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8/19/2019 Packrat Cardio Questions
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1. History & Physical/Cardiology
Which of the following conditions would cause a positive
Kussmaul's sign on physical examination?
Answers
A. Left ventricular failure
B. Pulmonary edema
C. Coarctation of the aortaD. Constrictive pericarditis
Explanations
(u) A. Left ventricular failure results in the back-up of blood int
the left atrium and then the pulmonary system so it would not
be associated with Kussmaul's sign.
(u) B. Pulmonary edema primarily results in increased
pulmonary pressures rather than having effects on the venou
inflow into the heart.(u) C. Coarctation of the aorta primarily affects outflow from th
heart du e to the stenosis resulting in d elayed and decreased
femoral pulses; it has no effect on causing Kussmaul's sign.
(c) D. Kussmaul's sign is an increase rather than the normal
decrease in the CVP during inspiration. It is most often caused
by severe right-sided heart failure; it is a frequent finding in
patients with constrictive pericarditis or right ventricular
infarction.
2. History & Physical/Cardiology
Anginal chest pain is most commonly described as which of the
following?
AnswersA. Pain changing with position or respiration
B. A sensation of discomfort
C. Tearing pain radiating to the back
D. Pain lasting for several hours
Explanations
(u) A. Pain changing with position or respiration is suggestive o
pericarditis.
(c) B. Myocardial ischemia is often experienced as a sensation odiscomfort lasting 5-15 minutes, described as dull, aching or
pressure.
(u) C. Tearing pain with radiation to the back represents aortic
dissection.
(u) D. Chest pain lasting for several hours is more suggestive fo
myocardial infarction.
3. History & Physical/Cardiology
Eliciting a history from a patient presenting with dyspnea due to
early heart failure the severity of the dyspnea should be
quantified by
Answers
A. amount of activity that precipitates it.B. how many pillows they sleep on at night.
C. how long it takes the dyspnea to resolve.
D. any associated comorbidities.
Explanations
(c) A. The amount of activity that precipitates dyspnea should
be quantified in the history.
(u) B. Orthopnea or paroxysmal nocturnal dyspnea can be
quantified by how many pillows a patient needs to sleep on to
be comfortable.(u) C. How long dyspnea takes to resolve or associated
comorbidities has no bearing on quantifying the severity of
dyspnea.
(u) D. See answer C above.
4. History & Physical/Cardiology
A 25 year-old female presents with a three-day history of chest
pain aggravated by coughing and relieved by sitting. She is febrile
and a CBC with differential reveals leukocytosis. Which of the
following physical exam signs is characteristic of her problem?
Answers
A. Pulsus paradoxus
B. Localized crackles
C. Pericardial friction rub
D. Wheezing
Explanations
(u) A. Pulsus paradoxus is a classic finding for cardiac
tamponade.
(u) B. Localized crackles are associated with pneumonia and
consolidation, not pericarditis.
(c) C. Pericardial friction rub is characteristic of an inflammator
pericarditis.
(u) D. Wheezing is characteristic for pulmonary disorders, such
as asthma.
CARDIO PACKRATStudy online at quizlet.com/_23pihf
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5. History & Physical/Cardiology
A 65 year-old white female presents with dilated tortuous veins on
the medial aspect of her lower extremities. Which of the following
would be the most common initial complaint?
Answers
A. Pain in the calf with ambulation
B. Dull aching heaviness brought on by periods of standing
C. Brownish pigmentation above the ankle
D. Edema in the lower extremities
Explanations
(u) A. Patients with deep venous thrombosis (DVT) may
present with complaints of pain in the calf with ambulation.
Secondary varicosities may result from DVT's.
(c) B. Dull aching heaviness or a feeling of fatigue brought on
by periods of standing is the most common complaint of
patients presenting initially with varicosities.
(u) C. Stasis Dermatitis and edema are most suggestive of
chronic venous insufficiency.(u) D. See C for explanation.
6. History & Physical/Cardiology
A 22 year-old male received a stab wound in the chest an hour ago.
The diagnosis of pericardial tamponade is strongly supported by
the presence of
Answers
A. pulmonary edema.
B. wide pulse pressure.
C. distended neck veins.
D. an early diastolic murmur.
Explanations
(u) A. Pulmonary edema may result with low output states as
seen with myocardial contusions, but it is not strongly
suggestive of tamponade.
(u) B. Wide pulse pressure is seen in conditions of high stroke
volume such as aortic insufficiency or hy perthyroidism.
