Quiz Questions

Question 1

A delta wave is a patho-pneumonic finding (indicates a specific diagnosis) in which arrhythmia?

a. Previous myocardial infarction
b. PAC
c. Wolf Parkinson White
d. Atrial Fibrillation

Answer 1

Wolf Parkinson White

Question 2

The DASH diet specifically addresses the sodium content of foods to help reduce hypertension in patients.
Select one:

a. True
b. False

Answer 2

False

a. Emphasis is on whole grains, vegetables, fruits, fish, non-fat dairy
b. The diet is more qualitative than quantitative thus easier to pick food choices.
c. Blood pressure reduction are proposed to be secondary to decrease gluten intake.

Question 3

Which dietary approach (comparatively) for atherosclerosis and coronary arterial disease has a high emphasis on achieving “very low” levels of fats and “high” levels of carbohydrates.

a. Paleo Diet
b. Ornish Diet
c. Mediterranean Diet
d. DASH

Answer 3

Ornish Diet

Question 4

According to lecture, supplementation with fish oil is equally effective for risk reduction of cardiovascular events as fish consumption.
Select one:

a. True
b. False

Answer 4

False

Question 5

Which of the following scenarios is the highest risk for serious adverse complications for a patient?

Select one:

a. A 72 year old male is diagnosed with atrial fibrillation and is currently only taking aspirin
b. A patient is experiencing sustained polymorphic ventricular tachycardia
c. A 47 year old female patient reports palpitations and is diagnosed with multiple episodes of premature ventricular contractions
d. A 32 year old asymptomatic male receives a diagnosis of Wolf Parkinson White pattern on a ECG in an educational lab setting

Answer 5

B. A patient is experiencing sustained polymorphic ventricular tachycardia

**The commonest cause of PVT is myocardial ischaemia.

Question 6

Which of the following is the most prevalent thrombophilia often diagnosed after a patient experiences a thrombotic event?

Select one:

a. Protein S Deficiency
b. Factor V Leiden
c. Protein C Deficiency
d. Homozygous MTHFR mutations

Answer 6

b. Factor V Leiden

Question 7

In a patient diagnosed with AVNRT without signs of WPW, the best course of treatment for symptoms of palpitations is which of the following?

Select one:

a. Beta blocker to gain rhythm control
b. Valsalva maneuver to alter vagal tone
c. Class I antiarrhythmic medications to block AV node transduction
d. Catheter ablation therapy first line

Answer 7

b. Valsalva maneuver to alter vagal tone

(Atrioventricular nodal reentrant tachycardia (AVNRT) is an arrhythmia that occurs because an extra pathway lies in or near the AV node, which causes the impulses to move in a circle and reenter areas it already passed through.)
**ECG tracing typical of AV nodal reentrant tachycardia, the P wave falls after the QRS complex.

Wolff-Parkinson White Syndrome (WPW): An extra electrical pathway between your heart’s upper and lower chambers causes a rapid heartbeat. The extra pathway is present at birth and fairly rare. The episodes of fast heartbeats usually aren’t life-threatening,

Question 8

Which of the following is NOT considered a red flag in evaluation of palpitations?

Select one:

a. The patient reports history of depressive disorder
b. The onset of palpitations came on around the same time as they started a new medication
c. The patient reports having history mitral valve regurgitation
d. The patient tells you that a few years ago they were diagnosed with a long QT interval
e. Patient reports episode of passing out a couple months ago during an episode

Answer 8

a. The patient reports history of depressive disorder

Question 9

In a patient on warfarin for anticoagulation with a diagnosis of atrial fibrillation, the addition of multiple supplements commonly described to thin the blood has been shown to alter the INR levels and thus reduce the effectiveness in risk reduction from the warfarin medication.

Select one:
A. True
B. False

Answer 9

A. True

Question 10

Primarily vasodilator - acting on smooth muscle.

Diltiazem
Verapamil
Amlodipine

Answer 10

Amlodipine

Question 11

Selective to L-type Ca channels in the myocardium without smooth muscle actions.

Diltiazem
Verapamil
Amlodipine

Answer 11

Verapamil

Question 12

Intermediate medication having effects on both myocardium and smooth muscle (vasodilator).

Diltiazem
Verapamil
Amlodipine

Answer 12

Diltiazem

Question 13

Hypokalemia should be monitored in patients for the appropriate drug classes during what period of time?

Select one:

a. Hypokalemia should be monitored during the first two weeks of therapy
b. Hypokalemia should be monitored at 3, 6, and 9 months of a stable dose of the medication.
c. Hypokalemia should be measured in patients only if they are symptomatic.
d. Hypokalemia needs to be monitored every 7 days for the first month of therapy.

Answer 13

A. Hypokalemia should be monitored during the first two weeks of therapy

Question 14

Patients taking the potassium sparing diuretic Spironolactone are at increased risk of which of the following:

Select one:

a. Gynecomastia
b. Hypokalemia
c. Metabolic alkalosis
d. Palpitations

Answer 14

a. Gynecomastia

Question 15

According to the lecture, patients may experience a dry cough with use of an ACE-inhibitor. The mechanism for this side effect is __________________.

