Internal 1 Cardiology Quizzes

An otherwise healthy 30-year-old man presents with a several-day history of

progressive, severe, retrosternal chest pain that is sharp and pleuritic in nature. The
pain is worse on lying down and improved with sitting forward. There is radiation to
the neck and shoulders and specifically to the trapezius muscle ridges. The pain is
constant and unrelated to exertion. On physical examination, a pericardial friction
rub is heard at end-expiration with the patient leaning forward. Which test is most
useful for to diagnose this patient
Echocardiography
Chest CT
Complete blood count
Chest X-Ray

Chest x-ray shows pericardial calcifications. Which of the following set of physical
findings is most likely to be present in this patient?
Tapping apex beat and malar flush
Pansystolic murmur at left lower sternal border
Pulsus paradoxus and hypotension
Water hammer pulse and pistol shot on femorals
Pericardial Knock

A 46-year-old gentleman presents with dyspnea and lower-extremity edema. For

the past 8-10 weeks, he has noted progressive symptoms. The past medical history
includes hypertension. Medications include chlorthalidone. He drinks 6-8 glasses
of wine and whisky per week. On examination, the blood pressure is 100/50 mm
Hg, with heart rate of 80 beats per minute, regular. The jugular venous pressure is
10 cm of water. The first heart sound is normal, and the second heart sound splits
with inspiration. A third heart sound is present, as is a 2 out of 6 pansystolic
murmur at the apex with radiation to the axilla. The extremities are warm, and there
is pitting edema to the knee. An echocardiogram reveals a dilated left ventricle,
moderate mitral regurgitation, and global left ventricular dysfunction with an LVEF
of <35%. Serum electrolytes are normal as are thyroid function tests. What is his
most likely diagnosis?
Acute Myocardial Infarct
Acute Myocarditis
Hypertrophic Cardiomyopathy
Dilated cardiomyopathy
Aortic Stenosis
Mitral Insufficiency
A 48-year-old man presents with dyspnea and dizziness. He notes several months
of progressive dyspnea, which has limited his ability to perform yard-work. In
addition, he notes pronounced dizziness and presyncope when moving from
squatting to standing position as he weeds his garden. His past medical history
includes hypertension. His medications include amlodipine. On examination, he
appears well. The jugular venous pressure is 8 cm of water. The first heart sound is
normal, and the second heart sound splits with inspiration. A fourth heart sound is
present. There is a grade 1 of 6 pansystolic murmur at the apex radiating to the
back. There is a grade 2 of 6 harsh, late-peaking diamond-shaped systolic murmur
at the base with radiation to the clavicles and carotid arteries. The murmur
increases in intensity with Valsalva and with squat-to-stand maneuvers. The lungs
are clear. Extremities are warm and well perfused. What is the most likely
diagnosis?
A. Dilated cardiomyopathy
B. Mitral stenosis
C. Aortic stenosis
D. Hypertrophic obstructive cardiomyopathy
E. Restrictive cardiomyopathy

A 48-year-old man presents with dyspnea and dizziness. He notes several months
of progressive dyspnea, which has limited his ability to perform yard-work. In
addition, he notes pronounced dizziness and presyncope when moving from
squatting to standing position as he weeds his garden. His past medical history
includes hypertension. His medications include amlodipine. On examination, he
appears well. The jugular venous pressure is 8 cm of water. The first heart sound is
normal, and the second heart sound splits with inspiration. A fourth heart sound is
present. There is a grade 1 of 6 pansystolic murmur at the apex radiating to the
back. There is a grade 2 of 6 harsh, late-peaking diamond-shaped systolic murmur
at the base with radiation to the clavicles and carotid arteries. The murmur
increases in intensity with Valsalva and with squat-to-stand maneuvers. The lungs
are clear. Extremities are warm and well perfused. What is the etiology of this
disease?
myocardial ischemia, and fibrosis.
A 78-year-old man is admitted to the intensive care unit with decompensated heart
failure. He has longstanding ischemic cardiomyopathy. ECG shows atrial fibrillation
and left bundle branch block. Chest radiograph shows cardiomegaly and bilateral
alveolar infiltrates with Kerley B lines. What is likely to be present on physical
examination? *
0/2

A fourth heart sound indicates left ventricular presystolic expansion and is common among
patients in whom active atrial contraction is important for ventricular filling. LBBB

A 67-year-old man presents to the emergency department with shortness of breath.

He is found to have an elevated serum BNP. What other physical findings will
confirm diagnosis of heart failure: *

3rd Heart sound S3 gallop

A 62-year-old Caucasian man with a history of diabetes and a myocardial infarction

2 years ago is hospitalized for acute decompensated heart failure. He is diuresed
with improvement in symptoms and is discharged on appropriate medications. He
is seen in clinic 4 months later with complaints of worsening symptoms over the
last month. Previously he became mildly short of breath after significant exertion,
but he now reports severe shortness of breath after walking only 50 m. He is
asymptomatic only at rest. His current medications include aspirin, captopril,
carvedilol, atorvastatin, omega-3 fatty acids, and pantoprazole. An ECG performed
in the office shows Q waves in leads V3 and V4, with a normal QRS duration. An
echocardiogram performed 1 week ago showed an ejection fraction of 35%. The
patient has been encouraged to quit smoking and drinking alcohol, and to eat a
low-sodium diet. What additional management and treatment is recommended at
this time? *
2/2

This patient has a hypertensive emergency, as evidenced by a very high blood pressure and
acute injury to target organs e.g., brain, kidneys. Hypertensive emergency is differentiated
from hypertensive urgency, which is not associated with acute target organ damage
A 64-year-old man with an ischemic cardiomyopathy, ejection fraction 35%, and
stage C heart failure is seen in the cardiology clinic for evaluation of his disease
status. The patient reports a regular exercise regimen of walking on the treadmill
several times weekly and occasional exacerbations of his leg edema that he
manages with an extra dose of furosemide. He has never been hospitalized for
heart failure. His current medical regimen includes lisinopril, aspirin, furosemide,
atorvastatin, digoxin, spironolactone, and metoprolol. He is interested in stopping
medications because of their expense. What could be etiology of his heart
failure? *
0/2