Narrow pu lse pressure is seen with cardiac tamponade.
(c) C. Cardiac compression will manifest with distended neck
veins and cold clammy skin.
(u) D. The onset of diastolic murmur is suggestive of valvular
disease, not tamponade.
7. Diagnostic Studies/Cardiology
Cardiac nuclear scanning is done to detect
Answers
A. electrical conduction abnormalities.
B. valvular abnormalities.
C. ventricular wall dysfunction.
D. coronary artery patency/occlusion.
Explanations
(u) A. An EKG is used to determine electrical conduction
abnormalities.
(u) B. An echocardiogram is a non-invasive test used to
determine valvular abnormalities and wall motion.
(c) C. Visualization of the cardiac wall can be done with cardiac
nuclear scanning. This is done to determine hypokinetic area
from akinetic areas.
(u) D. Patency or occlusion is assessed with cardiac
catheterization (invasive).
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8. Diagnostic Studies/Cardiology
A 72 year-old male with a new diagnosis of congestive heart
failure and atrial fibrillation, develops episodes of
hemodynamic compromise secondary to increased
ventricular rate. A decision to perform elective
cardioversion is made and the patient is anticoagulated
with heparin. Which test should be ordered to assess for
atrial or ventricular mural thrombi?
A. Electrocardiogram
B. Chest x-ray
C. Transesophageal Echocardiogram
D. C-reactive protein
(u) A. Electrical conduction will not assess for mural thrombi.
(u) B. A chest x-ray will not visualize the left atria and ventricles to
assess for mural thrombi.
(c) C. Transesophageal echocardiography allows for determination o
mural thrombi that may have resulted from atrial fibrillation.
(u) D. C-reactive protein is not going to give you any information
regarding thrombi. This test is used to identify the presence of
inflammation.
9. Diagnostic Studies/Cardiology
A 64 year-old patient with known history of type 1 diabetes
mellitus for 50 years has developed pain radiating from the
right buttock to the calf. Patient states that the pain is
made worse with walking and climbing stairs. Based upon
this history which of the following would be the most
appropriate test to order?
Answers
A. Venogram
B. Arterial duplex scanning
C. X-ray of the right hip and L/S spine
D. Venous Doppler ultrasound
Explanations
(u) A. See B for explanation.
(c) B. Given the patient's long h istory of type 1 diabetes mellitus the
patient most likely has vascular occlusive disease. Evaluation of arter
blood flow is assessed using the du plex scanner. X-ray of the L/S spi
and r ight hip while not harmful may give information regarding bon
structures. Venous Doppler u ltrasound will not give information of
arterial perfusion.
(u) C. See B for explanation.
(u) D. See B for explanation.
10. Diagnostic Studies/Cardiology
A 36 year-old male complains of occasional episodes of
"heart fluttering". The patient describes these episodes as
frequent, short-lived and episodic. He denies any
associated chest pain. Based on this information, which
one of the following tests would be the most appropriate
to order?
Answers
A. Holter monitor
B. Cardiac catheterization
C. Stress testing
D. Cardiac nuclear scanning
Explanations
(c) A. Holter monitoring is a non-invasive test done to obtain a
continuous monitoring of the electrical activity of the heart. This can
help to detect cardiac rhythm disturb ances that can correlate with t
patient symptoms. Cardiac catheterization is an invasive p rocedure
done to assess coronary artery disease. Stress testing and cardiac
nuclear scanning are non-invasive testing maneuvers done to asses
coronary artery disease.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
11. Diagnostic Studies/Cardiology
A patient with a mitral valve replacement was placed post-
operatively on warfarin (Coumadin) for anticoagulation
prophylaxis. To monitor this drug for its effectiveness,
what test would be used?
Answers
A. PTT
B. PT-INR
C. Platelet aggregation
D. Bleeding time
Explanations
(u) A. PTT is a reflection of the intrinsic clotting system and is used to
monitor heparin administration.
(c) B. PT-INR is a reflection of the extrinsic and common pathway
clotting system. Coumadin interferes with Vitamin K synthesis which
needed in the manufacture of factors II, VII , IX, X which are part of th
extrinsic clotting pathway.
(u) C. Platelet aggregation tests are utilized to assess platelet
dysfunction.
(u) D. Bleeding time is used to assess platelet function.