Select one:

a. ACE-I block the breakdown of bradykinin
b. Angiotensin II causes vasoconstriction in the pulmonary tree
c. AT1 receptors mediate broncho -dilation
d. Increased renin stimulates excessive cytokine production leading to broncho-constriction

Answer 15

a. ACE-I block the breakdown of bradykinin

Question 16

Hypokalemia should be monitored in what drug classes of hypertension medications?

Select one:

a. Thiazide and loop diuretics
b. Thiazide diuretics and calcium channel blockers
c. Potassium sparing diuretics and ACE inhibitors
d. Beta blockers and calcium channel blockers

Answer 16

a. Thiazide and loop diuretics

Question 17

The definition of heart failure is best explained by the presence of which of the following?

Select one:

a. Volume overload
b. Reduced ejection fraction
c. Impaired ability to fill and/or eject blood
d. BNP elevation > 50 -100 mg/dL

Answer 17

c. Impaired ability to fill and/or eject blood

Question 18

Which medication is considered first line in a patient with Stage B heart failure?

Select one:

a. ACE inhibitor
b. Calcium channel blocker
c. Thiazide diuretic
d. Cardiac glycoside

Answer 18

a. ACE inhibitor

• Stage A: Presence of heart failure risk factors but no heart disease and no symptoms
• Stage B: Heart disease is present but there are no symptoms (structural changes in heart before symptoms occur)
• Stage C: Structural heart disease is present AND symptoms have occurred
• Stage D: Presence of advanced heart disease with continued heart failure symptoms requiring aggressive medical therapy

Question 19

All of the following except which one is a listed typical presentation of acute myocardial infarction?

Select one:

a. Unprovoked chest pain
b. Feeling of doom
c. Tachycardia
d. Asymptomatic
e. Unilateral leg swelling

Answer 19

e. Unilateral leg swelling

Question 20

The NYHA classification uses what marker to determine “Class” of heart failure?

Select one:

a. Symptoms
b. BNP level
c. Ejection Fraction
d. Lead AVR
e. Family history

Answer 20

a. Symptoms

Question 21

According to the AHA guidelines in post myocardial infarctions it is recommended that patients be evaluated for symptoms of depression, sleep disorders and social support.

Select one:
A. True
B. False

Answer 21

A. True

Question 22

True or False: Cardiomyopathy is defined as a myocardial disorder in which the heart muscle is structurally and functionally abnormal in the absence of coronary artery disease, hypertension, valvular disease and congenital heart disease sufficient to explain the observed myocardial abnormality

Select one:
A. True
B. False

Answer 22

A. True

Question 23

All of the following EXCEPT which one are primary cardiomyopathies?

Select one:

a. Hypertrophic cardiomyopathy
b. Dilated cardiomyopathy
c. Tako-tsubo
d. Bi-cuspid aortic valve

Answer 23

d. Bi-cuspid aortic valve

Question 24

A 67 year old patient presents to your office with fatigue and shortness of breath on exertion. In your work up you discover that the patient does not have sufficient evidence of ischemia to explain the symptoms. After ordering an echocardiogram they find an enlarged ventricle with impaired function, yet normal ventricular wall thickness. On further history you discover that the patient has a long history of alcoholism. What is the most appropriate/likely diagnosis?

Select one:

a. Long standing hypertension
b. Dilated cardiomyopathy secondary to alcohol abuse
c. Patent foramen ovale
d. Hypertrophic cardiomyopathy

Answer 24

b. Dilated cardiomyopathy secondary to alcohol abuse

Question 25

In hypertrophic cardiomyopathy all of the following are true EXCEPT for which one?

Select one:

a. Hypertrophy of the septum and obstruction of the anterior leaflet of the mitral valve produce a left ventricular outflow obstruction which may sound like aortic stenosis on auscultation of the heart
b. HCM is also know as idiopathic hypertrophic subaortic stenosis or IHSS
c. An ECG is almost always normal
d. Beta blockers are the mainstay of therapy

Answer 25

c. An ECG is almost always normal

Question 26

Diseases such as hemochromatosis or glycogen storage diseases may be the causative reason for patients to develop hypertrophic cardiomyopathy.

Select one:
A. True
B. False

Answer 26

The correct answer is ‘False’.

Diseases such as hemochromatosis or glycogen storage diseases may be the causative reason for patients to develop RESTRICTIVE cardiomyopathy.

Question 27

Match the life expectancy (in years) with the onset of symptom in patients with aortic valve stenosis.

Angina
Syncope
CHF

A. 2-3 yrs
B. 1-2 yrs
C. 5 yrs

Answer 27

Angina – 5 years,
Syncope – 2-3 years,
CHF – 1-2 years

Question 28

Left ventricular hypertrophy (LVH) is associated with (choose one):

Select one:

a. Aortic Stenosis
b. Mitral Stenosis
c. Tricuspid Stenosis
d. Pulmonic Stenosis

Answer 28

a. Aortic Stenosis

Question 29

In a patient with acute pericarditis which of the following is not suggested as a first line therapy for treatment?

Select one:

a. ASA (aspirin)
b. Steroids
c. Colchicine
d. NSAIDS

Answer 29

b. Steroids

Question 30

In the definition of an MI, per the 2012 universal consensus of European and American Cardiology groups, an MI is evidenced by a change in cardiac biomarkers – cardiac troponin elevation greater than one point over the 99th percentile of the upper range plus further evidence. All the following EXCEPT which one constitute the further evidence.

