Exam 1 - Cardiology Packrat Flashcards
(245 cards)
1
Q
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.
A
(c) C. Aortic regurgitation causes a bounding pulse and this is characteristic of conditions caused by increased stroke
volume and decreased peripheral resistance.
2
Q
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
A
(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.
3
Q
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
A
(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.
4
Q
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
A
(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.
5
Q
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
A
(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.
6
Q
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.
A
(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.
7
Q
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
A
(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.
8
Q
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
A
(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.
9
Q
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
A
(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.
10
Q
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
A
(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.
11
Q
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
A
(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.
12
Q
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
A
(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.
13
Q
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
A
(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.
14
Q
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.
A
(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.
15
Q
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
A
(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.
16
Q
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
A
(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.
17
Q
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
A
(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.
18
Q
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
A
(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.
19
Q
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)
A
(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.
20
Q
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
A
(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.
21
Q
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
A
(c) D. Dressler Syndrome occurs post MI as a type of post-inflammatory pericarditis.
22
Q
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
A
(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.
23
Q
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
A
(c) A. Stenting of the renal artery will dilated the narrowed area interfering with blood supply to the kidney.
24
Q
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
A
(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.
25
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.
26
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.
27
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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.
28
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.
29
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.
30
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.
31
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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.
32
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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.
33
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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
34
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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.
35
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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.
36
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.
37
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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.
38
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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.
39
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.
40
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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.
41
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.
42
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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.
43
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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.
44
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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.
45
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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.
46
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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.
47
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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.
48
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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.
49
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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.
50
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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.
51
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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.
52
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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.
53
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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.
54
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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.
55
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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
56
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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.
57
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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.
58
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.
59
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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.
60
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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.
61
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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.
62
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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.
63
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.
64
```
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.
65
```
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.
66
```
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.
67
```
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.
68
```
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.
69
```
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.
70
```
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.
71
```
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.
72
```
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.
73
```
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.
74
```
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.
75
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.
76
```
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.
77
```
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.
78
```
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.
79
```
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.
80
```
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.
81
```
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.
82
```
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.
83
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.
84
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.
85
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.
86
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%.
87
```
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.
88
```
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.
89
```
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.
90
```
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.
91
```
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.
92
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.
93
```
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.
94
```
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.
95
```
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.
96
```
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.
97
```
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.
98
```
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.
99
Which of the following factors in patients with chronic venous insufficiency predisposes them to development of skin ulcers?
A. Increased intravascular oncotic pressure
B. Leakage of fibrinogen and growth factors into the interstitial space
C. Decreased capillary leakage
D. Inherited deficiency of protein C
(c) B. Leakage of fibrinogen and growth factors into the interstitial space, leukocyte aggregation and activation, and obliteration of the cutaneous lymphatic network can predispose a patient to skin ulcers
100
A newborn is being evaluated for perioral cyanosis while feeding associated with sweating. Vital signs are rectal temperature, 37.8 degrees C (100 degrees F), blood pressure 80/45 mmHg, pulse 180/min, and respirations 40/min. A grade 3/6 harsh systolic ejection murmur with a single loud S2 is heard at the left upper sternal border. Electrocardiogram (ECG) shows right ventricular hypertrophy with right axis deviation. Chest x-ray shows a boot- shaped heart and decreased pulmonary vascular markings. Which of the following is the most likely diagnosis?
A. Atrial septal defect
B. Total anomalous pulmonary venous return
C. Coarctation of the aorta
D. Tetralogy of Fallot
(c) D. This is a common presentation for tetralogy of fallot.
101
```
A hospitalized patient is found with confirmed pulseless ventricular tachycardia. IV access is obtained following the second shock given. Which of the following medications is to be administered immediately?
A. Amiodarone
B. Magnesium
C. Atropine
D. Epinephrine
```
(c) D. Epinephrine should be given as soon as IV access is obtained before or after the second shock.
102
```
An electrocardiogram (ECG) shows a sinus rhythm with varying T wave heights, axis changes every other beat and a wandering baseline. Which of the following is most likely the diagnosis?
A. Artifact
B. Digoxin toxicity
C. Pericardial effusion
D. Poor lead placement
```
(c) C. This ECG pattern best represents pericardial effusion due to a swinging heart in fluid and is known as electrical alternans.
103
```
A 25 year-old female presents to the emergency department after an episode of substernal chest pain with radiation to the middle of her back that came on suddenly and lasted for about four minutes this morning while in bed. She denies previous episodes. Examination is unremarkable, but she appears jittery. Toxicology screen is positive for cocaine. Which of the following medications is contraindicated in this patient?
A. Lorazepam (Ativan)
B. Diltiazem (Cardizem)
C. Nitroglycerin (Nitrostat)
D. Propanolol (Inderal)
```
(c) D. Pure Beta blockers, such as propranol, can cause a paradoxical hypertension because of unopposed alpha- adrenergic effects.
104
A 56 year-old female four days post myocardial infarction presents with a new murmur. On examination the murmur is a grade 3/6 pansystolic murmur radiating to the axilla. She is dyspenic at rest and has rales throughout all her lung fields. Blood pressure is 108/68 mmHg, pulse 70 bpm. Which of the following would be the definitive clinical intervention?
A. Intra-aortic balloon counterpulsation
B. Mitral valve replacement
C. Coronary artery bypass surgery
D. Immediate fluid bolus
(c) B. MVR is the definitive intervention to correct MR caused by papillary muscle rupture.
105
```
A 16 year-old male with a history of tetralogy of Fallot presents to clinic for a follow-up visit status post replacement of his right ventricle to pulmonary artery conduit. He has complaints of chest pain with inspiration, fever and general malaise. Cardiac examination reveals a rub with muffled heart sounds. Labs show an elevated erythrocyte sedimentation rate (ESR) and leukocytosis. Which of the following is the most effective treatment?
A. Acetaminophen/oxycodone
B. Azithromycin
C. Indomethacin
D. Furosemide
```
(c) C. Indomethacin is suitable for controlling pain in Dressler's syndrome. ASA is preferred. Narcotics, diuretics or antibiotics are not recommended.
106
A 72 year-old male presents to the emergency department with crushing chest pain, dyspnea and palpitations for 2 hours in duration. Enzymes are pending and he has been given aspirin and sublingual nitroglycerin. He is rushed to the catheterization lab where they find a totally occluded distal right coronary artery. Which of the following electrocardiogram (ECG) findings supports the diagnosis?
A. Q waves in leads I, aVL, V5-V6
B. ST segment elevation in leads II, III, aVF
C. Hyperacute T waves in leads I, aVL
D. Flipped T waves with repolarization changes in leads V1-V4
(c) B. ST segment elevation in leads II, III, aVF, represents an acute process in the right coronary artery.
107
```
Which of the following population groups represent the greatest risk for developing primary hypertension?
A. White non-Hispanic
B. Hispanic
C. Mediterranean
D. Black non-Hispanic
```
(c) D. Black non-Hispanic adults have the highest risk of hypertension.
108
```
A 60 year-old male with hypertension is brought to the emergency department 30 minutes after the sudden onset of severe chest pain that radiates to his back and arms. His blood pressure is 180/80 mmHg in his left arm; no blood pressure reading can be obtained from the right arm. ECG shows sinus tachycardia with left ventricular hypertrophy. A high pitched decrescendo diastolic murmur is heard along the left mid-sternal border. Which of the following is the most likely diagnosis?
A. Acute myocardial infarction
B. Aortic dissection
C. Pulmonary embolism
D. Right subclavian arterial embolus
```
(c) B. This is a classic presentation for aortic dissection.
109
```
Which of the following conditions is most suggestive of an abdominal aortic aneurysm?
A. Abdominal mass
B. Hypertension
C. Chest pain
D. Syncope
```
(c) A. An abdominal aortic aneurysm presents with a pulsatile upper abdominal mass.
110
Who is most likely to require subacute bacterial endocarditis (SBE) prophylaxis prior to a dental procedure?
A. 22 year-old female with mitral valve prolapse
B. 36 year-old male with a bio-prosthesic mitral valve
C. 45 year-old female with an ASD closure 8 months ago with no residual defect
D. 15 year-old male with a bicuspid aortic valve
(c) B. The AHA recommends that patients with prosthetic heart valves receive antibiotic prophylaxis. As should cardiac transplant recipients with valve disease, unrepaired cyanotic CHD, repaired CHD with prosthetic material or device during the first six months of the procedure and repaired CHD with residual defects at site of patch or prosthetic device.
111
When evaluating jugular venous pulsations a prominent a wave represents which of the following?
A. Atrial contraction against a closed tricuspid valve
B. Rapid filling of the right atrium
C. Tricuspid regurgitation
D. Poor left ventricle compliance
(c) A. The a wave corresponds to right atrial contraction.
112
An 18 year-old male high school basketball player comes to clinic for a routine physical exam. His height is 193 cm (76 in.); arm span is 201 cm (79 in.). He has long fingers and toes. Blood pressure is 146/62 mmHg and pulse is 64/min. Which of the following exam findings is most consistent with the diagnosis?
A. Grade 2/6 high-frequency diastolic murmur at the third right intercostal space
B. Grade 2/6 systolic ejection murmur at the second left intercostal space with a fixed widely split S2
C. Grade 2/6 continuous murmur heard best at the high left sternal border
D. Grade 2/6 systolic murmur at the fourth left intercostal space that decreases with squatting
(c) A. This murmur is most consistent with aortic regurgitation which can be present in patients with Marfans syndrome and a dilated aortic root.
113
Which of the following is the most likely initial effect on the left ventricle from aortic stenosis?
A. Dilitation of the ventricle with diastolic dysfunction
B. Wall stiffness due to ischemia from decreased coronary blood flow
C. Paradoxical wall motion abnormalities due to increased preload
D. Concentric hypertrophy with preserved function
(c) D. Hypertrophy would be the initial changes of the left ventricle as a response to the increased pressure.
114
A 65 year-old female who recently had an anterior MI returns to clinic for follow-up six weeks after. She has no chest pain, but reports decreased exercise tolerance. Electrocardiogram (ECG) shows persistent ST elevation in leads V2- V4. Which of the following is the most likely diagnosis?
A. Right ventricular infarction
B. Re-occlusion of the right coronary artery
C. Pericarditis
D. Ventricular aneurysm
(c) D. Persistent ST elevation in the leads where a previous or recent anterior MI occurred is most likely due to ventricular aneurysm.