Several drugs have been shown to prevent disease progression in heart failure including ACE
inhibitors, angiotensin receptor blockers, beta blockers, and aldosterone antagonists. ACE
inhibition has been shown to improve symptoms and survival, reduce cardiac hypertrophy,
and reduce hospitalizations. Its use is often complicated by cough related to kinin
potentiation, which is an acceptable reason to switch to an angiotensin receptor (ARB)

1. What additional information do you need to collect from the patient

2. Define the required physical exam and why
3. What tests will you order
4. What is most likely diagnosis
The respondent's email (lodere@newvision.ge) was recorded on submission of this
form.
A 52-year-old man presents to the emergency department complaining of the worst
headache of his life that is unresolving. It began abruptly 3 days before presentation
and is worse with bending over. It rapidly increased in intensity over 30 minutes, but
he did not seek medical care at that time. Over the ensuing 72 hours, the headache
has persisted although lessened in intensity. He has not lost consciousness and has
no other neurologic symptoms. His vision is normal, but he does report that light is
painful to his eyes. His past medical history is notable for hypertension, but he takes
his medications irregularly. Upon arrival to the emergency department, his initial
blood pressure is 232/128 mmHg with a heart rate of 112 beats/min.
History, Lipid check,ECG, blood glucose, Tarchycardia possible diagnosis
A 52-year-old woman is admitted to the hospital with lethargy and marked symptoms
of volume overload. She has a past medical history of morbid obesity with a body
mass index of 52 kg/m2, severe obstructive sleep apnea, hypertension, and type 1
diabetes mellitus. She is in generally poor health and has been noncompliant with her
insulin as well as with continuous positive airway pressure (CPAP) as she reports
claustrophobia. She cannot recall when she last used CPAP therapy. On physical
examination, the patient is somnolent but arousable. Her vital signs are as follows:
blood pressure 168/92 mmHg, heart rate 92 bpm, respiratory rate 14 breaths/min,
afebrile, and SaO2 82% on room air. Her SaO2 increases to 92% on 6 L/min by nasal
cannula, but her mental status becomes more lethargic. She has distant heart and
lung sounds without crack- les. There is 4+ edema bilaterally to the thighs and onto
the abdominal wall. Chest x-ray shows low lung volumes. Initial arterial blood gas
values on 6 L/min nasal oxygen are pH 7.22, PaCO2 88 mmHg, and PaO2 72 mmHg. *
Medication history, Oxygen, loop diurectic (furosemide) (Nitropusside), pulmonary
hypertention or hepatic disease

Describe the ECG *

ST elevations at lead II and Lead III regular QRS and Displaced Q waves
HYPERTENSION

74. Stage 1 Hypertension is?

a. 140/90 mm Hg
b. 190/80 mm Hg
c. 110/70 mm Hg
d. 170/100 mm Hg

All of the following are the secondary causes of hypertension EXCEPT?

a. Apnea (obstructive sleep apnea), Acromegaly, Accuracy (incorrect measurement)
b. Birth control, Bad kidney
c. Coarctation of the aorta
d. Cushing’s syndrome,
e. Coronary heart disease
f. Drugs (alcohol, nasal decongestants, estrogens)
g. Endocrine disorders, Erythropoietin
h. Fibromuscular dysplasia of renal arteries

Which test is the most important for 23 yo pregnant lady who came for evaluation because
of High blood pressure? *
Complete blood count
Urine analysis
Glucose
Lipids

A 46-year-old white female presents to your office with concerns about her diagnosis of
hypertension 1 month previously. She asks you about her likelihood of developing
complications of hypertension, including renal failure and stroke. She denies any past
medical history other than hypertension and has no symptoms that suggest secondary
causes. She currently is taking hydrochlorothiazide 25 mg/d. She smokes half a pack of
cigarettes daily and drinks alcohol no more than once per week. Her family history is
significant for hypertension in both parents. Her mother died of a cerebrovascular accident.
Her father is alive but has coronary artery disease and is on hemodialysis. Her blood
pressure is 138/90 mmHg. Body mass index is 23. She has no retinal exudates or other
signs of hypertensive retinopathy. Her point of maximal cardiac impulse is not displaced but
is sustained. Her rate and rhythm are regular and without gallops. She has good peripheral
pulses. An electrocardiogram reveals an axis of –30 degrees with borderline voltage criteria
for left ventricular hypertrophy. Creatinine is 1.0 mg/dL. Which of the following items in her
history and physical examination is a risk factor for a poor prognosis in a patient with
hypertension?
Family history of renal failure and cerebrovascular disease
Maintaining blood pressure in normal range after the initiation of therapy
Ongoing tobacco use
Ongoing use of alcohol
A 47-year-old man presents for a general medical examination. He is asymptomatic
and runs 1 mile 3 times a week. His elder brother recently had coronary artery
bypass grafting at the age of 49 years. The patient is a smoker. The physical
examination is normal, and the blood pressure is 124/80 mm Hg. His body mass
index is 26. In addition to recommendations regarding smoking cessation, which of
the following set of investigations is most appropriate?
Lipid profile and CT for a coronary calcium score
Lipid profile and fasting plasma glucose and plasma homo- cysteine tests
Exercise sestamibi stress test and C-reactive protein test
Lipid profile and fasting plasma glucose and serum lipopro- tein (a) tests
High-sensitivity C-reactive protein test and lipid profile

64yr smoker man in planning surgery for cholelithiasis. His BMI- 36, BP is 160/100
mm Hg, Past medical history significant with significant peripheral arterial disease.
What is his first line treatment?
BB
ACE
CCB
Diuretic