Select one:

a. Symptoms of ischemia
b. New or presumed new significant ST elevation or T wave or LBBB
c. New onset PVCs
d. Pathologic Q waves
e. Imaging of myocardial loss or wall abnormality

Answer 30

c. New onset PVCs

Question 31

All the following medications EXCEPT which one, are likely to be prescribed to a patient on discharge after having a myocardial infarction without heart failure

Select one:

a. Beta blocker
b. Statin
c. Spironolactone
d. Aspirin
e. Clopidogrel

Answer 31

c. Spironolactone

Question 32

True or False: Patients with a diagnosis of heart failure with preserved ejection fraction have a worse prognosis than patients with reduced ejection heart failure

Select one:
A. True
B. False

Answer 32

False

Question 33

A patient has elevated serum creatinine and BUN along with a diagnosis of heart failure. They come into your office because their cardiologist discussed possible need for heart transplant. The patient reports she started taking on her own herbal dandelion capsules, CoQ10, and was told to take Taurine by a friend. Which of the following self-prescribed treatments is the most concerning for the patient

Select one:

a. Herbal dandelion capsules
b. CoQ10
c. Taurine

Answer 33

a. Herbal dandelion capsules

Question 34

Poor Cholesterol Pete

HPI: Pete (a 47 yo male) enters today for his regular interval preventive wellness and physical exam. He has been in good health, and has been treated historically for food allergies, and other minor complaints. He is being seen at six month intervals for hypothyroidism (on Rx), and he has had a history of elevated cholesterol in the past that typically reduced with exercise, but he has seemingly been less able to control his lipids with lifestyle. He has no complaints today- you query about cardiac sxs specifically. He has a PHx of pneumothorax (spontaneous). FHx: No early CAD/ MI. SHx: swims daily for 45 min; avoids sugar and caffeine; rare alcohol, remote history of tobacco for 4 years. Works as a technician in a refinery- denies chemical exposures.

O: Vitals 129/75. Full screening exam is unremarkable. Labs reveal unremarkable chemistry, CBC, and UA. TSH 1.5. PSA 1.2. Lipids: TC: 245 mg/dL; HDL: 42 mg/dL; TRGs: 96 mg/dL; LDL-c: 184 mg/dL; TC/HDL: 5.8

1. List three of Pete’s risk factors for MI or Stroke? What is his 10-year ASCVD risk?

Answer 34

1. Pete is a male >45 years.
2. Elevated serum Triglycerides.
3. Total Cholesterol >240mg/dL.

***10-year ASCVD Risk: 4.3% calculated risk; 1.5% risk with optimal risk factors

Question 35

Poor Cholesterol Pete

HPI: Pete (a 47 yo male) enters today for his regular interval preventive wellness and physical exam. He has been in good health, and has been treated historically for food allergies, and other minor complaints. He is being seen at six month intervals for hypothyroidism (on Rx), and he has had a history of elevated cholesterol in the past that typically reduced with exercise, but he has seemingly been less able to control his lipids with lifestyle. He has no complaints today- you query about cardiac sxs specifically. He has a PHx of pneumothorax (spontaneous). FHx: No early CAD/ MI. SHx: swims daily for 45 min; avoids sugar and caffeine; rare alcohol, remote history of tobacco for 4 years. Works as a technician in a refinery- denies chemical exposures.

O: Vitals 129/75. Full screening exam is unremarkable. Labs reveal unremarkable chemistry, CBC, and UA. TSH 1.5. PSA 1.2. Lipids: TC: 245 mg/dL; HDL: 42 mg/dL; TRGs: 96 mg/dL; LDL-c: 184 mg/dL; TC/HDL: 5.8

2. Would it be appropriate to work him up further or treat him empirically?

Answer 35

With Pete’s lack of FHx of CAD, his past success of controlling his cholesterol levels with diet/lifestyle, the results from the recently drawn labs, treating him empirically would be the most appropriate approach rather than continuing to work him up.

Question 36

Poor Cholesterol Pete

HPI: Pete (a 47 yo male) enters today for his regular interval preventive wellness and physical exam. He has been in good health, and has been treated historically for food allergies, and other minor complaints. He is being seen at six month intervals for hypothyroidism (on Rx), and he has had a history of elevated cholesterol in the past that typically reduced with exercise, but he has seemingly been less able to control his lipids with lifestyle. He has no complaints today- you query about cardiac sxs specifically. He has a PHx of pneumothorax (spontaneous). FHx: No early CAD/ MI. SHx: swims daily for 45 min; avoids sugar and caffeine; rare alcohol, remote history of tobacco for 4 years. Works as a technician in a refinery- denies chemical exposures.

O: Vitals 129/75. Full screening exam is unremarkable. Labs reveal unremarkable chemistry, CBC, and UA. TSH 1.5. PSA 1.2. Lipids: TC: 245 mg/dL; HDL: 42 mg/dL; TRGs: 96 mg/dL; LDL-c: 184 mg/dL; TC/HDL: 5.8

3. Are there other blood tests you would have to assess his risk factors?

Answer 36

1. Fasting blood glucose or HgA1c could be done to assess for risk of diabetes.
2. CRP/hsCRP may be helpful
3. Interleukin-6 (inflammatory marker)
4. Myeloperoxidase (inflammatory marker)

Question 37

Poor Cholesterol Pete

HPI: Pete (a 47 yo male) enters today for his regular interval preventive wellness and physical exam. He has been in good health, and has been treated historically for food allergies, and other minor complaints. He is being seen at six month intervals for hypothyroidism (on Rx), and he has had a history of elevated cholesterol in the past that typically reduced with exercise, but he has seemingly been less able to control his lipids with lifestyle. He has no complaints today- you query about cardiac sxs specifically. He has a PHx of pneumothorax (spontaneous). FHx: No early CAD/ MI. SHx: swims daily for 45 min; avoids sugar and caffeine; rare alcohol, remote history of tobacco for 4 years. Works as a technician in a refinery- denies chemical exposures.

