Refer her to a cardiac surgeon for aortic valve replacement

Answer 105

b. Obtain serial echocardiograms to monitorfor the onset of LV dysfunction or dilatation  In patients with asymptomatic severe AR,serial echocardiograms should be obtained to monitor for the onset of LVdysfunction or dilatation.

Question 106

A 60-year-old female presents with progressive shortness of breath on exertion over several months.She has also experienced episodes of palpitations and was diagnosed with rheumatic fever as a child.On examination: she is flushed on her cheeks, has an irregularly, irregular pulse. On palpation of thechest a tapping impulse is felt over the heart. On auscultation there is an opening snap and rumbling mid-diastolic murmur, best heard when thepatient is lying on her left side. Lungs are clear on auscultation. Where would an abnormal heart soundbe heard on the anatomy of the heart? a. Left mid-axillary line b. Left 2nd intercostal space, sternal edge c. Right 2nd intercostal space, sternal edge d. Left 5th intercostalspace, midclavicularline e. Right 4th intercostal space, mid-sternal border

Answer 106

d. Left 5th intercostalspace, midclavicularline  Mitral murmurs are best heard over the apex of the heart, whichmay be displaced downwards and towards the axilla with heartfailure

Question 107

A 50-year-old man presents complaining of chest pain that occurs at gradually diminishing levels ofphysical exertion, as well as two recent episodes of syncope while golfing. Cardiovascular examinationreveals a blood pressure of 120/90 mmHg, a loud crescendo-decrescendo systolic murmur bestappreciated at the upper right sternal border (with radiation to both carotid arteries), and a weak anddelayed carotid upstroke. What is the best next step? a. ECGandEcho b. Right heart catheterization c. Ventriculography d. CXR and CTPA

Answer 107

a. ECGandEcho  The combination of ECG and echocardiography (Echo) is the best initial diagnosticapproach for suspected aortic stenosis, given the patient's symptoms and physicalexamination findings. ECG can provide information on heart rhythm andhypertrophy, while an echo is crucial for assessing valve structure, function, andventricular performance

Question 108

Abnormalities in blood flow through damaged heart valves produce murmurs. Which murmur isproduced by mitral regurgitation? a. Ejection systolic murmur b. Mid-diastolic murmur c. Early diastolic murmur d. Machinery murmur e. Pansystolicmurmur

Answer 108

e. Pansystolicmurmur  Incompetent atrioventricular valves allow blood to flow back into the atriaduring ventricular systole. This regurgitation of blood produces a longmurmur that lasts the whole length of systole, called a pansystolic murmur

Question 109

A 78-year-old woman with severe mitral regurgitation is preparing to undergo surgery for a mechanicalmitral valve replacement. You are explaining to her the risks associated with having a mechanical heartvalve. Which of the following treatments will she require for the rest of her life? a. Vitamin Kantagonists b. ACE inhibitors c. Antibiotics d. Calcium channel blockers e. Beta blockers

Answer 109

a. Vitamin Kantagonists  Patients with mechanical heart valves require lifelong anticoagulation toprevent thromboembolism. Vitamin K antagonists, such as warfarin, arecommonly used to maintain an appropriate INR range and prevent clotformation on the mechanical valve

Question 110

Heart sounds are produced by the opening and closing of heart valves, heard on auscultation using astethoscope. Which of the following conditions is associated with the correct abnormality of the secondheart sound? a. Left bundle branch block – wide splitting Right bundle branch block is associated with wide splitting b. Mitral stenosis – soft aortic component c. Pulmonary stenosis – reverse splitting d. Left ventricular outflow obstruction – fixed splitting e. Pulmonaryhypertension –loudpulmonarycomponent

Answer 110

e. Pulmonaryhypertension –loudpulmonarycomponent  The types of second heart sound abnormalities can be deduced by thefact that closure of the aortic heart valve usually precedes thepulmonary valve, and that the difference is more pronounced ininspiration than expiration

Question 111

A 50-year-old man with asymptomatic severe chronic MR secondary to myxomatous degeneration presents to the clinic for routine follow-up. He is an attorney and has been quite busy with work. He denies symptoms of congestive heart failure. His examination is unchanged from his prior visit. His echocardiogram today shows interval worsening of his LV ejection fraction to 45%. What is the next best step in management? a. Refer for mitral valve replacement with bioprosthetic valve b. Refer for mitral valve replacement with mechanical valve c. Repeat echocardiogram in 3 months d. Start an ACE inhibitor e. Refer for mitral valverepair.

