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For questions number 1-5, refer to scenario below:

A 62-year-old man came to emergenct room last night with chief complaint severe left chest

pain. After history taking, physical exam, lab tests and ECG, he was dx as having Myocardial

infarction. The blood test revealed :

  Total cholesterol: 285 mg/dL

  HDL: 20 mg/dL

  LDL: 185 mg/dL

  Triglyceride: 235 mg/dL

  CKMB 28 IU

He was hospitalized and given Atorvastatin 20mg once daily, low carbo low fat diet.

1.  Which blood test result is the most likely to determine his dx?A.  Cholesterol total

B.  HDL

C.  LDL

D.  Triglyceride

E.  CKMB

2.  What is the cause of increasing CKMB level?

A.  The undamaged part of the heart produces some enzymes to compensate

the dysfx of the damaged partB.  Increasing this enzymes synthesis is needed to maintain the undamaged

heart muscle metabolism optimally

C.  The damaged part of the heart releases the intracellularly enzymes into the

blood stream

D.  The growth factors stimulate this enzymes production in order to repair the

damaged part of the heart

E.  Heart dysfx causes physical inactivity that leads to less degradation of this

enzymes

3.  Tha patient must increase the HDL level bcoz HDL facilitates cholesterol uptake by

the liver. This uptake can be done bcoz liver is an organ that:

A.  Has ability to synthesize bile acid using cholesterol as its precursor

B.  Secretes HDL cholesterol into the bile duct

C.  Filtrates cholesterol from portal venous blood that enter to the liver

D.  Has receptors that suite to HDL apoprotein

E.  Can synthesize endogen cholesterol

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4.  In atherogenesis process, which of the cells below are mostly responsible for

appearance of more ECM inside the atheroma plaque?

A.  Smooth muscle celss

B.  Foam cells

C.  PMN cellsD.  Macrophages

E.  Endothelial cells

5.  Atorvastatin is given to reduce cholesterol level by:

A.  Inhibits HMG CoA synthetase

B.  Inhibits HMG CoA reductase

C.  Stimulates cholesterol degradation

D.  Stimulates bile acids synthesis from cholesterol

E.  Stimulates cholesterol excretion into the bile

6.  Human tissues use cholesterol to build cell membranes and also steroid hormone

synthesis. Which of the following lipoprotein below that transport cholesterol to the

tissue?

A.  HDL

B.  LDL

C.  IDL

D.  VLDL

E.  Chylomicron

For questions no 7-12, refer to scenario below:

Mr. A, 52 y/o man was hospitalized with left chest pain as his chief complaint and was dx as

having a myocardial infarction. His lab exam revealed high blood cholesterol level, high

blood triglyceride level, high LDL level, and low HDL level.

7.  This disease was basically caused by atherosclerosis of his heart blood vessel. Which

of these options below is the first step that initiates the development of the

atherosclerosis?

A.  Oxidation of LDL

B.  Endothelial injury

C.  Foam cell formation

D.  Fibrin clot formation

E.  Monocyte recruitment

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8.  Foam cell formation also played an important role in developing this condition. This

formatio was mostly caused by:

A.  Fusion of macrophages

B.  Uptake of cholesterol through LDL receptors

C.  Uptake of cholesterol thru scavenger receptorsD.  Increase of cholesterol synthesis inside the macrophages

E.  Increase of ECM synthesis inside the macrophages

9.  The pain was most probably caused by:

A.  Lack of ATP

B.  Lack of oxygen

C.  Accumulation of lactate

D.  Cardiac muscle cell lysis

E.  Cardiac muscle cell spasm

10. The most possible factor that lead to Mr. A condition was:

A.  His high cholesterol level

B.  His high triglyceride level

C.  His high LDL level

D.  His low HDL level

E.  His old age

11. Mr. A’s blood CK-MB level might be increased, bcoz:

A.  Lack of oxygen decreased the CKMB degradation

B.  Increased of CKMB synthesis by cardiac muscle cells

C.  Increased CKMB synthesis by skeletal muscle cells

D.  Liver hypoperfusion decreased the CKMB degradation

E.  Cardiac muscle cells lysis released the cell content, including CKMB, into the

blood circulation

12. If you measured the CKMB level 10hrs and 24hrs after Mr. A felt the pain, what was

the most possible result?

A.  10hrs and 24hrs CKMB level were both normal

B.  10hrs and 24hrs CKMB were both increased

C.  10hrs CKMB level was normal but 24hrs CKMB level increased

D.  10hrs CKMB level was increased but 24hrs CKMB level was back to normal

E.  10hrs CKMBlevel was increased but 24hrs CKMB level was less than normal

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13. The thorax is the superior part of the trunk between the neck and abdomen. The

thoracic skeleton takes the form of a domed birdcage, the thoracic cage.

Which of the following structures is most likely osteocartilaginous thoracic cage?

A. Clavicles

B. ScapulaeC. Diaphragm

D. Pectoral girdle

E. Costal cartilage

14.Thoracic cavity have the shape of a truncated cone, being narrowest superiorly, with the

circumference increasing inferiorly, reaching its maximum at the junction with the

abdominal portion of the trunk. The thoracic cavity is divided into three major spaces.

Which of the following structures is most likely thoracic cavity?

A. DiaphragmB. Esophagus

C. Sternal angle

D. Costal cartilages

E. Transverse thoracic plane

15. Ribs are curved, flat bones that form most of the thoracic cage. They are remarkably

light in weight yet highly resilient. Each rib has a spongy interior containing bone marrow

(hematopoietic tissue), which forms blood cells.

The typical ribs have the following components, EXCEPT:

A.  Head

B.  Neck

C.  Shaft

D.  Lamina

E.  Tubercle

16. Some muscles attached to and/or covering the thoracic cage are primarily involved in

serving other regions. Several muscles extend from the thoracic cage to bones of the upper

limb. Similarly, some muscles of the anterolateral abdominal wall, back and the neck

muscles have attachments to the thoracic cage.

Which of the following are muscles of the thoracic wall?

A.  Pectoralis major

B.  Pectoralis minor

C.  Scalene muscles

D.  Seratus anterior

E.  Serratus porterior

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17. These muscles occupy the intercostal space from the tubercles of the ribs posteriorly to

the costochondral junctions anteriorly. These muscles run inferioanteriorly from the rib

above to the rib below. Each muscle attaches superiorly to the inferior border of the rib

above and inferiorly to the superior border of the rib below.

Which of the following muscles is correct?A.  External intercostal

B.  Internal intercostal

C.  Innermost intercostal

D.  Levator costarum

E.  Transverse thoracic

18. A group of medical students were asked to observe on an open thorax surgery. After

removing the sternum, the surgeon come upon an organ slightly larger than a clenched fist,

lies in the middle of it.Which of the following statement is correct regarding the organ?

A.  It lies obliquely in the middle mediastinum

B.  Its base is directed anteriorly and slightly posteriorly

C.  Its apex is directed posteriorly and slightly inferiorly

D.  Two-thirds of it’s mass lies to the right of the midline of the sternum 

E.  It lies bare without fibrous cover on its outer surface

19. Which one is correct statement about the membranes that cover the said organ above?

A.  The pericardium is an open sac composed of two layers

B.  The epicardium is a fibroserous membrane that covers the heart and the roof og

great vessels

C.  The tough external layer, the serous pericardium is in continuation to central tendon

of diaphragm

D.  The internal surface of pericardium is glistening with fibrous membrane

E.  The fibrous epicardium is composed mainly of mesothelium, a single layer of cells

For Q number 20 to 22, refer to scenario below:

A 56-year-old man with a history of hypertension came to the ER complaining sustained

chest pain. The pain felt dull on his left chest and felt to his left neck as well, he felt it for the

last 1 hour. He said he had chest pain before but dissipates within 10 minutes. You were

told to perform ECG examination and found ST segment elevation on lead V4-V6

20. Which arterial occlusion is most possible cause of his symptoms?

A.  The SA nodal branch of the left coronary artery

B.  The AV nodal branch of the right coronary artery

C.  The marginal branch of the right coronary artery

D.  The anterior descending branch of the left coronary artery

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E.  The circumflex branch of the left coronary artery

21. Which of the vessel below is supplying venous blood from the affected area?

A.  Several marginal veins emptying into great cardiac vein

B.  The anterior ascending vein into left coronary veinC.  The middle cardiac vein

D.  The anterior coronary vein

E.  The small cardiac vein

22. What is the correct sentence regarding the patient’s pain? 

A.  The heart is sensitive to touch, cutting, cold and heat

B.  Accumulation of metabolic products stimulate pain endings in myocardium

C.  Afferent pain fibers runs laterally in the left and anterior cervical branches of

symphathetic trunkD.  The axons of these primary sensory neurons enters the spinal cord segments C5-C8

on the left side

E.  A reffered pain is a phenomenon where the pain is felt because the noxious stimuli is

not strong enough

For Q number 23 to 27, refer to image given below:

23. What number is pointing to atrioventicular valves?

A.  Number 11

B.  Number 13

C.  Number 5

D.  Number 9

E.  Number 1

24. Where would you find the trabeculae carnae?

A.  Number 11

B.  Number 12

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C.  Number 13

D.  Number 2

E.  Number 9

25. What is the function of the structure pointed by number 5?

A. To pump oxygenated blood to the whole body

B. To receive deoxygenated blood from the whole body

C. To prevent backflow to atrium during diastole

D. To prevent backflow to ventricle during systole

E. To deliver blood to the aorta

26. What is the correct explanation about structure pointed by number 9 ?

A. It forms most of the apex of the heart

B.The valveness pairs of right and left pulmonary veins enter its smooth-wall chamber

C. The tubular auricle with trabeculaecarnae forms the inferior part of its border

D. It has slightly thinner wall compared to its right counterpart

E. It is separated with the left ventricle by tricuspid valve

27. What is the correct sentence regarding structure pointed by number 6?

A. Receives blood from superior and inferior vena cava

B. Deliver blood to the aorta

C. Its blood drain to great cardiac vein

D. Has pectinate muscles on its wall

E. Supplied mainly by the right coronary artery

28. A 49 year old main complained of palpitation. He had history of hypertension since 4

years ago. On thoracic examination, you found the point of maximal impulse is at the level

of 5th intercostal space 2 cm to the left of the midclavicular line. Which part was being

actually assessed in the examination ?