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12. Diagnosis/Cardiology
A 64 year-old male, with a long history of COPD, presents with increasing fatigue over the last
three months. The patient has stopped playing golf and also complains of decreased appetite,
chronic cough and a bloated feeling. Physical examination reveals distant heart sounds,
questionable gallop, lungs with decreased breath sounds at lung bases and the abdomen reveals
RUQ tenderness with the liver two finger-breadths below the costal margin, the extremities show
2+/4+ pitting edema. Labs reveal the serum creatinine level 1.6 mg/dl, BUN 42 mg/dl, liver function
test's mildly elevated and the CBC to be normal. Which of the following is the most likely
diagnosis?Answers
A. Right ventricular failure
B. Pericarditis
C. Exacerbation of COPD
D. Cirrhosis
Explanations
(c) A. Signs of right
ventricular failure are fluid
retention i.e. edema,
hepatic congestion and
possibly ascites.
(u) B. See A for explanatio
(u) C. See A for explanatio
(u) D. See A for explanatio
13. Diagnosis/Cardiology
A 56 year-old male with a known history of polycythemia suddenly complains of pain and
paresthesia in the left leg. Physical examination reveals the left leg is cool to the touch and the
toes are cyanotic. The popliteal pulse is absent by palpation and Doppler. The femoral pulse is
absent by palpation but weak with Doppler. The right leg and upper extremities has 2+/4+ pulses
throughout. Given these findings what is the most likely diagnosis?
Answers
A. Venous thrombosis
B. Arterial thrombosis
C. Thromboangiitis obliterans
D. Thrombophlebitis
Explanations
(u) A. See B for explanatio
(c) B. Arterial thrombosis
has occurred and is
evidenced b y the loss of th
popliteal and dorsalis ped
pulse. This is a surgical
emergency. Venous
occlusion and
thrombophlebitis do not
result in loss of arterial
pulse.
(u) C. See B for explanatio
(u) D. See B for explanatio
14. Diagnosis/Cardiology
A 48 year-old male with a known history of hypertension is brought to the ED complaining of
headache, general malaise, nausea and vomiting. The patient currently takes nifedipine
(Procardia)90mg XL every day and atenolol (Tenormin) 50 mg every day. Vital signs reveal
temperature 98.6°F, pulse 72/minute, respiratory rate 20/minute, and the blood pressure is
168/120 mmHg. BP reading taken every 15 minutes from the time of admission reveal the systolic
to run from 176 to 186 mmHg and the diastolic to run from 135 to 150 mmHg. Physical
examination reveals papilledema bilaterally. There are no renal bruits noted. The EKG is normal.
Based upon this presentation, what is the most likely diagnosis?
Answers
A. Meningitis
B. Secondary hypertension
C. Pseudotumor cerebri
D. Malignant hypertension
Explanations
(u) A. See D for explanatio
(u) B. See D for explanatio
(u) C. Pseudotumor cereb
presents with p apilledema
but not hypertension and
more common in young
females.
(c) D. Malignant HTN is
characterized by diastolic
reading greater than 140
mm Hg with evidence of
target organ damage.
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15. Diagnosis/Cardiology
A 55 year-old male is seen in follow-up for a complaint of chest pain. Patient states
that he has had this chest pain for about one year now. The patient further states that
the pain is retrosternal with radiation to the jaw. "It feels as though a tightness, or
heaviness is on and around my chest". This pain seems to come on with exertion
however, over the past two weeks he has noticed that he has episodes while at rest. If
the patient remains non- active the pain usually resolves in 15-20 minutes. Patient has
a 60-pack year smoking history and drinks a martini daily at lunch. Patient appears
overweight on inspection. Based upon this history what is the most likely diagnosis?Answers
A. Acute myocardial infarction
B. Prinzmetal variant angina
C. Stable angina
D. Unstable angina
Explanations
(u) A. Pain does not resolve in an acute
MI, it gradually gets worse.
(u) B. Pain typically occurs at rest is one o
the hallmarks of Prinzmetal variant
angina. This patient has just started to
develop pain at rest.
(u) C. Pain in stable angina is relieved
with rest and usually resolves within 10minutes. angina does not have pain at
rest.
(c) D. Pain in un stable angina is
precipitated by less effort than before o
occurs at rest.
16. Diagnosis/Cardiology
Stable
A 60 year-old male is brought to the ED complaining of severe onset of chest pain and
intrascapular pain. The patient states that the pain feels as though "something is
ripping and tearing". The patient appears shocky; the skin is cool and clammy. The
patient has an impaired sensorium. Physical examination reveals a loud diastolic
murmur and variation in blood pressure between the right and left arm. Based upon
this presentation what is the most l ikely diagnosis?
