1. What part of the intrinsic conduction system starts the heart beat?

A. the atrioventricular node

B.

the Bundle of His

C.

the Perkinje fibers

D.

the sinoatrial node

Answer: D

A 56 year-old male was referred to you with progressive easy fatigueability,

moderate exertional dyspnea and two pillow orthopnea of a 1 year duration.
Relevant physical findings include BP 104/64 mm Hg, pulse 104/min and
unlabored repirations at 20/min. Neck veins are engorged 3 cm above the
clavicle at 30 degrees and the abdomino-jugular (also referred to as hepatojugular) reflux is positive. The apical impulse is located two cm lateral to the left
mid-clavicular line in the 6th interspace. Soft S3 and S4 gallops together with a
grade 2/6 holosytolic murmur are heard at the apex. There are bibasilar
inspiratory rales and 2+ pitting edema of the legs.
Chest x-ray reveals moderate cardiomegaly with pulmonary congestion. EKG
shows a sinus mechanism with a CLBBB and frequent unifocal premature
ventricular contractions. Echocardiography reveals a left ventricular enddiastolic dimension of 62 mm with global hypokinesia, EF of 38% and moderate
MR. The inferior vena cava is moderately distended and demonstrates poor
inspiratory collapse

Which ONE of the following is initially indicated in the management of

this patient?
A. Furosamide
B. Enalapril
C. Amiodarone
D. Beta-blocker
E. Digoxin

Answer: A
2. A 56-year-old-male is referred to you because of generalized edema and
increasing abdominal girth. Eight years ago, the patient underwent 5vessel coronary artery bypass (CABS) surgery. Six years, he underwent
radiation therapy for lymphoma. Comorbidities include Type II diabetes
mellitus, hyperlipidemia and tobacco abuse. He has 2-pillow orthopnea
and mild exertional dyspnea but denies paroxysmal nocturnal dyspnea
(PND) and recurrance of angina.
Physical examination reveals marked anasarca. BP is 100/60 mm Hg.
Pulse is 80/min and regular. Neck veins are distended to the angle of the
jaw in the sitting position. There are no murmurs but an extra sound is
noted in early to mid-diastole. Breath sounds are diminished at the
bases.There are no rales. Abdominal girth is increased and there is a fluid
thrill with shifting dullness. There is scrotal edema and 3+ pitting edema
of the legs.
What is the most likely diagnosis?
A. Constrictive pericarditis
B. Ischemic cardiomyopathy
C. Restrictive cardiomyopathy
D. Large Pericardial effusion secondary to effusive pericarditis
E. Occult constrictive pericarditis
Answer: A

4. Which one of the following statement about constrictive pericarditis

is LEAST likely to be true?
A. Complete pericardiectomy carries a perioperative mortality of around
5-10%
B. Complete pericardiectomy results in clinical improvement in 90% of
patients
C. Chronic steroid therapy results in clinical improvement in nearly 70%
of patients
D. Patients with minimal symptoms can be managed with fluid and salt
restriction
E. Mildly symptomatic patients can be treated with careful use of diuretics
Answer: A

5. Which one of the following jugular venous pulse findings is most likely
to be seen in patients with constrictive pericarditis?
A. Inspiratory elevation
B. Expiratory elevation
C. Inspiratory decrease
D. Expiratory decrease
E. No respiratory variation
Answer: A

6.A 69-year-old male is referred for a one month complaint of progressively

increasing exertional dyspnea and palpitations. Two months ago, he was placed
on digitalis because of an irregular heart rate of around 140/min. Comorbidities
inclued hypertension and dyslipidemia and history of drinking a 6-pack beer per
week. He had a negative stress test with a reportedly normal left ventricular
(LV) ejection fraction (EF) a year ago.
On examination, the patient is in moderate respiratory distress. His BP is
150/92 mm Hg and the pulse is irregularly irregular at 160/min. There is an S3
gallop at the apex together with a grade 1/6 holosystolic murmur. The lungs are
clear.
The Chest x-ray shows moderate cardiomegaly, interstitial pulmonary edema
and small bilateral pleural effusions. The EKG shows atrial fibrillation with a
ventricular response of around 170/min. There is slow progression of R waves

across the precordium and nonspecific ST-T changes in the inferior and lateral
leads. Dig level is 0.2 ng/dl. Echocardiogram shows mild LV hypertrophy, mild
left atrial and LV enlargement and an LV EF of 35%.

What is the most likely diagnosis?

A. CHF secondary to Hypertensive disease
B. Ethanol-induced cardiomyopathy
C. Idiopathic dilated cardiomyopathy
D. Ischemic cardiomyopathy
E. Tachycardia-induced cardiomyopathy

f Answer: E

7. A 60-year-old male is referred for management of paroxysmal atrial

fibrillation. These subjective episodes occur several times a week, lasting 1 to 6
hours and are associated with incapacitating palpitations and dizziness .
Multiple episodes of sinus rhythm and atrial fibrillation with ventricular
response of 100-130/min have been documented. There is history of an
extensive anterior and lateral wall myocardial infarction two years ago.
Echocardiography showed a left ventricular ejection fraction of around 25%
with expected segmental wall motion abnormalities. The patient is on chronic
anticoagulation with warfarin.
What is the antiarrhythmic agent of choice in this patient?
A. Flecainide
B. Sotalol
C. Amiodarone
D. Quinidine
E. Procainamide

Answer: C

8. This is a 76 year old w/m who presents to the ED with headache, nausea,
vomiting, confusion, and new onset of brief seizure activity.
BP = 220/140 mm Hg in both arms. Pulse = 84/min
Examination reveals papilledema, mild somnolence and disorientation.
Which one of the following is the treatment of choice?
A. Nitroprusside
B. Clonidine
C. Methyldopa
D. Reserpine
E. Diazoxide
Answer: A

9.A 61-year-old man requires intubation in the emergency department for

respiratory distress. He has a known heart murmur for 20 years and receives
SBE prophylaxis. His wife reports two weeks of progressive dyspnea and
weight gain, culminating in severe rest dyspnea.
On physical examination, his pulse is 104/min and regular, BP is 80/50 mm Hg.
Jugular venous pressure is 5 cm H20 and the carotid artery shows a small
volume. Crackles are audible in the lower two-thirds of both lung fields. There
is a 1+ LV heave, normal S1 and a single S2. A grade 1/6 SEM is audible at the
base and apex and an S3 is present. The skin is cool and mottled and there is no
pitting edema.
Chest x-ray shows mild cardiomegaly, interstitial edema, and moderate sized
bilateral effusions. The ECG shows sinus tachycardia, slow R wave
progression, and down sloping ST segment depression in the lateral leads.

What is the most likely diagnosis:

A. Acute mitral regurgitation
B. Recent anterior MI
C. Aortic stenosis
D. Papillary muscle dysfunction
E. Infarct related VSD
Answer: C

10.

Pericarditis is a term describing inflammation of

A.
B.
C.
D.
E.

the inside lining of heart chambers

the tough sac surrounding the heart
the muscular layer of the heart
a coronary artery
a heart valve
Answer: B

11. A 72 year old female with no significant past medical history passes out
while exercising. He has intermittent exertional chest pains and dyspnea on
exertion as well. Her physical examination reveals a III/VI late-peaking
creshendo-decreshendo murmur at the right upper sternal border and a III/VI
holosystolic murmur at the apex. Her S2 heart sound is very soft and her carotid
upstroke is weak and delayed. Which of the following is most likely causing her
symptoms?
A) Aortic valve regurgitation
B) Aortic valve stenosis
C) Mitral valve regurgitation
D) Mitral valve stenosis
E) Mitral valve prolapse
Answer: B

12. A 56 year old African American female with a history of asthma is

diagnosed with hypertension. Laboratory studies reveal a creatinine of 3.0
mg/dL and a potassium level of 5.1 mg/dL. Which of the following medications
is appropriate to treat her hypertension?
A) amlodipine
B) hydrochlorothiazide
C) enalapril
D) propranolol
E) spironolactone
Answer: A

13. A 45 year old male with a history of hypertension and hyperlipidemia

complains of generalized weakness. His laboratory studies are below.
Serum
Na+ 144 mEq/L
K+ 5.9 mEq/L
Cl- 101 mEq/L
HCO3- 16 mEq/L
Urea nitrogen 66 mEq/L
Cr 2.8 mEq/L
Uric acid 13.1 mEq/L
Calcium 6.1 mEq/L
Urine dipstick
Specific gravity 1.030
Blood - positive
Nitrates negative
Leukocyte esterase negative
Urine microscopic examination
No WBCs
No RBCs
Which of the following medications is likely the cause of his symptoms?