115
```
A 15 year-old male is brought to the emergency department 1 hour after an episode of syncope while running in a 400-meter race. He had a similar episode 2 years ago. His mother and maternal first cousin died suddenly at the ages of 32 and 17 years, respectively. Examination shows abrasions of the face, hands, and knees. Neurologic examination shows no abnormalities. Which of the following is the most appropriate initial test?
A. Tilt table test
B. CT scan of the head
C. Electrocardiogram
D. Electroencephalography
```
(c) C. ECG is the most appropriate to rule out any underlying rhythm abnormalities, Holter or event monitoring would also be included.
116
```
What is the optimal INR for a patient with a mechanical mitral valve prosthesis on warfarin (Coumadin)?
A. 1.5-2.5
B. 2.0-3.0
C. 2.5-3.5
D. 3.5-4.5
```
(c) C. Patients with mechanical MV prostheses should maintain an INR between 2.5-3.5. Aortic mechanical valves can be maintained at an INR of 2.0-3.0.
117
Which of the following can optimize quality of life and is an definitive treatment for a patient with refractory heart failure?
A. Ventricular assist device
B. Intra-aortic balloon counterpulsation
C. Cardiac transplantation
D. Partial resection of the left ventricle
(c) C. Cardiac transplantation is effective, with survival rates of 80-90% in 1 year, 60-70% over 5 years. It does improve quality of life despite the immunosuppression medications.
118
Which of the following physical exam findings suggests worsening or severe aortic stenosis?
A. An ejection click preceding the murmur
B. A split S2 with respiration variation
C. Grade 2/6 systolic murmur radiating to the carotids D. Palpable thrill over the right second intercostal space
(c) D. A palpable thrill or LV heave with associated murmur suggests severe AS.
119
```
Perfusion of the coronary arteries occurs primarily during which of the following?
A. Systole
B. Diastole
C. Afterload
D. Preload
```
(c) B. Coronary artery perfusion occurs primarily during diastole.
120
What is the mechanism of action for aspirin?
A. Inhibits platelet aggregation by blocking cyclooxygenase-1 activity
B. Exerts antiplatelet effects by blocking the platelet membrane adenosine diphosphate receptors
C. Inhibits the platelet membrane glycoprotein IIb/IIIa receptor
D. Converts plasminogen to the natural fibrinolytic agent plasmin
(c) A. Aspirin inhibits platelet aggregation by blocking cyclooxygenase-1 activity.
121
A 56 year-old male with a 30 pack-year smoking history presents with substernal chest pain. The pain is described as a pressure that radiates to his jaw. The pain has lasted consistently for 30 minutes with variable relief. His current medications include atorvastatin (Lipitor) and glyburide (Micronase). Which of the following aggravating or relieving factors about the pain would support the diagnosis?
A. Precipitated by exercise and relieved with rest
B. Unrelieved by nitroglycerin
C. Aggravated by deep breaths
D. Relieved with food
(c) B. Patient is having a myocardial infarction which is unrelieved by rest or nitroglycerin.
122
A 26 year-old female presents to clinic with a left arm that is swollen and non-tender with bluish discoloration along the upper arm and forearm. She is status post pacemaker insertion in the left upper chest for third degree heart block, one week ago. Pulses are present and the arm is warm, but not red. The pacemaker incision is healing well despite a hematoma and tenderness at the site. Which of the following statements would be appropriate patient education about this condition?
A. Reassurance that the discoloration is an expected finding.
B. Apply cold compresses to the site of the hematoma.
C. Elevation of the involved extremity will increase the swelling.
D. Aspirin should be taken to help manage pain.
(c) A. This is indicative of migratory ecchymosis and expected after insertion of a pacemaker.
123
A 66 year-old female with a history of coronary artery disease presents with a new onset of dizziness and fatigue for two weeks. She recalls nearly passing out on one occasion. Examination is unremarkable except for bradycardia. Electrocardiogram (ECG) reveals a heart rate of 50 with a normal PR interval followed by a normal QRS. There are several non-conducting P waves and no lengthening of the PR interval. Which of the following interventions is the therapy of choice?
A. Permanent pacemaker
B. Radio-frequency ablation
C. Maze procedure
D. Automatic Implantable Cardioverter Defibrillator
(c) A. This patient has symptomatic second degree type II heart block and requires a pacemaker.
124
Pulmonary capillary wedge pressure indirectly measures which of the following?
A. Right ventricular end-diastolic pressure
B. Right atrial filling pressure
C. Left ventricular systolic pressure
D. Left atrial filling pressure
(c) D. Pulmonary capillary wedge pressure indirectly measures left atrial filling pressures.
125
A 26 year-old male presents with increased dyspnea with exercise. He has noted a decrease in his exercise tolerance over the past several months. He denies chest pain or skipped heart beats. Echocardiogram reveals left ventricular hypertrophy with asymmetric septal hypertrophy. Ejection fraction is 65%. Which of the following is the most likely presenting history or physical exam finding?
A. He has an older brother with the same diagnosis.
B. An S3 gallop is heard.
C. Patient notes completing a course of adriamycin.
D. Elevated jugular venous distension is noted.
(c) A. Hypertrophic cardiomyopathy can be genetic and present in 25% of first degree relatives.
126
```
Which of the following lifestyle recommendations would most benefit the heart failure patient's quality of life?
A. Begin a regular exercise program
B. Total salt restriction
C. Home monitoring of blood pressure
D. Increase home oxygen requirements
```
(c) A. Exercise training improves activity tolerance and deconditioning offering some recompensation.
127
```
A newborn presents with blue discoloration of the peripheral extremities which worsens with exposure to cold and improves with warming. Which of the following is the most likely cause?
A. Raynauds phenomenon
B. Livedo reticularis
C. Erythromelagia
D. Acrocyanosis
```
(c) D. Acrocyanosis is a blue discoloration of the digits, usually of the peripheral extremities in newborns, which worsens with exposure to cold and improves with warming.
128
A two month-old infant appeared well until three weeks ago when he became dyspneic and had difficulty feeding. A 4/6 holosystolic murmur is heard at the left lower sternal border in the 3rd ICS. An electrocardiogram (ECG) shows left and right ventricular hypertrophy. Which of the following is the most likely diagnosis?
A. Atrial septal defect
B. Pulmonary hypertension
C. Ventricular septal defect D. Tricuspid insufficiency
(c) C. This is a classic presentation for a ventricular septal defect.
129
```
Which of the following laboratory tests would be elevated in a patient with symptomatic heart failure?
A. Lactate dehydrogenase (LDH)
B. Troponin I (TnI)
C. C-reactive protein (CRP)
D. Brain natriuretic peptide (BNP)
```
(c) D. BNP is expressed in the ventricles and is a sensitive assay in patients with heart failure.
130
```
When prescribing loop diuretics which of the following electrolytes should be most closely monitored?
A. Calcium
B. Potassium
C. Sodium
D. Chloride
```
(c) B. Potassium along with magnesium should be monitored when prescribing loop diuretics.
131
```
Which of the following studies is the best initial diagnostic evaluation to estimate ventricular size and hypertrophy?
A. Electrocardiogram (ECG)
B. Cardiac CT scan
C. Echocardiogram
D. Myocardial perfusion imaging
```
(c) C. Echocardiogram provides the safest and most reliable means to evaluate ventricular size, hypertrophy and function.
132
```
A 44 year-old female presents to clinic for evaluation of a syncopal episode that occurred while walking her dog two days ago. She denies amnesia or head trauma. She has had increasing dyspnea on exertion and pedal edema. Physical examination reveals clubbing of her fingers and central cyanosis. Auscultation of the heart reveals tricuspid insufficiency, widely split second heart sound with a palpable P2. Echocardiogram reveals a large ostium secundum atrial septal defect with bidirectional flow. Which of the following is a secondary complication in this patient?
A. Left heart failure
B. Ebsteins anomaly
C. Tricuspid stenosis
D. Pulmonary hypertension
```
(c) D. Her symptoms and exam findings are consistent with pulmonary hypertension and in her case, Eisenmengers disease, which is a late finding.
133
```
Which of the following treatments will most benefit the diabetic patient with two vessel coronary disease?
A. Stent placement
B. Percutaneous balloon angioplasty
C. Medical management
D. Coronary artery bypass graft
```
(c) D. CABG is the treatment of choice in a diabetic with two or three vessel disease.
134
A 24 year-old male comes to the clinic with a one week history of pain and swelling that involves the entire right upper extremity. He exercises frequently and has noticed the pain worsening while lifting weights. Examination shows enlarged cutaneous veins over the right anterior chest wall with a palpable cord. His right hand appears dusky. Which of the following is the most likely diagnosis?
A. Axillary-subclavian venous thrombosis
B. Thromboangiitis obliterans
C. Superficial thrombophlebitis of the cephalic vein
D. Brachial artery occlusion
(c) A. Axillary-subclavian venous thrombosis can occur in someone who strenuously exercises, has had a central venous catheter or history of venous thrombosis.
135
When performing a pre-participation sports physical in the adolescent population, a murmur with which of the following qualities indicates a risk for sudden death during exercise?
A. Increases with the Valsalva maneuver
B. Increases with squatting maneuver
C. Associated with a mid-systolic click
D. Mid-systolic without radiation to the carotids
(c) A. Hypertrophic cardiomyopathy (HCM) is a known cause of sudden death during or just after physical exertion and competitive sports. The murmur associated with HCM is worsened by conditions that cause reduced ventricular volume such as the Valsalva maneuver, sudden standing, and tachycardia.
136
```
Which of the following antiarrhythmic drugs can be associated with hyper- or hypothyroidism following long-term use?
A. Quinidine
B. Amiodarone
C. Digoxin
D. Verapamil
```
(c) B. Amiodarone is structurally related to thyroxine and contains iodine, which can induce a hyper- or hypothyroid state.
137
```
A 56 year-old male with a known history of polycythemia suddenly complains of pain and paresthesia in the left leg. Physical examination reveals the left leg to be cool to the touch and the toes to be cyanotic. The popliteal pulse is absent by palpation and Doppler. The femoral pulse is absent by palpation but weak with Doppler. The right leg and upper extremities have 2+/4+ pulses throughout. Given these findings what is the most likely diagnosis?
A. Venous thrombosis
B. Arterial thrombosis
C. Thromboangiitis obliterans
D. Thrombophlebitis
```
(c) B.