O: Vitals 129/75. Full screening exam is unremarkable. Labs reveal unremarkable chemistry, CBC, and UA. TSH 1.5. PSA 1.2. Lipids: TC: 245 mg/dL; HDL: 42 mg/dL; TRGs: 96 mg/dL; LDL-c: 184 mg/dL; TC/HDL: 5.8

4. What diagnostic imaging could you order to assess presence of coronary disease? (Note he is pain free).

Answer 37

The following diagnostic imaging should be considered:

1. Ultrasound: Carotid, abdominal
2. Nuclear Imaging/MRI
3. Electron beam CT for coronary calcium
4. Myocardial perfusion tests
5. Ankle-Brachial Index
6. Measuring asymptomatic ischemia with exercise or a resting ECG (not imaging, but valuable in monitoring heart electrical activity and used in conjunction with other diagnostic imagings)

The diagnostic imaging methods mentioned above are non-invasive, and are recommended if the patient develops more risk factors or symptoms indicative of coronary disease. More invasive diagnostic imaging should be considered if signs and symptoms get worse.

At the moment, the patient is not experiencing symptoms. Therefore, without any symptoms, diagnostic imaging is not indicated at this time.

Question 38

Poor Cholesterol Pete

HPI: Pete (a 47 yo male) enters today for his regular interval preventive wellness and physical exam. He has been in good health, and has been treated historically for food allergies, and other minor complaints. He is being seen at six month intervals for hypothyroidism (on Rx), and he has had a history of elevated cholesterol in the past that typically reduced with exercise, but he has seemingly been less able to control his lipids with lifestyle. He has no complaints today- you query about cardiac sxs specifically. He has a PHx of pneumothorax (spontaneous). FHx: No early CAD/ MI. SHx: swims daily for 45 min; avoids sugar and caffeine; rare alcohol, remote history of tobacco for 4 years. Works as a technician in a refinery- denies chemical exposures.

O: Vitals 129/75. Full screening exam is unremarkable. Labs reveal unremarkable chemistry, CBC, and UA. TSH 1.5. PSA 1.2. Lipids: TC: 245 mg/dL; HDL: 42 mg/dL; TRGs: 96 mg/dL; LDL-c: 184 mg/dL; TC/HDL: 5.8

5. Based on the result of the test(s), what would be your recommendations for him regarding his poor lipid status?

Answer 38

Based on his ASCVD risk, and if future blood tests are negative for diabetes, then more aggressive dietary and lifestyle modifications are recommended at this time.

The patient should continue his current swimming routine and add resistance training at least 2x per week.

Consider nutritional counseling, with the goal of developing a nutrient-rich diet that the patient will comply with. The Mediterranean, Dash, and Portfolio diets have been shown to reduce cholesterol and help with CVD risk.

Consider supplementation of fish oil, niacin, fiber, red yeast rice, artichoke extract, and plant sterols.

Pete has a history of hypothyroidism, which can further contribute to the hyperlipidemia, therefore, we should continue to monitor his thyroid levels.

If blood work indicates that he is diabetic, then consider a statin, largely based on his age and high LDLs.

Question 39

Based upon the statistics regarding the top seven cardiovascular risk factors in the US, which factor can save American lives?

a. Body Mass index
b. Total Cholesterol
c. Healthy diet
d. Blood pressure

Answer 39

c. Healthy diet

Question 40

In a patient that you are suspicious of Stable angina, what noninvasive diagnostic testing would you perform first line to access for ischemia? Be specific.

a. Coronary Angiogram
b. Stress ECG
c. Echocardiogram
d. Coronary Calcium score

Answer 40

b. Stress ECG (New onset murmur->ECHO///ECG->only with activity)

Question 41

Upon auscultation you may appreciate an S3 early in diastole. At what age and above is the general population would this finding be almost always pathologic?

a. 40 years and older
b. 35 years and older
c. 24 years and older
d. 8 years and older

Answer 41

a. 40 years and older

ST pathologic-16 yo “Normal flow murmur*

Question 42

Which of the following when above a value 190 mg/dL, suggest that cardiac risk is most likely of genetic etiology?

a. Total Cholesterol
b. Blood pressure
c. LDL Cholesterol
d. HDL Cholesterol

Answer 42

c. LDL Cholesterol (Can’t use risk calculator-tougher management->ASC risk calc.)

Question 43

In the assessment of cardiac risk for asymptomatic patients, which calculator has been set as the new standard of assessment starting in 2014.

a. CHAD2-VASC
b. The MESA score
c. The Framingham Risk Calculator
d. ASCVD Calculator

Answer 43

d. ASCVD Calculator

Question 44

An ECG can permit you to access five things, pick 2: (From earlier article)

a. valve disorder and infection (Maybe infection)
b. Inflammation and severity
c. Hypertrophy and infarction
d. PAD and ischemia

Answer 44

c. Hypertrophy and infarction

Question 45

Given the scenario, answer the following question. A patient present to your office with a diagnosis of diabetes, hyperlipidemia and hypertension with no history of cardiac event. In this case you want to prevent the patient from experiencing a major cardiovascular event. Which level of prevention is this?

a. Primordial Prevention
b. Primary Prevention
c. Secondary Prevention
d. Tertiary Prevention

Answer 45

b. Primary Prevention (For the reduction of CV event-Heart outcomes)

Diabedes, HTN no hx of CVD- Primary prevention for cardio vascular event

Question 46

What condition is this sign? (Corneal arcus) associated with?

a. Cerebral Vascular event
b. Hyperlipidemia
c. Diabetes
d. Corneal Neoplasm

Answer 46

b. Hyperlipidemia

Question 47

True/False: Coronary Calcium score is a CT scan that identifies calcified plaque burden of coronary arteries. This may be helpful for assessment of risk, however, actual soft plaque burden is unknown and the test should be used in intermediate risk patients in determination of therapy intensity i.e. Lipid lowering therapy.

a. True
b. False

Answer 47

a. True

Question 48

Which supplement has variable levels of monacolin which can lower cholesterol levels and has been shown to be effective for this purpose in patients who do not tolerate statins?

a. Policosanol
b. Fiber
c. COQ10
d. Red yeast rice

Answer 48

d. Red yeast rice (Monascus purpureus)

Question 49

Which of the following is FALSE regarding the DASH diet?

a. Emphasis is on whole grains, vegetables, fruits, fish, non-fat dairy
b. Greater reduction in blood pressure is seen with concurrent decrease in dietary sodium intake.
c. The diet is more qualitative than quantitative thus easier to pick food choices.
d. Blood pressure reduction are proposed to be secondary to decrease gluten intake.

Answer 49

d. Blood pressure reduction are proposed to be secondary to decrease gluten intake.

Question 50

Of the following diets, which one is associated with very low diatary fat intake?

a. Ornish
b. Mediterranean
c. DASH
d. Low-carb

Answer 50

a. Ornish

Question 51

In 1-2 sentences describe the effect of treating high Homocystine levels with vitamin B12, B6 and Folic acid and the impact on Cardiovascular risk/outcome.

Answer 51

Student should describe the fact that elevated levels are associated with increased risk however treatment with this regimen has not been effective for lowering events. The exception to this is in younger patients with high homocysteine - specifically hereditary Cystathionine synthase deficiency.
(Decrease homocysteine but not events->You can target kids)

Question 52

According to the research presented the top 10 sources of antioxidant in the US diet (based upon per capita consumption and antioxidant concentration) which dietary source was the most highly consumed?

Answer 52

Coffee

Question 53

What is the most common form of inherited thrombophilia that carries a 2.2X higher risk of thrombosis and is often found after a diagnosis of various thromboembolisms. It was discussed in the disorders of coagulation powerpoint.

Answer 53

-Factor 5 laden

Question 54

True or False: Palpitations are synonymous with arrythmias

Answer 54

True

Question 55

Name 3 red flags associated with your history taking in a patient whom has a chief complaint of palpitation:

Answer 55

a. Syncope or pre-syncope,
b. Family history of sudden cardia death,
c. Palpitations with medications
d. History of cardiac disease

Question 56

A patient presents to your clinic with records from their primary care providers office. The patient reports that she has some type of heart problem - she states “the electrical system is wonky.” Reviewing the chart, you see that the primary care provider calculated the CHA2DS2-Vasc score and Suggested anticoagulation. The risk calculator is used primarily to predict risk of stroke risk in patients with which cardiac arrhythmia?

Answer 56

CHA2DS2-Vasc=> Atrial Fibrillation

Question 57

Name 3 different naturopathic therapies that may be useful in the treatment of atrial fibrillation and discuss the mechanism of protection or treatment.

Answer 57

Coq10
Green tea
Caffeine 
Fish oil
Magnesium
Vitamin D
Herbs

Question 58

What medication is not normally prescribed by primary care physician for arrhythmias?

a. verapamil (Class IV anti-arhythmic)
b. Amidarone (Class 3 anti-arrhythmic)
c. Metoprolol (Class 2 anti-arrhythmic)

Answer 58

b. Amidarone (Class 3 anti-arrhythmic)

Question 59

All following scenarios Except which one should be considered an emergency and patient sent to the ER?

a. Patient has heart rate of 42 ppm and reports episodes of syncope in the past 2 days. You palpate an irregular rhythm on the patient.
b. Patient has ventricular tachycardia for the past 30 minutes with wide QRS complexes on the ECG.
c. Patient reports palpitation with anxiety, the patient experiences PVCs and PACs multiple times a day.

Answer 59

c. Patient reports palpitation with anxiety, the patient experiences PVCs and PACs multiple times a day. (PAC-atrial)

Question 60

True or false: All pt’s with paroxysmal or sustained atrial fibrillation or atrial flutter should be assessed for the risk of stroke with the CHA2DS2-vasc. score.

Answer 60

True

Question 61

Per the Reading for class from uptodate on “rate vs rhythm control in atrial fibrillation”. The authors stated that although both rate and rhythm control are acceptable with comparable rates of mortality and stroke, which one do they recommend for initial care in asymptomatic patients. with atrial fibrillation?

a. Rate control
b. Rhythm Control

Answer 61

a. Rate control

Question 62

In reviewing this ECG (V6); what arrhythmia condition would you most likely suspect is present in this patient and explain briefly why? Atrial Fib

Answer 62

Atrial Fib

Question 63

In reviewing this ECG below what are the arrows identifying in this case?

a. Premature atrial complexes
b. Premature Ventricular complexes
c. Ventricular tachycardia
d. Left bundle branch block

Answer 63

a. Premature atrial complexes

Question 64

According to the guidelines, the “white coat effect” is defined as a discrepancy of more than _______ (systolic bp) ________ (Diastolic bp) mmhm between clinic and average daytime ambulatory blood pressure monitoring or average home blood pressure monitoring blood pressure measurement at the time of diagnosis.

a. 10/20
b. 15/30
c. 20/10
d. 10/10

Answer 64

c. 20/10 (Meds 20/10 over goal)

Question 65

Which 2 antihypertensive medication carry the risk of hypokalemia?

a. CCB and ARBs
b. Thiazide and Loop diuretics
c. ACE-I and Beta blockers
d. ARB and Beta Blockers

Answer 65

b. Thiazide and Loop diuretics

Hypokalemia should be monitored in what drug classes of hypertension medications? same!

Question 66

If a patient presents with a diagnosis of chronic kidney disease without significant comorbidity, per the American guidelines for hypertensive management, a medication from which 2 classes of anti-hypertensive medications may recommended for this patient 1st line med?

a. Thiazide or ACE-1
b. CCB or Thiazide dieretic
c. Alpha blocker or ARB
d. ACE-1 or ARB

Answer 66

d. ACE-1 or ARB

Question 67

True or False: Patients in the 7th decade of life with stage 1 hypertension should all be treated using pharmaceutic intervention to a target blood pressure of 110/70 as this is the level in which the benefit of treatment outweigh the risk of pharmacological effects.

Answer 67

True

Question 68

Select from the following cases the best management scenario:

a. Patient presents w/BP of 180/106, he has a constant HA and says his vision is “funny.” He is not feeling well at all and reports a hx of angina. He took the bus to see you. Upon PE you see retinal hemorrhages yet his diastolic isn’t too high so you can tell him to reduce his salt intake, give him a dose of hypertension tincture and tell him to follow up in one month.
b. Patient BP is 204/118, patient has a constant HA and says his vision is “funny”. He is not feeling well at all and reports hx of angina. You go to the IV shift closet and find Bicarb hydrochloride and administer it at 50mg/hour IV to the patient.
c. Pt. BP is 204/118 pt has constant HA and says his vision is “funny.” He is not feeling well at all and reports hx of angina. He took the bus to see you. You decide to call 911 for transport and then the ED to alert them of your patient’s arrival and for follow up.

Answer 68

c. Pt. BP is 204/118 pt has constant HA and says his vision is “funny.” He is not feeling well at all and reports hx of angina. He took the bus to see you. You decide to call 911 for transport and then the ED to alert them of your patient’s arrival and for follow up.

Question 69

Recall from normal physiology the following in response to low blood pressure renin.

a. Increase
b. Decrease

Answer 69

a. Increase

Question 70

Current guidelines for classification and management of hypertension in the USA is called by the name __________. In the UK the guidelines for hypertension are referred to by which acronym _______.

a. AACHA and UKPDS
b. JNC-8 and NICE
c. ADA-2 and TENSE
d. US2DA-GRANT

Answer 70

b. JNC-8 and NICE

Question 71

True/False: The following medications may cause elevated blood pressure; OCP, Naproxen, caffeine, pseudoephedrine

Answer 71

True

Question 72

All of the following are major complications of hypertension except which one?

a. Retinal damage
b. Cataracts
c. Myocardial Infarction
d. CerebralVascular accident

Answer 72

b. Cataracts

Question 73

A 43 yo male patient presents to your office with elevated blood pressure at 180/96 mmhg. He is currently on 3 different antihypertensive and has not been able to control his blood pressure. If the patient was then given spironolactone or Elepranone and his blood pressure improved dramatically which of the following causes of secondary hypertension was the likely culprit?

a. Hyperthyroidism
b. Renal artery stenosis
c. Primary aldosteronism
d. Cushing syndrome

Answer 73

c. Primary aldosteronism

Question 74

A 72 year old female with a BMI of 31 arrives to the emergency room. She is complaining of SOB for the past five days which has gotten progressively worse. Her SOB gets worse when she is lying down especially at night and also whenever she does exercise. However she says that when she sits up she can breathe better. She also mentions that she has a cough, especially at night. You notice that there is increased swelling in her legs bilaterally and she also mentions that she has chest pain while she points at the sub-sternal area.She does not drink or smoke.

The patient has a history of hypertension, diabetes and NO history of MI. Her vital signs are as follows: BP 212/104, HR 115, RR 26, T 98.1. On exam you note rales in the lung bases bilaterally as well as 1+ pitting edema in the lower extremities bilaterally. Her oxygen saturation is 94%. Heart examination S3 heart sound and LVEF = 52%.