Answers
A. Aortic dissection
B. Acute myocardial infarction
C. Cardiac tamponade
D. Pulmonary embolism
Explanations
(c) A. The scenario presented here is
typical of an ascending aortic dissection
In an acute myocardial infarction the
pain builds up gradually. Cardiac
tamponade may occur with a dissection
into the pericardial space; syncope is
usually seen with this occurrence.
Pulmonary embolism is usually associat
with dyspnea along with chest pain.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
17. Diagnosis/Cardiology
A 42 year-old male is brought into the ED with a complaint of chest pain. The pain
comes on suddenly without exertion and lasts anywhere from 10-20 minutes. The
patient has experienced this on three previous occasions. Today the patient
complains of light- headedness with the chest pain lasting longer. Vital signs T-99.3°F
oral, P-106/minute and regular, R-22/minute, BP 146/86 mm Hg. EKG reveals sinus
rhythm with a rate of 100. Intervals are PR = 0.06 seconds, QRS = 0.12 seconds. A delta
wave is noted in many leads. Based upon this information what is the most likely
diagnosis?
Answers
A. Sinus tachycardia
B. Paroxysmal supraventricular tachycardia
C. Wolff-Parkinson-White syndrome
D. Ventricular tachycardia
Explanations
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. Wolff-Parkinson-White syndrome
hallmarks on EKG include a shorten PR
interval, widened QRS, and delta waves
Sinus tachycardia has a normal PR
interval and no delta waves. PSVT usual
has a retrograde P wave or it may be
buried in the QRS complex.
(u) D. Ventricular tachycardia has a
widened QRS as it originates in the
ventricles.
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18. Diagnosis/Cardiology
A 63 year-old male is admitted to the hospital with an exacerbation of
COPD. The electrocardiogram shows an irregularly, irregular rhythm at a
rate of 120/minute with at least three varying P wave morphologies. These
electrocardiogram findings are most suggestive of
Answers
A. atrial fibrillation.
B. multifocal atrial tachycardia.
C. atrioventricular junctional rhythm.D. third degree heart block.
Explanations
(u) A. Atrial fibrillation is an irregularly, irregular
rhythm with no definable P waves.
(c) B. Multifocal atrial tachycardia is seen most
commonly in patients with COPD. Electrocardiogram
findings include an irregularly, irregular rhythm
with a varying PR interval and various P wave
morphologies (Three or more foci).
(u) C. Atrioventricular junctional rhythm is an escaprhythm, because of depressed sinus node fun ction
with a ventricular rate between 40-60/minute.
(u) D. Third degree heart block presents with a wid
QRS at a rate less than 50/minute and blocked atria
impulses.
19. Health Maintenance/Cardiology
A 72 year-old female is being discharged from the hospital following an
acute anterolateral wall myocardial infarction. While in the hospital the
patient has not had any dysrhythmias or hemodynamic compromise.
Which of the following medications should be a part of her d/c meds?
A. Warfarin (Coumadin)
B. Captopril (Capoten)
C. Digoxin (Lanoxin)
D. Furosemide (Lasix)
Explanations
(u) A. Warfarin is not indicated since there is no role
for anticoagulation in this patient.
(c) B. ACE inhibitors have been shown to decrease
left ventricular hypertrophy and remodeling to allo
for a greater ejection fraction.
(u) C. The patient does not have any dysrhythmias
so Lanoxin is not indicated.
(u) D. The patient does not have any hemodynami
compromise or indicators of CHF.
20. Health Maintenance/Cardiology
A 44 year-old male with a known history of rheumatic fever at age 7 and
heart murmur is scheduled to undergo a routine dental cleaning. The
murmur is identified as an opening snap murmur. Patient has no known
drug allergies. What should this patient receive for antibiotic prophylaxis
prior to the dental cleaning?
Answers
A. This patient does not require antibiotic prophylaxis for a routine dental
cleaning.
B. This should receive Pen VK 250 mg p.o. QID for 10 days after the
procedure.
C. This patient should receive Amoxicillin 3.0 gms. p.o. 1 hour before the
procedure and then 1.5 gm. 6 hours after the procedure.
D. This patient should receive Erythromycin 250 mg QID for 1 day before
the procedure and then 10 days after the procedure.
Explanations
(h) A. See C for explanation.
(u) B. See C for explanation.
(c) C. These are the current recommendations from
the American Heart Association if the patient is not
allergic to penicillin.