Arterial thrombosis has occurred and is evidenced by the loss of the popliteal and dorsalis pedis pulse. This is a surgical emergency. Venous occlusion and thrombophlebitis do not result in loss of arterial pulse.
138
```
A 25 year-old female presents with a three day history of chest pain aggravated by coughing and relieved by sitting and leaning forward. She is febrile and a CBC with differential reveals leukocytosis. Which of the following physical examination signs is characteristic of her problem?
A. Pulsus paradoxus
B. Localized crackles
C. Pericardial friction rub
D. Wheezing
```
C Pericardial friction rub is characteristic of an inflammatory pericarditis.
139
```
During physical examination an elderly patient is noted to have a painless, brown-colored ulceration in the area of the medial malleolus. Which of the following is the most likely diagnosis?
A. Arterial ulcer
B. Venous ulcer
C. Arterial insufficiency
D. Diabetic ulcer
```
(c) B. Venous ulceration develops in the lower extremity secondary to venous incompetence and chronic edema. The medial aspect of the ankle is the most common location.
140
```
Which of the following is a proven risk factor for the development of abdominal aortic aneurysm?
A. Infective endocarditis
B. Diabetes mellitus
C. Cigarette smoking
D. Alcohol abuse
```
(c) C. Cigarette smoking is the primary risk factor for the development of aortic aneurysms.
141
```
When instituting diuretic therapy for patients with heart failure, which of the following is considered the treatment of choice as first-line therapy in a failing kidney due to its improved sodium clearance?
A. Hydrochlorothiazide (Diuril)
B. Bumetanide (Bumex)
C. Spironolactone (Aldactone)
D. Acetazolamide (Diamox)
```
(c) B. Loop diuretics remain active in severe renal insufficiency and are the most effective type of diuretics used in the management of heart failure symptoms. These agents have a rapid onset and result in natriuresis due to their activity in the ascending limb in the Loop of Henle.
142
```
High ventricular filling pressures are indicated by a rise in which of the following?
A. Brain natriuretic peptide
B. Troponin
C. Myoglobin
D. Creatinine
```
(c) A. Brain natriuretic peptide (BNP) is a hormone released from the myocardium when stretched such as with high ventricular filling pressures from CHF. It can indicate or be used as prognostic evaluation in patients with acute CHF.
143
```
Which of the following is first-line treatment for a symptomatic bradyarrhythmia due to sick sinus syndrome?
A. Permanent pacemaker
B. Radiofrequencyablation
C. Antiarrhythmic therapy
D. Anticoagulation therapy
```
(c) A. Permanent pacemakers are the therapy of choice in patients with symptomatic bradyarrhythmias in sick sinus syndrome.
144
```
What is the most likely mechanism responsible for retinal hemorrhages and neurologic complications in a patient with infective endocarditis?
A. Metabolicacidosis
B. Embolizationofvegetations
C. Hypotension and tachycardia
D. Activation of the immune system
```
(c) B. The vegetations that occur during infective endocarditis can become emboli and can be dispersed throughout the arterial system.
145
```
Which of the following is a non-invasive quick method of evaluating a patient with suspected lower extremity arterial insufficiency?
A. Ankle-Brachial Index
B. Striker Tonometry
C. CT Angiography
D. Lower extremity arteriography
```
(c) A. The single most useful index is the ankle pressure. This can be obtained with an Ankle-Brachial Index (ABI) which the severity of signs and symptoms of arterial insufficiency are correlated to the findings on the ABI. It is a non-invasive study that can be performed in an office setting.
146
```
Which of the following is the earliest symptom for patients with left ventricular failure?
A. Dependentedema
B. Dyspneaonexertion
C. Congestion
D. Chest pain
```
(u) A. Right ventricular failure is manifested by dependent edema and congestion in the lungs.
147
```
When utilizing medical treatment for hypertension, which of the following classes of medications should be used with caution in those with elevated potassium levels or intrinsic renal disease?
A. Beta blockers
B. Calcium channel blockers
C. Central alpha agonists
D. ACE inhibitors
```
(c) D. ACE inhibitors are recognized as valuable agents in the management of hypertension but they may result in hyperkalemia in patients with intrinsic renal disease. They should be used with caution in patients who are taking potassium-sparing diuretics. These agents reduce glomerular filtration pressure resulting in retention of potassium since less filtration occurs in the kidney.
148
A 60 year-old male has unstable angina, but is otherwise healthy. A 90% lesion is found in the left main coronary artery. Which of the following interventions is most appropriate?
A. Thrombolysis with t-PA
B. Medical management with nitrates
C. Coronary artery bypass graft (CABG)
D. Percutaneous transluminal coronary angioplasty
(c) C. CABG is indicated in patients with stenosis of the left main coronary artery and those with three-vessel coronary artery disease.
149
```
Which of the following pathogens has been linked 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.
150
```
A patient is having a routine physical examination. Funduscopic examination reveals AV narrowing and venous nicking. The nasal border of the optic disc appears blurred. Which of the following is the most likely underlying cause?
A. Hypertension
B. Maculardegeneration
C. Retinal detachment
D. Diabetes mellitus
```
(c) A. Hypertensive retinopathy may cause AV narrowing and venous nicking due to these blood vessels having increased pressures.
151
```
A 33 year-old female presents to the office with a complaint of palpitations. There is no history of any significant heart disease in the past and her symptoms begin and end abruptly on their own. Which of the following is the most likely explanation for these symptoms?
A. Atrialfibrillation
B. Atrialflutter
C. Benign supraventricular tachycardia
D. Sinus tachycardia
```
(c) C. Benign supraventricular tachycardia tends to occur in a young patient without pre-existing heart disease. Symptoms begin and end abruptly without therapy and occurrences happen only intermittently. It is the most likely diagnosis in this setting.
152
```
A patient's EKG reveals widened P waves in lead II and large negative deflection of the P wave in lead V1. Which of the following is the most likely underlying cause for this?
A. Right atrial enlargement
B. Left atrial enlargement
C. Right ventricular hypertrophy
D. Left ventricular hypertrophy
```
B. Wide P waves in lead II and a deep negative deflection in lead V1 is due to P-mitrale which is caused by left atrial enlargement.
153
According to the American College of Cardiology/American Heart Association classification of heart failure, which of the following patients fits the Stage B Classification system?
A. Asymptomatic patient with no structural disease or patients who are at high risk for the development of heart failure.
B. Asymptomatic patient with structural heart disease.
C. Symptomatic patient with structural heart disease.
D. Patients with refractory symptoms despite intervention.
(c) B. According to the ACC/AHA 2005 guidelines, patients with structural heart disease who have not yet experienced symptoms are classified as Stage B. This is the initial stage in which medication therapy other than just ACE inhibitors are recommended.
154
```
A 15 year-old male presents acutely to the office. His legs are cool to the touch. Examination reveals that his pulses and blood pressure are higher in the upper extremities than the lower extremities. Femoral pulses are delayed and weakened. Which of the following is the most likely underlying diagnosis?
A. Pheochromocytoma
B. Conn's Syndrome
C. Cushing'sSyndrome
D. Coarctation of the aorta
```
(c) D. Coarctation of the aorta typically has narrowing of the aorta proximal to the left subclavian artery with resultant high blood pressure in the upper extremities and decreased run off to the lower extremities following this narrowed segment.
155
```
Which of the following valvular heart abnormalities will most likely be seen on echocardiography as a complication of acute myocardial infarction?
A. Aortic stenosis
B. Aortic regurgitation
C. Mitral stenosis
D. Mitral regurgitation
```
(c) D. In patients with acute myocardial infarction, echocardiogram can show the severity of mitral regurgitation and the presence of ventricular septal defect if one is present. Acute inferior wall myocardial infarction is associated with acute mitral regurgitation due to necrosis of the posterior papillary muscle which is supplied by the right coronary artery.
156
```
Which of the following conditions is most closely associated with an increased intensity of the P2 heart sound?
A. Atrial septal defect
B. Aortic stenosis
C. Ventricular septal defect
D. Mitral valve prolapse
```
(c) A. Atrial septal defect can cause a left to right shunt with resultant increased volume in the right ventricle. The net result of this is that the P2 heart sound will be accentuated because of the increased blood flow in the right ventricle and increased force of contraction in the right ventricle to remove this blood. Atrial septal defect will also cause a fixed split S2 heart sound.
157
```
Which of the following medication classes is considered first-line therapy for patients with Raynaud's phenomenon?
A. Beta blockers
B. Calcium channel blockers
C. Central alpha agonists
D. Oral nitrates
```
(c) B. Calcium channel blockers are first line therapy for patients who have uncontrolled symptoms related to Raynaud's phenomenon. They are vasodilating agents which may play a role in preventing the vasospasm that occurs with this disorder.
158
Elevated levels of LP(a) (Lipoprotein a) are considered to be a risk factor for coronary artery disease through which of the following proposed mechanisms?
A. Direct inhibition of HDL
B. Increasing the formation of VLDL cholesterol
C. Competes for binding to the plasminogen receptor D. Enhancement of naturally circulating triglycerides
(c) C. Lp(a) lipoproteins are secreted by the liver, constitute 10% or less of the total plasma lipoprotein mass, possess kringle domains homologous to plasminogen, and are associated with vascular disease risk. Having domains homologous to plasminogen, Lp(a) will compete with actual plasminogen for its receptor sites. Plasminogen activates plasmin, which facilitates degradation of fibrin and matrix components. The main component of LP (a) is LDL, a known risk factor for atherosclerosis.
159
```
Which of the following medication classes is the recommended treatment for patients who have an anterior wall myocardial infarction with poor left ventricular function?
A. Beta blockers
B. Calcium channel blockers
C. Potassium sparing diuretics
D. ACE inhibitors
```
(c) D. ACE inhibitors have been proven to be effective in the therapy of heart failure, especially in the setting of left ventricular dysfunction. They are considered first-line therapy in patients with symptomatic left ventricular systolic function.
160
```
The 35 year-old patient presents after a syncopal episode while throwing a football with his son. Examination reveals regular heart rate and EKG is normal. There were no symptoms prior to the episode. Right radial pulse is decreased. Which of the following is the most likely explanation for the syncope?