A 68-year-old man presents with a 4-day history of an intense headache, chest pain,
blurry vision, and tea-colored urine. He says he ran out of his blood pressure
medications and could not afford to buy more pills. His exam reveals blood
pressure of 210/115, a pulse of 111, and respiration of 20. The eye exam reveals
flame hemorrhage and papilledema. What is the next step in his management?
1.Give oral medications to lower blood pressure
2.Admit patient and administer intravenous blood pressure lowering medications
3.Observe patient in emergency department and discharge when blood pressure is stable
4.Order CT scan of head and, if normal, the patient can be discharged
Option 5
Feedback
Answer B. Malignant hypertension must be promptly treated to avoid mortality. In most cases,
patients with symptomatic malignant hypertension need to be admitted. The goal is to lower the
blood pressure by no more than 20% in the first hour of treatment. If the patient remains stable, the
blood pressure can be lowered to 160/100 in the next 4-6 hours. Rapid reduction of blood pressure
can result in poor perfusion of cerebral, renal, and cardiac organs.

Which of the following statements regarding blood pressure measurements is

true? *
A. Systolic pressure increases and diastolic pressure decreases when measured in more
distal arteries.
B. Systolic leg blood pressures are usually as much as 20 mmHg lower than arm blood
pressures.
C. The concept of “white coat hypertension” (blood pressures measured in office or hospital
settings significantly higher than in nonclinical settings) has been shown to be a myth.
D. The difference in blood pressure measured in both arms should be less than 20mmHg.
E. Using a blood pressure cuff that is too small will result in a marked underestimation of the
true blood pressure.

H19. II-7. A 63-year-old man with a history of hypertension and hyperlipidemia

comes to the emergency department complaining of 1 hour of chest pain that
came on at rest. The pain is substernal and radiates to both shoulders. He
describes the pain as “diffuse pressure, not sharp” and says he feels nauseated
and sweaty. He also feels like the pain improves when he curls up on his left side.
His physical examination is notable only for some mild diaphoresis and a heart rate
of 105 bpm with blood pressure of 140/ 88 mmHg. All of the following aspects of
his history increase the likelihood of acute coronary syndrome EXCEPT: *
A. Associated with feeling sweaty
B. Associated with nausea
C. Improved when lying on left side
D. Pressure, not sharp pain
E. Radiation to both shoulders

A 68-year-old man presents with a 4-day history of an intense headache, chest pain,
blurry vision, and tea-colored urine. He says he ran out of his blood pressure
medications and could not afford to buy more pills. His exam reveals blood pressure
of 210/115, a pulse of 111, and respiration of 20. The eye exam reveals flame
hemorrhage and papilledema. What is the next step in his management?
1.Give oral medications to lower blood pressure
2.Admit patient and administer intravenous blood pressure lowering medications
3.Observe patient in emergency department and discharge when blood pressure is stable
4.Order CT scan of head and, if normal, the patient can be discharged
Option 5

A 58-year-old African American female with a history of severe asthma presents with a
headache that started 2 days ago. She has no significant past medical history and is on no
medications. Vital signs show a blood pressure of 240/130, pulse 105 bpm, and respirations
18/minute. Extraocular muscles are intact. The pupils are equal round and reactive to light.
There is bilateral papilledema. the cardiovascular exam shows a regular rate and rhythm
without murmurs or extra heart sounds. Lungs have scattered expiratory wheezes. Which of
the following should be the initial treatment?
• 1.IV nitroprusside
• 2.IV esmolol
• 3.IV furosemide
• 4.Sublingual nitrates
Option 5
A 68-year-old male patient is admitted to the emergency department with a severe
headache and blurred vision. On exam, he is awake, Sat 98% on 6 L of O2 by mask,
BP 190/130 mmHg, HR 106 beats per min, and RR 20 cycles per min. What is the
initial management goal for this patient?
• 1.A decrease in BP of 20 to 30 percent during the first hour
• 2.A decrease in BP of 30 percent during the first 24 hours
• 3.A decrease in BP of approximately <180/<120 mmHg in the first-hour and <160/<110
mmHg for the next 24 hours
• 4.Prevention of complications (eg: neurologic, cardiac, vascular, renal)
Option 5

1, BRADYARRYTHMIAS

Most common causes of bradycardia are all EXCEPT *

a. SA node dysfunction
b. II degree AV block
c. III degree AV block
d. Left bundle branch block

The most common causes of extrinsic SA node dysfunction are all EXCEPT *
a. drugs
b. autonomic nervous system influences that suppress automaticity and/or compromise
conduction
c. hypothyroidism
d. sleep apnea，
e. diabetes

All of the following are reversible causes of sinoatrial node dysfunction EXCEPT:
A. Hypothermia
B. Hypothyroidism
C. Increased intracranial pressure
D. Radiation therapy

SA node dysfunction manifest as an ECG anomaly such as all of the following

EXCEPT one *
Sinus tachycardia
sinus bradycardia
sinus arrest
exit block
Which of the following options describes the primary finding in the ECG shown in
Figure? *

Left ventricular hypertrophy

Normal ECG
Peaked T waves, possibly hyperkalemia
Sinus bradycardia
ST elevation in the anterior precordial leads; suspect anterior myocardial ischemia
A 48-year-old woman visits you in primary care clinic for initial evaluation after
moving across the country. You have no past medical records, although she insists,
they were mailed a week prior. She states that she has had “some heart troubles,”
but she is not clear on the details. Also, she is on pills for “cholesterol and blood
pressure.” The initial ECG is shown in Figure V-17. Which of the following
statements regarding this ECG is true? *