Select one:

a. Systolic heart failure (SHF)
b. Diastolic heart failure
c. Emphysema
d. Nephrotic Syndrome

Answer 74

b. Diastolic heart failure***

This question is the right answer as evidenced by the patient’s signs and symptoms of coughing, dyspnea, SOB with exertion and edema which are all sign that lead to diastolic heart failure. This condition has the greatest prevalence in elderly, female, obese, history of hypertension and diabetes which the patient fits in that category.

As far as the pathophysiology of DHF the cardiac function of the heart is dependent on diastolic physiology to provide an adequate left ventricular (LV) filling which would be the cardiac input along with the LV ejection which would be the cardiac output. These functions go under many physiological conditions which are both at rest and during exercise. When there is an increase in LV diastolic pressure this will increase pulmonary venous pressure which in return causes our patient to have dyspnea, exercise limitation with the SOB on exertion and possible pulmonary congestion. In general the gold standard for heart failure is the following list of diagnostic tools: Running lab levels of brain natriuretic peptide (BNP), if you are trying to differentiate between systolic and diastolic heart failure an ECG can show the residual Q waves that helps to confirm if past MI; ST segment changes in IHD; Sn of hypertrophy. But we already know this patient does not have a history of MI which would have us lean more towards diastolic heart failure compared to systolic heart failure. You can also do a chest X-ray that is non-specific to cardiac enlargement, echocardiogram which provides EF and residual ventricular pressure plus can show diastolic dysfunction. A few more diagnostic tools to use would be Radionuclide ventriculography which is used for to indicate LV function and perfusion defects which for DHF LVEF >50% and normal. Lastly cardiac catheterization can be used to measure EF along with hemodynamic features of DHF 1.

Question 75

Mr. Hansen is a 56 year old, with a BMI at 33 he is an Accountant who presents tonight in the office following an episode of “chest pain” that he experienced earlier in the day while playing baseball. Although he minimizes the severity of the pain and attributes it to being “out of shape,” his wife insisted that he see a physician because he has had similar episodes during the past six months.

Mr. Hansen describes the pain as being more of a discomfort or heaviness. It is localized to “my breast bone” and does not radiate. Today, following a brief rest, the pain subsided and he returned to his baseball game. Previous episodes of the heavy feeling tended to occur following large meals and one occasion, while dancing crazy at a wedding. None of the episodes lasted more than “several minutes.”

Although Mr. Hansen did not experience nausea or vomiting today, he notes many episodes in the past of feeling a burning sensation in his chest. He describes the sensation as being “like acid behind my breast bone.” This feeling occurs most often late at night when he lays down. Usually he has had a large meal or drank alcohol. The sensation does not radiate. You decide to do a stress ECG test and his chest pain comes back you administer nitroglycerine and it helps the symptoms go away. Also his ECG is normal.
What is the most likely diagnosis at this point?

Select one:

a. MI
b. Stable angina
c. Unstable angina
d. GERD

Answer 75

b. Stable angina

This question is the right answer as evidenced by the patient experiencing having a pain or heaviness at his chest bone area but only for several minutes and then at rest it goes away. Also his ECG is normal and when having the symptoms again in office during a stress test when given nitroglycerine his symptoms go away these are all gold standard for stable angina.

Question 76

A 32-year-old presented with a 5-day history of substernal chest pain that is sharp and radiated to his shoulders. He finds that the pain is worse when he takes in deep breaths or when he is lying down but he finds that it improves when he leans forward. He denies having dyspnea. On examination he had no chest-wall tenderness and denies having any recent trauma. Labs show that there is an elevation in the white-cell count, erythrocyte sedimentation rate, and D-dimer level. When he was sent to the emergency department, his cardiac-enzyme levels were found to be normal. The next day, a three-component friction rub was heard during auscultation while the patient was holding his breath. An ECG showed PR-segment depression and diffuse ST-segment elevation.

What is the most likely diagnosis?

Select one:

a. Acute pericarditis
b. Stable angina
c. GERD
d. MI

Answer 76

a. Acute pericarditis

This question is the right answer as evidenced by the patient’s presentation of sub sternal sharp chest pain, pain being worse with inspiration, worse lying down but better leaning forward. The patient also has a friction rub of the heart (heard on auscultation while holding breath), lastly the patient had an ECG reading of PR-segment depression and diffuse ST-segment elevation which all of these are signs and diagnosis’s of Acute pericarditis

Question 77

A 52 year old black African American man complains of chest pain at rest and fatigued. He is overweight and his diet is a standard American diet with very few fruits and vegetables. You are concerned this could be a heart condition and give him nitroglycerine to see if that will help but it does nothing for him. He tells you that while he was working in the garden today he was experiencing shortness of breath and at night he has a hard time breathing but when he sits up he feels he can breathe again. You do a heart exam on him and find an S4 heart sound and a mid-systolic murmur. You decide to send him to the ER. They do an ECG which showed a nonspecific ST- and T-wave abnormalities and a left atrial enlargement.

Based on the patient signs symptoms and findings what is the most likely diagnosis at this point?

Select one:

a. Dilated Cardiomyopathy
b. Restrictive Cardiomyopathy
c. Hypertrophic Cardiomyopathy
d. MI

Answer 77

c. Hypertrophic Cardiomyopathy

This question is the right answer as evidenced by signs and symptoms of chest pain shortness of breath at night while lying down and during exertion and also fatigued which all of these are also signs for dilated cardiomyopathy (DCM) and MI but also you found an S4 heart sound and mid-systolic murmur which is also typical in Hypertrophic cardiomyopathy (HCM). The other thing is you found and abnormal ECG of nonspecific ST- and T-wave abnormalities these are all golden diagnosis’s for HCM and for DCM, ECG is not really used to diagnose DCM, but echocardiogram is more used for DCM 16. The greatest prevalence of HCM is about one in 500 and it tends to affect men and black people more often which does fit the patients prevalence. The obstructive form is seen in 25% of cases 20. The pathogenesis is “classical myocardial fiber disarray with cardiomyoctes thickened up to 100 µm arranged in whirls and branched. It is suspected that the loss of contractility associated with this cellular disarray and interstitial fibrosis triggers the myocardial hypertrophy process. The mitral valve leaflets often appear enlarged relative to the cavity of the left ventricle” and more specific of the pathophysiology is that the pump function (ejection fraction, EF) usually remains normal for years with HCM. However, fibrosis and hypertrophy cause diastolic dysfunction and this is often already present at diagnosis. Depending on left ventricular morphology, it may result in dynamic obstruction with formation of an intracavitary systolic pressure gradient.

Question 78

A 5 year old Japanese male presents with 5 days of fever up to 103 degrees F. He has developed red lips and a polymorphous rash over his torso. He also has conjunctivitis in both eyes. On exam you notice he has a strawberry tongue and today his mother mentions that the swelling of his hands and feet are new as of this morning along with a diffuse red-purple discoloration over the palms and soles. The child is fussy and irritable. The child is also not immunized.

Exam: VS T 103, P 128, RR 42, BP 102/65, oxygen saturation 98%. You notice that his neck is supple with bilateral small lymph nodes. The boys’ heart is slightly tachycardic, with no murmurs or gallop. Lungs are clear.

At this point what is the most likely diagnosis?

Select one:

a. Kawasaki disease
b. Measles
c. Hypertrophic Cardiomyopathy
d. Rheumatic fever

Answer 78

a. Kawasaki disease

This question is the right answer as evidenced by the fever, bilateral conjunctivitis, erythema of the lips and oral mucosa, polymorphous rash, and extremity changes which all of these are sign and characteristics to diagnose Kawasaki disease (KD). Also the prevalence of this condition is common in Japan which is about 1 in 100 Japanese children who will develop KD by the age of five. The most common season is more prevalent in the winter.

Question 79

A 75 year old male presents to the clinic with symptoms of chest pain, syncope, dizziness and dyspnea. She mentions that over the last 6 months that her energy has gone down and gets tired more easily. Physical exam revealed a normal S1, a reduced intensity in S2, a carotid upstroke, and a crescendo-decrescendo systolic ejection murmur. No extra heart sounds were noted. No opening snap was heard and S2 was not palpable. No systolic thrill was noticed. No widened pulse pressure was noted. Patient reports no cough, palpitations, history of rheumatic fever orthopnea, hypotension, or shock. This patient has had elevated LDL and cholesterol levels since she was in her early 40s. The patient reports no hoarseness of her voice. Her lungs were clear to auscultation.

What is this patient’s most likely diagnosis?

Select one:

a. Mitral Stenosis
b. Mitral Regurgitation
c. Aortic Stenosis
d. Aortic Regurgitation

Answer 79

c. Aortic Stenosis

This is the right answer as evidenced by the symptoms of chest pain, syncope, dizziness and dyspnea. Physical examination revealed a carotid upstroke, a reduction in the intensity of S2 and a crescendo-decrescendo murmur; all of which are signs that aortic stenosis is present. This condition has the greatest prevalence in adults 75 years old and up. Aortic stenosis is reported in 12.4% of patients 75 and up. The general pathophysiology of this disease is caused by a calcified aortic valve that causes the left ventricle to generate a higher systolic pressure.

Question 80

A 45 year old male presents to the clinic with a recent onset of heart palpitations. He mentions that there is a correlation when he drinks alcohol and exercises too vigorously. He also mentions that he has had some SOB and some lightheadedness. On physical exam an irregularly irregular pulse was felt on palpation of the pulse and heard on auscultation. When the JVP was assessed he was found to have very irregular jugular venous pulsations. An ECG was ordered and ran in office. Results showed an absence of p waves and an irregularly irregular ventricular response. The patient has had no previous history of MI.
What is the most likely type of arrhythmia this male is presenting with?

Select one:

a. Atrial Fibrillation
b. Atrial Flutter
c. Wolf-Parkinson White Syndrome
d. Ventricular Tachycardia

Answer 80

a. Atrial Fibrillation

This is the right answer as evidenced by the signs and symptoms as well as the ECG reading in this case. The male in this case presented with a recent onset of palpitations accompanied with some SOB and lightheadedness.

Although this alone doesn’t differentiate A-fib from other types of palpitations, our physical exam findings help to build our case that A-Fib is the likely diagnosis. An irregularly irregular pulse was felt and heard on examination and when JVP was assessed, he was found to have irregular jugular venous pulsations. A definitive diagnosis was made when an ECG was run in the office and showed an absence of p waves and irregularly irregular RR intervals. A-fib is the most common arrhythmia with a reported prevalence of 1-2% of the general population.