A. Apex of the heart

B. Superior vena cava

C. Right ventricle

D. SA node

E. The base of the heart

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29. A 55 year old woman was brought to the emrgency room. she complained chest pain for

the ast hour. The pain was dull and it won't dissipate even after she rested. She also

complained breathing difficulty and excessive sweating. She has no history of having chest

pain, but usually lasted for 10 minutes then dissipates after taking rest. Her ECG record

shows sinus rythm with ST elevation in lead I, aVL. V4-V6. She was diagnosed with acutemyocardial infarct. Where is her electrical impulse originated ?

30. A. From the node in junction of the superior vena cava and the right atrium

B. From the node located in posteroinferior region of interatrial septum

C. From the walls of the ventricles

D. From the junction between atrial and ventricular myocardium

E. From the fibers that penetrated deep into subendocardial layer in ventricles

31. The pericardium is an enclosed sac covering the heart. During development, it has

formed reflections. Which of the sentences below is TRUE ?

A. The transverse sinus is found at the anterior surface of the heart

B. The oblique sinus connects the anterior and posterior part of the heart

C. The tranverse sinus separates the veins and arteries

D. The oblique sinus accessible by sliding one finger between the venous and arterial outlet

E. The oblique and tranverse sinus has a passage that connects them

32. A 2 year old girl came to the clinic with swelling in the leg and abdomen as a chief

complaint. her mother explained that at 8 month old, she was taken to a doctor because of

blusih lips and fingertips. She was diagnosed TOF. her parents refused operative treatment

then, and had chosen the conservative treatment. Where would you look for murmur?

A. At the elft parasternal line 3rd or 4th ICS

B. At the left midclavicular line, 5th ICS level

C. At the right parasternal line, 2nd ICS level

D. At the left parasternal line, 2nd ICS level

E. At the right midclavicular line, 5th ICS level

33. A 34 year old man was brought to the outpatient clinic complaining of shortness of

breath. He had shortness of breath even during rest since 3 days ago. He uses 3 pillows to

sleep, urinating more frequently than usuals especially at night. He noticed his feet become

swollen. He had history of rheumatic fever in his childhood, but didngt comply after the

initial visit. His physical exam shows T: 100/70, RR : 34x/min, PR: 112 x/min , JVP 5+3

cmH2O, PMI was found in the 5th intercostals space at the left midvlavicular line, S3 gallop,

holosystolic murmur at the apex, bilateral rales at the basal area in lung auscultation. Which

structure isrelated to his murmur ?

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A. The semilunar aortic leaflets

B. The double leaflet mitral valves

C. Chordae tendinae

D. Papillary muscles

E. The anterior and posterior cusps of tricuspid valve

34. After birth, when lungs circulation begins and obliterating the the oval foramen and

separating the right and left atria. Which of the following is the most likely caused of

obliterating the oval foramen after birth?

A. Premature closure of the oval foramen

B. the valve of the oval foramen is pressed against the septum primum

C. Excessive cell death andresorption of the septum primum

D. Pressure in the left atrium increases and the valve of the oval foramen is pressed againstthe septum secundum\

E. Extensions of the superior and inferior endocardial cushions grow along the edge of the

septum primum, closing the foramen ovals

35. A 9 year old boy present with complaints of numbness and tingling in both feet.

Examintaion reveals no pulse in the femoral artery, increased blood pressure in the arteries

of the upper extremities and enlarged intercostal veins. Which of the following congenital

heart diseases should be suspected?

A. Patent ductus arteriousus

B. Pre ductal coarctation of the aorta

C. Post ductal coarctation of the aorta

D. Double aortic arch

E. TOF

36. A 6 week old infant has a pulmonary infundibular stenosis, a large defect of the

interventricular septum and the right aorta arises directly above the septal defect from both

ventricular cavities and hypertrophy of the right ventricular wakk. The infant is cyanosis.

Which of the following congenita; heart disease is the most likely to be present ?

A. Patent ductus arteriosus

B. Ventricular septal defect

C. Coaarctaiom of the aorta

D. Dextrocardia

E. Tetrallogy of fallot

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37. During the fifth week, pairs of opposing ridges appear in the truncus. These

ridges twist around each other, foreshadowing the spiral course of the future septum.

 After complete fusion, the ridges form the aorticopulmonary septum, dividing the

truncus into an aortic and a pulmonary channel. When the conotruncal ridges fail to

fuse and to descend toward the ventricles, which of the following congenital heart

diseases is the most likely to be present?

 A. Transposition of the great vessels

B. Ventricular septal defect

C. TOF

D. PDA

E. Persistent Truncus Arteriosus

38. The aortic arches and the dorsal aorta perform transformation into the definitive

vascular pattern. Which of the following aortic arch is most likely transform into archof aorta?

 A. 2nd aortic arch

B. 3rd aortic arch

C. Left 4th aortic arch

D. Right 4th aortic arch

E. Left 5th aortic arch

39. A condition in which the aortic lumen below the origin of the left subclavian artery

is significant narrowed. The aortic narrowing primarily an abnormality in the media of

the aorta followed by intima proliferations. Which of the following congenital heart

diseases is the most likely to be above?

 A. Aortic valvular stenosis

B. Aortic valvular atresia

C. Probe patency of the ovale foramen

D. Coarctation of aorta

E. Interrupted aortic arch

40. A condition in which the conotruncal septum fails to follow its normal spiral

coarse and runs straight down, as a consequence, the aorta originates from the right

ventricle, and the pulmonary artery originates from left ventricle. It is usually

accompanied by an open ductus arteriosus.

Which of the following congenital heart diseases is the most likely to be present?

 A. Transposition of The Great Vessels

B. Ventricular Septal Defect

C. TOF

D. Persistent truncus areriosusE. PDA

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41. After birth, when lung circulation begins and pressure in left atrium increases, the

valve of the oval foramen is pressed against the septum secundum, obliterating the

oval foramen and separating the right and left atria. In about 20% of cases, fusion of

the septum primum and septum secundum is incomplete, and a narrow oblique cleft

remains between the two atria. Which of the following condition is the most likely tobe present?

 A. Atrial Septal Defect

B. Probe patency of oval foramen

C. Persistent truncus Arteriosus

D. Transposition of the Great Vessels

E. Premature closure of the oval foramen

42. Atrial septal defect is a congenital heart abnormality with an incidence of

6.4/10.000 births. One of the most significant defect is the ostium secundum defect,

characterized by a large opening between the left and right atria. Which of the

following is the most likely caused of the ostium secundum defect?

 A. Probe patency of oval foramen

B. Hypoplasia endocardial cushion

C. Excessive cell death and reposition of the septum primum

D. Inadequate development of the septum primum

E. Premature closure of the oval foramen

43. The aortic arches are embedded in the mesenchyme of the branchial arches and

terminate in the drsal aortae. With the formation of the successive branchial arches

,the aortic sac contributes a branch to each new arch, thus giving rise to a total of six

pairs of aortic arches.

The dorsal aortas and the aortic arches perform transformation into definitive blood

vessels.

Which of the following aortic arch is most likely transfom into ductus arteriosus

during intra uterine life?

 A. Left 2nd aortic arch

B. First aortic arch

C. Left 4th aortic arch

D. The Distal part of the left 6th aortic arch

E. The distal part of left 4th aortic arch

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44. The oval foramen normally closes during afterbirth, when lung circulation begins

and pressure in the left atrium increases. Occasionally, the oval foramen close

during prenatal life. This abnormality, leads to massive hypertrophy of the right

atrium and ventricle and underdevelopment of the left side of the heart. Death

usually occurs shortly right after birth. Which of the following condition is the mostlikely to be present?

 A. Oval foramen in premature infant

B. Probe patency of the oval foramen

C. Atrial septal defect

D. Transposition of the great vessels

E. Premature closure of the oval foramen

45. The sudden changes occurring in the vascular system at birth are caused by the

cessation of the placental blood flow and the beginning of the lung respiration. Which

of the following change is not occurring in the vascular system after birth?

 A. Closure of the umbilical arteries

B. Closure of the umbilical vein and ductus venosus

C. Closure of ductus arteriosus

D. Closure of the vitelline artery

E. Closure of the oval foramen

46. The lining of the inner walls of the heart’s chambers is termed the: 

 A. Visceral pericardium

B. Serous pericardium

C. Epicardium

D. Myocardium

E. Endocardium

47. The heart’s electrical conduction network found within the ventricular

myocardium is termed the:

 A. SA node

B. AV node

C. Bundle of HIS/ AB bundle

D. Left and right bundle branches

E. Purkinje fibers

48. Which tunic of an artery contains endothelium?

 A. Tunica interna/intimaB. Tunica media

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C. Tunica externa

D. Tunica adventitia

E. None of the above is true

49. The exchange of gases and nutrients between blood and tissues is a majorfunction of :

 A. Arterioles

B. Arteries

C. Capillaries

D. Veins

E. Venules

50. Which of the following statements about veins is correct?

 A. Venous valves are an extension of the tunica media

B. Up to one third of the total blood volume is stored in the venous circulation at any

given time

C. Veins have a small lumen in relation to the thickness of its wall

D. The flow of venous blood is not a major result of one’s blood pressure 

E. Veins have valve that prevent the backflow of the blood

51. The most abundant tissue element forming the media of the aorta is:

 A. Cardiac muscle

B. Smooth muscle

C. Collagen

D. Elastin

E. Cartilage

52. The most abundant tissue element forming the media of small, muscular arteries

is:

 A. Cardiac muscleB. Smooth muscle

C. Collagen fibers

D. Elastic fibers

E. Cartilage

53. The muscular layer of blood vessels is called:

 A. Tunica intima

B. Tunica media

C. Tunica adventitiaD. Endothelium

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E. Mesothelium

54. A prominent inner elastic membrane (internal elastic lamina), often appearinf in

cross section as a wavy o sinous line, is characteristic of:

 A. Muscular arteries

B. Small veins

C. Large veins

D. Venules

E. Capillaries

55. Vasa vasorum are:

 A. Blood vessels of the myocardium

B. Nerves that supply the blood vessels

C. Nerves of the heart

D. Blood vessels within the walls of the blood vessels

E. Blood vessels of he endocardium

56. A 50-year-old male came to Primary Health Care with chief complain discomfort

in his left chest. The doctor asks many question related to risk factor of heart

problem as working diagnosis. If the cholesterol level 250mg/dL, LDL 140 mg/dL and

normal triglyceride level, the nutritional supportive therapy of this patient is:

 A. Decrease only animal food sources in his dietB. Decrease lipid conmposition in his diets without the other nutrient

C. Low cholesterol food sources

D. Decrease total calorie and improve nutrient composition of cholesterol, triglyceride

and carbohydrate

E. Decrease total calorie and give supplementation

57. Sedentary lifestyle and high energy source intake contribute to higher risk factor

for endotel inflammation due to atherosclerosis with myocardia; infarction as

comorbidity. To reduce risk of coonary heart disease and lipid disorders:

 A. Reduce fat intake and balance fat composition between SAFA, MUFA and PUFA

B. Reduce protein intake and substitute lipoproteins for saturated fat

C. Fat intake and substitute trans-far for saturated fat

D. Reduce carbohydrate intake and substitute complex carbohydrate for simple

carbohydrate

E. Reduce protein intake and substitute with vegetables

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58. Medical Nutrition Therapy for Dyslipidemia include:

 A. Low saturated, low trans fat and low cholesterol diet

B. Moderate carbohydrate intake

C. Emphasize soluble fiber and lose weight as needed

D. Emphasize monounsaturated fats

E. All of the above

59. Limitation aof salt intake in heart failure needed for normalize water and

electrolyte balance. The regulation of fluid imbalance that results in cardiac edema,

thiss condition need restriction of specific mineral because it ineral* influence to fluid

balance:

 A. Potassium

B. Magnesium

C. CalciumD. Selenium

E. Sodium

60. Metabolic Disorder, a state of insulin resistance is commonly present in

dyslipidemia patient. Treatment for insulin resistance must direct toward:

 A. Without caloric restriction

B. Increased weight training activity and caloric restriction

C. Use drugs designed generally to reduce insulin resistance

D. Moderate fiber intake

E. Increase high intensity training

R, 22 month-old boy came to the clinic and you aret the doctor at the clinic. His

mother complaints with bluish discoloration of the lips, tongue and fingertips which

noticed since 2 months old and seemed to increase as he grows up.The bluish

discoloration is getting worse while cying.He was born as a first child, termed infant

and spontaneous.Birth weight was 3000g. For auscultation you heard a long loud 3/6

systolic ejection murmur best heard at upper left sternal border. You referred to the

pediatric cardiologist, and he diagnosed him TOF.

61. What are the classic descriptions of TOF?

 A. overriding aorta, pulmonary vein stenosis, VSD, PDA

B. overriding aorta, pulmonary artery stenosis, VSD, RVH

C. overriding aorta, pulmonary artery stenosis, VSD, LVH

D. ASD, pulmonary artery stenosis, VSD, LVH

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62. What are the x-ray showed for TOF?

 A. Egg shaped

B. Boot shaped

C. LVH

D. Increase pulmonary vascular markingE. Heart enlargement

63. Suddenly after defecation this child become paroxysm hyperapnea, what has

happened to this child?

 A. Tet spell

B. Breath holding spell

C. Apnea

D. Pneumonia

E. Sudden death

64. What is the first step you should do to treat the patient condition?

 A. Knee chest position

B. CPR

C. Diazepam per rectal

D. Sit position and oxygen therapy

E. Adrenaline IV

65. What are the complication for TOF?

 A. Rheumatic heart disease, Infective endocarditisB. Acute rheumatic fever, brain abscess

C. Cyanosis, PDA

D. Brain abscess, Infective endocarditis

E. Polycythemia, patent foramen ovale

66. Systolic ejection murmur from TOF originates from:

 A. Pulmonary vein stenosis

B. Infundibular stenosis

C. VSD

D. Overriding aorta

E. Tricuspid regurgitation

67. The following statement are important determinants of Rheumatic Fever and

rheumatic heart disease, EXCEPT

 A. Poverty, under nutrition, overcrowding, poor housing

B. shortage of resources for health care

C. in adequate diagnosis and treatment of streptococcal pharyngitis

D. Expertise of health-care providers in tertiary center

E. Low level awareness of the disease in the community

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68. The following statement is NOT TRUE for rheumatic fever:

 A. Rheumatic fever is delayed suppurative

complication of Group A streptococcal pharyngitis

B. The clinical manifestation and its severity its

determined by host genetic susceptibility, thevirulence of the infecting organism and

conducive environment

C. Streptococci serogroup of B, C, G and F can cause

pharyngitis and have not been linked to the

etiology of RF or Rheumatic heart disease

D. An aoutomimmune response to streptococcal

antigen mediates the developmemt of RF and

RHD in a susceptiblr host

E. The activation of T-cell and B lymphocytes by

streptococcal antigen and superantigens which

Results in the production of cytokines and

antibodies directed against streptococcal

carbohydrate and myosin

69. The major clinical features of RF are, EXCEPT 

 A. Carditis

B. Sydenham chorea

C. AnthralgiaD. Subcutaneous nodule

E. Erythema marginatum

70. Clinical features of rheumatic carditis which may find on physical examination,

EXCEPT 

 A. Audible friction rub

B. Unexplained congestive heart failure or cardiomegaly

C. Continuous murmur at ICS II left sternal border

D. Presence of apical holosystic murmur at mitral regurgitation

E. Basal early diastolic murmur

71. the statement are NOT TRUE for secondary prevention of RF

 A. The purpose is to prevent the colonization or

infection of the upper respiratory tract with

Group A beta-hemolytic streptococci and the

development of recurrent attacks of RF

B. Life-long IV injection of benzathinebenzylpenicillin every three weeks in patient post

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  mitral replacement for rheumatic heart disease

C. For patient allergic to penicillin, oral sulfadiazine

or sulfasoxazole are acceptable substitute

D. Life-long Penicillin V 250mg orally taken twice

daily In patient with carditis post initial attackRheumatic fever

E. If the patient is allergic both to penicillin and sulfa

drugs, or if these drugs are not available, oral

erythromycin may be used

For question 72 and 73 refer to scenario below:

 A 50 year old male was hospitalized with chronic cough and progressive shortness

of breath which have marked increasely since one week. He has been a heavy

smoker since youth. On examination he was dyspneic and slightly cyanotic. His

chest was hyper inflated and wheezing as well as scattered moist rales was heard.

The pulmonic component of his heart sound was increased. His liver was enlarged

and there was bilateral ankle edema.

72. Most likely finding on chest radiography would be:

 A. An enlarged left atrium and right ventricle

B. A widened pulmonary artery and pulmonary emphysema

C. Chronic bronchitis and pulmonary emphysema

D. Pulmonary tuberculosis and pericarditis

E. Pulmonary edema

73. Cyanosis in this patient is caused by one of the following factors:

 A. Shunting of systemic venous into the arterial circuit

B. Reduced cardiac output

C. Arterial blood oxygen unsaturation

D. Peripheral cutaneous vasoconstriction

E. Ventilation-perfusion inequality

74. A 28-year-old woman came to the emergency unit with complaints of dyspnea on

ordinary activity. Physical findings revealed a diastolic thrill at the apex, an

accentuated P2 and low pitched diastolic murmur at the apex. What is the most likely

diagnosis of this patient?

 A. Mitral valve prolapse

B. Pulmonal regurgitation

C. Aorta regurgitation

D. Mitral stenosis

E. Tricuspid stenosis

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75. The compliance of the left atrium is an important determinant of the

hemodynamic and clinical picture in mitral regurgitation. Which of the following

statement is TRUE?

 A. Moderately increased compliance is most commonly seen in acute mitral

regurgitationB. In acute mitral regurgitation, the left atrial compliance is normal

C. Markedly increased compliance can be found in chronic mitral regurgitation

D. Slight enlargement of the left atrium is common in chronic mitral regurgitation

patients

E. In chronic mitral regurgitation, the left atrial pressure is markedly elevated

76. Which of the following statements regarding aortic stenosis is NOT TRUE?

 A. Atrial contraction plays an important role in filling the left ventricle

B. Atrial contraction prevents pulmonary congestion

C. Atrial fibrillation may precipitate heart failure

D. Left ventricular end-diastolic volume usually remains normal

E. Left ventricular mass decreases in response to the chronic pressure overload

77. The complication of valvular heart disease that can be detected by laboratory is:

 A. Genetic anomaly

B. Carcinoid syndrome

C. Bacterial endocarditis

D.Rheumatic fever

E.Congenital defects

78. Unstable angina pectoris is characterized by:

 A. Angina during exercise

B. Angina pain relieved with sublingual nitrate

C. Angina of less than 10 minutes

D. First onset angina

E. Angina relieved after rest

79. A patient with symptoms of acute myocardial infarction has ST-segment

depression of 2mm on the ECG in the lead I and aVL. This may reflect:

 A. Inferior wall infarction

B. Anterior wall infarction

C. Anteroseptal wall infarction

D. High lateral wall infarction

E. Anterolateral wall infarction

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80. A gentleman came to the ER complaining of chest pain of first onset lasting for

10 minutes that occurred 2 hours ago. The ECG did not show any changes

indicating ischemia.

What is the proper management of this patient?

 A. Do a treadmill testB. Treat as a patient with acute coronary syndrome and send him to the in-patient

ward

C. Treat as a patient with acute coronary syndrome and send him to the coronary

care unit

D. Observe patient and do serial cardiac markers and ECG tests

E. Send him home because this is not an emergency case

81. Which of the following statements regarding the mechanism of heart failure is

TRUE?

 A. Salt and water retention leads to the long-term maladaptive response of cell death

B. Hyperplasia and apoptosis play a large role in myocardial remodeling

C. A systemic compensatory mechanism for heart failure is decreased oxygen

extraction by tissues

D. Maladaptive remodeling of myocytes occurs long before clinical heart failure

begins

E. The role of neurohormones in heart failure is to protect perfusion pressure

82. All of the following statements regarding the ECG of a patient with history of

coronary disease below are true, EXCEPT:

 A. Sinus rhythm with 1st degree AV block

B. Myocardial infarction, age undetermined

C. PVC with on R-on-T phenomenon

D. Pair of PVCs

E. Ventricular tachycardia

83. Which of the following statements regarding atrioventricular block is NOT TRUE?

 A. Second-degree AV block type I is usually located at the AV-nodal level

B. Second-degree AV block type II is usually located at the infranodal level

C. Asymptomatic patients with a third-degree AV block at the AV-nodal level should

have permanent pacing

D. There is a slight variation in the P-P interval in patients in sinus rhythm and third-

degree blockE. Pacing is not the indicated in patients with first-degree AV block

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84. Which of the following statements regarding electrical abnormalities in the heart

and sudden cardiac death is TRUE?

 A. Arrythmic events in patients with long-QT syndrome 1 are often triggered by

auditory stimuliB. The risk of sudden death in Wollf-Parkinson-White syndrome is high and often

occurs in other healthy individuals

C. Patients with idiopathic polymorphic ventricular tachycardia have a good

prognosis

D. Younger patients who have survived SCD have a higher incidence of idiopathic

ventricular fibrillation

85. Compared with stable atherosclerotic plaque, composition of unstable

atherosclerotic plaque is characterized as consisting of:

 A. Thick fibrous capB. More inflammatory cells

C. Less foam cells

D. More smooth muscle cells

E. Small lipid core

86. A 64-year-old woman was diagnosed as heart failure for the last 1 year. Last

year she can have her regular work without symptom. But now she

experience shortness of breath in her daily activity. Which functional class

according to the New York Heart Association classification does she has

now?

 A. Class IB. Class II

C. Class III

D. Class IV

E. Between class III and IV

87. A 44-year-old male come to the hospital to have a medical check up. After

completed the test he was told that he has cardiac abnormality. The doctor

showed the electrocardiography.

What is the abnormality in the rhythm strip?

 A. Premature junctional contraction

B. Premature atrial contraction with aberrant conduction

C. Premature atrial contraction

D. Premature atrial contraction with sinus arrhythmia

E. Premature ventricular contraction

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88. Which of the following is the most likely approach to the older patient with

suspected valvular disease?

 A. Physically examination can reliably assess the severity of valvular

lesions in most older patients

B. Doppler echocardiography is the clinical standard for diagnosis andevaluation of the severity of valve lesions

C. Age is not a predictor of worse outcomes for the natural history of

valvular lesions, as well as surgical approaches

D. Surgery is not definitive therapy for valvular lesions

E. Antibiotic prophylaxis should not be used to prevent bacterial

endocarditis

For questions number 89 to 90, refer to scenario bellows.

Since 3 years ago, Mr. Fahmi usually takes medications when he feels chest pain.He has been controlling regularly for his blood cholesterol level. He just got the

laboratory result yesterday; his blood cholesterol level was 289mg/dL. The doctor

prescribed some medications and gave dietary program for his cholesterol. The

medications were ISDN, simvastatin and acetylsalicyl acid.

89. When is the best time to consume the drug for lowering the blood cholesterol

level that has been prescribed by the doctor?

 A. Morning

B. At the midday

C. AfternoonD. Evening

E. Midnight

90. How is the mechanism of action of the antiplatelet drug that has been

prescribed by the doctor?

 A. Irreversibly inhibits COX1 and COX2 

B. Reversibly inhibits COX1 

C. Reversibly inhibits COX2 

D. Irreversibly inhibits COX1 selectively

E. Irreversibly inhibits COX2 selectively

91. Mr. Zendy, 59 years old man, was admitted to the emergency room becauseof shortness of breath. After being interviewed and examined by the doctor,

she was diagnosed as acute heart failure. What is the first line therapy for the

patient?

 A. Diuretics and vasodilator

B. Diuretics and ACE inhibitors

C. ACE inhibitors and diuretics

D. ACE inhibitors and angiotensin receptor antagonist

E. Diuretics and aldosterone antagonist

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For questions number 92 to 93, refer to scenario below:

Mrs. Xency, 60 years old woman, was admitted to the Emergency Room because of

shortness of breath and cold sensation in extremities. After being interviewed and

examined by the doctor, she was diagnosed as cardiogenic shock and she was

given dobutamin injection, and then referred to intensive cardiac care unit.

92. How is the mechanism of action of the drug given to the patient?

 A. Inhibits Na-K-ATPase

B. Reduces Ca expulsion

C. Activities adenylyl cyclase

D. Inhibits angiotensin converting enzyme

E. Reduce aldosterone secretion

93. What will happen if the patient suffered from toxicity of the drug given?

 A. Hypokalemic

B. ArrhythmiasC. Cough

D. Diarrhea

E. Hypomagnesia

94. A 54-year-old man came to emergency with dyspnea. From history taking and

physical examination, he was diagnosed with CHF fc. IV. After given O2 and

was put on IV line, the patient needed immediate treatment of digoxin drip,

diuretic was put on IV line, and Calcium Slow Release. Which of the following

is the best diuretic choice for this patient?

 A. FurosemideB. Acetazolamide

C. Hydrochlorothiazide

D. Spironolactone

E. Mannitol

95. A 65-year-old man was brought to the doctor due to shortness of breath. He

notice a shortness of breath when climbing 1 flight of stairs and he frequently

awake at night due to a sensation of “lack of air” for the last year. Physical

examination revealed: BP 170/60 mmHg, HR 96 bpm, RR 28 x/min, laterally

apex beat, gallop rhythm, heart murmur, hepatomegaly, pretibial pittingedema, other in normal limits. One of prescribed drug was captopril. What is

the most expected effect of the drug besides decreasing blood pressure?

 A. Decrease heart rate

B. Relief dyspnea

C. Countering heart murmur

D. Myocardial remodeling

E. Reduce pretibial edema

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96. A 62-year-old man was brought to the doctor with an abrupt of chest pain for

half an hour, it is never lasted longer than 10 minutes. He denied have the

same experiences before. The doctor gave him propranolol. What is the most

expected mechanism of the drug?

 A. Negative inotropic and chronotropic effects

B. Vasodilation of coronary arteryC. Decreasing blood pressure

D. Increasing perfusion of the myocardium

E. Its effect on the bronchus

97. A 60 year old man came to emergency with dyspnea. From HT and PE , he was

diagnosed with CHF fc. IV. After given oxygen and was put on IV line , the patient

was planned digoxin and got arrhythmia . Which of the following is the most directly

describes the mechanism of action of the drug ?

A.  Decrease intracellular sodium concentration

B.  Increases the intracellular level of ATP

C.  Inhibit sodium - potassium ATPase

D.  Stimulates production of cAMP

E.  Decreases release of calcium from the sacroplasmic reticulum

98. A 60 year old man got heart attack. He was treated with digoxin and captopril

orally , and must be given furosemide 40 mg8 hr IV immediately. Which of the

following is the most appropriate prescription for the furosemide IV ?