A. It is likely she has suffered a prior myocardial infarction.

B. She is in normal sinus rhythm.
C. The presence of a left bundle branch block on this ECG indicates dyssynchronous
mechanical contraction. The presence of premature ventricular contractions and tachycardia
is concerning for electrolyte imbalance.
D. The presence of anterior T-wave inversions is concerning in this ECG for acute myocardial
ischemia.
Feedback
E. H19. V-17. The answer is A. (Chap. 269e) This ECG demonstrates sinus rhythm with premature
atrial contractions (not normal sinus rhythm; note the fifth and ninth beats occurring early and
preceded by an abnormal P wave indicating atrial origin). Also, the QRS is wide and in a right bundle
branch block (RBBB) pattern as indicated by the large terminal R wave in the anterior precordial
leads and broad-based terminal S wave in the lateral limb leads (I and aVL). In the presence of an
RBBB, T waves in the anterior lead are often inverted and do not indicate acute ischemia. No
premature ventricular contractions are present in this ECG. However, Q waves are present in the
anterior precordial leads (V1–V3) so that the usual RBBB rsR’ is simply a qR pattern, indicating a
prior anterior-septal myocardial infarction
A 19-year-old long-distance runner, who finished in the top 10 of the local marathons
last year, presents for cardiac evaluation after his primary care physician ordered a
Holter monitor for screening purposes. On his Holter report, several episodes of
second-degree, Mobitz I (Wenckebach) AV block were noted, all occurring during
sleep. The patient reports no symptoms but thinks he may have a grandfather who
had a pacemaker implanted at an advanced age. What is the most appropriate next
step? *
Exercise treadmill stress ECG
Invasive electrophysiology study
Reassurance
Refer for pacemaker implantation
Serologic testing including thyroid-stimulating hormone levels

A 47-year-old woman with a history of tobacco abuse and ulcerative colitis is

evaluated for intermittent palpitations. She reports that for the last 6 months, every
2–4 days she notes a sensation of her heart “flip-flopping” in her chest for
approximately 5 minutes. She has not noted any precipitating factors and has not
felt light headed or had chest pains with these episodes. Her physical examination
is normal. A resting ECG reveals sinus rhythm and no abnormalities. Aside from
checking serum electrolytes, which of the following is the most appropriate testing?
Abdominal computed tomography (CT) with oral and intravenous (IV) contrast
Event monitor
Holter monitor
Reassurance with no further testing needed
Referral for electrophysiology study
Feedback
H19. V-32 and V-33. The answers are B and D, respectively. (Chap. 276) The patient has persistent,
non–life-threatening palpitations that distress her enough to seek medical attention. A continuous
Holter monitor for 24 hours is appropriate for patients in whom the symptoms happen several times
over 24 hours, whereas an event monitor is triggered by the patient when symptoms occur and thus
can be worn for longer period of time, which is appropriate in this patient. There is no indication of
gastrointestinal triggers, so abdominal computed tomography (CT) would not be helpful. The atrial
premature contractions are uncomplicated, do not require additional diagnostic evaluation at this
time, and pose no additional health risk. Electrophysiology (EP) referral is indicated for patients with
life-threatening or severe symptoms such as syncope.

A 68-year-old man with ischemic cardiomyopathy has been treated with digoxin 250
μg daily for the past year. He has chronic kidney disease with a stable baseline
creatinine of 2.1 mg/dL. He is initiated on an oral amiodarone load for new-onset
atrial fibrillation with rapid ventricular response. Over 1 week, he develops increasing
nausea, vomiting, and fatigue. On presentation to the emergency department, he is
lethargic and difficult to arouse with a heart rate of 45 beats/min and a blood
pressure of 88/50 mmHg. His laboratory values demonstrate a potassium of 5.2
meq/L, creatinine of 3.0 mg/dL, and a digoxin level of 13 ng/mL. His ECG shows
complete heart block. What is the most appropriate treatment for this patient? *
A. Digitalis-specific antibody (Fab) fragments alone
B. Digitalis-specific antibody fragments plus hemodialysis
C. Digitalis-specific antibody fragments plus hemoperfusion
D. Plasmapheresis alone
E. Volume resuscitation and observation

A 58-year-old man is admitted to the hospital after experiencing 2 days of severe

dyspnea. Three weeks ago he had an ST elevation myocardial infarction that was
treated with thrombolytics. He reports excellent adherence to his medical regimen
that includes atorvastatin, lisinopril, metoprolol, and aspirin. On examination, his
heart rate is 44 beats/min, his blood pressure is 100/45 mmHg, his lungs have
bilateral crackles, and his cardiac examination is notable for elevated neck veins,
bradycardia, and 2+ bilateral leg edema. There are no gallops or new murmurs.
ECG shows sinus bradycardia and evidence of the recent infarct, but no acute
changes. Which of the following is the most appropriate next management step? *
A. Begin dopamine
B. Hold metoprolol
C. Measure TSH
D. Refer for pacemaker placement
E. Refer for urgent coronary angiography
Feedback
A. H18. V-23. The answer is D. (Chap. 232) When there is evidence of sinoatrial node dysfunction,
as manifest in this patient with sinus bradycardia, the first approach is to search for reversible
causes. In this case, excessive beta blockade is the most likely explanation for his brady- cardia and
symptoms. Stopping the metoprolol at least temporarily is in order. There are no urgent indications
for temporary or permanent pacemaker placement, as he does not have a high-level AV block,
syncope, or shock. His heart failure should reverse when his heart rate increases. Although
pharmacologic chronotropic stimulation can increase heart rate temporarily, his moderate
symptoms suggest that simply waiting for the beta blocker to be metabolized will be adequate.
There is no evidence of new infarction or post-infarct angina; thus the patient does not require
urgent revascularization. Once the patient is stabilized, the risks and benefits of restarting the beta
blocker at a lower dosage may be considered.

Characteristic Clinical findings in myocarditis are all EXCEPT:

abnormal ECG changes

arterial hypertension
congestive heart failure
irregular heartbeat
cardiomegaly

Which of the following statement is false: Peripartum cardiomyopathy*

Etiology is narrowing of coronary artery

can occur during the last trimester or within the first 6 months postpartum
Twin pregnancy is the risk factor of peripartum cardiomypathy
Is related to advanced maternal age and malnutrition

29yr female complains on nonintensive dull chest pain and dyspnoea. She had viral infection
4 months ago, HR - 98’, regular, BP – 100/70 mm Hg, t- 37.2, and grade II systolic murmur
over apex, dull heart sounds. What tests will you order to evaluate this patient: *

CRP
Chest X-Ray
All of above
CBC
ECG

29 yr female complains on nonintensive dull chest pain and dyspnoea. She had viral
infection 4 months ago, HR - 98’, regular, BP – 100/70 mm Hg, t- 37.2, and grade II systolic
murmur over apex, dull heart sounds. Define most likely diagnosis *

Rheumatic fever
Acute myocarditis
Pulmonary stenosis
Mitral stenosis
Aortic regurgitation

An otherwise healthy 30-year-old man presents with a several-day history of progressive,

severe, retrosternal chest pain that is sharp and pleuritic in nature. The pain is worse on
lying down and improved with sitting forward. There is radiation to the neck and shoulders
and specifically to the trapezius muscle ridges. The pain is constant and unrelated to
exertion. On physical examination, a pericardial friction rub is heard at end-expiration with
the patient leaning forward. What is your diagnosis

A. Pleuritis
B. Dry pericarditis
C. Pericardial effusion
D. Pneumonia

An otherwise healthy 30-year-old man presents with a several-day history of

progressive, severe, retrosternal chest pain that is sharp and pleuritic in nature. The
pain is worse on lying down and improved with sitting forward. There is radiation to
the neck and shoulders and specifically to the trapezius muscle ridges. The pain is
constant and unrelated to exertion. On physical examination, a pericardial friction
rub is heard at end-expiration with the patient leaning forward. Which test is most
useful for to diagnose this patient

Complete blood count

Chest CT
Echocardiography
Chest X-Ray

Chest x-ray shows pericardial calcifications. Which of the following set of physical
findings is most likely to be present in this patient?

Pansystolic murmur at left lower sternal border

Water hammer pulse and pistol shot on femorals
Tapping apex beat and malar flush
Pericardial Knock
Pulsus paradoxus and hypotension
49. A 46-year-old gentleman presents with dyspnea and lower-extremity edema. For
the past 4 weeks, he has noted progressive symptoms. The past medical history
includes hypertension. Medications include chlorthalidone. He drinks 2 glasses of
wine per week. On examination, the blood pressure is 100/50 mm Hg, with heart rate
of 80 beats per minute. The jugular venous pressure is 10 cm of water. The first heart
sound is normal, and the second heart sound splits with inspiration. A third heart
sound is present, as is a 2 out of 6 pansystolic murmur at the apex with radiation to
the axilla. The extremities are warm, and there is pitting edema to the knee. An
echocardiogram reveals a dilated left ventricle, moderate mitral regurgitation, and
global left ventricular dysfunction with an LVEF of 35%. Serum electrolytes are
normal as are thyroid function tests. What is the next step for to define the
diagnosis?

A. Urine and serum metanephrines

B. Coronary angiography
C. Transesophageal echocardiogram
D. Cardiac MRI
E. Serum protein electrophoresis
Feedback
This patient presents with new-onset dilated cardiomyopathy. Although young, his hypertension is a
risk factor for coronary disease, which should be excluded as a cause of heart failure, as
revascularization could possibly improve myocardial performance. Transesophageal
echocardiogram could be considered if a shunt lesion not visible on transthoracic echo were
considered, but this is unlikely to be responsible for this patient’s left heart failure. Cardiac mRI can
be considered if infiltrative diseases were suspected, but coronary artery disease should be
excluded first. Similarly, there are no symptoms to suggest pheochromocytoma or amyloid
cardiomyopathy.
A 48-year-old man presents with dyspnea and dizziness. He notes several months of
progressive dyspnea, which has limited his ability to perform yard-work. In addition, he notes
pronounced dizziness and presyncope when moving from squatting to standing position as
he weeds his garden. His past medical history includes hypertension. His medications
include amlodipine. On examination, he appears well. The jugular venous pressure is 8 cm
of water. The first heart sound is normal, and the second heart sound splits with inspiration.
A fourth heart sound is present. There is a grade 1 of 6 pansystolic murmur at the apex
radiating to the back. There is a grade 2 of 6 harsh, late-peaking diamond-shaped systolic
murmur at the base with radiation to the clavicles and carotid arteries. The murmur
increases in intensity with Valsalva and with squat-to-stand maneuvers. The lungs are clear.
Extremities are warm and well perfused. What is the most likely diagnosis?
1/1
Aortic stenosis
Dilated cardiomyopathy
Atrial septal defect
Mitral stenosis
Hypertrophic obstructive cardiomyopathy

Feedback
31. ANSWER: D. Hypertrophic obstructive cardiomyopathy. This patient presents with dizziness
evoked by squatting to standing and dyspnea. The examination reveals a harsh systolic murmur
that becomes louder with maneuvers that decrease preload—a cardinal physical examination
finding present in hypertrophic obstructive cardiomyopathy. In this condition, there is left ventricular
outflow tract obstruction caused by a hypertrophied interventricular septum. Decreased preload
decreases left ventricular cavity size and worsens obstruction with attendant increase in the
loudness of the murmur. The obstruction can cause a “Venturi effect,” leading to systolic anterior
motion of the mitral valve and mitral regurgitation, as is also appreciated in this patient. An
echocardiogram should be ordered to confirm the diagnosis. Dilated cardiomyopathy can present
with a third heart sound and murmurs of mitral and tricuspid regurgitation. Mitral stenosis presents
with a diastolic rumbling murmur at the apex. The harsh systolic murmur of aortic stenosis would
be expected to decrease with Valsalva. Atrial septal defect presents with fixed splitting of the
second heart sound and murmurs of tricuspid regurgitation and increased pulmonary artery flow.
52 years old man complains of dull pain around the heart area for three weeks after
acute respiratory infections. The ECG shows PQ segment adepression, ST-segment
depression 1.5 mm and a negative T wave. ESR - 45 mm/hr. Most likely diagnosis
is: *

Myocarditis
Pericarditis
NDCs
CHD
Alcoholic cardiomyopathy
2. Coronary Artery Disease (CAD)

Acute coronary syndrome is?

unstable angina, stable angina and ST elevation infarction
stable angina, non–ST elevation MI, and ST elevation infarction
unstable angina, stable angina, non–ST elevation MI
unstable angina, non–ST elevation MI, and ST elevation infarction

4. In a patient with chest pain which of these features is most suggestive of a myocardial
infarction?
Pain is sharp like a knife
Sweating and vomiting
Pain has lasted for over a week
Very severe pain

32. A 70-year-old woman presents with a 2-hour history of central chest pain radiating to her
left arm. She is nauseated and diaphoretic. Her past medical history is remarkable for
hypertension and a stroke 6 months ago from which she has made a good neurologic
recovery. On physical examination, her pulse is 100 beats per minute, blood pressure is
122/78 mm Hg, jugular venous pressure is increased, and heart sounds are normal. There are
no murmurs, and the lungs are clear to auscultation. Her medications include aspirin 325 mg
daily and lisinopril 20 mg daily. The patient’s electrocardiogram is shown below. In addition
to the administration of oxygen, analgesic, and intravenous beta-adrenergic blockers, what is
the most appropriate next step in the management of this patient?

d. Administer clopidogrel 300 mg.

e. Perform emergency coronary angiography.

c. Administer a nitroglycerin bolus.

a. Administer indomethacin.
26. A 57 yo smoker man with a history of stable angina was admitted to hospital with a 2 hour
history of increasing chest pain associated with shortness of breath, diaphoresis and radiation
into the left arm and neck. He is taking Amlodipine, Lisinopril and aspirin by the moment. An
old ECG from 3 months ago was normal. His ECG shows: Define his further evaluation and
treatment

There are differential diagnoses, the most likely etiology given the clinical picture and risk
factors is one of cardiac ischemia. Risk factors include gender, smoking status and age
making the diagnosis of acute coronary syndrome
 A 70-year-old woman presents with a 2-hour history of central chest pain radiating to her left
arm. She is nauseated and diaphoretic. Her past medical history is remarkable for
hypertension and a stroke 6 months ago from which she has made a good neurologic
recovery. On physical examination, her pulse is 100 beats per minute, blood pressure is
122/78 mm Hg, jugular venous pressure is increased, and heart sounds are normal. There are
no murmurs, and the lungs are clear to auscultation. what you see on ECG

non St elevation infarct lateral wall

non-St elevation infarct lateral wall
St elevation infarct anterior wall
non-St elevation infarct anterior wall
St elevation infarct lateral wall
non-St elevation infarct inferior wall
St elevation infarct inferior wall

Long-term management of patient with stable CAD include:

A) Lipid lowering agents

B) Beta-blockers

C) ACE

D) Antithrombotic

E) All of above

62 years old smoker man comes for general check-up, his blood pressure was 160/90 mm Hg. How
many modifiable risk-factors does he have

4
31. A 47-year-old man presents for a general medical examination. He is asymptomatic and
runs 1 mile 3 times a week. His elder brother recently had coronary artery bypass grafting at
the age of 49 years. The patient is a smoker. The physical examination is normal, and the
blood pressure is 124/80 mm Hg. His body mass index is 26. In addition to recommendations
regarding smoking cessation, which of the following set of investigations is most appropriate?

d. Exercise sestamibi stress test and C-reactive protein test

c. High-sensitivity C-reactive protein test and lipid profile

e. Lipid profile and fasting plasma glucose and plasma homocysteine tests

b. Lipid profile and fasting plasma glucose and serum lipoprotein (a) tests

a. Lipid profile and CT for a coronary calcium score

32. A 70-year-old woman presents with a 2-hour history of central chest pain radiating to her
left arm. She is nauseated and diaphoretic. Her past medical history is remarkable for
hypertension and a stroke 6 months ago from which she has made a good neurologic
recovery. On physical examination, her pulse is 100 beats per minute, blood pressure is
122/78 mm Hg, jugular venous pressure is increased, and heart sounds are normal. There are
no murmurs, and the lungs are clear to auscultation. what you see on ECG

non-St elevation infarct inferior wall

St elevation infarct lateral wall

St elevation infarct inferior wall

non-St elevation infarct anterior wall

non-St elevation infarct lateral wall

St elevation infarct anterior wall

non St elevation infarct lateral wall

All of the following factors increase the risk of developing coronary heart disease, EXCEPT:
increased the level of high-density lipoproteins
diabetes
arterial hypertension
family history smoking

How long does Troponin T levels (Tr¬T) remain elevated

a. 2 hours

b. >24 hours

c. 30 min

d. 12 hours

H18. V-55. Mitral stenosis is frequently complicated by pulmonary hypertension.

Which of the following is a cause of pulmonary hypertension in mitral stenosis? *
Interstitial edema in the walls of small pulmonary vessels
Passive transmission of elevated left atrial pressure
Obliterative changes in the pulmonary vascular bed
Pulmonary arteriolar constriction
All of the above

A 12-year-old boy presents with a high fever. History reveals the child was seen two
weeks earlier for a strep throat infection and given antibiotics for Group A
streptococcus. However, the guardian never filled the prescription. A Carey-Combs
murmur is heard as a low-pitched mid-diastolic rumble at the apex. An opening
snap is heart after S2. Which of the following is most likely?
A. Aortic insufficiency (AI)
B. Pulmonic insufficiency (PI)
C. Tricuspid stenosis (TS)
D. Mitral stenosis (MS)
E. Hypertrophic cardiomyopathy (HCM)

20. An 18-year-old man presents for a physical examination prior to joining his
college basketball team. A II/ VI crescendo-decrescendo murmur without radiation
is heard at the left lower sternal border on cardiac examination. The murmur
increases with Valsalva maneuvers and there is an extra heart sound preceding S1.
What is the most likely underlying etiology?
A. Congenital aortic stenosis
B. marfan’s syndrome
C. Hypertrophic cardiomyopathy
D. Early-onset hypertension
E. Rheumatic heart disease
A high-pitched, decrescendo, blowing diastolic murmur that is best heard over the
right II intercostal area of the precordium indicates *
Tricuspid stenosis
Aortic regurgitation
Pulmonary stenosis
Ventricular septal defect

34 yo man presents with exertional chest pain II functional class Canadian

Cardiovascular Society. Family history significant with sudden death. His physical
exam revealed gr. IV systolic murmur in the II right intercostal space which
increases after squatting, T/A – 130/90 mm Hg. His ECG shows: *
What disease is the most likely he have
Hypertrophic cardiomyopathy
Aortic stenosis
Arterial hypertension
Aortic Regurgitation

Normal Endothelial function is all EXCEPT?

A) Optimization balance between vasodilation and vasoconstriction
B) Antithrombotic，profibrinolytic
C) Anti-inflammatory
D) Antiproliferative
E) Antioxidant
F) Permselectivity
G) Proproloferative

1. A 38-year-old file clerk presents to your office for evaluation of fatigue. She has
a 20-pack-a- year history of smoking and had rheumatic heart fever in childhood.
On auscultation of her heart, the S2 sound is widely split; that is, it persists
throughout the respiratory cycle. What is the most likely cause of the widely split
S2?
Physiologic cause
Pulmonic stenosis
Atrial septal defect
Left bundle branch block
Feedback
The correct answer is (B) Pulmonic stenosis. Pulmonic stenosis means that the pulmonic valve has
delayed closure. This results in a widely split S2, which means that the usual splitting is increased
and persists throughout the respiratory cycle (including expiration).Physiologic splitting of the S2
sound means that it varies with inspiration and expiration; it is usually accentuated with inspiration
and disappears with expiration. It is best heard in the 2nd or 3rd left interspace. Atrial septal defect
means that there is a fixed splitting of the S2 sound, which does not vary with inspiration and
expiration—it is always of the same intensity. The fixed split of S2 can also occur with right
ventricular failure. In a left bundle branch block, the split is paradoxical or reversed. This means that
the splitting of the S2 sound occurs with expiration and disappears with inspiration—this is the
exact opposite of what you would expect physiologically. This is caused by a delayed closure of the
aortic valve, the most common cause of which is a left bundle branch block.
Which from the following statements is not true?
Cardiac output is the product of heart rate and stroke volume
Stroke volume depends in turn on preload, myocardial contractility, and afterload.
Contractility of heart muscle increases when stimulated by action of the sympathetic nervous
system
Preload refers to the degree of vascular resistance to ventricular contraction.

Under normal physiologic circumstances, the:

Aortic valve closes before the pulmonary valve.
Pulmonary valve closes before the aortic valve.
Mitral valve opens before the tricuspid valve.
Mitral valve and aortic valve are both open during isovolumic relaxation.
Mitral valve and aortic valve are both open during isovolumic contraction

In which phase of cardiac cycle does atria contract?

a. Ventricular Systole
b. Ventricular Diastole

What is the cardiac output?

the amount of blood received by ventricle at each beat
the amount of blood pumped out at each beat
the amount of blood received by ventricle in a minute
the amount of blood pumped out in a minute

Which from the following statements is not true?

Cardiac output is the product of heart rate and stroke volume
Stroke volume depends in turn on preload, myocardial contractility, and afterload.
Contractility of heart muscle increases when stimulated by action of the sympathetic nervous
system
Preload refers to the degree of vascular resistance to ventricular contraction.

What is afterload
pressure against which the ventricles contract to eject blood out of the heart into pulmonary
artery and aorta
stretch of ventricles before contraction

Pathologic increase in afterload is called

volume overload
pressure overload
all of them

What is producing S2
Opening aortic and pulmonary valves
Closure Aortic and pulmonary valves
Opening mitral and tricuspid valves
Opening aortic and tricuspid valves
Splitting of the semilunar valves (aortic valve and pulmonary valve):
Occurs normally in expiration
In left bundle branch block, occurs during inspiration
In right bundle branch block, occurs during inspiration and expiration
Occurs only in severe aortic stenosis
Occurs in patients with mitral valve prolapsed

Elevation of jugular venous pressure indicates

Increased pressure in aorta
Increased pressure in left atrium
Increased pressure in left ventricle
Increased pressure in right atrium

Displaced apical beat lateral to the midclavicular line represents enlargement of:
A. left ventricle
B. right ventricle
C. left atrium
D. right atrium

What is the Pulse deficit?

The difference between the rate of a radial pulse on inspiration and expiration
The difference between the rate of a radial and brachial pulse
The difference between the rate of a systolic and diastolic pressure
The difference between the rate of a radial and an apical pulse

What is pulsus paradoxus

Difference between systolic and diastolic heart rate
Difference between systolic and dastolic pressure
Difference of systolic pressures on inspiration and expiration

Which of the following characteristics makes a heart murmur more likely to be

caused by tricuspid regurgitation than mitral regurgitation? *
Inaudible A2 at the apex
Onset signaled by a midsystolic click
Prominent c-v wave in jugular pulse
Wide splitting of S2
Decreased intensity with amyl nitrate

Systolic crescendo–decrescendo ejection murmur heard best in the at II intercostal

space on the left sternal line area of the precordium and increases with inspiration
indicates *
Pulmonary regurgitation
Tricuspid stenosis
Aortic regurgitation
Pulmonary stenosis
Grade 1 murmur is?
Is heard on effort
Moderately loud
Loud, with palpable thrill
Very faint, heard only after listener has “tuned in”; may not be heard in all positions

Carotid bruits are caused by?

By diabetes
By rise of blood pressure
Kidney failure
Turbulent flow due to atherosclerosis of the common, internal or external carotid artery

What are the changes in peripheral pulses seen in pulmonic regurgitation?

Bounding pulse
No abnormality
Asymmetry of pulse
+1 pulse
Decreased pulse

Central cyanosis is (mark correct DESCRIPTION)

A. A blue/purple discolouration of the feet
B. A blue/purple discolouration of the tongue, lips and mucous membranes
C. A blue/purple discolouration of fingers and lips

4. Cardiology

Normal Endothelial function is all EXCEPT?

A) Optimization balance between vasodilation and vasoconstriction
B) Antithrombotic，profibrinolytic
C) Anti-inflammatory
D) Antiproliferative
E) Antioxidant
F) Permselectivity
G) Proproloferative

1. A 38-year-old file clerk presents to your office for evaluation of fatigue. She has
a 20-pack-a- year history of smoking and had rheumatic heart fever in childhood.
On auscultation of her heart, the S2 sound is widely split; that is, it persists
throughout the respiratory cycle. What is the most likely cause of the widely split
S2?
Physiologic cause
Pulmonic stenosis
Atrial septal defect
Left bundle branch block
Feedback
The correct answer is (B) Pulmonic stenosis. Pulmonic stenosis means that the pulmonic valve has
delayed closure. This results in a widely split S2, which means that the usual splitting is increased
and persists throughout the respiratory cycle (including expiration).Physiologic splitting of the S2
sound means that it varies with inspiration and expiration; it is usually accentuated with inspiration
and disappears with expiration. It is best heard in the 2nd or 3rd left interspace. Atrial septal defect
means that there is a fixed splitting of the S2 sound, which does not vary with inspiration and
expiration—it is always of the same intensity. The fixed split of S2 can also occur with right
ventricular failure. In a left bundle branch block, the split is paradoxical or reversed. This means that
the splitting of the S2 sound occurs with expiration and disappears with inspiration—this is the
exact opposite of what you would expect physiologically. This is caused by a delayed closure of the
aortic valve, the most common cause of which is a left bundle branch block.

Which from the following statements is not true?

Cardiac output is the product of heart rate and stroke volume
Stroke volume depends in turn on preload, myocardial contractility, and afterload.
Contractility of heart muscle increases when stimulated by action of the sympathetic nervous
system
Preload refers to the degree of vascular resistance to ventricular contraction.

Under normal physiologic circumstances, the?

Aortic valve closes before the pulmonary valve.
Pulmonary valve closes before the aortic valve.
Mitral valve opens before the tricuspid valve.
Mitral valve and aortic valve are both open during isovolumic relaxation.
Mitral valve and aortic valve are both open during isovolumic contraction

In which phase of cardiac cycle does atria contract?

a. Ventricular Systole
b. Ventricular Diastole

What is the cardiac output?

the amount of blood received by ventricle at each beat
the amount of blood pumped out at each beat
the amount of blood received by ventricle in a minute
the amount of blood pumped out in a minute

Which from the following statements is not true?

Cardiac output is the product of heart rate and stroke volume
Stroke volume depends in turn on preload, myocardial contractility, and afterload.
Contractility of heart muscle increases when stimulated by action of the sympathetic nervous
system
Preload refers to the degree of vascular resistance to ventricular contraction.

What is afterload?
pressure against which the ventricles contract to eject blood out of the heart into pulmonary
artery and aorta
stretch of ventricles before contraction

Pathologic increase in afterload is called?

volume overload
pressure overload
all of them

What is producing S2?

Opening aortic and pulmonary valves
Closure Aortic and pulmonary valves
Opening mitral and tricuspid valves
Opening aortic and tricuspid valves

Splitting of the semilunar valves (aortic valve and pulmonary valve)?

Occurs normally in expiration
In left bundle branch block, occurs during inspiration
In right bundle branch block, occurs during inspiration and expiration
Occurs only in severe aortic stenosis
Occurs in patients with mitral valve prolapsed

Elevation of jugular venous pressure indicates

Increased pressure in aorta
Increased pressure in left atrium
Increased pressure in left ventricle
Increased pressure in right atrium

Displaced apical beat lateral to the midclavicular line represents enlargement of:?
A. left ventricle
B. right ventricle
C. left atrium
D. right atrium

What is the Pulse deficit?

The difference between the rate of a radial pulse on inspiration and expiration
The difference between the rate of a radial and brachial pulse
The difference between the rate of a systolic and diastolic pressure
The difference between the rate of a radial and an apical pulse

What is pulsus paradoxus?

Difference between systolic and diastolic heart rate
Difference between systolic and dastolic pressure
Difference of systolic pressures on inspiration and expiration

Which of the following characteristics makes a heart murmur more likely to be

caused by tricuspid regurgitation than mitral regurgitation? *
Inaudible A2 at the apex
Onset signaled by a midsystolic click
Prominent c-v wave in jugular pulse
Wide splitting of S2
Decreased intensity with amyl nitrate

Systolic crescendo–decrescendo ejection murmur heard best in the at II intercostal

space on the left sternal line area of the precordium and increases with inspiration
indicates ?*
Pulmonary regurgitation
Tricuspid stenosis
Aortic regurgitation
Pulmonary stenosis

Grade 1 murmur is?

Is heard on effort
Moderately loud
Loud, with palpable thrill
Very faint, heard only after listener has “tuned in”; may not be heard in all positions

Carotid bruit are caused by?*

By diabetes
By rise of blood pressure
Kidney failure
Turbulent flow due to atherosclerosis of the common, internal or external carotid artery

What are the changes in peripheral pulses seen in pulmonic regurgitation?

Bounding pulse
No abnormality
Asymmetry of pulse
+1 pulse
Decreased pulse

Central cyanosis is (mark correct DESCRIPTION)?

A. A blue/purple discolouration of the feet
B. A blue/purple discolouration of the tongue, lips and mucous membranes
C. A blue/purple discolouration of fingers and lips