A) lisinopril
B) verapamil
C) digoxin
D) rosuvastatin
E) hydralazine
Answer: D

14. A 29 year old male with a history of ectopialentis presents for a routine
physical examination. He is noted to have pectusexcavatum, pesplanus, a high
arched palate, and a positive wrist and thumb sign. Which of the following
cardiac disorders is associated with his condition?
A) Aortic valve stenosis
B) Coarctation of the aorta
C) Mitral valve prolapse
D) Ventricular septal defect
E) Ebsteins anomaly
Answer: C

15. A 52 year old male with a history of hypertension, dyslipidemia, and

congestive heart failure presents to the emergency department with acute onset
swelling of the lips, eyes, and tongue causing airway obstruction and respiratory
distress. He also has an urticarial rash. Which of the following medications is
the likely culprit of his current symptoms?
A) pindolol
B) clonidine
C) felodipine
D) captopril

E) methyldopa
Answer: D

16.A 45 year old female with a history of hypertension previously controlled

with diet and lifestyle modifications presents to her primary care physician with
increasing headaches. Her blood pressure is 160/90. She is diagnosed with
worsening migraine headaches. Which of the following medications is
appropriate to treat her hypertension and headaches simultaneously?
A) hydrochlorothiazide
B) metoprolol
C) clonidine
D) methyldopa
E) lisinopril
Answer: B

17.A 67 year old male suffers a large myocardial infarction complicated by

sustained ventricular tachycardia. He is started on a lidocaine infusion. He
subsequently develops shock liver from hypotension during the ventricular
tachycardia and his serum lidocaine levels become significantly elevated.
Which of the following is a manifestation of lidocaine toxicity?
A) Stroke
B) Seizures
C) Renal failure
D) Congestive heart failure
E) Hyperkalemia
Answer: B

18. Which of the following describes the cardiac anomalies associated with
the tetralogy of Fallot?
A) Atrial septal defect, ventricular septal defect, a common atrioventricular
valve, and pulmonic valve stenosis
B) Atrial septal defect, right ventricular hypertrophy, pulmonic valve stenosis,
and an overriding aorta
C) Ventricular septal defect, left ventricular hypertrophy, aortic valve stenosis,
and an overriding aorta
D) Ventricular septal defect, right ventricular hypertrophy, pulmonic valve
stenosis, and an overriding aorta
Answer: D

19.A 62 year old female with a history of hypertension presents with

increasing shortness of breath, abdominal pain, and diarrhea. Computed
tomography reveals a mass in the appendix and multiple nodules in the liver.
Chest x-ray is normal. Serum 5-hydroxyindoleacetic acid levels are elevated.
Which of the following cardiac disorders is she likely to have?
A) Aortic valve stenosis
B) Aortic valve regurgitation
C) Mitral valve stenosis
D) Mitral valve regurgitation
E) Tricuspid valve stenosis
Answer: E

20. A 48 year old male with a history of hypertension and high cholesterol
presents to the emergency department with chest pains for 60 minutes. He
describes a substernal chest pressure like an elephant on my chest associated
with shortness of breath and diaphoresis. His ECG shows ST elevations
consistent with myocardial infarction. Which of the following laboratory results
would be expected?
A) Elevated myoglobin, elevated troponin I, and elevated CK-MB

B) Normal myoglobin, elevated troponin I, and normal CK-MB

C) Elevated myoglobin, normal troponin I, and normal CK-MB
D) Normal myoglobin, normal troponin I, and elevated CK-MB
E) Normal myoglobin, normal troponin I, and normal CK-MB
Answer: C

21.A 29 year old male with no past medical history has been experiencing
headaches for the past few months. His blood pressure is noted to be 210/110.
Physical examination reveals an S4 heart sound and reduced femoral pulses.
Which of the following is associated with his condition?

A) Atrial septal defect

B) Wolff-Parkinson-White syndrome
C) Bicuspid aortic valve
D) Mitral valve regurgitation
Answer: C

22. A 68 year old male suffers a myocardial infarction. Six weeks later he
begins to have sharp substernal chest pains radiating to his left neck worse with
laying flat and better while sitting up and leaning forward. His
electrocardiogram shows diffuse ST segment elevation and PR segment
depression. Which of the following is his likely diagnosis?
A) Ventricular free wall rupture
B) Acute mitral valve regurgitation
C) Dresslers syndrome
D) Left ventricular aneurysm
E) Aortic dissection

Answer: C

23.A 76 year old female with a history of coronary artery disease and prior
inferior wall myocardial infarction presents with gradual onset of increased
shortness of breath on exertion and lower extremity swelling. Her physical
examination reveals a IV/VI holosystolic murmur at the 5thintercostals space at
the mid-clavicular line. Which of the following is likely the cause of her
symptoms?
A) Tricuspid valve regurgitation
B) Mitral valve regurgitation
C) Ventricular septal defect
D) Mitral valve stenosis
E) Left ventricular aneurysm
Answer: B

24. A 67 year old female with a history of breast cancer and tobacco use
complains of dizziness and dyspnea on exertion. Her heart sounds are distant
and her systolic blood pressure is noted to markedly decrease with inspiration.
Which of the following is the likely diagnosis?
A) Restrictive cardiomyopathy
B) Mitral valve regurgitation
C) Congestive heart failure
D) Pulmonary embolus
E) Cardiac tamponade
Answer: E

25. A 22 year old female is noted to have a reduced upper to lower body
segment ratio, positive Walker and Steinberg signs, and pectuscarinatum. Her
father died suddenly at the age of 34. She is subsequently diagnosed with
Marfans syndrome. Which of the following was the likely cause of death of her
father?

A) Mitral valve prolapse

B) Aortic valve regurgitation
C) Myocardial infarction
D) Aortic dissection
E) Congestive heart failure
Answer: D

26. A 60 year old male with a history of congestive heart failure and atrial
fibrillation states his vision has been mostly yellow recently. He has noted lack
of appetite and weight loss. Laboratory studies reveal and elevated potassium
level. Which of the following is the likely causing his symptoms?
A) Nitroglycerine
B) Digoxin
C) Amiodarone
D) Spironolactone
Answer: B

27. A 45 year old male with severe asthma is having a myocardial infarction.
Which of the following beta-blockers can potentially treat his myocardial
infarction while causing minimal bronchoconstriction?
A) metoprolol
B) propranolol
C) carvedilol
D) nadolol
Answer: A

28. An 18 year old male dies suddenly during a track and field event. During
a recent sports physical he was noted to have a II/VI systolic crescendodecreshendo murmur at the right upper sternal border that became louder with
Valsalva. A paradoxical split S2 heart sound was heard. Which of the following
is his likely diagnosis?
A) Congenital coronary anomaly
B) Comotiocordis
C) Idiopathic hypertrophic subaortic stenosis
D) Dilated cardiomyopathy
Answer: C

29.A 34 year old male experiences shortness of breath with minimal exertion.
Physical examination reveals elevated jugular venous pressure markedly worse
with inspiration, a regular rhythm with an S4 heart sound and 2+ lower
extremity pitting edema. Laboratory studies are normal. Cardiac biopsy
revealed green birefringence with congo red staining. Genetic testing reveals a
mutation in the transthyretin gene. Which of the following is the correct
diagnosis?
A) Restrictive cardiomyopathy
B) Dilated cardiomyopathy
C) Constrictive pericarditis
D) Hypertrophic obstructive cardiomyopathy
E) Chagas cardiomyopathy
Answer: A

30.A 35 year old female with a history of anxiety and panic attacks presents
for a routine physical examination. She intermittently experiences palpitations
but in general feels well. Physical examination reveals a mid-systolic click at
the cardiac apex which moves earlier in systole with standing from a squatting
position. No murmur is present. Which of the following is the likely diagnosis?
A) Mitral valve regurgitation

B) Mitral valve stenosis

C) Mitral valve prolapse
D) Normal mitral valve
Answer: C

31.A 56 year old female with a history of mitral valve prolapse has been
experiencing fevers and joint pains for 3 weeks. She recently underwent a tooth
extraction. Physical examination reveals a III/VI holosystolic murmur at the
cardiac apex which was not present on prior examinations. Her erythrocyte
sedimentation rate is markedly elevated. A painful nodule on the pad of her left
index finger has developed. Which of the following is the most likely culprit?
A) Staphalococcusaureus
B) Pseudomonas auriginosa
C) Streptococcus viridins
D) Candida albicans
Answer: C

32.A 45 year old male presents with substernal chest pressure and is found to
have elevated troponin levels consistent with a large myocardial infarction.
Which of the following interventions can best decrease myocardial oxygen
demand and potentially reduce the size of the infarction?
A) Nitroglycerine infusion
B) Beta-blocker administration
C) Aspirin
D) Loop diuretic administration
E) Dobutamine infusion
Answer: B

33. A 58 year old female has been diagnosed with congestive heart failure.
She currently takes lisinopril, hydralazine, and furosemide. Which of the
following medications should be added to improve her symptoms and reduce
her mortality in the long-term?
A) carvedilol
B) nitroglycerine
C) amlodpine
D) verapamil
E) digoxin
Answer: A

34.A 84 year old male with a history of severe emphysema and myocardial
infarction becomes short of breath with exertion. Physical examination reveals a
III/VI holosystolic murmur at the cardiac apex, an S3 heart sound, and rales in
the lower lung fields. No lower extremity edema is present. Which of the
following is the likely diagnosis?
A) Left-sided congestive heart failure
B) Right-sided congestive heart failure
C) Left and right sided congestive heart failure
D) Corpulmonale
Answer: A

35. An 82 year old male with a history of hypertension and congestive heart
failure presents with palpitations. His heart rate is 140 beats per minute and his
physical examination reveals an irregularly irregular rhythm. He is diagnosed
with atrial fibrillation. Which of the following medications can reduce his heart
rate while improving left ventricular systolic function?
A) Propranolol

B) Verapamil
C) Digoxin
D) Amiodarone
Answer: C

36.A 56 year old female has a history of hypertension, diabetes mellitus type
II, elevated low density lipoprotein levels, and smokes tobacco. Which of the
above is the most significant risk factor for the development of atherosclerotic
heart disease?
A) Hypertension
B) Diabetes mellitus type II
C) Elevated low density lipoprotein
D) Tobacco use
Answer: B

37. A 28 year old female with no prior past medical history becomes
markedly shot of breath and hypotensive over a 3 day time period. She had been
suffering from an upper respiratory tract infection starting 1 week prior.
Physical examination reveals no murmurs, an S3 heart sound is present, elevated
jugular venous pressure, pulmonary rales, and lower extremity edema. An
echocardiogram confirms an ejection fraction of 10%. Which of the following is
the most common culprit of her condition?
A) Coxsackie B virus
B) Human immunodeficiency virus
C) Epstein-Barr virus
D) Influenza A virus
Answer: A

38. A 23 year old male presents to the emergency room with sharp chest
pains radiating to his left neck and altered mental status. For the past 3 days he

has had severe nausea and vomiting attributed to viral gastroenteritis. Physical
examination reveals a loud abnormal scratching sound in end systole and all of
diastole located near the cardiac apex. Chest x-ray is normal. His laboratory
studies are below:
Serum
Na+ 145 mEq/L
K+ 5.4 mEq/L
Cl- 103 mEq/L
HCO3- 22 mEq/L
Urea nitrogen 112 mEq/L
Cr 5.2 mEq/L
Troponin I - negative
Which of the following is likely causing his chest pain?
A) Myocardial ischemia
B) Aortic dissection
C) Esophageal rupture
D) Pericarditis
Answer: D

39.A 26 year old male is noted to have a V/VI holosystolic murmur associated
with a thrill at the left lower sternal border. He has no health complaints and is
able to exercise regularly without difficulty. Which of the following is the likely
diagnosis?
A) Atrial septal defect
B) Ventricular septal defect
C) Mitral valve regurgitation
D) Tricuspid valve regurgitation
Answer: B

40. A 36 year old female with no significant past medical history is being
evaluated for increasing shortness of breath. Her physical examination reveals a

II/IV early diastolic decrescendo murmur occurring after an early diastolic

opening snap. Which of the following is the ideal therapy for her cardiac
disorder?
A) Observation
B) Angiotensin converting enzyme inhibitor
C) Surgical mitral valve repair
D) Mitral valve balloon valvotomy
Answer: D

41.An 18 year old male with no significant past medical history presents to
his primary care physcician for a routine physical examination. He has no
physical complaints. His blood pressure is 115/85, heart rate 80, respirations 12,
and he is afebrile. His physical examination reveals normal lung sounds, a V/VI
holosystolic murmur with a thrill at the left lower sternal border and no change
in intensity with inspiration, no gallops or extra heart sounds, and normal
jugular venous pressures. His ECG and laboratory studies are normal. What is
his most likely diagnosis?
A) Mitral regurgitation
B) Patent ductusarteriosis
C) Tricuspid regurgitation
D) Ventricular septal defect
Answer: D

42. A 72 year old female with a history of diabetes mellitus and no history of
heart disease presents to the emergency department with chest pains at rest
intermittently for the past 4 hours. She has associated shortness of breath and
diaphoresis. Her heart rate is 59, blood pressure 134/72, respiratory rate 20, and
oxygen saturation 95% on room air. Physical examination reveals normal lung
sounds and an S4 gallop. Her ECG reveals ST segment depression in leads V1
to V3. She is given aspirin immediately. Her troponin levels remain negative.
She is currently chest pain free. Which of the following is the correct diagnosis?
A) Stable angina
B) Unstable angina

C) Non-ST segment elevation myocardial infarction

D) ST segment elevation myocardial infarction
Answer: A

43. An 48 year old male with a history of hypertension presents to the

emergency room with chest pain. He is diaphoretic and also complaining of
shortness of breath. His temperature is 37.1 C, blood pressure 120/82, heart rate
82, and respirations 20. His physical examination is significant for an S4 heart
sound. ECG reveals an inferior wall ST elevation myocardial infarction and
appropriate treatment is undertaken. He is discharged home and was doing well.
Two months later he develops a sharp chest pain worse with laying flat radiating
to his left neck. He returns to his cardiologist and his temperature is 38.5 C,
blood pressure 118/82, heart rate 80, and respirations 18. Physical examination
is normal. ECG reveals ST segment elevation in leads I, II, III, aVF, aVL, and
V1-V4 as well as PR depression in lead II. What is the most likely diagnosis at
this time?
A) Left ventricular rupture
B) Dressler's syndrome
C) Anterior myocardial infarction
D) Early repolarization
Answer: B

44.A 36 year old female with no past medical history presents to her primary
care office a complaint of chest pains for the past few months. She states that
intermittently she has a feeling that she is going to die and develops severe chest
pains and palpitations. The pain is substernal, pressure-like, and radiating to her
left arm. It can last for minutes or hours at a time. Her blood pressure is 120/80,
heart rate 80, and respirations 20. Physical examination reveals normal lung
sounds, no murmurs, and a mid-systolic click that moves to early systole with
standing from a squatting position. Her ECG is normal. Which of the following
is the most likely diagnosis?
A) Mitral valve regurgitation
B) Myocardial ischemia
C) Mitral valve prolapse

D) Mitral valve stenosis

Answer: C

45.A 62 year old male with a history of mitral valve prolapse, rheumatoid
arthritis, and colon cancer presents to the emergency room with increased
dyspnea on exertion, lower extremity swelling, and fevers slowly worsening
over the past month. His temperature is 38.0 C, blood pressure 95/65, heart rate
80, respirations 20, and oxygen saturation 92% on room air. Physical
examination reveals normal breath sounds, a II/VI holosystolic murmur at the
apex, and 1+ bilateral lower extremity pitting edema. Laboratory studies show a
WBC count of 20 thousand and an ESR of 100. Echocardiogram reveals an 8
mm mobile vegetation on the anterior leaflet of the mitral valve. Which of the
following is the most likely pathogen?
A) Staphalococcus aureus
B) Pseudomonas auriginosa
C) Candida albicans
D) Streptococcus bovis
Answer: D