A.  R/ Furosemide 40 mg IV /8 hr No I

S.s.d.d I

B. R/ Furosemide 40 mg / 2 ml Ampl. No III

S.I.m.m

C. R/ Furosemide 40 mg IV No. Amp. III

S.t.d.d I

D. R/ Furosemide 40 mg No. Amp. III

S.t.d.d I

E. R/ Furosemide 40 mg IV No IS.p.r.n

99. A 3 year old child has been suffering of dyspnea for one year , particularly after

physical activities. His CXR showed the heart is enlarged to the left with apex

downward to the diaphragm, the left upper border of the heart is prominent, the

aortic arch is small, the his are wider and the pulmonary vascular markings are

increased. Which of the following is the most likely diagnosis ?

A.   ASD

B.  PDA

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C.  VSD

D.  PTA

E.  PAPVR

100. Which of the following is found in CXR of CHF patient ?

A.  No cephalisation of vascular markings in upper part of the lungs

B.  Increased pulmonary markings in upper part of the lungs

C.  Increased pulmonary markings in lower part of the lungs

D.  No blurring of vascular markings in lower part of the lungs

E.  There are reticulonodular patterns in lower part of the lungs

101. Which of the following examination is the best to evaluate mitral regurgitation ?

A.  Cardiac CT scan

B.  Mediastinum CT scan

C.  MRI

D.  Thallium scanning

E.  Echocardiography

For question number 102 -103 , refer to scenario below :

Since 3 years ago , Mr. Fahmi usually takes medications when he felt chest pain. He

has been controlling regularly for his blood cholesterol level. He just got the lab resultyesterday ; his blood cholesterol level was 289 mg/dl. The doctor prescribed some

medication and gave dietary program for his cholesterol. The medication was ISDN ,

simvastatin and acetylsalicylic.

102. Which drug was used as anti platelet ?

A.   Acetylsalicylic

B.  ISDN

C.  Simvastatin

D.  Verapamil

E.  Captopril

103. How is the MOA of drug prescribed by the doctor for lowering the blood

cholesterol level ?

A.  Inhibit HMG-CoA reductase competitively

B.  Function primarily as ligands for the nuclear transcription receptor

C.  Inhibit VLDL secretion

D.  Activate guanylyl cyclase

E.  Increase the cGMP

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104. Post-mortem of histologic examination of the heart of the patient who died of a

confirmed AMI reveals coagulative necrosis of cardimyocytes , multiple small

haemorrhage and prominent PMN infiltration. What is the most likely “age” of MI in

this patient ?

A.  < 4 hr

B.  4 - 12 hrs

C.  12 - 24 hrs

D.  24 - 72 hrs

E.  4 - 7 days

105. Which of the following lab parameter most often associated with a VSD ?

A.  Leukopenia

B.  Thrombocytopenia

C.  Anemia

D.  Polycytemia

E.  Leukemia

106. Which of the following statements regarding the clinical use of CK-MB is correct

?

A.  CK-MB become elevated before myoglobin and Troponin I after MI

B.  CK-MB levels are normal in cases of cardiac ischemia

C.  Mass unit assay are more sensitive than the enzymatic methods

D.  An elevated CK-MB is always accompanied by an elevated CK

E.  CK-MB are specific for muscle injury caused by vigorous activity

107. A 46 year old male came to see the doctor complaining of chest pain. He also

sweating, malaise and headache. His BP was 150/105 mm/Hg. Family history

revealed that his father had diabetic and died at the age of 62 years old of AMI

secondary to DM. ECG revealed chafes from one done 6 months earlier. The

following results of the patient’s blood test ; CK: 400 U/L ( N: 50 - 350 ) , CK-MB : 4.9

ng/ml ( N< 5 ), AST : 35 U/L ( N: 5 - 30 ). What further cardiac markers should be run

on this patient ?

A.  CK-MM

B.  Troponin

C.  ALT

D.  Alkaline phosphatase

E.  CK-BB

108. Which apolipoprotein is inversely related to risk for coronary heart disease?

A.   Apoprotein AI

B.   Apoprotein B

C.  Apoprotein CII

D.  Apoprotein E IVE.   Apoprotein D

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109. A 61 year old female comes to the emergency department because of chest

pain. She has history of hypertension & does not take medicine regularly. She also

complaint of chronic fatigue after her daily activity. The doctor finds that she looks

severely ill, her blood pressure 170/110mmHg, pulse120 bpm & the heart soundmuffled. Which of the following is the most appropriate test to support diagnosis of

this patient?

 A. CK-MB

B. CPK

C. AST

D. ALT

E. LDH

110. Which of the following laboratory parameters is the most commonly associated

with congestive heart failure?

 A. Hyperkalemia

B. Hyponatremia

C. Hypernatremia

D. Hypercalcemia

E. Hypocalcemia

111. which of the following laboratory parameters is most often associated with

Tetralogy of Fallot?

 A. Leukopenia

B. ThrombocytopeniaC. Anemia

D. Polycytemia

E. Leukemia

112. A 46 y/o male come to see doctor complaining of chest pain. He has also

sweating, malaise and headaches. Family history reveals that his father had diabetic

& died at age 62 y/o of AMI. ECG reveal inverted T-waves on left precordial leads.

What cardiac maker should be run on this patient?

 A. CK-MM

B. Troponin T

C. ALT

D. LDH

E. CK-BB

113. A 45y/o women w complaints of chest pain for more than 30minutes an hour

before entering hospital & not relieved by rest.

What lab support you recommend to support diagnosis of AMI?

 A. Myoglobin

B. CK-MBC. Troponin T

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D. Troponin I

E. LDH

114. Several months later after medical checkup, Mr.Y taken to emergency

department because of suddenly left chest painand vague pain on left arm. Duringadmission in ICU, he was given the streptokinase therapy.

What is the most suitable lab test as monitoring for streptokinase?

 A. Activated thromboplastin time & prothrombine time

B. Prothrombin time & thrombocyte count

C. Activated thromboplastin time & thrombocyte count

D. Prothrombin time &D-Dimer

E. Activated thromboplastin time, D-Dimer & prothrombin time

115. A 35y/o man presents to Emergency Department following a car w several

muscle trauma & fracture. The patient getting blacked out while driving the car & now

has chest pain as well al wall tenderness. ECG examination is normal. The lab result

( 12hours after event) shows as below:

CK: 10,000 ng/ml ( N: 50-350 ng/ml), CK-MB : 150 ng/ml ( N:

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Question 117-118 refer scenario below:

 A 59 y/oman come to emergency w dyspnea . from HT & PE, he was diagnosed w

CHF fc.IV. After given O2 & was put on IV line, patient needed immediate treatment

of digoxindrip, diureticwas put on IV line & kalium slow release

117. which of following is best diureticchoice for this patient?

 A. Furosemide

B. Acetazolamid

C. Hydrochlorothiazide

D. Spironolactone

E. Manitol

118. Which of following is most appropriate prescription for diuretic?

 A. R/ Diuretic IV/ 8 hour No I S. s.d.d I

B. R/ Diuretic Amp. No III

S. I.m.m

C. R/ Diuretic IV No.Amp. III

S. 1.d.d.1

D. R/ Diuretic IV No.Amp. III

S. t.d.d.1

E. R/ Diuretic IV tab No. X

S. p.r.n

119. A 33y/o soldier present w a 5 day history of unremitting substrenal chest painthat radiated to his shoulders. The pain was worse when he was lying down &

improved when he lean forward. He reported having no dyspnea. He had no chest

wall tenderness & had not undergone any recent trauma. Lab analysis revealed no

elevation in white cell count & erythrocyte sedimentation rate. Blood culture

revealedno bacteria growth.

Which of following is most common virus that causethe disease?

 A. Herpes virus

B. Parvovirus

C. Coxsackie virus

D. Rubella virus

E. Measles virus

120. fungus & bacteria also can cause acute pericarditis. Which of following fungus

that can cause the disease?

 A. Candida sp

B. Aspergillus fumigates

C. Penicillium marnefei

D. Paracoccidioides

E. Cryptococcus

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121. Infection of the arteries such as aortitis is rare infection following bacteremia in

older persons with extensive atherosclerotic disease of the aorta. The cause of

infection could be from bacteremic intestinal infection.

Which of the following is the example one?

 A. Escherichia coliB. Salmonella

C. Shigella

D. Vibrio

E. Campylobacter

122. Patient with active tuberculosis can present with cardiac infection that usually

associated with concurrent pulmonary disease.

Which cardiac infection related to tuberculosis?

 A. Myocarditis

B. Endocarditis

C. Pericarditis

D. Aortitis

E. Thrombophlebitis

123. A doctor in charge in cardiology ward performs pericardiocentesis to a patient

suspected of chronic infective pericarditis and takes out some some bloody fluid.

What bacteria is most likely the cause?

 A. Pseudomonas aeruginosaB. Mycobacterium tuberculosis

C. Streptococcus pneumoniae

D. Haemophilus influenza

E. Staphylococcus aureus

124. A 45- year- old man admitted to hospital with low grade fever, night sweat,

fatigability, malaise, weight loss and valvular insufficiency. There’s also

erythematous subcutaneous nodules about the tips of digits and hemorrhagic retinal

lesion. After examine the patient, the doctor in charge thought that the man suffered

from subacute bacterial endocarditis.

What’s the common cause if the disease? 

 A. Staphylococcus aureus

B. Staphylococcus epidermidis

C. Streptococcus viridians

D. Streptococcus non haemolyticus

E. Streptococcus gamma haemolyticus

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For questions number 125 to 127, refer to scenario below:

 A 35-year- old man was found dead at home by the apartment manager, who had

been called by the decendent’s employer because of the failure to report to work for

past 3 days. An examination by the medical examiner showed splinter hemorrhages

under fingernails and no signs of trauma. The autopsy was done and the tissuesample from the tricuspidal valve was sent for Histopathological examination. The

microscopic appearance of the valve is shown in the figure below.

125. Which of the following laboratory finding is the most likely to provide evidence of

the cause of the disease?

 A. Positive ANCA determination

B. Elevated antistreptolysin O titer

C. High double stranded DNA autoantibody titer

D. Positive blood culture for Staphylococcus aureusE. Increased creatine kinase- MB fraction (CK-MB)

126. Which of the following structure is pointed by the blue arrow?

 A. Fibrin

B. Vegetation

C. Dead myocytes

D. Mononuclear cells

E. Polymorphonuclear cells

127. Which of the following structure is pointed by white stars?

 A. Fibrin

B. Vegetation

C. Dead myocytes

D. Mononuclear cells

E. Polymorphonuclear cells

For questions number 128 to 130, refer to scenario below:

Budi, a 55- year- old man experienced crushing substernal chest pain while playing

badminton one morning. His friend suggested that Budi went to hospital immediately,

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but Budi wanted to stay at home and take a rest. The pain was not subsided so he

decided to go to the hospital 5 hourslater when it began to radiate to his left arm. He

becomes diaphoretic and short of breath.

128. Which of the following microscopic ( light microscope) change that is most likelyappear in this patient’s myocardium while he was having rest at home? 

 A. No Histopathological changes can be seen

B. Beginning coagulation necrosis, edema and hemorrhage

C. Coagulation necrosis with loss of nuclei and dtriations and

interstitial infiltrate of neutrophils

D. Well- established granulation tissue with new blood vessels and

collagen deposition

E. Increased collagen deposition, with decreased cellularity

129. which of the following microscopic (light microscope) change that is most likely

appear in this patient’s myocardium before the pain radiate to his left arm?

 A. No Histopathological changes can be seen

B. Beginning coagulation necrosis, edema and hemorrhage

C. Coagulation necrosis with loss of nuclei and striations and

interstitial infiltrate of neutrophils

D. Well- establish granulation tissue with new blood vessels and

collagen deposition

E. Increased collagen deposition, with decreased cellularity

130. Regarding to the case above, if on echocardiography stiffening of the mitral

valves were found, which of the following statement is appropriate for the case?

 A. Large friable vegetation are seen on the mitral valve during

episodes of acute rheumatic fever

B. No fusion of the valve valve commisures may occur

C. Thinning of the chordae tendinae cause limitation of value mobility

D. A valve area of less than 2cm2 is defined as tight mitral stenosis

E. Fibrosis of the valve occurs

131. Postmortem histologic examination of the heart from the patient who died of a

confirmed acute myocardial infarction reveals coagulative necrosis of

cardiomyocytes, multiple small hemorrhages and prominent polymorphonuclear

Infiltration. What is the most likely “age” of myocardial infarction in this patient? 

 A. < 4 hours

B. 4- 12 hours

C. 12- 24 hours

D. 24- 72 hours

E. 4-7 days

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132. A 46- year- old female came to the outpatient clinic because of dilated veins in

her left leg. Physical examination revealed dilated superficial veins, bluish color in

left leg. Which of the following clinical conditions is most likely to complicate this

condition?

 A. Deep vein thrombosisB. Pulmonary thromboembolism

C. Systemic embolism

D. Gangrene

E. Ulceration

133. A newborn baby boy was observed at birth to be noncyanotic. The mother was

known to have been infected with rubella during the pregnancy. On examination, the

patient is found to have a continuous murmur that is present in both systole and

diastole. A non-steroidal anti-inflammatory drug was prescribed, and on follow-up,

the murmur was found to have disappeared. Which of the following is the most likely

congenital heart defect?

 A. Transposition of great arteries

B. Patent ductus arteriosus

C. Coarctation of aorta

D. Tetralogy of fallot

134. A 31 years old Caucasian male dies after seven days of a Dengue Hemorrhagic

Fever. Autopsy reveals a widely distended pericardial sac filled with serous fluid. The

heart is of normal weight. Both ventricular walls are of normal thickness and allchambers are of normal size. There is no history of cardiac abnormalities prior to

infection and a heart monitor during the course of illness shows no evidence of fatal

arrhythmia. Which of the following is the most likely mechanism for heart failure?

 A. Reduced preload

B. Increased preload

C. Increased afterload

D. Decreased afterload

E. Impaired contractility

135. A 1 year old boy is brought to the physician for routine health maintenance

examination. The physician notes a lesion on his cheek (shown in picture). The

lesion is excised and its microscopic appearance is shown in figure. Which of the

following is the most likely diagnosis?

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  A. Kaposi sarcoma

B. Angiosarcoma

C. Lymphangioma

D. Telangiectasia

E. Hemangioma

136. A 35 years old male who was a very heavy smoker came to outpatient clinic

because of pain in his left fingers. Physical examination showed gangrenous ulcer in

his left finger, Digit II – IV. Which of the following histopathologic change is the most

likely occur in this patient?

 A. Microabscess and thrombus in medium sized and small arteries

B. Microabscess and thrombus in medium sized and small veins

C. Microabscess and thrombus in large arteriesD. Microabscess and thrombus in large veins

E. Microabscess and thrombus in capillaries

137. In a clinical study of Tetralogy of Fallot, patients are examined before surgery to

determine predictors observed on echocardiography that correlate with the severity

of the disease and the need for more careful monitoring. A subset of patients is

found to have more severe congestive heart failure, poor exercise tolerance and

decreased arterial oxygen saturation levels. Which of the following is most likely to

predict a worse clinical presentation of these patients? A. Size of left ventricle

B. Diameter of tricuspid valve

C. Degree of pulmonary stenosis

D. Presence of an atrial septal defect

E. Size of the ventricular septal defect

For questions number 138 to 139, refer to scenario below:

 A 55 years old man died suddenly when he was watching a badminton final match. A

few hiurs before the game was started he complained of a chest pain.

138. Which of the following is the most likely type of this man’s death? 

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 A. Instant death

B. Not a sudden death

C. Sudden death

D. Natural death

E. Unnatural death

139. Which of the following is the most likely cause of death?

 A. Stagnant hypoxia

B. Anemic hypoxia

C. Histotoxic hypoxia

D. Anoxic hypoxia

E. Hypoxic hypoxia

140. A 50 years old man was found lying on the floor at 7.00 am, unawake and was

rushed to the hospital. Doctor found that there was cessation of cardiac function and

breathing. His family told him that he had breathing difficulty and edema in his

extremities since last year, but he seldom wnt to his doctor. The last time he was

seen alive was at 9.00pm last night, while he complained a little bit chest discomfort.

The doctor found no sign of trauma on his body and declared death on arrival (DOA).

Which of the following is the most likely type of this man’s death? 

 A. Unnatural death

B. Natural death

C. Accidental

D. HomicidalE. Suicidal

141. A 60 years old man was found lying on the floor at 7.00 am, and was rushed to

the hospital. Dr. Green declard him Death on Arrival. His wife told him that her

husband was often suffered from chest pain within the last two years. The last time

he was seen alive was at 9.00 pm last night while he was going to bed. Which of the

following statement is the most likely importance to establish the manner of the

patient death?

 A. To file a police report for investigation of death

B. To improve police method in death investigation

C. To improve our knowledge in cardiovascular disease

D. To decide whether a death certificate should be issue

E. To determine factors contributing to the cause of death

For questions number 142 to 143, refer to scenario below:

Mrs. Brown, a 45 years old man was found lying on the bathroom floor at 6.00 am,

unawake, and was rushed to the hospital. Dr Green examined her vital signs and

declared her death. Her medical record showed that Mrs. Brown suffered from

hypertension for years. Her husband told Dr Green that the last time she was seen

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alive was at 12.00 am last night before she was going to bed. Dr Green has a doubt

because he found two round bruises on her neck, just below her left and right jaw.

142. To make sure whether Mrs. Brown is dead or not, the doctor should examine

her pulse, respiration and: A. Ventilation

B. Pupil reflex

C. Babinsky reflex

D. Electro encephalogram

E. Peripheral nerve reflex

143. What kind of objective examination the doctor has to do to estimate the time of

death?

 A. Post mortem rigidity

B. The size of the pupils

C. Electro encephalogram

D. The color of the bruises

E. Information from the family

144. A man, 50 years old, comes to your clinics, complaining fatigue since 1 year

ago with leg swelling. After several examinations and diagnostic tools, he was

diagnosed having Pulmonary Hypertension. What do you expect of his mean

pulmonary artery pressure (mPAP) measured by right heart catheterization (RHC)

procedure? A. 20 mmHg. His systemic blood pressure is 110/80

B. 15 mmHg. His systemic blood pressure is 130/75

C. 25 mmHg or more, whatever his systolic BP

D. 20 mmHg while exercise

E. More than 15 mmHg if his systemic blood pressure is 150/75

145. A 64 y.o. woman was diagnosed as heart failure for the last 1 year. Last year

she can have her regular work without symptom. But now she experienced

shortness of breath in her daily activity.

Which functional class according to the New York Heart Association classification

does she has now?

 A. Class I

B. Class II

C. Class III

D. Class IV

E. Between class III and IV

146. Mr. TS, a 50 y.o. man had suffered for hypertension for last 5 years. To

maintain the hypertension and other related cardiac event, you as his doctor weregiven anti hypertension drug and aspirin. Aspirin was known as anti-platelet drug to

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inhibit the thrombus formation.

What kind of laboratory examination that you suggest to Mr. TS as monitoring of

aspirin therapy?

 A. Prothrombin time

B. Activated partial thromboplastin timeC. Thrombocyte

D. Fibrinogen

E. D-Dimer

147. 8 hours after Mrs. AM chest pain, the blood was drawn and taken to the

laboratory for several examinations. The laboratory results as followed: Hb 12.5 g/dl

(12-16 g/dl), Hct 36% (36-48%). Leukocyte 7000/mm3 (5000  –  10000/mm3).

Thrombocyte count 220.000/mm3 (150.000-300.000/mm3). CKMB 6 ng/mL (normal:

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E. The troponin T will be reported as range concentration in ng/mL

150. In the normal ECG the average duration of the action potentials of the

ventricular myocardium is indicated by:

 A. T waveB. QRS segment

C. ST segment

D. QT interval

E. PR interval

151. One of the most important functions of nervous control of the circulation is its

capability to cause very rapid increases in arterial pressure. For this purposes the

entire vasoconstrictor and cardio accelerator function of the sympathetic nervous

system are stimulated as a unit, resulting:

 A. Almost all arterioles of the body are constricted

B. The veins especially but the other large vessels of the circulation as well are

strongly constrictor

C. The heart itself is directly stimulated by autonomic nervous system

D. Enhancing cardiac pumping and increase heart rate

E. All above

152. The fourth heart sound is caused by:

 A. Closure of the aortic and pulmonary valves

B. Vibrations in the ventricular wall during systoleC. Ventricular filling at the end of diastole

D. Closure of the mitral and tricuspid valves

E. Retrograde flow in the vena cava

153. During cardiac cycle, contraction is occurring in the ventricles, but there is no

emptying. This is called:

 A. Period of Ejection

B. Period of Isovolemic (Isometric) Contraction

C. Period of Isovolemic (Isometric) Relaxation

D. End – Diastolic period

E. End – Systolic period

154. A 50 y.o. male came with peripheral edema due to heart failure and kidney

failure. He has shortness of breath and low albumin level.

Which of the following condition most likely cause decreasing of lymph flow?

 A. Interstitial hydrostatic pressure

B. Plasma colloid osmotic pressure

C. Capillary hydrostatic pressureD. Interstitial osmotic colloid pressure

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E. Capillary hydraulic permeability

155. On WOTF ventral surface of the chest is the second component of the heart

sound is usually most clearly heard?

 A. Second intercostal space to the right (patient’s right) of the sternum B. Second intercostal space to the left of the sternum

C. Fifth intercostal space to the left of the sternum

D. Fifth intercostal space at the sternum

E. Ventral tip of the xiphoid process.

156. in young people, the 2nd  heart (S2) is often split (has two audibly distinct

components).

 A. Increased filling of the left ventricle during inspiration

B. Increased filling of the left ventricle during expiration

C. Decreased ejection from the left ventricle during expiration

D. Increased filling of the right ventricle during inspiration

E. Decreased filling of the right ventricle during expiration

157. A 2y.o male ruptures his spleen in a motorcycle accident. A reduction in blood

pressure would cause a decrease in WOTF?

 A. Heart rate

B. Myocardial contractility

C. Total peripheral resistance

D. Venous complianceE. Venous compliance

158. If cardiac output =5.6L/min, heart rate=70bpm and end systolic volume=100mL;

then end diastolic volume and stroke volume are respectively:

 A. 180 and 70

B. 190 and 80

C. 170 and 70

D. 200 and 120

E. 180 and 80

159. WOTF statements concerning mitral valve is CORRECT?

 A. It requires the contraction of the papillary muscle in order to initiate closing

B. A systolic murmur is produced when it fails to close properly

C. It closes at the end of isovolumic contraction

D. It normally closes during PR interval

E. It prevents backflow of blood into ventricle during diastole

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160. A 30y.o female was admitted to the emergency room with palpitation. The

palpitation started one day before admission, which was felt as rapid and irregular

heart beat. She had also compliant of shortness of breath (SoB) in the last few

weeks, which worsen to dyspnea even at rest, after the palpitation occurred. She

was hospitalized two month ago, due to dyspnea on mild exertion accompanied witheasy fatigability and SoB.

3 month ago she was hospitalized because of heart disease and discharged after 10

days. At home, she continued to take medication a small white tablet which increase

her urination, but d=she refused to follow up. From PE found her pulse was irregular,

unequal, with a rate of 128bpm. Her heart was enlarged; S1 was variable with

normal S2 and no discernible cardiac murmur. The heart rate was irregularly

irregular with a rate 150bpm. The electrolytes examination showed sodium

concentration of 133mEq/L and potassium concentration of 2.5mEq/L. Hypoxemia,

with a normal pH was found in the blood gas analysis.

Sodium enters the cell during the upstroke of the action potential. What is the major

mechanism for removing Na from the cell?

 A. It passively diffuses out of the cell

B. It is extruded via an ATP-independent Na-Ca pump

C. It is extruded via an ATP-dependent Na-Ca pump

D. It is extruded via an ATP-independent Na-K pump

E. It is extruded via an ATP-dependent Na-K pump

161. WOTF is the best index of preload?

 A. Blood volumeB. Central Venous Pressure

C. Pulmonary Capillary wedge pressure

D. Left Ventricular end-diastolic volume

E. Left ventricular end-diastolic pressure

162. A 24y.o man goes to athletic field to exercise. He runs for 1 hour. WOTF are

physiologic changes of CVS found in that person?

 A. Decrease in pulmonary arterial pressure

B. Increase in pulmonary arterial pressure

C. Increase in total peripheral resistance

D. Decrease in diastolic pressure

E. Increase in stroke volume

163. A 50y.o woman came to the cardiology department for cardiac function

evaluation. She was diagnosed having prolapsed mitral valve. WOTF values is the

best index of preload on her heart?

 A. Blood volume

B. Central Venous Pressure

C. Pulmonary Capillary wedge pressureD. Left Ventricular end-diastolic volume

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E. Left ventricular end-diastolic pressure

164. A 48y.o male came to ER with intermittent chest pain. There was no myocardial

infarction based on ECG and blood test, but there was thickening of the left

ventricular muscle and narrowing aortic valve. The doctor gave him medication tolower the after load. WOTF values would provide the best measure of the

effectiveness of the medication?

 A. Left ventricular end-diastolic pressure

B. Left Ventricular end-diastolic volume

C. Pulmonary Capillary wedge pressure

D. Total peripheral resistance

E. Mean arterial blood pressure

165. A 22y.o male ruptures his spleen in a motorcycle accident. Reduction in blood

pressure cause a decrease WOTF?

 A. Heart rate

B. Myocardial contractility

C. Total peripheral resistance

D. Venous compliance

E. Cardiac output

166. A 30y.o healthy male just reclining from supine position. WOTF body adaptation

most likely occurred?

 A. Decreased peripheral resistance

B. Decreasing heart rate

C. Increasing sympathetic stimulationD. Decreasing parasympathetic stimulation

E. Increasing calcium plasma

167. A 35 y/o male was brought by the police to the ER due to traffic accident. He

was in hypovolemic condition. The doctor gave him oxygen therapy. Which of the

following reason is most likely correct for oxygen therapy?

 A. Inhibit chemoreceptor

B. Basic life support

C. Prevent decrease level of consciousness

D. Increase met Hb

E. Decrease bonding between Hb and CO2 

168. The expansion and widespread application of cardiac catheterization has been

established, from just investigate tool, become therapeutic innovations based on

advanced catheter technologies. Which is the best true statement about

interventional procedures and its purposes?

 A. Cardiac resynchronization therapy in Acute Coronary Syndrome

B. Trans-venous pacemakers for advanced heart failure

C. Right heart catheterization for LV dysfunctionD. Intra-aortic balloon pump for cardiogenic shock

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E. Balloon mitral valvuloplasty for Peripheral Arterial Stenosis

169. The expansion and widespread application of cardiac catheterization has been

established, from just investigate tool, become therapeutic innovations based on

advanced catheter technologies. Which one of the list below is the most frequentdone in the world?

 A. Coronary artery stenting / intervention

B. Pacemaker implantation

C. Holes/defect closure or Ductal occlude

D. Pericardiocentesis

E. Septal ablation

Question 170-171 refer:

 A 32 y/o man noted the onset of a substernal pressure-like discomfort while doing

some activities as walking up a hill. He has uncontrollable-diabetes for 15 years. An

elective coronary angiography found marked stenosis in 2 vessels. He was stented

with DES (Drug Eluting Stent) rather than BMS (Bare Metal Stent)

170. What is the main reason of DES intervention in 2003?

 A. Prevent in-stent thrombosis

B. Prevent restenosis

C. Prevent intra-procedural thrombosis

D. Decrease intra-procedural complication

E. All of the answer above true

171. What is the risk of major complications during coronary angiography?

 A. Less than 2%

B. 2 – 4 %

C. 4 – 8 %

D. 8 – 15 %

E. Larger, but benefit is still more than risk

Question 172 – 173, refer :

 A 22 y/o girl with worsening dyspnea come back to the clinics brought

echocardiography result that showed a severe mitral stenosis due to rheumatic

process, without significant mitral and tricuspid regurgitation.

172. What procedures should be performed first on her?

 A. Trans catheter Mitral Valvular Intervention (TMVI)

B. Balloon Mitral Valvuloplasty (BMV)

C. Mitral valve replacement (MVR)

D. Mitral Clips Intervention

E. All of the above

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173. Complication occur during the procedure; the wire was puncture to high in

septum, making hemopericardium and pericardial effusion. What is the interventional

technique can be done to overcome this situation?

 A. Inoue balloon technique

B. Percutaneous Balloon Aortic ValvuloplastyC. Intra Aortic Balloon Pulsation

D. Pericardiocentesis

E. Pericardiectomy

Question 174 – 175, refer:

 A 88 y/o woman gas worsening dizziness and had loss of consciousness twice. She

denied any chest pain or history of drug consumption. In ER, she was found marked

bradycardia with the ECG as below:

174. What is the diagnosis of ECG?

 A. Normal sinus rhythm

B. Atrial rhythm

C. AV Block Mobits type II

D. Total AV Block

E. Ischemic anteroseptal wall

175. What cardiac intervention could be done in this patient?

 A. Percutaneous coronary Intervention (PCI)B. Cardioversion

C. Cardiac Resynchronization Therapy (CRT)

D. Temporary and might be Permanent Pacemaker

E. Intra-Aortic Balloon Pump

176. A 40 y/o healthy male was running on the treadmill for 15 minutes. Which of the

following body adaptation that most likely occurred?

 A. GI Tract arterial resistance increase until 20%

B. Blood in the brain decrease 50%

C. Unchanged heart rate

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D. 5% increasing CO

E. Increasing RA pressure 10 mmHg

177. A patient with infective endocarditis is diagnosed on clinical grounds but

cultures do not confirm the etiologic agent. This patient is difficult to treat and theoverall prognosis is considered poorer than when a specific etiology has been

determined. The negative culture in this patient is NOT cause by one of all the

following:

 A. Prior antibiotics treatment

B. Infection caused by intracellular parasites

C. Other uncommon etiologies

D. Subacute endocarditis involving the right side of the heart

E. Nutritional deficiency

178. WOTF microorganism most commonly cause subacute infective endocarditis?

 A. Enterrobacteriaceae

B. Streptococci pneumonia

C. Enterococcus

D. Other streptococci

E. Staphylococcus aures

179. WOTF is NOT a characteristic of β–haemolytic streptococci?

 A. It has a concave colony morphology and specific haemolytic reaction on blood

agar

B. Serology test is by Lancefield classificationC. Group A is sensitive to bacitracin

D. The bacteria grows better in 5% C02 condition

E. It could be cultured on nutrient agar plate

180. A woman had been diagnosed with Rheumatic Fever. She has had symptoms

of swollen joints, fever, and heart murmur of recent onset. Laboratory findings from

blood cultures were obtained and showed positive for Streptococcus viridans. Which

characteristics can be used to identify Streptococcus viridans?

 A. α haemolytic in colony on BAP 

B. bacteria capsules in gram stains/smear

C. non sensitive to optochin

D. lyse negative tested in bile broth medium

E. streptolysine O test positive

181. Streptococcus sp. Cause endocarditis in about 70% of cases. Streptoccous

viridans are the most common pathogen, followed by enterococci. The procedure to

detect this organism is obtaining blood for:

 A. bacteria culture

B. microscopic observed

C. specific Ig G detectionD. immune detection

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E. haemolytic test

182. Which method is correct to detect A Streptococcal in rheumatic fever?

 A. Bacterial culture and identification

B. Anti-streptolysin O test

C. Bacitracin testD. Lancefield test

E. M. protein test

183. Group A streptococcus which causes rheumatic fever is characterized by one of

the following mechanism:

 A. It produces an erythrogenic toxin

B. It causes beta haemolysis

C. Its pathogenicity is by the M.protein

D. It causes anti streptolysin O production

E. It produces α haemolysin that dissoves red blood cell

184. The following is one of the major criteria of the Duke Criteria for Clinical

diagnosis of infective endocarditic:

 A. Predisposition

B. Fever over 38°C

C. Vascular phenomena

D. Immunologic phenomena

E. Positive blood culture

185. Rheumatic fever is often preceded by a bacterial infection, such as:

 A. Streptococcus alpha haemolytic

B. Staphylococcus auresC. Haemophilus influenza

D. Streptococcus beta haemolytic (group A)

E. Pneumococcus

186. A 62y.o man was seen in a hospital for complaint of low grade fever, night

sweats, and fatigue for 3 weeks. The patient had a history of a heart murmur but had

never undergone extensive evaluation. He had been generally excellent health with

normal exercise tolerance. Approximately 6 weeks ago he underwent an

uncomplicated extraction of a wisdom tooth but received noantibiotics prior to

procedure. After performing PE and some lab test, the doctor’s diagnosis is Infective

Endocarditis. WOTF is most appropriate examination to confirm above diagnosis?

 A. Clinical appearance

B. Radiologic examination

C. ECG examination

D. Echocardiography

E. Blood culture

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187. A 46y.o male comes to see doctor complaining of chest pain. He has also

sweating, malaise, and headaches. Family history reveals that his father had

diabetes and died at age 62y.o of AMI. ECG reveals inverted T waves on the left

precordial leads. What cardiac marker should be run on this patient?

 A. CK-MMB. Troponin T

C. ALT

D. LDH

E. CK-BB

188. WOTF laboratory results is characteristics of exudative pericardial fluid?

 A. Total protein < 0.3gr/Dl

B. Colorless

C. LD fluid/serum ratio > 0.6

D. LD fluid/serum ratio < 0.3

E. Volume is 10-20 MI

189.The method that is now universally used for triglyceride determination is: 

A.  Electrophoretic method B.  Chemical method C.  Chromatographic method D.  Enzymatic method E.  Immunoassay method 

190. A 61 year old female comes to the emergency department because of chest pain. She has

the history of hypertension and does not take medicine regularly. She also complains ofchronic fatigue after her daily activity.The doctor finds that she looks severely ill, her blood

 pressure 170/110 mmHg,pulse 120 bpm and the heart sound is muffled.Which of the

following is the most appropriate test to support the diagnosis of this patient?  

A.  CK -MB B.  CPK  C.  AST D.  ALT E.  LDH 

191. Which of the following statements regarding the clinical use of CK -MB is CORRECT? 

A.  CK -MB becomes elevated before myoglobin and Trop. I after MI B.  CK -MB levels are elevated in cases of cardiac ischemia C.  The level of troponin I normalized later than CK -MB in MI D.  An elevated CK -MB is always accompanied by an elevated CK  E.  CK -MB are specific for muscle injury caused by vigorous exercise 

192.A 61 year old female comes to Emergency Department because of chest pain.She has the

history of hypertension and does not take the medicine regularly. She also complains of

chronic fatigue after her daily activity.he doctor finds that her blood pressure is 170/110

mmHg, pulse 120 bpm, the heart sound is muffled and she looks severely ill. 

The result of the blood test (CBC) shows as follow: 

 Hemoglobin 11,3 g/dL (Normal 12-16 g/dL)  RBC 3,15 million/mm3( Normal 3.8-5.2 million/mm3) 

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 PCV 36% (Normal 36-46%)  Platelets 374000/mm3 (Normal 150000-440000/mm3)  WBC 4800/mm3 (Normal 4000-11000/mm3)  MCV 77fl (Normal 80-100 fl)  MCH 26 pg/dL (Normal 26-34 pg/dL) 

 MCHC 30% (Normal 31-37%) What is the most appropriate test chooseto help diagnosis this patient?  

A.  CK -MB B.  CPK  C.  AST D.  ALT E.  LDH 

193. Which apolipoprotein is inversely related to risk for Coronary heart disease? 

A.  Apoprotein A 1 B.  Apoprotein B 

C.  Apoprotein CII D.  Apoprotein E IV E.  Apoprotein D 

194. A 46 year old man comes to see a doctor complaining of chest pain.He has alsosweating, malaise and headaches.His blood pressure is 150/105 mmHg.Family history

revealedthat his father has diabetic and died at age of 62 year of AMI secondary to DM.ECG

revealed changes from one done 6 months earlier. The LD: 200 U/L (N : 100-225),AST :35

U/L (N: 5-30) 

What further cardiac markers should be run on this patient? 

A.  CK -MM B.  Troponin C.  ALT D.  Alkaline phosphatase E.  CK -BB 

195. A 55 year old white gentleman came to your clinic with complaints of left leg swellingand painful arising after a flight from New York in economy class.No history of trauma but

his right leg is edematous,pitting,warm,painful in palpation.What is most like diagnosis? 

A.  Edema due to heart disease B.  Acute lymphedema C.

  Cellulitis 

D.  Deep vein thrombosis (DVT) E.  Acute limb arterial occlusion 

196. A 50 year old woman who had been examined reliably excluded calf -limited DVT andshe elected to be followed clinically.She returned 3 days later with persistent swelling right

leg but no new symptoms.She came back 10 days later after she presents with acute onset of

dypsnea and pleuritic chest pain.The best dia