Answer 111

e. Refer for mitral valverepair  In asymptomatic patients with primary severe MR and LVdysfunction, mitral valve repair is preferred over mitral valve replacementbecause studies suggest better postoperative LV function and survival with repair.

Question 112

Which of the following is a known cause of functional tricuspid regurgitation? a. Endocarditis b. Tricuspid valve prolapse c. Dilatedcardiomyopathy d. Pulmonary stenosis e. Rheumatic heart disease

Answer 112

c. Dilatedcardiomyopathy  Dilated cardiomyopathy can lead to enlargement of the ventriculardimensions and, subsequently, the tricuspid annulus. This dilation canprevent the tricuspid leaflets from closing properly, resulting infunctional tricuspid regurgitation without direct damage to the valveleaflets

Question 113

SAQ: A previously healthy 55-year-old man presents to the primary care clinic with mild but progressiveexertional dyspnea and exercise intolerance. He also describes recent-onset orthopnea. His physicalexamination is remarkable for “water hammer” peripheral pulses and a hyperdynamic, laterallydisplaced apical impulse. Auscultation reveals a soft S1 and an S3 with an early, diastolic decrescendomurmur that is heard at the left upper sternal border. Extremity exam is notable for mild pitting edemaup to the midshin bilaterally. What is the most likely diagnosis? What is the next step in diagnosis? What is the next step in therapy?

Answer 113

What is the most likely diagnosis? Answer = Chronic aortic regurgitation Feedback = Chronic aortic regurgitation (AR) results from abnormalities in the valve leaflets or in theaortic root. Bicuspid aortic valves, rheumatic heart disease, and endocarditis are the leading causes ofleaflet dysfunction. Longstanding hypertension is a leading cause of aortic root disease What is the next step in diagnosis? Answer = Electrocardiogram and echocardiography. Feedback = Echocardiography, both transthoracic and transesophageal, is the mainstay for diagnosisand is used to determine both the severity and the mechanism of valvular dysfunction. Additionally,echocardiography provides insight into LV function and aortic root anatomy. In chronic AR, the ECGmay show left-axis deviation. Chest radiograph may reveal cardiomegaly, and a dilated aortic knob androot may be seen in chronic AR (just thought I would mention this last detail since we looked at thecardiac silhouette the first week with a check radiograph). What is the next step in therapy? Answer = Surgical evaluation if the regurgitation is severe. Feedback = Patients with symptomatic severe chronic left-sided valvular regurgitation should beconsidered for surgical treatment. Symptoms in the setting of severe aortic regurgitation, includingdyspnea or exercise intolerance, provide a clear indication for surgical management of that patient.Aortic valve surgery is indicated in symptomatic or asymptomatic patients with severe AR and either anLV ejection fraction of <50% or those undergoing cardiac surgery for another reason.

Question 114

Knowledge Check 1: Cardiac Muscle Question: In cardiac muscle, what is the order in which ion channels open to complete an action potential cycle? (Reorder the following): - Potassium channels - Fast sodium channels - Slow calcium channels

Answer 114

- Potassium channels - Fast sodium channels - Slow calcium channels

Question 115

Knowledge Check 2: SA Node Action Potential Question: Which of the following is a characteristic of the SA node action potential? Options: - Low resting membrane potential below the ventricular muscle - Funny current of Na, causing a slow drift of membrane potential toward the threshold - The action potential begins with the opening of potassium channels - The plateau phase results from the slow calcium channels

Answer 115

- Funny current of Na, causing a slow drift of membrane potential toward the threshold (This option is selected)