46.A50 year old male with a history of diabetes mellitus presents for a routine
clinic visit. He has been feeling well and has no complaints. He has been
exercising regularly and dieting as instructed for his diabetes. His medications
include metformin and glypizide. His blood pressure is 180/90, heart rate 70,
and respirations 20. His physical examination is normal. Which of the following
is the most appropriate management at this time?
A) Continue diet and lifestyle modifications only
B) Start lisinopril and hydrochlorothiazide
C) Start amlodipine
D) Start hydrochlorothiazide
E) Start spironolactone
Answer: B

47.A 68 year old female with a history of hypertension, diabetes, coronary

artery disease treated with coronary artery bypass grafting 20 years ago,
presents to the emergency room with increasing shortness of breath and lower
extremity edema. She denies any chest pains and does not drink alcohol. Her
temperature is 37.0 C, blood pressure 110/70, heart rate 110, and respirations

20. Physical examination reveals a cachectic appearance, marked jugular

venous distension worse with inspiration, decreased breath sounds at the left
base, pulmonary rales throughout the lung fields, a regular rhythm with an
extrasystolic heart sound, hepatomegaly with ascites, and 3+ pitting lower
extremity edema above the knees. ECG is normal. Laboratory studies reveal
elevated AST, ALT, and total bilirubin. A hepatitis profile is normal. Which of
the following is the most likely diagnosis?
A) Restrictive cardiomyopathy
B) Systolic congestive heart failure
C) Tricuspid regurgitation
D) Cardiac tamponade
E) Constrictive pericarditis
Answer: E

48.A 27 year old female with no significant past medical history is 40 weeks
pregnant and labor has just begun. She begins to complain of shortness of breath
which worsens throughout delivery to the point of requiring intubation. She had
never previously complained of any dyspnea or chest pains. Her temperature is
37.0, blood pressure 90/50, heart rate 130, respirations 26, and oxygen
saturation 100% on 60% FiO2 on the ventilator. Physical examination reveals
diffuse pulmonary rales, a II/IV early diastolic murmur, and no lower extremity
edema. Laboratory studies are normal. ECG shows sinus tachycardia and left
atrial enlargement. Her chest x-ray has significant pulmonary edema. Which of
the following is the most likely diagnosis?
A) Aortic dissection
B) Coronary artery dissection
C) Aortic valve stenosis
D) Mitral valve stenosis
Answer: D

49.A 42 year old female with no significant past medical history presents to
the emergency department with hemoptysis of acute onset. She has noted recent
dyspnea on exertion now to the point where she can only walk blocks before
having to rest. She denies chest pain. Her temperature is 37.0 C, blood pressure
110/60, heart rate 100, respirations 20, and oxygen saturation 95% on room air.
Physical examination reveals normal lung sounds, an irregularly irregular
rhythm, a II/IV early diastolic murmur heard best at the cardiac apex, and 1+
lower extremity pitting edema. Laboratory studies are normal. ECG shows sinus

tachycardia and left atrial enlargement. Which of the following is causing this
patients symptoms?
A) Mitral valve stenosis
B) Mitral valve prolapse
C) Mitral valve regurgitation
D) Aortic valve stenosis
E) Aortic valve regurgitation
Answer: A

50. A 35 year old male with no past medical history presents with increasing
shortness of breath and dyspnea on exertion and lower extremity edema
increasing over the past month. His temperature is 37.0, blood pressure 90/60,
heart rate 100, respirations 20, and oxygen saturation 95% on room air. Physical
examination reveals decreased breath sounds at the left base without wheezing,
elevated jugular venous pressure markedly worse with inspiration, a regular
rhythm with an S4 heart sound and 2+ lower extremity pitting edema.
Laboratory studies are normal. Cardiac biopsy revealed green birefringence
with Congo red staining. Genetic testing reveals a mutation in the transthyretin
gene. Which of the following is the correct diagnosis?
A) Constrictive pericarditis
B) Restrictive cardiomyopathy
C) Dilated cardiomyopathy
D) Hypertrophic obstructive cardiomyopathy
Answer: B

51.A 42 year old female presents to with increasing dyspnea on exertion and
lower extremity edema. She denies chest pains. Her temperature is 37.0, blood
pressure 150/90, heart rate 100, respirations 20, and oxygen saturation 92% on
room air. Physical examination reveals normal breath sounds, elevated jugular
venous pressure, a III/VI holosystolic murmur at the apex occurring after a midsystolic click, an S3 heart sound, and 1+ pitting lower extremity edema. Which
of the following is the best treatment at this time?
A) ACE inhibition
B) Beta-blockade
C) Mitral valve repair

D) Mitral valve replacement

Answer: C

52.A 55 year old male with a history of hypertension presents to the

emergency room with acute onset chest pains. His temperature is 37.0, blood
pressure 190/70 in the left arm and 150/70 in the right arm, heart rate 110,
respirations 22, and oxygen saturation 94% on room air. Physical examination
reveals normal lung sounds, elevated jugular venous pressures and a II/IV early
diastolic murmur at the right upper sternal border. ECG shows normal sinus
rhythm and left ventricular hypertrophy. Which of the following is the most
likely diagnosis?
A) Pulmonary embolus
B) Mitral valve stenosis
C) Aortic dissection
D) Ascending aortic aneurysm
E) Myocardial ischemia
Answer: C

53.An 18 year old male with no significant past medical history presents to
his primary care physcician for a routine physical examination. He has no
physical complaints. His blood pressure is 115/85, heart rate 80, respirations 12,
and he is afebrile. His physical examination reveals normal lung sounds, a V/VI
holosystolic murmur with a thrill at the left lower sternal border and no change
in intensity with inspiration, no gallops or extra heart sounds, and normal
jugular venous pressures. His ECG and laboratory studies are normal. What is
his most likely diagnosis?
A) Mitral regurgitation
B) Atrial septal defect
C) Tricuspid regurgitation
D) Ventricular septal defect
Answer: D

54.A 42 year old female with no significant past medical history presents to
the emergency department with hemoptysis of acute onset. She has noted recent
dyspnea on exertion now to the point where she can only walk blocks before
having to rest. She denies chest pain. Her temperature is 37.0 C, blood pressure

110/60, heart rate 100, respirations 20, and oxygen saturation 95% on room air.
Physical examination reveals normal lung sounds, an irregularly irregular
rhythm, a II/IV early diastolic murmur heard best at the cardiac apex, and 1+
lower extremity pitting edema. Laboratory studies are normal. ECG shows sinus
tachycardia and left atrial enlargement. Which of the following is causing this
patients symptoms?
A) Mitral valve stenosis
B) Mitral valve prolapse
C) Mitral valve regurgitation
D) Aortic valve stenosis
E) Aortic valve regurgitation
Answer: A

55. A 35 year old male with no past medical history presents with increasing
shortness of breath and dyspnea on exertion and lower extremity edema
increasing over the past month. His temperature is 37.0, blood pressure 90/60,
heart rate 100, respirations 20, and oxygen saturation 95% on room air. Physical
examination reveals decreased breath sounds at the left base without wheezing,
elevated jugular venous pressure markedly worse with inspiration, a regular
rhythm with an S4 heart sound and 2+ lower extremity pitting edema.
Laboratory studies are normal. Cardiac biopsy revealed green birefringence
with Congo red staining. Genetic testing reveals a mutation in the transthyretin
gene. Which of the following is the correct diagnosis?
A) Constrictive pericarditis
B) Restrictive cardiomyopathy
C) Dilated cardiomyopathy
D) Hypertrophic obstructive cardiomyopathy
Answer: B

56.A 60 year old female with no significant past medical history presents with
increasing dyspnea on exertion and chest pains with exertion. All of her
symptoms are relieved with rest. Her temperature is 37.0, blood pressure
120/80, heart rate 80, respirations 20, and oxygen saturation 95% on room air.
Physical examination reveals a late-peaking II/VI systolic ejection murmur at
the right upper sternal border radiating to her carotid arteries, a soft S2 heart
sound, and an S4 is present. Laboratory studies are normal. ECG reveals normal

sinus rhythm with left ventricular hypertrophy. Which of the following is likely
the culprit for this patients symptoms?
A) Bicuspid aortic valve
B) Coarctation of the aorta
C) Dilated aortic root
D) Rheumatic heart disease
E) Degenerative calcific aortic valve
Answer: A

57.A 62 year old male with a history of hypertension presents to the

emergency room with recurrent chest pains. He has been seen on numerous
occasions for these symptoms and no etiology has been discovered. His
medications include aspirin, metoprolol, and omeprazole. His temperature is
37.0, blood pressure 120/80, heart rate 80, and respirations 20. Physical
examination is normal without any chest wall tenderness. ECG during the chest
pain is normal. Laboratory studies are normal. He undergoes coronary
angiography, esophagogastroduodenoscopy, and pulmonary function testing all
of which are normal. Which of the following is the best treatment?
A) Psychiatric referral
B) Amitriptyline
C) Pantoprazole
D) Ibuprofen
Answer: B

58.A 45 year old prostitute presents to the emergency department with

increased shortness of breath and lower extremity edema slowly worsening over
a few months. Her temperature is 37.2, blood pressure 140/60, heart rate 100,
and respirations 20. Physical examination reveals a II/IV short early diastolic
murmur at the right upper sternal border loudest in end-expiration while having
her lean forward. Laboratory studies are normal. Which of the following is the
most likely diagnosis?
A) Bicuspid aortic valve
B) Aortic valve endocarditis
C) Aortic dissection
D) Syphilitic aortitis

Answer: D

59.What affect would severe mitral valve stenosis have on the S1 heart
sound?
A) Widened splitting
B) Absence of splitting
C) Increased intensity
D) Decreased intensity

60.Which component of the S

heart sound is the softest?

A) Pulmonic valve closure

B) Aortic valve closure
C) Tricuspid valve closure
D) Mitral valve closure

61.Tachycardia has what affect on the S

heart sound?

A) Widened splitting
B) Absence of splitting
C) Increase in intensity
D) Decrease in intensity

62.Left ventricular hypertrophy is related to what finding?

A) The presence of an S4 heart sound
B) A widened split S2 heart sound
C) Increased intensity of the S1 heart sound
D) The presence of a systolic ejection click

63.What causes an S

heart sound?

A) Passive filling into a compliant left ventricle causing sudden tensing of the
cordaetendonae
B) Active filling into a compliant left ventricle causing sudden tensing of the
cordaetendonae

C) Passive filling into a non-compliant left ventricle

D) Active filling into a non-compliant left ventricle

64.Which heart sound is also known as the "ventricular gallop"?

A) S1
B) S2
C) S3
D) S4
E) Physiologic split S1
F) Physiologic split S2

65.What condition results in a loud P

component of the S2 heart sound?

A) Pulmonary hypertension
B) Systemic hypertension
C) Hypertrophic obstructive cardiomyopathy
D) Pulmonic valve stenosis

66. A widened split S

heart sound can be causesd by:

A) A left bundle branch block

B) A right bundle branch block
C) A prolonged PR interval
D) A shortened PR interval

67. What causes an S

heart sound?

A) Passive filling into a compliant left ventricle causing sudden tensing of the
cordaetendonae
B) Active filling into a compliant left ventricle causing sudden tensing of the
cordaetendonae
C) Passive filling into a non-compliant left ventricle
D) Active filling into a non-compliant left ventricle

68.Inspiration has what effect on the P

A) P2 occurs earlier

component of the S2 heart sound?

B) P2 occurs later
C) P2 increases in intensity
D) P2 decreases in intensity

69. ST segment elevation is indicative of

A.
B.
C.

Infarction
Injury
Ischemia

Right answer: B

70 The intra-aortic balloon pump is used in severe CHF to

A.

B.

C.

increase afterload, augment diastole & improve perfusion to the

coronary arteries and kidneys
increase afterload, reduce diastolic volume & improve perfusion
to vital organs
decrease afterload, augment diastole, & improve perfusion to
coronary arteries

Right answer: C

as the resistance to blood flow including opening of the aortic

71 Defined
valves and pushing blood through the arteries (peripheral vascular
resistance).
A.
heart rate
B.
Afterload
C.
Contractility
D.
Preload
Right answer: B

risk factors for coronary artery disease include which of

72 Unmodifiable
the following?
A.
B.
C.
D.

low density lipoprotein levels, gender, obesity

sedentary lifestyle, race, oral contraceptive use
age, gender, family history, hyperlipidemia
hyperlipidemia, diabetes, stress, smoking

Right answer: C

73 Angina is chest pain or discomfort and causes cell death.

A.
B.

This statement is true.

This statement is false.

Right answer: B

74. Pulmonary edema is an acute, life threatening form of congestive

heart failure.
A.
This statement is true.
B.
This statement is false.

Right answer: A

patient who presents with gastrointestinal symptoms (nausea,

75. Avomiting,
indigestion) could be experiencing which type of MI?
A.
B.
C.
D.

Inferior
Anterior
Anterolateral
Anteroseptal

Right answer: A

and nursing treatment for the patient with CHF consist of a

76. Medical
threefold approach: treatment of existing symptoms, prevention of
further complications, and treatment of the underlying cause.
A. This statement is true.
B. This statement is false.
Right answer: A

results in which of the following abnormal

77. Hyperkalemia
electrocardiographic changes?

A.
B.
C.
D.

shortened QT interval
ventricular tachycardia
prominent U wave and prolonged T wave
increased conduction system block

Right answer: D

intervention for patients experiencing angina include the

78. Medical
administration of nitrates, beta adrenergic blocking agents and
calcium channel blockers.
A. This statement is correct.
B. This statement is false.
Right answer: A

rhythm can be heard with the bell of the stethoscope at the

79. Afifthgallop
intercostal space in a patient with
A.
B.
C.
D.

Hypovolemia
severely failing heart
fluid overload
over-forceful atrial contraction

Right answer: B

heart sound can be heard with the bell of the stethoscope and is a
80. This
sound of longer duration that can be caused by papillary muscle
rupture.
A. S3
B.

Murmur

C.

Gallop
S4

D.

Right answer: B

81. Closure of the pulmonic valve can be auscultated at the

A.
B.
C.
D.

second intercostal space, right sternal border

fifth intercostal space, left sternal border
third intercostal space, right sternal border
second intercostal space, left sternal border

Right answer: D

82. Congestive heart failure is a clinical syndrome where the heart is unable
to meet the metabolic needs of the body. Do the ventricular filling pressures
change?
A. yes
B.

no

Right answer: B

83. What is the number one cause of chronic congestive heart failure?
A.

hypertension

B.

alcohol abuse

C.

cocaine

D.

coronary artery disease

E.

thyrotoxicosis & viral myocarditis

Right answer: D

84. Short term treatment for acute congestive heart failure starts with the
administration of:
A. oral lasix
B.

IV hydralazine

C.

IV enalaprilat

D.

IV furosemide

Right answer: D

85.

If you were not sure whether a patient was in systolic or diastolic failure

and was told that that the patient's ejection fraction was 35%, you would
conclude that the patient was in:
A. systolic failure
B.

diastolic failure

Right answer: A

86. Between systolic and diastolic failure which one is related to decreased
compliance?
A. systolid failure
B.

diastolic failure

Right answer: B

87. Therefore systolic dysfunction is related to decreased contractility of the

myocardium. Decreased contractility is considered as an ejection fraction lower
than:
A. 50%
B.

45%

C.

40%

D.

35%

E.

30%

Right answer: C

88. Anything that can cause myocardial ischemia can cause systolic or
diastolic dysfunction?
A. systolic dysfunction
B.

diastolic dysfunction

Right answer: A

89. Which of the following are medications that are used in the management
of congestive heart failure?
A. diuretic
B.

ACE inhibitor

C.

beta blocker

D.

Aldosterone antagonist

E.

Digoxin

F.

All of above

Right answer: F

90. A patient with chronic pulmonary hypertension will probable develop

right or left sided heart failure?
A. left sided
B.

right sided

Right answer: B

91. What is the most common valvular abnormality in adults?

A.

tricupsid regurgitation

B.

mitral valve stenosis

C.

arotic regurgitation

D.

aortic stenosis

Right answer: D

92. If a patient is between 30-70 years old and they are diagnosed with aortic
stenosis. The reason is probably due to:

A.

a congenital bicupsid aortic valve

B.

calcific aortic valve

C.

congenital stenosis or rheurmatic heart disease

Right answer: C

93. Which of the following blood pressures is stage 1 hypertension?

A.

120-139/80-89

B.

140-159/90-99

C.

>160/>100

Right answer: B

94. Are there circumstances where an ACE inhibitor is the initial treatment
for hypertension?
A. yes, especially in patients in which the goal is to protect the kidneys eg
diabetics
B. no, the guidelines always state that a thiazide should be initiated first.
Right answer: A

95.

Patients with diabetes, asthma & COPD should not receive beta blockers.
True or false
A. true
B.

false

Right answer: A

96.

Stenosis of the renal artery can cause essential or secondary

hypertension?

A.

essential

B.

secondary

Right answer: B

97. Which of the following are emergent intravenous drugs used to manage a
hypertensiv crisis? Check all that apply.
A. nitroprusside
B.

labetalol

C.

nitroglycerin

D.

All of above

Right answer: D

98.

Papillary musclea dysfunction can cause mitral regurgitation or stenosis?

A.

mitral regurgitation

B.

mitral stenosis

Right answer: A

99. Mitral stenosis will most likely lead to what arrythmia?

A.

atrial flutter

B.

atrial fibrillation

C.

ventricular tachycardia

D.

ventricular fibrillation

Right answer: B

100.

Which valves are prediposed to infection, stenosis and regurgitation

due to rheumatic fever?
A.

the atrioventricular valves

B.

the semilunar valves

C.

all the valves

Right answer: C

101. A 60-year-old male patient on aspirin, nitrates, and a beta blocker, being
followed for chronic stable angina, presents to the ER with a history of two to
three episodes of more severe and long-lasting anginal chest pain each day over
the past 3 days. His ECG and cardiac enzymes are normal. The best course of
action of the following is to
A) Admit the patient and begin intravenous digoxin
B) Admit the patient and begin intravenous heparin
C) Admit the patient and give prophylactic thrombolytic therapy
D) Admit the patient for observation with no change in medication
E) Discharge the patient from the ER with increases in nitrates and beta
blockers
Right answer: B

102. A 60-year-old white female presents with epigastric pain, nausea and
vomiting, heart rate of 50, and pronounced first-degree AV block on ER cardiac
monitor. Blood pressure is 130/80. The coronary artery most likely to be
involved in this process is the
A)Right coronary
B)Left main

C)Left anterior descending

D)Circumflex
Right answer: A

103. You are seeing in your office a patient with the chief complaint of
relatively sudden onset of shortness of breath and weakness but no chest pain.
ECG shows nonspecific ST-T changes. You would be particularly attuned to the
possibility of painless, or silent, myocardial infarction in the
A)Advanced coronary artery disease patient with unstable angina on multiple
medications
B)Elderly diabetic
C)Premenopausal female
D)Inferior MI patient
E)MI patient with PVCs
Right answer: B

104. A 75-year-old African American female is admitted with acute

myocardial infarction and congestive heart failure, then has an episode of
ventricular tachycardia. She is prescribed multiple medications and soon
develops confusion and slurred speech. The most likely cause of this confusion
is
A)Captopril
B)Digoxin
C)Furosemide
D)Lidocaine
E)Nitroglycerin

Right answer: D

105. Two weeks after hospital discharge for documented myocardial

infarction, a 65-year-old returns to your office very concerned about low-grade
fever and pleuritic chest pain. There is no associated shortness of breath. Lungs
are clear to auscultation and heart exam is free of significant murmurs, gallops,
or rubs. ECG is unchanged from the last one in the hospital. The most effective
therapy is likely
A)Antibiotics
B)Anticoagulation with warfarin
C)An anti-inflammatory agent
D)An increase in antianginal medication
Right answer: C

106. A 72-year-old male presents to the ER with the chief complaint of

shortness of breath that awakens him at night and also night cough. Further
questioning confirms recent dyspnea on exertion. As you pursue the diagnosis
of congestive heart failure using the Framingham criteria, you note the physical
exam findings below. Which of the findings is considered among the less
specific minor criteria?
A)Neck vein distention
B)Rales
C)S3 gallop
D)Extremity edema
Right answer: D

107. A 55-year-old patient presents to you with a history of having recently

had a myocardial infarction with a 5-day hospital stay while away on a business
trip. He reports being told he had mild congestive heart failure then, but is
asymptomatic now with normal physical exam. You recommend which of the
following medications?
A)An ACE inhibitor
B)Digoxin

C)Diltiazem
D)Furosemide (Lasix)
E)Hydralazine plus nitrates
Right answer: A

108. A 26-year-old female is referred to you from an OB-GYN colleague

due to the onset of extreme fatigue and dyspnea on exertion 3 months after her
second vaginal delivery. By history, physical, and echocardiogram, which
shows systolic dysfunction, you make the diagnosis of postpartum
cardiomyopathy. Which of the following is correct?
A)Postpartum cardiomyopathy may occur unexpectedly years after pregnancy
and delivery
B)About half of all patients will recover completely
C)Since the condition is idiosyncratic, future pregnancy may be entered into
with no greater than average risk
D)The postpartum state will require a different therapeutic approach than
typical dilated cardiomyopathies
Right answer: B

109. Yesterday you admitted a 55-year-old white male to the hospital due to
chest pain and ruled out MI. The patient tends to be anxious about his health.
On admission, his lungs were clear, and his heart revealed a grade II/VI systolic
crescendo-decrescendo murmur at the upper right sternal border; cardiac
enzymes were normal, and resting ECG showed right bundle branch block with
less than 1 mm ST segment depression. The idea of performing a routine Bruce
protocol treadmill exercise test (stress test) to further assess coronary artery
disease was considered, but rejected primarily due to which of the following?
A)Anticipated difficulty with the patients anxiety (i.e., he might falsely claim
chest pain during the test)
B)Pulmonary embolus suspected as the primary diagnosis
C)Concern about the presence of aortic stenosis, a contraindication to stress
testing

D)The presence of RBBB, with this baseline ECG change obscuring typical
diagnostic ST-T changes

E)Concern that this represents the onset of unstable angina with unacceptable
risk of MI with stress testing

Right answer: C

110. A 75-year-old patient presents to the ER after a sudden syncopal

episode. He is again alert and in retrospect describes occasional substernal chest
pressure and shortness of breath on exertion. His lungs have a few bibasilar
rales, and his blood pressure is 110/80. On cardiac auscultation, the classic
finding you expect to hear is
A)A harsh systolic crescendo-decrescendo murmur heard best at the upper right
sternal border
B)A diastolic decrescendo murmur heard at the mid-left sternal border
C)A holosystolic murmur heard best at the apex
D)Amidsystolic click
Right answer: A

111. A 72-year-old male comes to the office with intermittent symptoms of

dyspnea on exertion, palpitations, and cough occasionally productive of blood.
On cardiac auscultation, a low-pitched diastolic rumbling murmur is faintly
heard toward the apex. The origin of the patients problem probably relates to
A)Rheumatic fever as a youth
B)Long-standing hypertension
C)Silent MI within the past year
D)Congenital origin
Right answer: A

112. You are helping with school sports physicals and see a 13-year-old boy
who has had some trouble keeping up with his peers. He has a cardiac murmur,
which you correctly diagnose as a ventricular septal defect based on which of
the following auscultatory findings?
A)A systolic crescendo-decrescendo murmur heard best at the upper right
sternal border with radiation to the carotids; the murmur is augmented with
transient exercise
B)A systolic murmur at the pulmonic area and a diastolic rumble along the left sternal
border
C)A holosystolic murmur at the mid-left sternal border
D)A diastolic decrescendo murmur at the mid-left sternal border
E)A continuous murmur through systole and diastole at the upper left sternal border
Right answer: C

113. A 40-year-old male presents to the office with a history of palpitations

that last for a few seconds and occur two or three times a week. There are no
other symptoms. ECG shows a rare single unifocal premature ventricular
contraction (PVC). The most likely cause of this finding is
A)Valvular heart disease
B)Hypertension
C)Idiopathic or unknown
Right answer: C

114. Subsequent 24-h Holter monitoring in the preceding patient confirms

occasional single unifocal PVCs plus occasional premature atrial contractions
(PACs). The best antiarrhythmic management in this case is
A)Beta blocker therapy
B)Digoxin
C)Quinidine
D)Observation, no medication
Right answer: D

115. An active 78-year-old female has been followed for hypertension but
presents with new onset of mild left hemiparesis and the finding of atrial
fibrillation on ECG, which persists throughout the hospital stay. She had been
in sinus rhythm 6 months earlier. Optimal treatment by the time of hospital
discharge includes antihypertensives plus
A)Close observation
B)Permanent pacemaker
C)Aspirin
D)Warfarin
E)Subcutaneous heparin

Right answer: D

116.A 36-year-old white female nurse comes to the ER due to a sensation of

fast heart rate, slight dizziness, and vague chest fullness. Blood pressure is
110/70. The following rhythm strip is obtained, narrow QRS complex without
clearly discernable P waves, with a rate in the 160 to 190 range, which shows
A)Atrial fibrillation
B)Atrial flutter
C)Supraventricular tachycardia
D)Ventricular tachycardia
Right answer: C

117.A 65-year-old man with diabetes, on an oral hypoglycemic, presents to

the ER with a sports-related right shoulder injury. His heart rate was noted to be
irregular and the following ECG shows Mobitz type I second-degree AV block,
also known as Wenckebach phenomenon, characterized by progressive PR
interval prolongation prior to block of an atrial impulse. The best immediate
therapy is

A)Atropine
B)Pacemaker
C)Electricalcardioversion
D)Digoxin
E)Diltiazem
F)Observation
Right answer: F

118. A 55-year-old African American female presents to the ER with lethargy

and blood pressure of 250/150. Her family members indicate that she was
complaining of severe headache and visual disturbance earlier in the day. They
report a past history of asthma but no known kidney disease. On physical exam,
papilledema and retinal hemorrhages are present. The best approach is
A)Intravenous labetalol therapy
B)Continuous-infusion nitroprusside
C)Clonidine by mouth to lower blood pressure slowly but surely
D)Nifedipine sublingually to lower blood pressure rapidly and remove the
patient from danger
E)Further history about recent home antihypertensives before deciding current
therapy
Right answer: B

119. A patient has been in the cardiac care unit with an acute anterior
myocardial infarction. He develops the abnormal rhythm The ECG shows
complete heart block. Although at first glance the P waves and QRS complexes
may appear related, on closer inspection they are completely independent of
each other, i.e., dissociated. You should
A)Give digoxin
B)Consult for pacemaker

C)Performcardioversion
D)Give propranolol
E)Givelidocaine
Right answer: B

120.A 48-year-old male with a history of hypercholesterolemia presents to

the ER after 1 h of substernal chest pain, nausea, and sweating. The ECG
shows acute ST segment elevations in the anterior precordial leads. There is no
history of hypertension, stroke, or any other serious illness. Which of the
following therapies is not appropriate?
A)Aspirin
B)Beta blocker
C)Morphine
D)Digoxin
E)Nitroglycerin
F)Thrombolytic agent
Right answer: D

121. A 55-year-old obese woman develops pressure like substernal chest pain
1 h in duration. The ECG shows ST segment elevation in inferior leads II, III.
The most likely diagnosis is
A)Costochondritis
B)Acute anterior myocardial infarction
C)Acute inferior myocardial infarction
D)Pericarditis
E)Esophageal reflux
F)Cholecystitis
Right answer: C

122. A 43-year-old woman with a 1-year history of episodic leg edema and
dyspnea is noted to have clubbing of the fingers. Her ECG include tall, peaked

P waves in leads II, III, and tall R waves in leads V1 to V3 and a deep S wave in
V6 with associated ST-T wave changes. The correct diagnosis is
A)Inferior wall myocardial infarction
B)Right bundle branch block
C)Acute pericarditis
D)Corpulmonale
Right answer: D

123. You are reviewing a number of patients with congenital heart disease
with specific attention to whether or not they need antibiotic prophylaxis for
dental work. Which of the following cardiac conditions creates the lowest risk
for development of infective endocarditis?
A)Coarctation of the aorta
B)Ventricular septal defect
C)Atrial septal defect
D)Patent ductusarteriosus

Right answer: C

124. A 68-year-old man with a history of hypertension, diabetes, and urinary

retention awoke feeling nauseated and light-headed. He did not respond to
questions from his wife. When the emergency medical technicians arrived, his
blood pressure was 60 by palpation. IV fluids and oxygen were administered.
Vital signs obtained in the ER were blood pressure 60, heart rate 120 and
regular, temperature 38.9C (102F), and respiratory rate 30. A brief physical
examination revealed coarse rales approximately halfway up in the chest
bilaterally and inaudible heart sounds. An indwelling urinary catheter was
placed with drainage of 10 to 20 mL of dark urine. Chest x-ray revealed
bilateral interstitial infiltrates; ECG was unremarkable except for sinus
tachycardia. Antibiotics were administered, and the patient was transferred to
the ICU, where a right heart catheterization was performed. Pulmonary capillary
wedge pressure was 28 mmHg. Cardiac output was 1.9 L/min. Right atrial mean
pressure was 10 mmHg. The most likely cause of this man's hypotension was
A)left ventricular dysfunction

B)right ventricular infarction

C)gram-negative sepsis
D)gastrointestinal bleeding
E)pulmonary emboli
Right answer: A

125. A 53-year-old man presents to the emergency room after the acute onset
of chest pain. The episode occurred 8 h prior to his arrival and lasted for a total
of 20 to 30 min. The chest pain is now resolved. The patient has a long history
of diabetes mellitus and hypocholesteremia and has smoked approximately 1 to
1 1/2 packs per day of cigarettes for the past 30 years. On physical exam he has
a blood pressure of 84/52, and his pulse is 54. He has jugular venous distention
to the angle of the mandible and clear lung fields. His rhythm strip reveals a
Wenkebach pattern. Given his hypotension, a Swan-Ganz catheter is placed.
Right atrial pressure is estimated at 16 mmHg (normal 0-5), pulmonary artery
pressure at 20/10 mmHg (normal 12-28/3-13), and the pulmonary capillary
wedge pressure is 8 mmHg (normal range 3-10). Which of the following is most
consistent with this clinical picture?
A)An anterior wall myocardial infarction
B)A right ventricular infarction
C)A ruptured mitral valve leaflet
D)A constrictive pericarditis following a myocardial infarction
E)A lateral wall myocardial infarction

Right answer: B

126. Examination of the carotid pulse reveals two impulses or peaks during
ventricular systole. Which of the following physical findings probably would be
associated with this finding?
A)Diastolic murmur beginning after an opening snap

B)Decrease in systolic arterial pressure during inspiration

C)Systolic murmur increasing during the Valsalva maneuver
Right answer: C

127. Digitalis glycosides enhance myocardial contractility primarily by

which of the following mechanisms?
A)Opening of calcium channels
B)Release of calcium from the sarcoplasmic reticulum
C)Stimulation of myosin ATPase
D)Stimulation of membrane phospholipase C
E)Inhibition of membrane Na+, K+-ATPase
Right answer: E

128. A 65-year-old man with a long history of untreated hypertension

complains of recurrent shortness of breath on minimal exertion. Examination of
the cardiovascular system is normal except for a prominent precordial impulse.
Chest x-ray is normal except for a prominent left ventricular shadow. An
exercise tolerance test with thallium scanning reveals no evidence of
myocardial ischemia. Two-dimensional echocardiography reveals left
ventricular hypertrophy. Radionuclide ventriculography reveals normal right
and left ventricular ejection fractions. What is the most likely explanation for
the patient's symptoms?
A)Chronic obstructive pulmonary disease
B)Reactive airways disease
C)Systolic congestive heart failure
D)Diastolic congestive heart failure
E)Myocardial ischemia
Right answer: D

129. Clues to the presence of atrioventricular nodal block (as opposed to

trifascicular block) include which of the following?
A)Clinical evidence of inferior myocardial infarction
B)No change in the escape rhythm with exercise
C)An escape-focus rate slower than 40 beats per minute
D)A widened QRS complex at the escape focus
E)Unresponsiveness of the escape focus to atropine
Right answer: A

130. Which of the following agents has been shown to reduce mortality in
patients with congestive heart failure?
A)Digitalis
B)Furosemide
C)Enalapril
D)Procainamide
E)Aspirin
Right answer: C

131. Each of the following patients was noted to have an abnormally high
serum cholesterol and was placed on a reduced calorie, cholesterol, and fat diet
for the past 3 months. None has any history of ischemic heart disease. In which
of the following patients would it be most appropriate to recommend lipidlowering drug therapy at this time?
A)A 52-year-old smoker and diabetic with an LDL cholesterol value of 3.2
mmol/L (120 mg/dL)
B)A 60-year-old hypertensive woman with an LDL cholesterol value of 3.5
mmol/L (140 mg/dL)
C)A 50-year-old man with cholesterol of 6 mmol/L (230 mg/dL)
D)A 45-year-old man with LDL cholesterol of 5 mmol/L (200 mg/dL)

E)A 58-year-old male smoker with cholesterol of 5.5 mmol/L (220 mg/dL) and
LDL cholesterol of 4 mmol/L (150 mg/dL)
Right answer: D

132. A 20-year-old woman has mild pulmonic stenosis (transvalvular

gradient is 20 mmHg). Which of the following statements regarding this
situation is true?
A)Heart size on chest x-ray is likely to be enlarged
B)Electrocardiogram is likely to be abnormal
C)There is loss of the jugular a wave
D)Compared to other valvular defects, the risk of endocarditis is relatively low
E)Frequent monitoring for progression of the stenosis is indicated
Right answer: D

133. Which of the following findings would be expected in a person with

coarctation of the aorta?
A)Both a systolic murmur and a diastolic murmur would be heard best along
the left sternal border
B)A higher blood pressure in the left arm than in the right
C)Inability to augment cardiac output with exercise
D)Often associated with a bicuspid aortic valve
E)Hypertension typically resolves after complete surgical repair
Right answer: D

134. A 15-year-old boy residing with his parents on a military base presents
with a fever of 38.6C (101.5F) and complains of lower back, knee, and wrist
pain. The arthritis is not localized to any one joint. He gives a history of a
severe sore throat several weeks earlier. Physical examination of the skin

reveals pea-sized swellings over the elbows and wrists. He also has two
serpiginous, erythematous pink areas on the anterior trunk, each about 5 cm in
diameter. Laboratory investigation includes negative blood cultures, negative
throat culture, normal CBC, and an erythrocyte sedimentation rate (ESR) of
100. An antistreptolysin-O (ASO) titer is elevated. At this point, appropriate
therapy would consist of
A)supportive care alone
B)parenteral penicillin
C)parenteral penicillin and glucocorticoids
D)parenteral penicillin and aspirin
E)parenteral penicillin, aspirin, and diazepam
Right answer: D

135. A 72-year-old man with a long history of tobacco use presents to the
emergency room with shortness of breath. He is mildly cyanotic and
hypotensive. On exam he has poor air movement bilaterally and has evidence
of an elevated jugular venous pressure. A Swan-Ganz is placed revealing right
atrial pressures of 15 mmHg (normal range 0-5), a pulmonary artery pressure
of 70/28 (normal range 12-28/3-13), and a pulmonary capillary wedge pressure
of 10 (normal range 3-11). Which of the following is most consistent with this
clinical picture?
A)Inferior myocardial infarction
B)Mitral stenosis
C)Cor pulmonale
D)Mitral regurgitation
E)Constrictive pericarditis
Right answer: C

136. A 14-year-old boy is brought into the emergency room pulseless and
undergoing cardiopulmonary resuscitation. He collapsed while playing
basketball. There is no history of trauma, and no prior history of cardiovascular
disease. Which of the following conditions would most likely be identified at
the time of autopsy?
A)Normal findings
B)Anomalous left coronary artery

C)Ruptured aorta
D)Hypertrophic cardiomyopathy
E)Coronary artery disease
Right answer: D

137. A 22-year-old female presents to your office with a history of

palpitations. You are able to capture the arrhythmia on the monitor in your
office: the rhythm strip shows evidence of isolated premature atrial contractions
(PACs). You take a history from this patient. She is taking no other medications
and there is no family history of any similar problems. All of the following are
salient points of the history with regard to PACs EXCEPT:
A)Aged cheese consumption.
B)Caffeine use.
C)Tobacco use.
D)Alcohol use.
E)COPD.
Right answer: A

138. Which of the following statements about PACs is true?

A)There is an increased incidence of PACs in patients with mitral valve
prolapse.
B)Mitral valve stenosis in patients without CHF is associated with PACs.
C)Bicuspid aortic valve in patients without CHF is associated with PACs.
D)None of the above is true.
Right answer: B

139. The patient is bothered by her PACs. She is rather aware of them and
finds them disconcerting. What is the best pharmacologic therapy to consider at

this point?
A)Metoprolol.
B)Amiodarone.
Right answer: A

140. Your congestive heart failure couple, as they now call themselves, are
doing so well that the wife refers her cousin to you. Her cousin, a 65-year-old
male, arrives at your office and you immediately notice the smell of tobacco
leaching from his clothing. The small burns in his clothing confirm to you that
he smokes, and he informs you that he has smoked 3 packs per day since I was
born. He recently he has noticed some swelling in his feet and increased
shortness of breath. He denies a history of cardiac disease. An ECG performed
in the office shows right axis deviation and a right bundle branch block. An
echocardiogram shows that he has normal left ventricular function but a
hypertrophied right heart with paradoxical bulging of the ventricular septum
into the left ventricle. This clinical picture is most consistent with which of the
following?
A)Constrictive pericarditis.
B)Chronic mitral valve prolapse.
C)Cor pulmonale.
D)Old right ventricular infarction with subsequent dysfunction.
E)Atrial myxoma.
Right answer: C

141. Cor pulmonale is the result of which of these processes?

A)Genetically determined muscular hypertrophy of the right ventricular muscle
fibers.
B)Calcium influx dysfunction in the right ventricular musculature.
C)Chronic cocaine abuse.
D)Chronic amphetamine use.

E)None of the above.

Right answer: E

142. Besides stopping smoking, the best treatment for this patients cor
pulmonale and pulmonary hypertension is:
A)Continuous prostacyclin infusion.
B)Continuous, low-flow oxygen
C)Calcium channel blockers (direct vasodilators to dilate the pulmonary
vascular bed).
D)Nitroglycerin.
E)Antibiotics to reduce pulmonary inflammation secondary to infection.

Right answer: B

143. A 75-year-old male presents to your office for a complete physical. On

exam, you notice a 3/6 systolic ejection murmur radiating to the neck. He has
never before been told that he has a murmur. You send the patient for an
echocardiogram, and the report notes mild aortic stenosis. Currently he is
asymptomatic.
The indications for valve replacement surgery in this patient include:
A)Grade 4/6 murmur.
B)Requirement for major, semi-elective surgery such as prostatectomy.
C)Evidence of left ventricular dysfunction.
D)None of the above.
Right answer: C

144. The patient would like to know how often he should have a repeat
echocardiogram given that he has mild disease. Your answer is:

A)Every 35 years.
B)Every year.
C)When he develops symptoms.
D)None of the above.
Right answer: A

145. Two years later, the patient returns for a checkup and states that he
believes he has been having symptoms from his aortic stenosis. All of the
following can occur with symptomatic aortic stenosis EXCEPT:
A)Left-to-right intracardiac shunt.
B)Syncope.
C)Angina.
Right answer: A

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