A. Carotid sinus hypersensitivity
B. Vasovagal episode
C. Cardiac dysrhythmia
D. Subclavian steal syndrome
```
(c) D. Subclavian steal syndrome occurs if the subclavian artery is occluded proximal to the origin of the vertebral artery which results in reversal in the direction of blood flow in the ipsilateral vertebral artery. Exercise of the ipsilateral arm may increase demand on the vertebral flow which produces a "subclavian steal".
161
```
Which of the following is the most common complication that occurs in the setting of acute pericarditis?
A. Pericardial effusion
B. Left ventricular failure
C. Superior vena cava syndrome
D. Subclavian steal syndrome
```
(c) A. Accumulation of transudate, exudate or blood in the pericardial sac can occur due to pericardial inflammation.
162
```
Which diagnostic study is considered to be the strategy of choice for symptomatic patients with recurrent ischemia, hemodynamic instability or impaired left ventricular dysfunction?
A. Stress echocardiography
B. Exercise treadmill testing
C. Coronary angiography
D. Cardiac magnetic resonance imaging
```
(c) C. Coronary or cardiac catheterization is the gold standard technique in the evaluation of patients with significant cardiac symptoms. Anatomical information along with degree of coronary artery blockages are provided and patients may be able to undergo coronary revascularization during or after this procedure.
163
```
Which of the following is a systemic manifestation of infective endocarditis?
A. Hemarthrosis
B. Petechiae
C. Cafe au lait spots
D. Bronzing of the skin
```
(c) B. Petechiae, splinter hemorrhages, Janeway lesions, and Osler's nodes are systemic manifestations of patients who have infective endocarditis.
164
```
A 76 year-old male presents after returning from a Safari in Africa. Seven days ago he experienced chest pressure lasting one hour that did not respond to three sublingual nitroglycerin tablets. There was no ability to have lab work or an EKG. The pain has not returned. If the patient had a non-STEMI myocardial infarction, which of the following studies will still be positive?
A. Electrocardiogram
B. Myoglobulin
C. CK-MB index
D. Troponin I
```
(c) D. Troponin I levels will stay positive for at least one week following myocardial infarction and is the preferred enzyme to measure in this setting.
165
```
A 52 year-old patient with episodes of syncope has an electrocardiogram which shows a consistently prolonged PR interval with a missing QRS every two beats. Which of the following is the most effective management?
A. Permanent pacing
B. Beta-blocker
C. ACEInhibitor
D. Defibrillation
```
(c) A. This is consistent with ECG findings of a Mobitz type II AV block. Since the patient is symptomatic this type of AV block requires a permanent pacing to prevent total AV disassociation.
166
```
A patient presents to the office following a syncopal episode. The patient claims that the syncope occurs when he changes position such as rolling over in bed or when he bends over to tie his shoes. Which of the following is the most likely explanation for this presentation?
A. Carotid sinus hypersensitivity
B. Vasovagal episode
C. Subclavian steal syndrome
D. Atrial myxoma
```
(c) D. Atrial myxoma most commonly presents with sudden onset of symptoms that are typically positional in nature due to the effect that gravity has on the tumor. Myxomas are the most common type of primary cardiac tumor in all age groups and are most commonly found in the atria.
167
```
Which of the following is the optimal therapy for a 76 year-old patient with no allergies who has chronic atrial fibrillation?
A. Aspirin
B. Clopidogrel (Plavix)
C. Warfarin (Coumadin)
D. Low molecular weight heparin
```
(c) C. Patients older than age 75 who have chronic atrial fibrillation should be anticoagulated with warfarin to maintain an INR between 2.5 and 3.0 for optimum therapy unless a contraindication to therapy exists.
168
```
Patients who undergo percutaneous angioplasty or who have coronary artery revascularization often are treated with glycoprotein IIb/IIIa inhibitors. What is the major side effect associated with these agents?
A. Hypotension
B. Bleeding
C. Coronary vasospasm
D. Acute renal failure
```
(c) B. Glycoprotein IIb/IIa inhibitors have their activity in the final stages of platelet bridging and are associated with bleeding when used in the management of acute myocardial infarction. Since they are effective at treating and preventing new clot formation, bleeding is the main concern and complication with the use of these agents.
169
Which of the following is an absolute contraindication for the performance of exercise stress testing for patients who wish to start an exercise program?
A. Second degree heart block type 1
B. Severe aortic stenosis
C. Atrial fibrillation with controlled ventricular response D. Recent diagnosis of lung cancer
(c) B. Contraindications to stress testing include rest angina within the last 48 hours, unstable cardiac rhythm, hemodynamically unstable patient, severe aortic stenosis, acute myocarditis, uncontrolled heart failure, and active infective endocarditis.
170
```
A 23 year-old male with recent upper respiratory symptoms presents complaining of chest pain. His pain is worse lying down and better sitting up and leaning forward. Electrocardiogram shows widespread ST segment elevation. Which of the following is the most likely physical examination finding in this patient?
A. Elevated blood pressure
B. Subungual hematoma
C. Diastolic murmur
D. Pericardial friction rub
```
(c) D. This patient has symptoms consistent with acute pericarditis and would most likely have a pericardial friction rub on examination
171
```
A 53 year-old male with history of hypertension presents complaining of recent 4/10 left-sided chest pain with exertion that is relieved with rest. He states the pain usually lasts approximately 4 minutes and is relieved with rest. Heart examination reveals regular rate and rhythm with no S3, S4, or murmur. Lungs are clear to auscultation bilaterally. Electrocardiogram reveals no acute changes. Which of the following is the most appropriate initial step in the evaluation of this patient?
A. Cardiac catheterization
B. CT Angiogram of the chest
C. Echocardiogram
D. Nuclear stress test
```
(u) C. This patient has signs and symptoms of stable angina. There are no signs of valvular heart disease on examination. While an echocardiogram may be performed at some point, it is not the best initial diagnostic step to determine the etiology of the patient's angina.
172
```
A 48 year-old male with diabetes mellitus presents for routine physical examination. Of note his blood pressure each of his last two follow-up visits was 150/90 mmHg. Today the patient's BP is 148/88 mmHg. The patient denies complaints of chest pain, change in vision, or headache. Which of the following is the most appropriate management for this patient?
A. Atenolol (Tenormin)
B. Nifedipine (Procardia)
C. Hydralazine (Apresoline)
D. Lisinopril (Zestril)
```
(c) D. ACE inhibitors are the first line treatment of choice in a patient with hypertension and diabetes.
173
A 36 year-old female presents for a routine physical. She has no current complaints and her only medication is oral contraceptives. The patient is preparing for a trip to Australia and is worried about the long flight as her mom has a history of deep vein thrombosis after a long trip several years ago. Physical examination reveals BP 110/60 mmHg, HR 66 bpm, regular. Heart is regular rate and rhythm without murmur, lungs are clear to auscultation bilaterally and extremities are without edema. Which of the following is the most appropriate recommendation for your patient?
A. Discontinue oral contraceptives
B. Recommend walking frequently during the flight
C. Begin daily aspirin therapy
D. Increase fluid intake 2-3 days prior to the flight
(c) B. The risk of deep vein thrombosis after air travel increases with flight duration. Preventive measures for patients include using support hose and performing in-flight exercises and walking.
174
```
A 3 month-old female presents with her mom for physical examination. The patient's mom denies any complaints. On examination you note a well-developed, well-nourished infant in no apparent distress. There is no cyanosis noted. Heart examination reveals a normal S1 with a physiologically split S2. There is a grade III/VI high-pitched, harsh, pansystolic murmur heard best at the 3rd and 4th left intercostal spaces with radiation across the precordium. Which of the following is the initial diagnostic study of choice in this patient?
A. CT angiogram
B. Electrocardiogram
C. Echocardiogram
D. Cardiac catheterization
```
(c) C. Echocardiogram is the initial diagnostic study of choice in the diagnosis of a VSD.
175
```
A 20 year-old male presents with complaint of brief episodes of rapid heart beat with a sudden onset and offset that have increased in frequency. He admits to associated shortness of breath and lightheadedness. He denies syncope. Electrocardiogram reveals a delta wave prominent in lead II. Which of the following is the most appropriate long-term management in this patient?
A. Implantable cardio defibrillator
B. Radiofrequency ablation
C. Verapamil (Calan)
D. Metoprolol (Lopressor)
```
(c) B. Radiofrequency ablation is the procedure of choice for long-term management in patients with accessory pathways (WPW) and recurrent symptoms.
176
```
A 60 year-old female recently discharged after an 8 day hospital stay for pneumonia presents complaining of pain and redness in her right arm. The patient thinks this was the area where her IV was placed. The patient denies fever or chills. Examination of the area reveals localized induration, erythema and tenderness. There is no edema or streaking noted. Which of the following is the most likely diagnosis?
A. Acute thromboembolism
B. Thrombophlebitis
C. Cellulitis
D. Lymphangitis
```
(c) B. This patient's signs and symptoms are consistent with thrombophlebitis. Short-term venous catheterization of a superficial arm vein is commonly the cause and thrombophlebitis characterized by dull pain, induration, redness and tenderness along the course of the vein.
177
```
A patient with a history of chronic venous insufficiency presents for routine follow-up. Which of the following findings is most likely on physical examination?
A. Cold lower extremities
B. Diminished pulses
C. Lower extremity edema
D. Palpable cord
```
(c) C. Patients with chronic venous insufficiency will commonly have lower extremity edema.
178
```
A 29 year-old female with history of IV drug abuse presents with ongoing fevers for three weeks. She complains of fatigue, worsening dyspnea on exertion and arthralgias. Physical examination reveals a BP of 130/60 mmHg, HR 90 bpm, regular, RR 18, unlabored. Petechiae are noted beneath her fingernails. Fundoscopic examination reveals exudative lesions in the retina. Heart examination shows regular rate and rhythm, there is a grade II-III/VI systolic murmur noted, with no S3 or S4. Lungs are clear to auscultation bilaterally, and the extremities are without edema. Which of the following is the diagnostic study of choice in this patient?
A. Electrocardiogram
B. CT angiogram of the chest
C. Cardiac catheterization
D. Transesophageal echocardiogram
```
(c) D. This patient's signs and symptoms are consistent with infective endocarditis. The diagnostic study of choice would be a transesophageal echocardiogram.
179
```
A 49 year-old female presents complaining of several episodes of chest pain recently. Initial ECG in the emergency department shows no acute changes. Two hours later, while the patient was having pain, repeat electrocardiogram revealed ST segment elevation in leads II, III, and AVF. Cardiac catheterization shows no significant obstruction of the coronary arteries. Which of the following is the treatment of choice in this patient?
A. Nifedipine (Procardia)
B. Metoprolol (Lopressor)
C. Lisinopril (Zestril)
D. Carvedilol (Coreg)
```
(c) A. This patient is most likely having coronary artery spasm. This can be treated prophylactically with calcium channel blockers such as nifedipine.
180
```
A 75 year-old female with a history of long-standing hypertension presents with shortness of breath. On examination you note a diastolic murmur at the left upper sternal border. Which of the following maneuvers would accentuate this murmur?
A. Sitting up and leaning forward
B. Lying on left side
C. Performing Valsalva maneuver
D. Standing upright
```
(c) A. This patient has history findings consistent with aortic insufficiency which is characterized by a diastolic murmur that is accentuated when the patient sits up and leans forward.
181
```
A 50 year-old male with history of alcohol abuse presents with complaint of worsening dyspnea. Physical examination reveals bibasilar rales, elevated jugular venous pressure, an S3 and lower extremity edema. Chest x-ray reveals pulmonary congestion and cardiomegaly. Electrocardiogram shows frequent ventricular ectopy. Echocardiogram shows left ventricular dilatation and an ejection fraction of 30%. Which of the following is the most likely diagnosis in this patient?
A. Hypertrophic cardiomyopathy
B. Dilated cardiomyopathy
C. Restrictive cardiomyopathy
D. Tako-Tsubo cardiomyopathy
```
(c) B. Dilated cardiomyopathy is often caused by chronic alcohol use. It is characterized by signs and symptoms of left-sided heart failure, a dilated left ventricle and decreased ejection fraction.
182
```
A 76 year-old active female with history of hypertension and hypothyroidism presents with complaints of palpitations and dyspnea on exertion. On examination vital signs are BP 120/80 mmHg, HR 76 bpm, irregular, RR 16. Heart examination reveals an irregularly, irregular rhythm without murmur. Lungs are clear to auscultation and extremities are without edema. Which of the following is the most important medication to initiate for chronic therapy in this patient?
A. Warfarin (Coumadin)
B. Verapamil (Calan)
C. Amiodarone (Cordarone)
D. Digoxin (Lanoxin)
```
(c) A. Anticoagulation is necessary in all patients with atrial fibrillation to prevent thromboembolic events unless there is contraindication.
183
```
A 58-year old male presents for a six week follow-up after an acute anterior wall myocardial infarction. He denies chest pain and shortness of breath. Electrocardiogram shows persistent ST segment elevation in the anterior leads. Echocardiogram reveals a sharply delineated area of scar that bulges paradoxically during systole. Which of the following is the most likely diagnosis in this patient?
A. Left ventricular aneurysm
B. Postinfarction ischemia
C. Ischemic cardiomyopathy
D. Constrictive pericarditis
```
(c) A. Left ventricular (LV) aneurysm develops in about 10-20 percent of patients following acute myocardial infarctions, especially anterior wall myocardial infarctions. LV aneurysm is identified by ST segment elevation that is present beyond 4-8 weeks after the acute infarct and a scar that bulges paradoxically during systole on echocardiogram.
184
```
A 75 year-old female with history of coronary artery disease and dyslipidemia presents for routine follow-up. Physical examination reveals loss of hair on the lower extremities bilaterally with thinning of the skin. Femoral pulses are +2/4 bilaterally, pedal pulses are diminished bilaterally. Ankle brachial index is reduced. Which of the following signs or symptoms is this patient most likely to have?
A. Lower extremity edema
B. Calf pain with walking
C. Numbness of the lower extremities
D. Itching of the lower extremities
```
(c) B. This patient has signs and symptoms consistent with arterial insufficiency and would most likely complain of intermittent claudication.
185
```
A 55 year-old male with history of hypertension and diabetes mellitus presents to the emergency department. The patient's wife states that the patient developed progressive irritability and confusion today after complaining of a headache. Physical examination reveals a BP of 230/130 mmHg and papilledema. Which of the following is the most accurate diagnosis in this patient?
A. Resistant hypertension
B. Hypertensive urgency
C. Hypertensive emergency
D. Malignant hypertension
```
(c) D. Malignant hypertension is significantly elevated BP with progressive retinopathy, including papilledema, encephalopathy, and headache.
186
```
A patient undergoes biopsy for suspected myocarditis. Which of the following is the most likely etiologic agent?
A. West Nile virus
B. Rhinovirus
C. Coxsackie B virus
D. Cytomegalovirus
```
(c) C. Coxsackie B virus, Hepatitis C, adenovirus, and HIV are the predominant agents in clinically significant acute viral myocarditis in the US.
187
```
A 65 year-old male with coronary artery disease, hypertension, and diabetes mellitus is admitted with dyspnea and lower extremity edema. The chest x-ray reveals small bilateral pleural effusions. Echocardiogram shows an ejection fraction of 30% with no valvular heart disease. The patient is treated in the hospital with furosemide (Lasix) and lisinopril (Zestril). What education should be given to this patient upon discharge to help prevent readmission?
A. Elevate the head of bed at home
B. Avoid physical activity
C. Monitor daily weights
D. Restrict fluid intake
```
(c) C. Strategies to prevent rehospitalization can include monitoring daily weights, case management and patient education regarding self-adjustment of diuretics.
188
```
A 60 year-old male nonsmoker with history of coronary artery disease presents with complaint of worsening dyspnea on exertion for three weeks. He admits to orthopnea and lower extremity edema, but denies chest pain, palpitations, and syncope. The patient's last echocardiogram revealed an ejection fraction of 30%. Which of the following would you most likely find on physical examination?
A. Pericardial friction rub
B. Third heart sound
C. Accentuated first heart sound
D. Mid-systolic click
```
(c) B. An S3 on physical examination is consistent with heart failure.
189
```
A 78 year-old male with history of coronary artery disease s/p coronary artery bypass grafting, hypertension, and dyslipidemia presents for routine physical examination. He feels well except for occasional brief episodes of substernal chest pain with exertion that are relieved with rest. He denies associated dyspnea, nausea or diaphoresis. Physical examination reveals a BP of 110/70 mmHg, HR 56 bpm, regular, RR 14, unlabored. Lungs are clear to auscultation, heart is bradycardic, but regular with no S3, S4 or murmur. Electrocardiogram done in the office shows no acute ST-T wave changes. Which therapy is indicated for the acute management of this patient's symptoms?
A. Sublingual nitroglycerine
B. Metoprolol (Lopressor)
C. Verapamil (Calan)
D. Lisinopril (Zestril)
```
(c) A. Sublingual nitroglycerine is the drug of choice for the acute management of chronic stable angina.
190
```
A 36 year-old male presents for follow-up of his hypertension. The patient is currently on three anti-hypertensive medications without improvement of his blood pressure. On examination his BP is 170/86mmHg and his HR is 60bpm and regular. His heart examination reveals a regular rate and rhythm without S3, S4 or murmur and his lungs are clear to auscultation bilaterally. Abdominal examination reveals a bruit over his left upper abdomen. Which of the following is the most likely underlying etiology for this patient's hypertension?
A. Pheochromocytoma
B. Renal artery stenosis
C. Cushing syndrome
D. Coarctation of the aorta
```
(c) B. Renal artery stenosis is characterized by hypertension that is resistant to three or more medications and renal artery bruits on examination.
191
```
A 16 year-old male presents with complaint of syncope after basketball practice today. Physical examination reveals a systolic murmur along the left sternal border that increases with Valsalva maneuver. An electrocardiogram reveals left ventricular hypertrophy. Echocardiogram shows asymmetric left ventricular hypertrophy with a hypercontractile left ventricle. Which of the following is the initial medication of choice in this patient?
A. Metoprolol (Lopressor)
B. Losartan (Cozaar)
C. Lisinopril (Zestril)
D. Hydrochlorothiazide (Diuril)
```
(c) A. Beta-blockers are the initial drug of choice in a symptomatic patient with hypertrophic cardiomyopathy.
192
An 80 year-old female presents with syncope and recent fatigue and lightheadedness over the past month. She denies chest pain or dyspnea. Physical examination reveals BP 130/70 mmHg, HR 40 bpm, regular, and RR 16. Electrocardiogram reveals two p waves before each QRS complex. Which of the following is the treatment of choice for this patient?
A. Cardio defibrillator insertion
B. Atropine as needed
C. Permanent dual chamber pacemaker insertion
D. Ritalin therapy daily
(c) C. This patient has findings consistent with symptomatic second degree AV block Mobitz type II for which permanent pacing is the treatment of choice.
193
Which of the following would be expected on physical examination of a newborn diagnosed with Tetrology of Fallot?
A. Palpable right ventricular lift
B. Pulsediscrepancybetweenarmsandlegs
C. Mid-diastolic murmur with opening snap
D. Polymorphous exanthema
(c) A. Tetralogy of Fallot is commonly associated with a palpable right ventricular lift.
194
```
A 67 year-old male with history of mitral valve stenosis undergoes a mechanical valve replacement. Which of the following is the appropriate duration of anticoagulation therapy if the patient has no other risk factors for thromboembolic events or significant bleeding risks?
A. One month
B. Three months
C. Six months
D. Lifelong
```
(c) D. Patients with mechanical valves require lifelong anticoagulation to prevent thrombosis.
195
```
A 60 year-old female with history of radiation therapy for the treatment of cancer presents with progressive dyspnea and fatigue. On examination the patient has lower extremity edema, significant ascites, and an elevated jugular venous pressure that does not fall with inspiration. Heart examination reveals a pericardial knock. Echocardiogram shows rapid early filling and reduced mitral inflow velocities with inspiration. Which of the following is the most likely diagnosis in this patient?
A. Pulmonaryhypertension
B. Atrialmyxoma
C. Constrictive pericarditis
D. Tako-Tsubo cardiomyopathy
```
(c) C. Constrictive pericarditis is associated with TB, radiation therapy, cardiac surgery, or following viral pericarditis. There is evidence of right-sided heart failure, a positive Kussmaul sign, and a septal bounce and reduced mitral inflow velocities with inspiration on echocardiogram.
196
```
A 59 year-old male with history of hypertension and dyslipidemia presents with complaint of substernal chest pain for two hours. The pain woke him from sleep, does not radiate, and is associated with nausea and diaphoresis. Electrocardiogram reveals ST segment elevation in leads II, III, and AVF. Which of the following walls of the ventricle is most likely at risk?