(u) D. See C for explanation.
21. Health Maintenance/Cardiology
A 36 year-old female presents for a refill of her oral contraceptives. She
admits to smoking one pack of cigarettes per day. She should be counseled
with regard to her risk of
Answers
A. venous thrombosis.
B. varicose veins.
C. atherosclerosis.
D. peripheral edema.
Explanations
(c) A. Women over age 35 who smoke are at
increased risk for the development of venous
thrombosis.
(u) B. Varicose veins are the result of pressure
overload on incompetent veins and not due to the
use of oral contraceptives.
(a) C. The defined risks of atherosclerosis includes
smoking, but does not include the use of oral
contraceptives.
(u) D. There is no relationship between the use of
oral contraceptives and the development of
peripheral edema.
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22. Health Maintenance/Cardiology
A 68 year-old female comes to the office for an annual physical examination. Her past
medical history is significant for a 40-pack year cigarette smoking history. She takes no
medications and has not been hospitalized for any surgery. Family medical history
reveals that her mother is living, age 87, in good health without medical problems. Her
father is deceased at age 45 from a motor vehicle crash. She has two siblings that are
alive and well. From this information, how many identifiable risk factors for
cardiovascular heart disease exist in this patient?
AnswersA. 0
B. 1
C. 2
D. 3
Explanations
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. This patient has 2 identifiable ris
factors based upon the information
provided. These include her age 68 an
her history of cigarette smoking.
(u) D. See C for explanation.
23. Clinical Intervention/Cardiology
Following an acute anterolateral myocardial wall infarction two days ago, a patient
suddenly develops hemodynamic deterioration without EKG changes occurring. What
complication can explain this scenario?
Answers
A. Free wall rupture
B. CVA
C. Atrial fibrillation
D. Sick sinus syndrome
Explanations
(c) A. Free wall rupture is a complicatio
that occurs within 72 hours of infarctio
It is seen mainly in Q wave transmural
and lateral wall infarctions.
(u) B. See A for explanation.
(u) C. See A for explanation. Atrial
fibrillation would have EKG evidence o
irregularly, irregular rate and rhythm
(u) D. Sick sinus syndrome would have
EKG ev idence of decreased rate and
loss of P waves.
24. Clinical Intervention/Cardiology
A 48 year-old male with a history of coronary artery disease and two myocardial
infarctions complains of shortness of breath at rest and 2-pillow orthopnea. His oxygen
saturation is 85% on room air. The patient denies any prior history of symptoms. The
patient denies smoking. Results of a beta-natriuretic peptide (BNP) are elevated. What
should be your next course of action for this patient?
Answers
A. Send him home on 20 mg furosemide (Lasix) p.o. every day and recheck in one week
B. Send him home on clarithromycin (Biaxin) 500 mg p.o. BID and recheck in 1 week
C. Admit to the hospital for work up of left ventricular dysfunction
D. Admit to the hospital for work up of pneumonia
Explanations
(h) A. See C for explanation.
(h) B. See C for explanation.
(c) C. An elevated BNP is seen in a
situation where there is increased
pressure in the ventricle during
diastole. This is representative of the le
ventricle being stretched excessively
when a patient has CHF. Sending a
patient home would be inappropriate
in this case.
(u) D. See C for explanation.
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25. Clinical Intervention/Cardiology
A 48 year-old male presents to the ED with complaints of chest pressure,
dyspnea on exertion, and diaphoresis that has been present for the last
one hour. Electrocardiogram reveals normal sinus rhythm at 92/minute
along with ST segment elevation in leads V3-V5. Initial cardiac enzymes
are normal. What is the next most appropriate step in the management
of this patient?
Answers
A. Coronary artery revascularizationB. Admission for medical management
C. Administer lidocaine
D. Administer nitrates
Explanations
(c) A. The standard of care for the management of acu
ST-segment elevation MI is coronary artery
revascularization. This patient is diagnosed with an ST
segment elevation MI based upon his history and EKG
findings. Cardiac enzymes are normal because of the
early p resentation of this patient.
(u) B. Although this patient will be admitted to the
hospital, this patient needs to have acute managemenof the myocardial infarction without delay.
(h) C. Prophylactic lidocaine has b een shown to increa
morbidity and mortality from acute MI when used in
this setting.
(u) D. Although pain control is a goal for patients with
acute MI, it is not the essential medication that will
impact this patient's care to the greatest degree.
