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

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 hepato-jugular) 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 end-diastolic 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

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 5-vessel
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

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

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

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

fE
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

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

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

10. Pericarditis is a term describing inflammation of

A.

the inside lining of heart chambers

B.

the tough sac surrounding the heart

C.

the muscular layer of the heart

D.

a coronary artery

E.

a heart valve

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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 crescendo-decreshendo
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
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
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
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
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
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
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
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
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
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
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
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

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

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
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
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
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
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
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
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
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
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
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
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 mid-systolic 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

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
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
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
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
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
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
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
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 S2 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 S1 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 S4 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 P2 component of the S2 heart sound?

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

66. A widened split S1 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 S3 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 P2 component of the S2 heart sound?

A) P2 occurs earlier

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

69.

ST segment elevation is indicative of

Infarction

Injury

Ischemia

70

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

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
C
71
Defined as the resistance to blood flow including opening of the aortic valves
and pushing blood through the arteries (peripheral vascular resistance).

heart rate

Afterload

Contractility

Preload
B
72
Unmodifiable risk factors for coronary artery disease include which of the
following?

low density lipoprotein levels, gender, obesity

sedentary lifestyle, race, oral contraceptive use

age, gender, family history, hyperlipidemia

hyperlipidemia, diabetes, stress, smoking

C
73

Angina is chest pain or discomfort and causes cell death.

This statement is true.

This statement is false.

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

This statement is true.

This statement is false.

A
75.
A patient who presents with gastrointestinal symptoms (nausea, vomiting,
indigestion) could be experiencing which type of MI?

Inferior

Anterior

Anterolateral

Anteroseptal

A
76.
Medical and nursing treatment for the patient with CHF consist of a threefold
approach: treatment of existing symptoms, prevention of further complications, and
treatment of the underlying cause.

This statement is true.

This statement is false.

A
77.
Hyperkalemia results in which of the following abnormal electrocardiographic
changes?

shortened QT interval

ventricular tachycardia

prominent U wave and prolonged T wave

increased conduction system block

D
78.
Medical intervention for patients experiencing angina include the
administration of nitrates, beta adrenergic blocking agents and calcium channel
blockers.

This statement is correct.

This statement is false.

A
79.
A gallop rhythm can be heard with the bell of the stethoscope at the fifth
intercostal space in a patient with

Hypovolemia

severely failing heart

fluid overload

over-forceful atrial contraction

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

S3

Murmur

Gallop

S4
B
81.

Closure of the pulmonic valve can be auscultated at the

second intercostal space, right sternal border

fifth intercostal space, left sternal border

third intercostal space, right sternal border

second intercostal space, left sternal border

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

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

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

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

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

B. diastolic failure

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%

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

B. diastolic dysfunction

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

F
90. A patient with chronic pulmonary hypertension will probable develop right or left
sided heart failure?
A. left sided

B. right sided

B
91. What is the most common valvular abnormality in adults?
A. tricupsid regurgitation

B. mitral valve stenosis

C. arotic regurgitation

D. aortic stenosis

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

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

A. 120-139/80-89

B. 140-159/90-99

C. >160/>100

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.

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

B. false

A
96. Stenosis of the renal artery can cause essential or secondary hypertension?
A. essential

B. secondary

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
D

98. Papillary musclea dysfunction can cause mitral regurgitation or stenosis?

A. mitral regurgitation

B. mitral stenosis

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

B. atrial fibrillation

C. ventricular tachycardia

D. ventricular fibrillation

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

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
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
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
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
D
105. Two weeks after hospital discharge for documented myocardial infarction, a 65year-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
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

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
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
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

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
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
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

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
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
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

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
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
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
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
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
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
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
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

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
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 1228/3-13), and the pulmonary capillary wedge pressure is 8 mmHg (normal range 310). 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

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
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
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 xray is normal except for a prominent left ventricular shadow. An exercise tolerance
test with thallium scanning reveals no evidence of myocardial ischemia. Twodimensional 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
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
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
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 lipid-lowering 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)

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
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
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

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
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
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.
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.
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.
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.
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.
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.

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.
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.

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.
A

http://www.cardiologysite.com
www.learntheheart.com
www.heartsite.com
http://highered.mcgraw-

hill.com/sites/0071402357/student_view