A. Anterior
B. Inferior
C. Lateral
D. Posterior
```
(c) B. Inferior wall myocardial infarction is characterized by ST segment elevation in leads II, III and AVF.
197
```
A 24 year-old female presents complaining of palpitations described as occasional "skipped" beats. The patient denies chest pain, lightheadedness, syncope, or dyspnea. On examination you note a midsystolic click without murmur. Which of the following is the most likely diagnosis in this patient?
A. Mitral valve prolapse
B. Aortic stenosis
C. Atrial septal defect
D. Pulmonic stenosis
```
(c) A. Patients with mitral valve prolapse will often present with complaint of palpitations. Auscultation would reveal a mid-systolic click with or without a late systolic murmur.
198
```
A 10 year-old female experiences fever and polyarthralgia. On examination you note a new early diastolic murmur. Laboratory results are positive for antistreptolysin O. The patient has no known drug allergies. Which of the following is the recommended prophylaxis for this condition?
A. Doxycycline
B. Erythromycin
C. BenzathinepenicillinG
D. Trimethoprim/sulfamethoxazole
```
(c) C. Recurrences of rheumatic fever are most common in patients who have had carditis during their initial episode and in children. The preferred method of prophylaxis is Benzathine penicillin G every four weeks.
199
```
A 26 year-old patient is brought to the emergency department after a head on collision. The patient complains of chest pain, dyspnea and cough. Examination reveals the patient to be tachypneic and tachycardic with a narrow pulse pressure. Jugular venous distension is noted. Electrocardiogram reveals nonspecific t wave changes and electrical alternans. Which of the following is the most appropriate management plan for this patient?
A. Serial echocardiograms
B. Pericardiocentesis
C. Cardiac catheterization
D. Pericardiectomy
```
(c) B. Urgent pericardiocentesis is the initial treatment of choice in a patient with cardiac tamponade.
200
```
A 40 year-old G3P3003 female presents complaining of dull aching discomfort of her lower extremities, which is worse in the evening. The patient currently works as a waitress. Examination reveals dilated, tortuous veins beneath the skin in the thigh and leg bilaterally. Which of the following is the best initial approach to prevent progression of disease and complications in this patient?
A. Compression stockings
B. Warfarin (Coumadin) therapy
C. Sclerotherapy
D. Clopidogrel (Plavix)
```
(c) A. Graduated compression stockings can be used in patients with early varicosities to prevent progression of the disease and when used with leg elevation complications from varicose veins can be avoided.
201
```
A 60 year-old male with history of hypertension presents for routine physical examination. He has no current complaints. Vital signs are BP of 136/70 mmHg, HR 60 bpm, regular, RR 14, unlabored. Heart shows regular rate and rhythm with no S3, S4 or murmur, Lungs are clear to auscultation bilaterally, and the abdomen is soft, nontender. There is a 5cm palpable pulsatile abdominal mass noted. Which of the following is the best initial diagnostic study in this patient?
A. Magnetic resonance imaging (MRI)
B. Arteriography
C. Ultrasound (US)
D. Plain film
```
(c) C. Abdominal ultrasound is the diagnostic study of choice for the initial diagnosis of an abdominal aortic aneurysm.
202
```
A 70 year-old female with history of hypertension, diabetes, and hypothyroidism presents with complaint of sudden onset of left lower extremity pain. Examination reveals a cool left lower extremity with a mottled appearance. Dorsalis pedis and posterior tibialis pulses are absent. Which of the following is the most likely diagnosis?
A. Acute arterial occlusion
B. Thromboangiitis obliterans
C. Deep vein thrombosis
D. Peripheral neuropathy
```
(c) A. Acute arterial occlusion presents with sudden onset of extremity pain, with absent or diminished pulses. The extremity will be cool to the touch and have a mottled appearance.
203
```
A 45 year-old male presents to the Emergency Department complaining of sudden onset of tearing chest pain radiating to his back. On examination the patient is hypertensive and his peripheral pulses are diminished. Electrocardiogram shows no acute ST-T wave changes. Which of the following is the diagnostic study of choice in this patient?
A. Computed tomography (CT) scan
B. Transthoracic echocardiogram
C. Magnetic resonance imaging (MRI)
D. Cardiac catheterization
```
(c) A. This patient has signs and symptoms of acute aortic dissection for which CT scan is the diagnostic study of choice.
204
```
A 60 year-old male complains of progressive fatigue and dyspnea. On examination his lungs are clear to auscultation bilaterally, heart exam reveals regular rate and rhythm without S3, S4 or murmur, and extremities show 1+ edema bilaterally. Chest x-ray reveals cardiomegaly. electrocardiogram shows low voltage, and echocardiogram shows an ejection fraction of 55% with a small, thickened left ventricle that has rapid early filling with diastolic dysfunction. Which of the following is the most likely underlying etiology of this patient's cardiomyopathy?
A. Alcoholism
B. Myocarditis
C. Amyloidosis
D. Chronic hypertension
```
(c) C. Amyloidosis is the most common cause of restrictive cardiomyopathy and is associated with a small thickened left ventricle that has rapid early filling with diastolic dysfunction.
205
```
A 70 year-old male with history of ischemic cardiomyopathy presents with a syncopal episode. He denies complaints of chest pain, palpitations, or dyspnea. ECG shows no acute ST-T wave changes. Echocardiogram reveals an ejection fraction of 25% with no valvular abnormalities. Which of the following is the most appropriate management for this patient?
A. Dual chamber permanent pacemaker
B. Diltiazem (Cardizem)
C. Implantable cardio defibrillator
D. Midodrine (ProAmatine)
```
(c) C. This patient has ischemic cardiomyopathy and syncope, which is most likely due to ventricular tachycardia. Instertion of a cardio defibrillator is the management of choice in this patient.
206
```
S3 and S4 gallops are both signs of which type of cardiac abnormality?
A. Atrial non-compliance
B. Ventricular septal defect
C. Valvular insufficiency
D. Ventricular dysfunction
```
(c) D. S3 may be louder if filling pressure is increased or if ventricular compliance is reduced. S4 is most commonly heard when there is increased resistance to filling because of loss of compliance of the ventricular walls or the increased stroke volume of high-output states.
207
```
A 51 year-old patient presents for follow-up after a recent stroke. Cardiac examination reveals a moderately loud systolic ejection murmur in the 2nd and 3rd interspaces parasternally. The second heart sound is fixed and widely split. Which of the following is the most likely diagnosis in this patient?
A. Aortic stenosis
B. Mitral valve regurgitation
C. Patent foramen ovale
D. Ventricular septal defect
```
(c) C. A patent foramen ovale is present in 25% of the population and can lead to paradoxic emboli and cerebrovascular events. Suspicion should be highest in patients who have cryptogenic stroke before age 55 years.
208
Which subset of the asymptomatic general population should undergo one-time screening for abdominal aortic aneurysm?
A. 65 year-old female with chronic kidney disease
B. 65 year-old healthy male who has smoked since age 20
C. 74 year-old male who has diabetes mellitus
D. 74 year-old female who has smoked since age 15
(c) B. Data support the use of abdominal ultrasound to screen 65- to 74-year old men, but not women, who have a history of smoking. Repeated screening does not appear to be needed if the aorta shows no enlargement.
209
```
Empiric treatment for infective endocarditis should target which organism?
A. Haemophilus influenzae
B. Moraxella catarrhalis
C. Mycoplasma pneumoniae
D. Staphylococcos aureus
```
(c) D. Empiric regimens for endocarditis while culture results are pending should include agents active against staphylococci, streptococci, and enterococci.
210
```
A 9 year-old presents with increasing shortness of breath while playing basketball recently. On examination, radial pulses are exaggerated while femoral pulsations are weak. Chest radiograph shows rib notching and a mildly enlarged heart. Which of the following is the most likely diagnosis for this patient?
A. Atrial septal defect
B. Coarctation of the aorta
C. Patent ductus arteriosus
D. Tetralogy of Fallot
```
In older children, the ECG and chest x-ray usually show left ventricular hypertrophy and amildly enlarged heart. Rib notching may also be seen in older children (>8 years old) with large collaterals.
211
A 59 year-old male with longstanding uncontrolled hypertension presents with nausea and a 5 pound weight gain in the last 2 days. He states "my belly is getting bigger and I can't fasten my pants." Which of the following physical examination findings would be most likely in this patient?
A. Ankle edema and elevated jugular venous pressure
B. Dry cough and mitral regurgitation murmur
C. Hypotension and cyanotic extremities
D. S3 heart sound heard along the left sternal border and bilateral wheezing
(c) A. This patient's symptoms indicate right heart failure with bloating.
212
```
You are evaluating a patient who was brought in secondary to an acute onset of repeated syncopal episodes. His electrocardiogram (ECG) shows wide QRS complexes with a fixed R-R interval at a rate of 40 bpm. The P waves occur with a fixed P-P interval at a rate of 70 bpm. The PR interval is variable. Which of the following is the most appropriate initial treatment for this condition?
A. Balloon angioplasty
B. Endarterectomy
C. Transthoracic pacemaker
D. Unsynchronized cardioversion
```
(c) C. The ECG this patient's symptoms are consistent with a third degree heart block. Patients with episodic or chronic infranodal complete heart block require permanent pacing, and temporary pacing is indicated if implantation of a permanent pacemaker is delayed.
213
```
A patient presents with complaints of headaches during strenuous exercise. Twenty-four hour ambulatory blood pressure readings indicate he is hypertensive with exercise. A chest radiograph reveals mild cardiomegaly. An echocardiogram shows an ejection fraction of 75% with interventricular septal hypertrophy. Which of the following is the most appropriate initial choice of medications for this patient?
A. Phentolamine (Regitine)
B. Metoprolol (Lopressor)
C. Disopyramide (Norpace)
D. Isoproterenol (Isuprel)
```
(c) B. Beta-blockers should be the initial drug in symptomatic individuals, especially when dynamic outflow obstruction is noted on the echocardiogram. Diuretics may also be required to decrease pre-load.
214
A 71 year-old male with a history of diabetes and dyslipidemia presents to the emergency department with complaints of exertional chest pain for the past two hours. He gets some relief with rest but admits to associated nausea and left- sided jaw pain. On examination he appears diaphoretic and tachypnic. Electrocardiogram (ECG) is unchanged from a previous ECG 1 year ago. His cardiac enzymes are within normal limits. Which of the following is the most appropriate next step?
A. Referral to cardiology for outpatient thallium stress test
B. Discharge patient home with nitroglycerine
C. Transfer to cardiac catheterization lab
D. Monitor with repeat enzymes and ECG in 4-6 hours
(c) D. In one-fourth to one-half of patients with acute MI, the first ECG does not demonstrate typical ST segment changes. Serial ECG's should be obtained to increase diagnostic yield. Serologic identification of myocyte necrosis is another beneficial diagnostic tool. CK-MB is detectable in the blood within 3-6 hours of the onset of the MI. Troponins begin to rise within 4-6 hours and remain elevated for 7-10 days.
215
A 1 month-old infant is brought to your office by his mother for routine evaluation and immunizations. Examination reveals a continuous, rough machinery pansystolic murmur that is best heard in the first and second interspaces of the left sternal border associated with a thrill. Which of the following is the most likely diagnosis in this patient?
A. Atrial septal defect
B. Coarctation of the aorta
C. Patent ductus arteriosus D. Ventricular septal defect
(c) C. In an infant with patent ductus arteriosus, there are no symptoms unless left ventricular failure or pulmonary hypertension develops. The pulse pressure is wide, and diastolic pressure is low. A continuous, rough, machinery murmur, accentuated in late systole at the time of S2 is heard best in the left first and second interspaces at the left sternal border. Thrills are common.
216
```
An ambulance transports a patient to your facility from the nursing home with anuria and diminished level of consciousness. Paramedics report a blood pressure of 225/130mm Hg. Which of the following medications is most appropriate for this patient?
A. Esmolol(Brevibloc)
B. Nitroprussidesodium(Nipride)
C. Nitroglycerine(Nitrostat)
D. Nifedipine(Procardia)
```
(c) B. Parenteral therapy is indicated in most hypertensive emergencies, especially if encephalopathy is present. Nitroprusside lowers blood pressure in seconds by direct arteriolar and venous dilation.
217
A patient admitted with substernal chest pain undergoes cardiac catheterization. Angiography reveals 98% occlusion of the right coronary artery. All other vessels are 100% patent. Which of the following is the most expected electrocardiogram finding in this patient?
A. ST elevation in leads I, avL, V5 and V6
B. ST elevation in leads II, III, and avF
C. ST elevation across V2, V3 and V4
D. Tall upright R and T waves in V1 and V2
(c) B. The right coronary artery is responsible for inferior wall of the heart. Inferior wall of the heart is best illustrated on EKG in leads II, III, aVF
218
```
A patient who was recently diagnosed with viral pericarditis now complains of severe dyspnea and non-productive cough with pain over the precordial region. His vital signs reveal a heart rate 130bpm and respiratory rate 26. Blood pressure is 130/105 mmHg but fluctuates with inspiration resulting in a 20 mmHg decline in the systolic pressure. Which of the following is the most appropriate therapy for this patient?
A. Serial echocardiography
B. Urgent pericardiocentesis
C. Surgery for pericardial window
D. Furosemide (Lasix) bolus
```
(c) B. This patient has signs and symptoms consistent with pericardial tamponade. Urgent pericardiocentesis is required.
219
```
A 48 year-old male patient presents with a recent onset of anterior chest pain. The pain increases with deep breathing and coughing. He says he slept in the recliner last night as his discomfort worsens when he lies down. He also complains of feeling feverish although did not have a thermometer to check his temperature. An electrocardiogram (ECG) shows ST elevations in the precordial and limb leads. Additionally you note PR depression predominantly over leads I, II and III. Past medical history is significant for pharyngitis diagnosed as mononucleosis about 10 days ago. What is the most appropriate next step in the evaluation of this patient?
A. Streptokinase
B. Pericardiocentesis
C. Indomethacin
D. Cardiac catheterization
```
(c) C. Acute inflammatory pericarditis presents with anterior pleuritic chest pain that is worse supine than upright. ECG reveals diffuse ST segment elevation with associated PR depression. Viral infections (including Epstein- Barr) are the most common cause of acute pericarditis. Treatment for viral pericarditis is generally symptomatic. ASA or other NSAIDs are usually effective.
220
```
A patient 10 years status-post deep vein thrombosis presents with chronic lower extremity edema. Which of the following prevention strategies is most appropriate for this patient?
A. Catheter directed thrombolysis
B. Compression stockings
C. Warfarin (Coumadin) therapy
D. Vein stripping
```
(c) B. Irreversible tissue damage changes and associated complications in the lower legs can be minimized through early and aggressive anticoagulation of acute DVT to minimize the valve damage and by prescribing stockings if chronic edema develops in subsequent years.
221
```
You are discharging a patient who had a myocardial infarction with a post infarction ejection fraction of 35%. You place the patient on the following medications: atorvastatin (Lipitor), metoprolol (Toprol-XL), aspirin, and nitroglycerin spray. Which of the following is also indicated in the patient provided there are no contraindications?
A. Enalapril (Vasotec)
B. Felodipine (Plendil)
C. Furosemide (Lasix)
D. Valsartan (Diovan)
```
(c) A. Patients who sustain substantial myocardial damage often experience subsequent progressive LV dilation and dysfunction, leading to clinical heart failure and reduced long-term survival. In patients with ejection fractions less than 40% long-term ACE inhibitor therapy prevents LV dilation and the onset of heart failure and prolongs survival.
222
```
A 16 year-old athlete with no past medical history collapses after running 50 yards down the field. He is unresponsive, pulseless and cyanotic. Which of the following is the most likely cause of this student's collapse?
A. Hypertrophic cardiomyopathy
B. Myocardial infarction
C. Pulmonary embolism
D. Reactive airway disease
```
(c) A. This presentation is consistent with hypertrophic cardiomyopathy which may initially be difficult to diagnose. Infants but not older children frequently present with signs of CHF. Older children may be asymptomatic, with sudden death as the initial presentation
223
```
A 65 year-old male 5 days status-post myocardial infarction is evaluated for anterior chest pain. The pain improves with sitting up. The patient has associated fever, leukocytosis and a pericardial friction rub. Which of the following is the most likely diagnosis?
A. Tako-tsubo cardiomyopathy
B. Dressler syndrome
C. Rupture of papillary muscles
D. Recurrent myocardial infarction
```
(c) B. Pericarditis may occur 2-5 days after infarction due to an inflammatory reaction to transmural myocardial necrosis. This is known as postmyocardial infarction pericarditis or Dressler syndrome.
224
A 34 year-old male presents with an acute onset of fatigue and dyspnea. He has experienced repeated episodes of near-syncope and an unresolved chest discomfort described as a "fluttering" sensation over the past 3 hours. His electrocardiogram reveals no definable p waves and his R-R interval is irregular. His blood pressure is 88/60 mmHg. Which of the following is most appropriate for this patient?
A. Initiate warfarin (Coumadin) therapy to an INR target of 2.0
B. Consult for radiofrequency ablation therapy
C. Transfer to cardiac catherization lab
D. Sedate for synchronized cardioversion
(c) D. The patient has symptoms and ECG findings consistent with atrial fibrillation. Urgent cardioversion is indicated with shock or severe hypotension, pulmonary edema, or ongoing myocardial infarction or ischemia.
225
```
A new patient with a history of hypertension on verapamil (Calan) presents for routine examination. Electrocardiogram reveals irregular R-R intervals, with narrow QRS complexes. There are no definable P-waves. Which of the following is most appropriate for this patient?
A. Annual echocardiogram
B. Warfarin (Coumadin) therapy
C. Internal defibrillator
D. Infective endocarditis prophylaxis
```
(c) B. For patients with atrial fibrillation, even when it is paroxysmal or occurs rarely, anticoagulation with warfarin to an INR target of 2.0-3.0 should be established and maintained indefinitely.
226
```
A 13 year-old patient is hospitalized with a fever of 102.5 F and a rash. After 36 hours the rash has rapidly progressed to enlarging macules that appear ring orcrescent shaped with central clearing. He also complains of multiple arthralgias involving his ankles, knees, and now his elbows. The electrocardiogram shows evidence of a first degree AV block. Labs were significant for an elevated erythrocyte sedimentation rate and leukocytosis. Which of the following physical examination findings would be most likely in this patient?
A. Cord-like palpable calf vein
B. Diminished lower extremity pulses
C. Mitral regurgitation murmur
D. Oral cyanosis
```
(c) C. Jones criteria of rheumatic fever include 1 major (erythema marginatum) and 3 minor (fever, polyarthralgies, prolonged PR interval). Cardiovascular manifestations typically associated with rheumatic fever include mitral regurgitation.
227
```
A 35 year-old male status-post patent ductus arteriosus repair at 5 years of age, presents with low-grade fever, fatigue and dyspnea worsening over the past 10 days. Prior to the onset of these symptoms, he was healthy and free of any complaints. Examination is significant for petechiae on the palate, a high pitched holo-systolic murmur heard best at the apex, and splinter hemorrhages on both hands under his fingernails. Which of the following is the most appropriate next step in the evaluation of this patient?
A. Cardiac catheterization
B. Echocardiogram
C. MUGA scan
D. Chest radiograph
```
(c) B. The history is most representative of a patient with infectious endocarditis. The clinical criteria, referred to as the modified Duke criteria include (1) two positive blood cultures for a microorganism that typically causes infective endocarditis or persistent bacteremia (2) evidence of endocardial involvement documented by echocardiography or (3) development of a new regurgitant murmur. Diagnosis is made if one major and one minor criterion or three minor criteria are met.
228
```
A 67 year-old patient with a 15 year history of chronic obstructive pulmonary disease (COPD) presents with worsening respiratory symptoms and abdominal pain. On examination, you observe peripheral edema, jugular venous distention, epigastric pulsations, and tender hepatomegaly. You auscultate a systolic ejection murmur. Echocardiogram reveals a dilated right ventricle with decreased ejection fraction and a normal appearing left ventricle. Which of the following is the most appropriate diagnosis for this patient?
A. Cor pulmonale
B. Hepatitis
C. Portal hypertension
D. Pulmonic stenosis
```
(c) A. Cor pulmonale denotes RV hypertrophy and eventual failure resulting from pulmonary disease. It is most commonly caused by COPD. The signs and symptoms presented are classic for the diagnosis.
229
```
A 67 year-old presents as a new patient complaining of progressive dyspnea. Examination reveals 3+ pitting edema of the lower extremities bilaterally and wheezing audible in lower lung fields bilaterally. Which of the following tests is the most appropriate initial study in the patient?
A. Electrocardiogram
B. Brain natriuretic peptide
C. Spiral computed tomography
D. Spirometry
```
(c) B. The most common complaint of patients with heart failure is progressive shortness of breath. Peripheral edema is most suggestive of right-sided failure which is most frequently caused by left-sided failure. Serum BNP is a powerful prognostic marker that adds to clinical assessment in differentiating dyspnea due to heart failure from non-cardiac causes.
230
```
You are evaluating a trauma patient who was unrestrained during a head-on collision. His chest struck the steering wheel and he is complaining of pain in the pre-cordial region. He is short of breath and complains of a non-productive cough since the injury. Vital signs indicate a heart rate of 140 bpm, respiration rate of 24, and blood pressure of 80/60 mmHg. His electrocardiogram shows nonspecific T wave changes and low QRS voltage. Which imaging modality would be the most appropriate given this history of present illness?
A. Chest radiograph
B. CT of the chest
C. Echocardiogram
D. MRI of the chest
```
(c) C. Echocardiography is the primary method for demonstrating pericardial tamponade.
231
Which of the following physical examination findings is consistent with chronic aortic regurgitation?
A. Cannon wave visualized on examination of jugular venous pressure
B. Decreased blood pressure in the lower extremity compared to upper
C. Dependent edema
D. Wide pulse pressure
(c) D. Major physical examination findings in chronic aortic regurgitation relate to the high stroke volume being ejected into the systemic vascular system with rapid runoff as the regurgitation takes place. This results in a wide pulse pressure.
232
An 80 year-old male from an assisted living facility is brought in for evaluation of repeated near-syncopal episodes when getting up from a seated position. His past medical history is significant for diabetes and hypertension for which he takes enalapril (Vasotec). Which of the following would you expect on physical examination?
A. A drop in systolic blood pressure of at least 5 mmHg and a rise in pulse rate of 30 beats per minute after arising from a supine position.
B. A rise in systolic blood pressure of 10 mmHg and a fall in pulse rate of 10 beats per minute after arising from a supine position.
C. A rise in systolic blood pressure of 15 mmHg or a fall in heart rate by more than 15 beats per minute after arising from a supine position.
D. Drop in systolic blood pressure of at least 20 mmHg and a rise in pulse rate of more than 15 beats per minute immediately upon arising from a supine position.
(c) D. A greater than normal decline (20 mmHg) in BP immediately upon arising from the supine to the standing position is observed. With/without tachycardia depending on the status of autonomic (baroreceptor)
233
```
A 63 year-old patient was admitted with an acute non-ST elevation myocardial infarction 3 days ago confirmed by elevated CK, CK-MB, troponin I and troponin T. He begins to experience recurrent chest pain. Which laboratory study is most appropriate to evaluate his recurrent chest pain?
A. Creatine kinase
B. CK-MB
C. Troponin
D. Myoglobin (Mb)
```
(c) B. Cardiac specific markers of myocardial infarction include quantitative determinations of CK-MB, troponin I and T. Troponins are more sensitive and specific than CK-MB. All tests should become positive as early as 4-6 hours after onset of a myocardial infarction and should be abnormal by 8-12 hours. Troponins may remain elevated for 5-7 days or longer. CK-MB generally normalizes within 24 hours, thus being more helpful for evaluation of reinfarction.
234
```
You are evaluating a patient who complains of worsening orthopnea and dyspnea on exertion for the past year. He admits to drinking a 12-pack of beer on a nightly basis for approximately 20 years. Physical examination shows a laterally displaced PMI, audible rales, and an audible S3 on cardiac auscultation. Echocardiogram shows a dilated left ventricular and an ejection fraction of 35%. Which of the following is the most appropriate counseling to slow the progression of this patient's condition?
A. Discontinuealcoholuse
B. Initiatevigorousexerciseprogram
C. Recommend immunosuppressive therapy
D. Initiate sodium restricted diet
```
(c) A. Dilated cardiomyopathy is manifested with traditional signs and symptoms of heart failure (most commonly dyspnea). LV dilation and systolic dysfunction (EF < 50%) are essential for diagnosis. Alcohol use should be discontinued, since there is often marked recovery of cardiac function following a period of abstinence in alcoholic cardiomyopathy.
235
```
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.
236
You are caring for a 35 year-old patient with a peripherally inserted central catheter (PICC). There is a progressive linear induration that stretches 3 inches proximal from the antecubital fossa with associated erythema and tenderness. The PICC line is removed. Which of the following additional measures should be taken in the treatment of this patient?
A. Heparin therapy
B. Surgery for ligation and division of the vein
C. Naproxyn sodium (Naprosyn) and local heat
D. Cephalaxin (Keflex) for 7 days duration
(c) C. If the superficial thrombophlebitis is well localized and not near the cephaloaxillary junction, local heat, and non-steroidal anti-inflammatory mediations are usually effective in limiting the process.
237
```
A 58 year-old male presents for evaluation after an episode of chest pain noted last night after an argument with his wife. The pain lasted about 20 minutes and was described as a tightness and burning sensation in his chest behind the sternum and radiated to the left shoulder and upper arm. He states the pain improved after he rested. The patient states this is the third such episode during stressful situations this month. Which of the following is the most likely diagnosis for this patient?
A. Anginal equivalant
B. Tietze syndrome
C. Stable angina
D. Unstable angina
```
(c) C. The diagnosis of angina pectoris depends principally on the history. Stable angina is generally of short duration and subsides completely without residual discomfort. Attacks following a heavy meal or brought on by anger last 12-20 minutes. Attacks lasting more than 30 minutes are unusual and suggest the development of unstable angina, myocardial infarction or an alternative diagnosis.
238
```
What is the hallmark finding that is essential to the diagnosis of primary dilated cardiomyopathy?
A. Asymmetric septal enlargement
B. Atrial enlargement
C. Infiltrative myocardial disease
D. Systolic dysfunction
```
(c) D. Systolic dysfunction and left ventricular dilation are essential for the diagnosis of primary dilated cardiomyopathy.
239
```
On cardiac auscultation, you hear a mid-diastolic low-pitched mitral murmur heard best at the cardiac apex. The presence of this sound is most characteristic of which valvular abnormality?
A. Aortic regurgitation
B. Mitral regurgitation
C. Pulmonic stenosis
D. Tricuspid stenosis
```
(c) A. The Austin Flint murmur is a mid or late diastolic low-pitched mitral murmur heard in advanced aortic regurgitation, owing to partial obstruction of mitral inflow produced by partial closure of the mitral valve by the regurgitant jet and the rapidly rising left ventricular diastolic pressure.
240
```
A 23 year-old male with recent upper respiratory symptoms presents complaining of chest pain. His pain is worse lying down and better sitting up and leaning forward. Electrocardiogram shows widespread ST segment elevation. Which of the following is the most likely physical examination finding in this patient?
A. Elevated blood pressure
B. Subungual hematoma
C. Diastolic murmur
D. Pericardial friction rub
```
(c) D. This patient has symptoms consistent with acute pericarditis and would most likely have a pericardial friction rub on examination.
241
```
A 53 year-old male with history of hypertension presents complaining of recent 4/10 left-sided chest pain with exertion that is relieved with rest. He states the pain usually lasts approximately 4 minutes and is relieved with rest. Heart examination reveals regular rate and rhythm with no S3, S4, or murmur. Lungs are clear to auscultation bilaterally. Electrocardiogram reveals no acute changes. Which of the following is the most appropriate initial step in the evaluation of this patient?
A. Cardiac catheterization
B. CT Angiogram of the chest
C. Echocardiogram
D. Nuclear stress test
```
(c) D. Nuclear stress testing is the most appropriate initial diagnostic study in the evaluation of a patient with signs and symptoms consistent with stable angina.
242
```
A 48 year-old male with diabetes mellitus presents for routine physical examination. Of note his blood pressure each of his last two follow-up visits was 150/90 mmHg. Today the patient's BP is 148/88 mmHg. The patient denies complaints of chest pain, change in vision, or headache. Which of the following is the most appropriate management for this patient?
A. Atenolol (Tenormin)
B. Nifedipine (Procardia)
C. Hydralazine (Apresoline)
D. Lisinopril (Zestril)
```
(c) D. ACE inhibitors are the first line treatment of choice in a patient with hypertension and diabetes.
243
A 36 year-old female presents for a routine physical. She has no current complaints and her only medication is oral contraceptives. The patient is preparing for a trip to Australia and is worried about the long flight as her mom has a history of deep vein thrombosis after a long trip several years ago. Physical examination reveals BP 110/60 mmHg, HR 66 bpm, regular. Heart is regular rate and rhythm without murmur, lungs are clear to auscultation bilaterally and extremities are without edema. Which of the following is the most appropriate recommendation for your patient?
A. Discontinue oral contraceptives
B. Recommend walking frequently during the flight
C. Begin daily aspirin therapy
D. Increase fluid intake 2-3 days prior to the flight
(c) B. The risk of deep vein thrombosis after air travel increases with flight duration. Preventive measures for patients include using support hose and performing in-flight exercises and walking.
244
```
A 3 month-old female presents with her mom for physical examination. The patient's mom denies any complaints. On examination you note a well-developed, well-nourished infant in no apparent distress. There is no cyanosis noted. Heart examination reveals a normal S1 with a physiologically split S2. There is a grade III/VI high-pitched, harsh, pansystolic murmur heard best at the 3rd and 4th left intercostal spaces with radiation across the precordium. Which of the following is the initial diagnostic study of choice in this patient?
A. CT angiogram
B. Electrocardiogram
C. Echocardiogram
D. Cardiac catheterization
```
(c) C. Echocardiogram is the initial diagnostic study of choice in the diagnosis of a VSD.
245
```
A 20 year-old male presents with complaint of brief episodes of rapid heart beat with a sudden onset and offset that have increased in frequency. He admits to associated shortness of breath and lightheadedness. He denies syncope. Electrocardiogram reveals a delta wave prominent in lead II. Which of the following is the most appropriate long-term management in this patient?
A. Implantable cardio defibrillator
B. Radiofrequency ablation
C. Verapamil (Calan)
D. Metoprolol (Lopressor)
```
(c) B. Radiofrequency ablation is the procedure of choice for long-term management in patients with accessory pathways (WPW) and recurrent symptoms.