26. Clinical Intervention/Cardiology
An unresponsive patient is brought to the ED by ambulance. He is in
ventricular tachycardia with a heart rate of 210 beats/min and a blood
pressure of 70/40 mmHg. The first step in treatment is to
Answers
A. administer IV adenosine.
B. DC cardiovert.
C. administer IV lidocaine.
D. apply overdrive pacer.
Explanations
(u) A. Adenosine is used to treat PSVT.
(c) B. The first step in treatment of unstable ventricula
tachycardia with a pulse is to cardiovert using a 100 J
countershock.
(u) C. See B for explanation.
(u) D. Overdrive pacing is indicated in Torsades de
Pointes.
27. Clinical Therapeutics/Cardiology
Which of the following antiarrhythmic drugs can be associated with
hyper- or hypothyroidism following long-term use?
Answers
A. Quinidine
B. Amiodarone
C. Digoxin
D. Verapamil
Explanations
(u) A. See B for explanation.
(c) B. Amiodarone is structurally related to thyroxine
and contains iodine, which can induce a hyper- or
hyp othyroid state.
(u) C. See B for explanation.
(u) D. See B for explanation.
28. Clinical Therapeutics/Cardiology
Which of the following hypertensive emergency drugs has the potential
for developing cyanide toxicity?
Answers
A. Sodium nitroprusside (Nipride)
B. Diazoxide (Hyperstat)
C. Labetalol (Normodyne)
D. Alpha-methyldopa (Aldomet)
Explanations
(c) A. Sodium nitroprusside metabolization results in
cyanide ion production. It can be treated with sodium
thiosulfite, which combines with the cyanide ion to form
thiocyanate, which is nontoxic.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
29. Clinical Therapeutics/Cardiology
Contraindications to beta blockade following an acute myocardial
infarction include which of the following?Answers
A. Third degree A-V block
B. Sinus tachycardia
C. Hypertension
D. Rapid ventricular response to Atrial fibrillation/flutter
Explanations
(c) A. Beta blockade is contraindicated in second and
third heart block.(u) B. Beta blockade has been proven to be beneficial
sinus tachycardia, hypertension and in atrial fib/flutte
with a rapid ventricular response.
(u) C. See B for explanation.
(u) D. See B for explanation.
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30. Clinical Therapeutics/Cardiology
A 74 year-old male is diagnosed with pneumonia. The physician
assistant should ensure the patient is not on which of the following
before starting therapy with clarithromycin (Biaxin)?
Answers
A. Lisinopril (Zestril)
B. Furosemide (Lasix)
C. Simvastatin (Zocor)
D. Dipyridamole (Persantine)
Explanations
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. Statins are known to interact with the macrolides as
they may cause prolonged QT interval, myopathy and
rhabdomyolysis.
(u) D. See C for explanation.
31. Clinical Therapeutics/Cardiology
According to the recent JNC VII guidelines, a 34 year-old male who has
type 1 diabetes mellitus and hypertension should be started on
which type of antihypertensive agent?
Answers
A. Beta-blocker
B. Loop diuretic
C. ACE inhibitor
D. Thiazide diuretic
Explanations
(u) A. Beta blockers could potentially be harmful in a
patient with diabetes mellitus. Use a cardioselective beta-
blocker to reduce the incidence of hypoglycemia.
(u) B. See C for explanation.
(c) C. ACE inhibitors are effective in young patients. They
are capable of providing protection to the kidn ey
especially in diabetes mellitus.
(u) D. See C for explanation.
32. Clinical Therapeutics/Cardiology
Which of the following beta-adrenergic blocking agents hascardioselectivity for primarily blocking beta-1 receptors?
Answers
A. Propranolol (Inderal)
B. Timolol (Blocadren)
C. Metoprolol (Lopressor)
D. Pindolol (Visken)
Explanations
(u) A. Propranolol and timolol are nonselective beta-adrenergic antagonists.
(u) B. See A for explanation.
(c) C. Metoprolol is selective for beta-1 antagonists
(u) D. Pindolol is an antagonist with partial agonist activity
33. Scientific Concepts/Cardiology
Which of the following is the mechanism of action of Class III
antiarrhythmic drugs?
Answers
A. Na+ channel blocker
B. K+ channel blockerC. Beta adrenoreceptor blocker
D. Ca++ channel blocker
Explanations
(u) A. Na+ channel blockers are Class I.
(c) B. K+ channel blockers are Class II I.
(u) C. Beta adrenoreceptor blockers are Class II.
(u) D. