Exam 1 - Cardiology Packrat Flashcards
A patient's carotid pulse has a quick upstroke associated with wide pulse pressure. These findings are suggestive of A. mitral stenosis. B. pericardial tamponade. C. aortic regurgitation. D. congestive heart failure.
(c) C. Aortic regurgitation causes a bounding pulse and this is characteristic of conditions caused by increased stroke
volume and decreased peripheral resistance.
Which of the following is the ideal method for the prevention of venous thromboembolism in a 38 year-old male undergoing an inguinal hernia repair? A. early ambulation B. elastic stockings C. intermittent pneumatic compression D. low-molecular weight heparin
(c) A. Early ambulation is the most effective preventive strategy for the prophylaxis of venous thromboembolism in low-risk; minor procedures when the patient is under 40 years of age and there are no clinical risk factors.
Which of the following is considered to be the first EKG evidence of acute myocardial infarction? A. ST segment depression B. ST segment inversion C. Peaking of T waves D. Q wave formation
(c) C. The initial EKG of a patient experiencing an acute MI may not reveal any significant changes at all. When an infarction pattern does occur, the first change that is seen is the peaking of the T waves.
The highest pressure gradients between the left ventricle and the aorta occurs with which of the following valvular abnormalities? A. Aortic regurgitation B. Aortic stenosis C. Mitral stenosis D. Mitral regurgitation
(c) B. The aortic valve is a tricuspid valve that is positioned between the left ventricle and the aorta. The valve is open during systole and closed during diastole. In AS, the highest pressure gradient differences between the left ventricle and aorta will be seen. As AS progresses, the pressure in the left atrium will increase as the aortic stenosis worsens and blood is unable to leave the left ventricle. The pressure in the aorta will decrease secondary to the progressing outlet obstruction.
A patient has an EKG performed revealing peaked P waves in lead II, tall R waves in V1 with strain and right axis deviation. Which of the following is the most likely explanation for these EKG findings? A. Anterior wall MI B. Acute pericarditis C. Cor pulmonale D. Systemic hypertension
(c) C. In the presence of severe pulmonary hypertension associated with cor pulmonale the EKG will show P
pulmonale (peaked T waves), right axis deviation, and RV hypertrophy.
A 28 year-old female, 3 months post-partum, complains of gradually increasing dyspnea on exertion. She also complains of near syncope last week. She denies chronic medical conditions and hospitalizations other than for the delivery of her child. She denies tobacco, alcohol or illicit drug abuse. Cardiovascular examination is noteworthy for a laterally displaced apical impulse, an S3 and a systolic murmur best heard in the left axilla. Which of the following is the most likely diagnosis? A. Pulmonary embolism. B. Pericardial effusion C. Tricuspid insufficiency D. Dilated cardiomyopathy.
(c) D. Dilated cardiomyopathy complicates 1 in 3000 to 1 in 15,000 pregnancies and can present from the last month of pregnancy to five months post-partum. Signs and symptoms of congestive heart failure are typical on presentation. The mitral insufficiency is the result of the dilation of the annulus.
Which of the following physical examination findings will be associated with hypertrophic cardiomyopathy?
A. Murmur will worsen with squatting
B. Murmur will decrease with deep breathing
C. Fixed splitting of S2
D. Narrowed S2
(c) B. In hypertrophic cardiomyopathy, maneuvers that reduce left ventricular volume, such as standing, further
narrow the left ventricular outflow and increase the degree of obstruction. An increase in the left ventricular volume that occurs with squatting will expand the outflow tract and reduce the pressure gradient decreasing the murmur.
Which of the following is considered to be the most common pathology leading to angina pectoris?
A. Sudden rupture of a lipid laden plaque.
B. Progressive narrowing of the coronary vessels by atherosclerotic plaque
C. Coronary artery vasospasm over an area affected by endothelial injury
D. Sudden hemorrhage into an atherosclerotic plaque
(c) B. Angina pectoris involves the gradual narrowing of the coronary arteries by which increased myocardial demand results in insufficient blood flow to the myocardium resulting in symptoms.
Which of the following anti-hypertensive medications should be used with caution in a patient with pre- existing heart block? A. Alpha blockers B. Beta blockers C. Central alpha agonists D. Diuretics
(c) B. Patients with pre-existing heart block already have slowed conduction through the AV node. Beta blockers will further block sympathetic impulses from reaching the heart causing the HR to decrease and AV conduction to decrease. Beta blockers will enhance any heart block already present and can cause progression to complete heart block.
The acute onset of congestive heart failure associated with a loud systolic murmur along the left sternal border in a patient with myocardial infarction suggests which of the following? A. Pericarditis B. Cardiac rupture C. Ventricular aneurysm D. Papillary muscle rupture
(c) D. Papillary muscle rupture occurs in 1% of patients with a myocardial infarction. It presents 2 to 7 days after the
infarction with sudden appearance of pulmonary edema and a loud systolic murmur.
The treatment of choice for a patient with WPW (Wolff-Parkinson-White Syndrome) who has recurrent episodes of supraventricular tachycardia is which of the following?
A. IV Verapamil (Calan, Isoptin)
B. Digoxin (Lanoxin)
C. Surgical ablation of the accessory pathway
D. Radiofrequency ablation of bypass tracts
(c) D. Catheter ablation of bypass tracts is possible in more than 90% of patients and is the treatment of choice in patients with symptomatic arrhythmias. It is safer, more cost-effective, and just as successful as surgery.
Which of the following heart murmurs is most likely to radiate into the axilla? A. Mitral insufficiency B. Mitral stenosis C. Aortic insufficiency D. Aortic stenosis
(c) A. MR produces a holosystolic murmur best heard at the apex and radiating to the axilla and back. (u) B. MS produces a low-pitched rumbling diastolic murmur best heard at the left ventricular apex with the patient in the left lateral decubitus position. Mitral stenosis murmur radiates into the apex of the heart.
Which of the following is indicated for use in patients with rheumatic fever that is complicated by carditis?
A. Daily oral cephalosporins
B. Daily vasodilators such as ACE inhibitors
C. Monthly benzathine penicillin injections
D. Immediate heart valve replacement
(c) C. Patients will rheumatic heart disease should receive prophylaxis indefinitely because of the high rate of recurrence in these individuals. The recommended therapy for prophylaxis is an IM injection of 1.2 million units of benzathine penicillin monthly. Alternatively, oral penicillin or erythromycin may be used.
Which of the following is the mechanism of action for the medication adenosine (Adenocard)?
A. It raises the threshold for ventricular tachycardia.
B. It enhances conductivity through the AV node.
C. It blocks the AV node completely.
D. It serves to replace magnesium.
(c) C. Adenosine is an endogenous nucleoside that, when given IV, results in profound, transient, slowing or even termination of AV conduction and sinus discharge rate. Its main use is in the treatment of PSVT.
Which of the following medications used in the long-term management of coronary artery disease is associated with tolerance? A. Calcium channel blockers B. Nitrates C. Beta blockers D. ACE inhibitors
(c) B. Patients taking nitrates rapidly develop tolerance with their use and need to have a nitrate-free period every day in order to continue to benefit from their use. This condition is known as tachyphylaxis. The other agents in this question do not have tolerance as a result of their use.
Which of the following is the first complication seen with mitral stenosis? A. Aortic regurgitation B. Aortic stenosis C. Left ventricular failure D. Right ventricular failure
(c) D. In long standing, severe MS, patients may develop elevated right-sided pressures and right ventricular dysfunction due to blood backing up from the left atrium. These patients can present with signs and symptoms of right-sided heart failure such as peripheral edema.
Which of the following physical examination maneuvers should you have the patient perform to best identify a pericardial friction rub?
A. Lean on the left side and exhale
B. Lean on the left side and inhale deeply
C. Perform valsalva
D. Take a deep breath while leaning forward
(c) D. Having the patient lean slightly forward while sitting can enhance the pericardial friction rub. Inhaling will cause an increase in the negative thoracic pressure which will increase venous return to the heart. This increased venous return will cause the heart to fill with blood and will put more pressure against the already inflamed pericardium.
Which of the following is considered to be a key finding on a patient’s physical examination when the patient has coarctation of the aorta?
A. Femoral artery bruits
B. BP greater in upper extremities than lower extremities
C. Costovertebral angle tenderness
D. Bilateral flank bruising
(c) B. Clinically, most patients with coarctation have upper extremity hypertension with forceful carotid and upper extremity pulses. The pulses in the lower extremity are typically weak and delayed relative to the carotid upstroke. The key physical finding that helps in the diagnosis of coarctation is the upper extremity hypertension compared with a much lower blood pressure in the lower extremities.
A patient is scheduled for an elective cardioversion. Which of the following agents should be used prophylactically? A. Unfractionated heparin B. Low-molecular weight heparin C. Aspirin. D. Warfarin (Coumadin)
(c) D. Patients with more than 72 hours of atrial fibrillation or in whom duration of the arrhythmia is unknown, are at increased risk of having atrial thrombi and should be treated with rate control and anticoagulation for at least 3 weeks before an attempt at cardioversion. Anticoagulation with warfarin to an INR of 2-3 is recommended.
A patient presents with chest pain that initially occurred three days ago. The EKG shows loss of R wave progression across the anterior chest leads. Which of the following is the best explanation for this finding? A. Unstable angina B. Acute myocardial infarction C. Prinzmetal’s angina D. Hyperventilation
(c) B. Chest pain that is ongoing and that has been present for several days may be due to ongoing infarction or recurrent infarction. EKG changes revealing loss of R waves across the precordium may reflect an acute anterior wall myocardial infarction.
Several weeks following an acute MI, a patient presents with pericarditis, pleuritis, myalgias, fever, arthralgias, leukocytosis, and increased erythrocyte sedimentation rate. Which of the following is the most likely diagnosis? A. Levine syndrome B. Tietze’s syndrome C. Leriche syndrome D. Dressler syndrome
(c) D. Dressler Syndrome occurs post MI as a type of post-inflammatory pericarditis.
A patient presents with pericarditis and exhibits Kussmaul’s sign. Which of the following best describes this finding?
A. Systolic ejection murmur
B. Inspiratory rise in jugular venous pressure
C. Bilateral rales
D. Left ventricular heave
(c) B. Kussmaul’s sign is the occurrence that jugular venous pressure rises during inspiration when normally it decreases. Kussmaul’s sign occurs secondary to blood moving into the right-side of the heart and is a common finding in patients with constrictive pericarditis.
A patient with renal artery stenosis is unresponsive to medica therapy. Which of the following is the next most appropriate intervention? A. Stenting of the renal artery B. Nephrectomy C. Radioactive iodine D. Lifestyle modifications
(c) A. Stenting of the renal artery will dilated the narrowed area interfering with blood supply to the kidney.
Which of the following is the only cardiovascular abnormality that is increasing in incidence in the United States? A. Chronic heart failure B. Myocardial infarction C. Cerebral vascular events D. Prinzmetal's angina
(c) A. Heart failure represents a major public health problem in industrialized nations. It appears to be the only common cardiovascular condition that is increasing in prevalence and incidence. In the United States, chronic heart failure is responsible for almost 1 million hospital admissions and 40,000 deaths annually. Since heart failure is more common in the elderly, its prevalence is likely to continue to increase as the population ages.
In an acute MI, in which of the following locations is most likely to require large infusions of saline order to maintain blood pressure?
A. Posterior wall B. Anterior wall C. Lateral wall D. Inferior wall
(c) D. Patients with inferior wall myocardial infarctions are most likely to have infarction involving the right ventricle. Patients with right ventricular infarction are dependent on volume resuscitation and need to continue to have appropriate amounts of fluid in order to maintain cardiac output.
A patient presents with a heart murmur that occurs when regurgitant blood in the left ventricle strikes the anterior leaflet of the mitral valve. Which of the following would best describe this murmur?
A. High-pitched sound following S2
B. Low-pitched rumbling diastolic murmur C. Soft, low-pitched rumbling mid-diastolic
murmur
D. Holosystolic murmur
(c) C. The Austin Flint murmur is a soft, low-pitched, rumbling mid-diastolic bruit. It is produced by the displacement of the anterior leaflet of the mitral valve by the aortic regurgitation stream but does not appear to be associated with hemodynamically significant mitral obstruction.
Which of the following pathogens has been inked with the development of acute myocarditis? A. Human papilloma virus B. Rotavirus C. Human Herpes Virus 6 D. Coxsackie B virus
(c) D. Although associated with a number of infectious and systemic diseases, myocarditis is most frequently the result of a viral infection, with Coxsackie B virus and echovirus being the most frequently implicated in the infection.
Which of the following is better visualized with transesophageal echocardiogram (TEE) than transthoracic echocardiogram?
A. Ventricular wall motion B. Pulmonary arteries
C. Right ventricle
D. Left atrial appendage
(c) D. TEE allows 2-D and Doppler imaging of the heart through the esophagus. Given the close proximity of the esophagus to the heart, high-resolution images can be obtained, especially of the left atrium, mitral valve apparatus, and aorta.
Which of the following is the most common initial chest x-ray manifestation of chronic left-sided heart failure?
A. Left ventricle elongation B. Cardiomegaly
C. Kerly B lines
D. Apical cavities
(c) B. Cardiomegaly occurs as the left ventricle attempts to compensate for the failing heart by enlarging. Cardiomegaly is the heart’s compensation mechanism that occurs secondary to rising end diastolic pressures in the left ventricle. Cardiomegaly results from hypertrophy of the myocytes in the left ventricle responding to increased pressures and an increased work load. This is seen early in the course of chronic heart failure and may even predate symptoms.
A 55-year-old male presents complaining of episodic substernal chest pain that occurs especially during strenuous exercise. Suspecting coronary artery disease (CAD), an exercise stress test is ordered. The test is considered to be abnormal if which of the following occurs?
A. Systolic blood pressure increases during exercise.
B. The heart rate reaches maximal value during exercise.
C. Random premature ventricular beats occur at peak exercise.
D. A 2 mm ST-segment depression is seen on the ECG at peak exercise.
(c) D. A 2 mm ST-segment depression is suggestive of cardiac ischemia and is considered to be an abnormal finding.
A patient presents with a holosystolic murmur. Which of the following diagnoses is consistent with this finding? A. Mitral insufficiency B. Mitral stenosis C. Aortic insufficiency D. Aortic stenosis
(c) A. Mitral insufficiency murmur produces a holosystolic murmur best heard at the apex and radiating to the axilla and back.
Which of the following newly diagnosed hypertensive patients should be suspected of having hypertension due to a secondary cause? A. Person diagnosed at age 35 B. Person diagnosed at age 45 C. Person diagnosed at age 55 D. Person diagnosed at age 65
(u) A. See D for explanation.
(u) B. See D for explanation.
(c) C. See D for explanation.
(u) D. In middle-aged men, however, the most likely cause of the HTN is essential. However, when the initial diagnosis of HTN is made in the elderly patient the probability of the HTN being produced by a secondary cause increases. Causes of secondary HTN usually have a more abrupt onset and can present at any time. Patients with new-onset HTN who are younger than the age of 30 or older than the age of 55 have a greater likelihood of having a reversible underlying cause. Patients who are resistant to medications and who fail to respond to multiple medications should also be suspected of having a secondary cause.
Which of the following is the most common cause of secondary hypertension? A. Renal parenchymal disease B. Primary aldosteronism C. Oral contraceptive use D. Cushing's syndrome
(c) A. Renal parenchymal disease is the most common cause of secondary hypertension
Which of the following medication classes is the treatment of choice in a patient with variant or Prinzmetal's angina? A. Calcium channel blockers B. ACE inhibitors C. Beta blockers D. Angiotensin II receptor blockers
(c) A. Calcium channel blockers are effective prophylactically to treat coronary vasospasm associated with variant or Prinzmetal’s angina.
A 63 year-old female with history of diabetes mellitus presents for blood pressure follow-up. At her last two visits her blood pressure was 150/92 and 152/96. Today in the office her blood pressure is 146/92. Recent blood work shows a Sodium 140 mEq/L, Potassium 4.2 mEq/L, BUN of 23 mg/dL, and Creatinine of 1.1 mg/dL. Which of the following is the most appropriate initial medication in this patient? A. Terazosin (Hytrin) B. Atenolol (Tenormin) C. Lisinopril (Zestril) D. Hydrochlorothiazide (HCTZ)
(c) C. ACE inhibitors should be part of the initial treatment of hypertension in diabetics because of beneficial effects in diabetic nephropathy and is the most appropriate initial medication.
What is the EKG manifestation of cardiac end-organ damage due to hypertension?
A. Right bundle branch block
B. Left ventricular hypertrophy
C. Right ventricular hypertrophy
D. ST segment elevation in lateral precordial leads
(c) B. Long-standing hypertension can lead to left ventricular hypertrophy with characteristic changes noted on EKG.
Annual blood pressure determinations should be obtained beginning at the age of A. 3 years. B. 5 years. C. 12 years. D. 18 years.
(c) A. Periodic measurements of blood pressure should be part of routine preventive health assessments beginning at the age of 3 years.
Which of the following conditions would cause a positive Kussmaul's sign on physical examination? A. Left ventricular failure B. Pulmonary edema C. Coarctation of the aorta D. Constrictive pericarditis
(c) D. Kussmaul’s sign is an increase rather than the normal decrease in the CVP during inspiration. It is most often caused by severe right-sided heart failure; it is a frequent finding in patients with constrictive pericarditis or right ventricular infarction.
Which of the following physical findings is suggestive of atrial septal defect?
A. Fixed split S2
B. Increased pulse pressure
C. Continuous mechanical murmur
D. Difference in blood pressure between the left and right arm
(c) A. An atrial septal defect will cause a shunt of blood from the left to the right atrium. This will result in an equalization in the amount of blood entering both the left and right ventricles which effectively eliminates the normally wide splitting that inspiration typically causes in hearts without an atrial septal defect.
A 29 year-old male presents with complaint of substernal chest pain for 12 hours. The patient states that the pain radiates to his shoulders and is relieved with sitting forward. The patient admits to recent upper respiratory symptoms. On examination vital signs are BP 126/68, HR 86, RR 20, temp 100.3 degrees F. There is no JVD noted. Heart exam reveals regular rate and rhythm with no S3 or S4. There is a friction rub noted. Lungs are clear to auscultation. EKG shows diffuse ST segment elevation. What is the treatment of choice in this patient? A. Pericardiocentesis B. Nitroglycerin C. Percutaneous coronary intervention D. Indomethacin (Indocin)
(c) D. Indomethacin, a nonsteroidal anti-inflammatory medication, is the treatment of choice in a patient with acute pericarditis.
A 24 year-old male presents for routine physical examination. On physical examination, you find that the patient’s upper extremity blood pressure is higher than the blood pressure in the lower extremity. Heart exam reveals a late systolic murmur heard best posteriorly. What is the most likely diagnosis in this patient?
A. Hypertrophic obstructive cardiomyopathy
B. Patent foramen ovale
C. Coarctation of the aorta
D. Patent ductus arteriosus
(c) C. Coarctation of the aorta commonly presents with higher systolic pressures in the upper extremities than the lower extremities and absent or weak femoral pulses.
A 63 year-old female presents with a complaint of chest pressure for one hour, noticed upon awakening. She admits to associated nausea, vomiting, and shortness of breath. 12 lead EKG reveals ST segment elevation in leads II, III, and AVF. Which of the following is the most likely diagnosis? A. Aortic dissection B. Inferior wall myocardial infarction C. Acute pericarditis D. Pulmonary embolus
(c) B. Myocardial infarction often presents with chest pressure and associated nausea and vomiting. ST segment elevation in leads II, III, and AVF are classic findings seen in acute inferior wall myocardial infarction.
A 12 month-old child with tetralogy of Fallot is most likely to have which of the following clinical features? A. Chest pain B. Cyanosis C. Convulsions D. Palpitations
(c) B. Cyanosis is very common in tetralogy of Fallot.
A 23 year-old male presents with syncope. On physical examination you note a medium-pitched, mid-systolic murmur that decreases with squatting and increases with straining. Which of the following is the most likely diagnosis? A. Hypertrophic cardiomyopathy B. Aortic stenosis C. Mitral regurgitation D. Pulmonic stenosis
(c) A. Hypertrophic cardiomyopathy is characterized by a medium- pitched, mid-systolic murmur that decreases with squatting and increases with straining.
A patient with which of the following is at highest risk for coronary artery disease? A. Congenital heart disease B. Polycystic ovary syndrome C. Acute renal failure D. Diabetes mellitus
(c) D. Patients with diabetes mellitus are in the same risk category for coronary artery disease as those patients with established atherosclerotic disease.
Acute rebound hypertensive episodes have been reported to occur with the sudden withdrawal of A. verapamil (Calan). B. lisinopril (Prinivil). C. clonidine (Catapres). D. hydrochlorothiazide (HCTZ)
(c) C. Clonidine (Catapres) is a central alpha agonist and abrupt withdrawal may produce a rebound hypertensive
crisis.
A 38 year-old female with history of coarctation of the aorta repair at the age of two presents with fevers for four weeks. The patient states that she has felt fatigued and achy during this time. Maximum temperature has been 102.1 degrees F. She denies cough, congestion, or other associated symptoms. Physical examination reveals a pale tired appearing female in no acute distress. Heart reveals a new grade III-IV/VI systolic ejection border at the apex, and a II/VI diastolic murmur at the right sternal border. What is the most likely diagnosis? A. Acute myocardial infarction B. Bacterial endocarditis C. Acute pericarditis D. Restrictive cardiomyopathy
(c) B. Bacterial endocarditis presents as febrile illness lasting several days to weeks, commonly with nonspecific
symptoms, echocardiogram often reveals vegetations on affected valves.
A 23 year-old female with history of palpitations presents for evaluation. She admits to acute onset of rapid heart beating lasting seconds to minutes with associated shortness of breath and chest pain. The patient states she can relieve her symptoms with valsalva. Which of the following is the most appropriate diagnostic study to establish a definitive diagnosis in this patient? A. Cardiac catheterization B. Cardiac MRI C. Chest CT scan D. Electrophysiology study
(c) D. Electrophysiology study is useful in establishing the diagnosis and pathway of complex arrhythmias such as
supraventricular tachycardia.
Which of the following is the chief adverse effect of thiazide diuretics? A. Hypokalemia B. Hypernatremia C. Hypocalcemia D. Hypermagnesemia
(c) A. Thiazide diuretics can induce electrolyte changes. Principle among those is hypokalemia.
A 25 year-old male with history of syncope presents for evaluation. The patient admits to intermittent episodes of rapid heart beating that resolve spontaneously. 12 Lead EKG shows delta waves and a short PR interval. Which of the following is the treatment of choice in this patient? A. Radiofrequency catheter ablation B. Verapamil (Calan) C. Percutaneous coronary intervention D. Digoxin (Lanoxin)
(c) A. Radiofrequency catheter ablation is the treatment of choice on patients with accessory pathways, such as Wolff-Parkinson-White Syndrome.
A patient presents for a follow-up visit for chronic hypertension. Which of the following findings may be noted on the fundoscopic examination of this patient? A. cherry-red fovea B. boxcar segmentation of retinal veins C. papilledema D. arteriovenous nicking
(c) D. Arteriovenous nicking is common in chronic hypertension.
A 36 year-old patient with cardiomyopathy secondary to viral myocarditis develops fatigue, increasing dyspnea, and lower extremity edema over the past 3 days. He denies fever. A chest x-ray shows no significant increase in heart size, but reveals prominence of the superior pulmonary vessels. Based on these clinical findings, which of the following is the most likely diagnosis? A. Heart failure B. Subacute bacterial endocarditis C. Pulmonary embolus D. Pneumonia
(c) A. Given the presence of cardiomyopathy, the patient’s heart has decreased functional reserve. The symptoms and chest x-ray findings are typical of congestive heart failure.
Which of the following is first-line treatment for symptomatic bradyarrhythmias due to sick sinus syndrome (SSS)? A. Permanent pacemaker B. Radiofrequency ablation C. Antiarrhythmics D. Anticoagulation therapy
(c) A. Permanent pacemakers are the therapy of choice in patients with symptomatic bradyarrhythmias in sick sinus syndrome.
What type of chest pain is most commonly associated with a dissecting aortic aneurysm? A. Squeezing B. Dull, aching C. Ripping, tearing D. Burning
(c) C. A dissecting aortic aneurysm often presents with a very severe ripping, tearing-like pain.
A 52 year-old obese female with a history of hypertension, tobacco abuse, and hyperlipidemia presents for routine follow-up. Which of her risk factors for coronary atherosclerosis is not modifiable? A. Age B. High LDL C. Hypertension D. Obesity
(c) A. Age is a non modifiable risk factor, as is family history of premature coronary heart disease
An 8 year-old boy is brought to a health care provider complaining of dyspnea and fatigue. On physical examination, a continuous machinery murmur is heard best in the second left intercostal space and is widely transmitted over the precordium. The most likely diagnosis is A. ventricular septal defect. B. atrial septal defect. C. congenital aortic stenosis. D. patent ductus arteriosus.
(c) D. Patent ductus arteriosus is classically described in children as a continuous machinery-type murmur that is
widely transmitted across the precordium.
A 63 year-old male with history of hypertension and tobacco abuse presents complaining of dyspnea on exertion for two weeks. The patient admits to one episode of chest discomfort while shoveling snow which was relieved after five minutes of rest. Vital signs are BP 130/70, HR 68, RR 14. Heart exam reveals regular rate and rhythm, normal S1 and S2, no murmur, gallop, or rub. Lungs are clear to auscultation bilaterally. There is no edema noted. Which of the following is the most appropriate initial diagnostic study for this patient? A. Helical CT scan B. Chest x-ray C. Nuclear stress test D. Cardiac catheterization
(c) C. In patients with classic symptoms of angina, nuclear stress testing is the most widely used test for diagnosis of ischemic heart disease.
A 52 year-old male with history of hypertension and hyperlipidemia presents with an acute myocardial infarction. Urgent cardiac catheterization is performed and shows a 90% occlusion of the left anterior descending artery. The other arteries have minimal disease. Ejection fraction is 45%. Which of the following is the treatment of choice in this patient?
A. Coronary artery bypass grafting (CABG)
B. Streptokinase
C. Percutaneous coronary intervention (PCI)
D. Warfarin (Coumadin)
(c) C. Immediate coronary angiography and primary percutaneous coronary intervention have been shown to be superior to thrombolysis.
A patient presents with an acutely painful and cold left leg. Distal pulses are absent. Leg is cyanotic. There are no signs of gangrene or other open lesions. Symptoms occurred one hour ago. Which of the following treatments is most appropriate? A. Vena cava filter B. Embolectomy C. Amputation D. Aspirin
(c) B. Embolectomy within 4 to 6 hours is the treatment of choice.
Which of the following medications used in the treatment of supraventricular tachycardia is able to cause sinus arrest and asystole for a few seconds while it breaks the paroxysmal supraventricular tachycardia? A. Digoxin (Lanoxin) B. Adenosine (Adenocard) C. Verapamil (Calan) D. Quinidine (Quinaglute)
(c) B. Adenosine is an endogenous nucleoside that results in profound (although transient) slowing of the AV
conduction and sinus node discharge rate. This agent has a very short half-life of 6 seconds.
An elderly female presents for evaluation of exertional syncope, dyspnea, and angina. She admits that previous to these symptoms she had insidious progression of fatigue that caused her to curtail her activities. Which of the following is the most likely diagnosis? A. Aortic stenosis B. Aortic regurgitation C. Mitral stenosis D. Mitral valve prolapse
(c) A. The major symptoms of aortic stenosis are exertional syncope, dyspnea, and angina. Symptoms do not become apparent for a number of years and usually are not present until the valve is narrowed to less than 0.5 cm to 2 cm of valve surface area.
Which of the following would you expect on physical examination in a patient with mitral valve stenosis? A. Systolic blowing murmur B. Opening snap C. Mid-systolic click D. Paradoxically split S2
(c) B. Mitral stenosis is characterized by a mid-diastolic opening snap.
Which of the following is the most common cause for acute myocardial infarction?
A. Occlusion caused by coronary microemboli
B. Thrombus development at a site of vascular injury C. Congenital abnormalities
D. Severe coronary artery spasm
(c) B. Acute myocardial infarction occurs when a coronary artery thrombus develops rapidly at a site of vascular injury. In most cases, infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates and when conditions favor thrombogenesis, so that a mural thrombus forms at the site of rupture and leads to coronary artery occlusion.
A 78 year-old male with history of coronary artery disease status post CABG and ischemic cardiomyopathy presents with complaint of progressive dyspnea and orthopnea. He also complains of lower extremity edema. The patient denies fever, chest pain, or cough. On physical examination, vital signs are BP 120/68, HR 75 and regular, RR 22, afebrile. You note the patient to have an S3 heart sound, jugular venous distention, and 2+ lower extremity edema. The patient is admitted and treated. Upon discharge from the hospital, the patient should be educated to monitor which of the following at home? A. Daily weights B. Daily spirometry C. Daily blood glucose D. Daily fat intake
(c) A. Home monitoring of daily weights can alert the health care provider to the early recognition of worsening heart failure.
Which of the following is the most common cause of arterial embolization? A. Rheumatic heart disease B. Myxoma C. Atrial fibrillation D. Venous thrombosis
(c) C. Atrial fibrillation is present in 60-70% of patients with arterial emboli and is associated with left atrial appendage thrombus.
The most common arrhythmia encountered in patients with mitral stenosis is A. atrial flutter. B. atrial fibrillation. C. paroxysmal atrial tachycardia. D. atrio-ventricular dissociation.
(c) B. Mitral stenosis leads to enlargement of the left atrium, which is the major predisposing risk factor for the
development of atrial fibrillation.
Long term use of which of the following drugs may cause a drug-induced lupus-type eruption? A. prednisone B. tetracycline C. procainamide D. oral contraceptives
(c) C. Procainamide and hydralazine are the most common drugs that may cause a lupus-like eruption.
Which of the following is a cause of high output heart failure? A. myocardial ischemia B. complete heart block C. aortic stenosis D. thyrotoxicosis
(c) D. High output heart failure occurs in patients with reduced systemic vascular resistance. Examples include: thyrotoxicosis, anemia, pregnancy, beriberi and Paget’s disease. Patients with high output heart failure usually have normal pump function, but it is not adequate to meet the high metabolic demands.
A 46 year-old male with no past medical history presents complaining of chest pain for four hours. The patient admits to feeling very poorly over the past two weeks with fever and upper respiratory symptoms. The patient denies shortness of breath or diaphoresis. On examination the patient appears fatigued. Vital signs reveal a BP of 130/80, HR 90 and regular, RR 14. The patient is afebrile. Labs reveal a Troponin I of 10.33 ug/L (0-0.4ug/L). Cardiac catheterization shows normal coronary arteries and an ejection fraction of 40% with global hypokinesis. Which of the following is the most likely diagnosis? A. myocarditis B. pericarditis C. hypertrophic cardiomyopathy D. coronary artery disease
(c) A. Myocarditis often occurs secondary to acute viral illness and causes cardiac dysfunction. Patients will commonly have a history of a recent febrile illness. Chest pain may mimic that of a myocardial infarction and Troponin I levels maybe elevated in one-third of patients. Contractile dysfunction is seen on catheterization and/or echocardiogram.
Which of the following antihypertensive agents is considered to have both alpha- and beta-blocker activities? A. carvedilol (Coreg) B. hydralazine (Apresoline) C. minoxidil (Loniten) D. spironolactone (Aldactone)
(c) A. Carvedilol has both alpha- and beta-blocker activities.
A 12 year-old boy presents to the office with pain in his legs with activity gradually becoming worse over the past month. He is unable to ride a bicycle with his friends due to the pain in his legs. Examination of the heart reveals an ejection click and accentuation of the second heart sound. Femoral pulses are weak and delayed compared to the brachial pulses. Blood pressure obtained in both arms is elevated. Chest x-ray reveals rib notching. Which of the following is the most likely diagnosis? A. abdominal aortic aneurysm B. pheochromocytoma C. coarctation of the aorta D. thoracic outlet syndrome
(c) C. Coarctation is a discrete or long segment of narrowing adjacent to the left subclavian artery. As a result of the coarctation, systemic collaterals develop. X-ray findings occur from the dilated and pulsatile intercostal arteries and the “3” is due to the coarctation site with proximal and distal dilations.
A patient presents with moderate mitral stenosis. Which of the following complications is associated with an increased risk of systemic embolization in this patient? A. atrial fibrillation B. pulmonary hypertension C. increased left atrial pressure D. left ventricular dilatation
(c) A. 50-80% of patients with mitral stenosis will develop paroxysmal or chronic atrial fibrillation; 20-30% of patients with atrial fibrillation will have systemic embolization.
A 19 year-old female presents with complaint of palpitations. On examination you note the patient to have particularly long arms and fingers and a pectus excavatum. She has a history of joint dislocation and a recent ophthalmologic examination revealed ectopic lentis. Which of the following echocardiogram findings would be most consistent with this patient's physical features? A. right atrial enlargement B. aortic root dilation C. pulmonic stenosis D. ventricular septal defect
(c) B. This patient has the signs and symptoms consistent with Marfan’s syndrome. Ectopia lentis, aortic root dilation and aortic dissection are major criteria for the diagnosis of the disease.
A patient presents with chest pain. ECG done in the emergency department reveals ST segment elevation in leads II, III, and AVF. This is most consistent with a myocardial infarction in which of the following areas? A. anterior wall B. inferior wall C. posterior wall D. lateral wall
(c) B. Inferior wall myocardial infarction is characterized by ST segment elevation in leads II, III, and AVF.
Which of the following is an absolute contraindication to thrombolytic therapy in a patient with an acute ST segment elevation myocardial infarction?
A. history of severe hypertension presently controlled B. current use of anticoagulation therapy
C. previous hemorrhagic stroke
D. active peptic ulcer disease
(c) C. Absolute contraindications to thrombolytic therapy include a previous hemorrhagic stroke, a stroke within one year, a known intracranial neoplasm, active internal bleeding, and a suspected aortic dissection. Severe, but controlled hypertension, use of anticoagulation, and active peptic ulcer disease are relative contraindications in which the risk/benefit ratio must be weighed in each patient.
A postmenopausal woman is at greatest risk of death from which of the following? A. stroke B. heart disease C. ovarian cancer D. breast cancer
(c) B. Although women tend to be concerned about dying from breast cancer, heart disease is the number one killer of postmenopausal women.
A 54 year-old female who has diabetes presents with rubor, absence of hair, and brittle nails of her left foot. She complains of leg pain that awakens her at night. Examination reveals a femoral bruit with diminished popliteal and pedal pulses on the left side. The most appropriate therapy would be A. vasodilator therapy. B. bypass surgery. C. exercise program. D. embolectomy.
(c) B. Bypass surgery is indicated in the presence of rest pain and provides relief of symptoms in 80 to 90% of patients.
Which electrolyte abnormality is associated with an increase in the risk for digoxin toxicity?] A. hypercalcemia B. hypokalemia C. hypermagnesemia D. hyponatremia
(c) B. Decreased concentration of potassium results in the increased activity of cardiac glycosides by increasing tissue binding and decreasing renal excretion of digoxin. Potassium loss is the only significant electrolyte abnormality that significantly affects digoxin metabolism.
A 56 year-old male, status post myocardial infarction, is noted to have left ventricular hypertrophy and an ejection fraction of 38%. Which of the following medications should be prescribed to prevent the development of heart failure symptoms? A. amlodipine (Norvasc) B. furosemide (Lasix) C. hydrochlorothiazide (HCTZ) D. lisinopril (Zestril)
(c) D. ACE inhibitors have been shown to markedly improve survival and are also recommended for prevention of symptoms in patients at risk for heart failure.
A 74 year-old patient presents with signs and symptoms of heart failure. EKG shows the patient to be in atrial fibrillation at a rate of 80 bpm. Blood pressure is 120/76. The patient denies complaint of palpitations, chest pain, or syncope. Which of the following is the most important long term therapy in this patient? A. verapamil (Calan) B. amiodarone (Cordarone) C. furosemide (Lasix) D. warfarin (Coumadin)
(c) D. Patients with atrial fibrillation have an increased risk for stroke, therefore these patients need anticoagulation with warfarin to an INR of 2.0-3.0.
Which of the following ECG findings is consistent with hyperkalemia? A. prolonged QT interval B. delta wave C. peaked T waves D. prominent U waves
(c) C. Narrowing and peaking of T waves are the beginning EKG changes associated with hyperkalemia.
A 58 year-old male presents with chest pain. Vital signs include blood pressure of 210/175, pulse 80, RR 20. Which of the following would you expect to find on physical examination? A. papilledema B. carotid bruit C. diastolic murmur D. absent peripheral pulses
(c) A. Malignant hypertension is characterized by marked blood pressure elevation with papilledema, often with encephalopathy or nephropathy.
A 55 year-old diabetic female presents for a 3 month blood pressure follow-up. At the last visit the BP was 160/90 for the third consecutive visit. She was placed on an ACE inhibitor and educated regarding lifestyle modifications. At today’s visit the patient complains of persistent annoying dry cough that has been going on since the last visit. BP today is 120/70. What is the best recommendation to control her BP?
A. add a diuretic
B. stop the ACE inhibitor and continue lifestyle modifications
C. switch patient to an Angiotensin II Receptor Blocker (ARB)
D. do nothing and recheck BP in 3 months
(c) C. This patient’s chronic dry cough is likely secondary to the ACE inhibitor, the medication should be stopped. Angiotensin II Receptor Blockers (ARBs) are similar to ACE inhibitors for BP control, but do not cause cough.
A newborn is seen for an initial two week visit. Physical examination reveals a thrill and a continuous machinery murmur in the left second intercostal space. Which of the following is the most likely diagnosis?
A. patent ductus arteriosus
B. ventricular septal defect C. tetralogy of Fallot
D. coarctation of the aorta
(c) A. Patent ductus arteriosus is characterized by a classic harsh, machinery-like murmur that is continuous through systole and diastole. This is heard best at the left second interspace and is commonly associated with a thrill.
A patient had an acute inferior, transmural myocardial infarction 4 days ago. A new murmur raises the suspicion of mitral regurgitation due to papillary muscle rupture. Which of the following murmur descriptions describes this condition?
A. A grade III/VI diastolic murmur heard best at the apex without radiation.
B. A grade IV/VI systolic ejection murmur heard best at the base with radiation to the left clavicle.
C. A grade II/VI systolic murmur heard best at the apex preceded by a click and without radiation.
D. A grade IV/VI systolic murmur heard best at the apex with radiation to the left axilla.
(c) D. This is a classic description of mitral regurgitation. The papillary muscle rupture is a complication of an acute inferior transmural myocardial infarction, and results in a failure of the mitral valve leaflets to close. The direction of regurgitant flow of blood is toward the left axilla.
A 58 year-old male who is otherwise healthy presents with chest pain and is found to have left main coronary artery stenosis of 75%. The most important aspect of his management now is
A. daily aspirin to prevent MI.
B. nitrate therapy for the angina.
C. aggressive risk factor reduction.
D. referral for coronary artery revascularization.
(c) D. Although medical therapy is important, revascularization is indicated when stenosis of the left main coronary artery is greater than 50%.
A 17 year-old woman presents to the office with recurrent episodes of palpitations and near syncope. Initial ECG was normal. She is concerned about these episodes since they can occur at any time. Which of the following is the most appropriate step to pursue in her evaluation? A. cardiac catheterization B. tilt table testing C. echocardiogram D. Holter monitoring
(c) D. Holter monitoring will identify the heart rhythm; an event recorder may also be useful in this setting if the Holter monitor is not diagnostic.
A 37 year-old female with history of Turner's syndrome and coarctation of the aorta repaired at the age of 3 presents for routine examination. The patient is without complaints of chest pain, dyspnea, palpitations, or syncope. On examination vitals signs reveal a BP of 130/76, HR 70, regular, RR 16. On cardiac examination you note a grade II/VI systolic ejection murmur at the left sternal border and a grade III/VI blowing diastolic murmur. Which of the following does this patient require? A. antibiotic prophylaxis B. beta blocker therapy C. chest CT D. exercise stress test
(c) A. This patient has a history of congenital heart disease and presently has a murmur consistent with aortic regurgitation. This patient requires antibiotic prophylaxis against infective endocarditis.
A 60 year-old male with history of hypertension and hyperlipidemia presents with intermittent chest heaviness for one month. The patient states he has had occasional heaviness in his chest while walking on his treadmill at home or shoveling snow. He also admits to mild dyspnea on exertion. His symptoms are relieved with 2-3 minutes of rest. He denies lightheadedness, syncope, orthopnea or lower extremity edema. Vitals reveal a BP of 130/90, HR 70, regular, RR 14. Cardiac examination revealed a normal S1 and S2, without murmur or rub. Lungs were clear to auscultation. Extremities are without edema. EKG reveals no acute change and cardiac enzymes are negative. Which of the following is the most appropriate next diagnostic study? A. cardiac catheterization B. nuclear exercise stress test C. helical (spiral) CT D. transthoracic Echocardiogram
(c) B. This patient has signs and symptoms of classic angina; nuclear stress testing is the most useful noninvasive procedure for diagnosis of ischemic heart disease and evaluation of angina in this patient.
A 28 year-old patient presents with complaint of chest pain for two days. The patient describes the pain as constant and sharp. It is worse with lying down, better with sitting up and leaning forward. Vital signs are BP 120/80, HR 80, regular, RR 14 and Temperature 100.1 degrees F. Which of the following would you expect to find on physical examination? A. lower extremity edema B. carotid bruit C. pericardial friction rub D. splinter hemorrhages
(c) C. This patient has signs and symptoms of pericarditis. A pericardial friction rub is characteristic of acute pericarditis.
A 22 year-old male received a stab wound in the chest an hour ago. The diagnosis of pericardial tamponade is strongly supported by the presence of A. pulmonary edema. B. wide pulse pressure. C. distended neck veins. D. an early diastolic murmur.
(c) C. Cardiac tamponade will manifest with distended neck veins and cold clammy skin.
A 45 year-old female presents with complaint of lower extremity discomfort. The patient admits to dull aching of the left lower extremity. The discomfort is worse after standing for long periods of time. Examination reveals dilated, tortuous and elongated veins on the medial aspect of the left leg. Pedal pulses are +2/4 bilaterally. There are no skin changes or lower extremity edema noted. Which of the following is the most appropriate initial treatment of choice in this patient?
A. heparin
B. compression stockings C. furosemide (Lasix)
D. thrombectomy
(c) B. This patient has signs and symptoms of varicose veins. Initial treatment with compression stockings may prolong or avoid the need for surgery.
A 55 year-old male presents with complaint of sudden ripping chest pain that radiates into the abdomen. On examination the patient is found to have diminished peripheral pulses and a diastolic murmur. EKG reveals left ventricular hypertrophy. Which of the following is the most likely diagnosis? A. acute myocardial infarction B. pulmonary embolism C. acute pericarditis D. aortic dissection
(c) D. Aortic dissection is characterized by a ripping or tearing type pain with radiation to the neck, back or abdomen. Left ventricular hypertrophy is often seen on EKG secondary to longstanding hypertension. A diastolic murmur is often present secondary to aortic insufficiency.
A 78 year-old patient who is in acute distress with near-syncope and lightheadedness is being examined. The patient's pulse is 40/min and blood pressure is 90/56 mm Hg. Examination of the patient at 45 degrees of elevation reveals cannon "a" waves. Which of the following is the most likely explanation for these abnormal waves? A. atrioventricular dissociation B. aortic stenosis C. systolic hypertension D. left ventricular hypertrophy
(c) A. The patient is in a third-degree heart block with the atria contracting against a closed atrioventricular valve, which would be the scenario in a patient who has an escape rate of 40. Elderly patients are at risk for heart conduction problems such as complete heart block.
Which of the following occurs as a result of pulmonary hypertension? A. left atrial enlargement B. aortic stenosis C. coronary artery spasm D. right ventricular enlargement
(c) D. In pulmonary hypertension increased resistance within pulmonary circulation causes the right ventricle to work harder and eventually enlarge in response. Other changes that may occur are right atrial enlargement, decreased left ventricular cavity size, and tricuspid regurgitation.
A 56 year-old male presents to the office with a history of abdominal aortic aneurysm. He was told that he will need ongoing evaluation to assess whether the aneurysm is expanding. What is the recommended study to utilize in this situation? A. plain film of the abdomen B. serial abdominal exam C. ultrasound of the abdomen D. angiography of the abdominal aorta
(c) C. An abdominal ultrasound can delineate the transverse and longitudinal dimensions of an abdominal aortic aneurysm and may detect mural thrombus. Abdominal ultrasound is best used to screen patients at risk for the development of this condition.
A 55 year-old morbidly obese male is seen in the office for routine examination. He has a history of pulmonary hypertension and cor pulmonale. Examination reveals a visible jugular venous pulse and a systolic flow murmur on the right side of the sternum. Which of the following is the most likely diagnosis? A. mitral insufficiency B. tricuspid insufficiency C. hepatic vein thrombosis D. aneurysm of the thoracic aorta
(c) B. Tricuspid insufficiency will result in blood being put back into the right side of the body with increased jugular pulsation in the neck, along with a palpable venous pulse in the liver.
Which of the following is the most common cause of infective endocarditis in an IV drug abuser? A. Haemophilus parainfluenza B. Enterococci C. Staphylococcus aureus D. Viridans streptococci
(c) C. S. aureus accounts for more than 60% of all cases of endocarditis in IV drug abusers.
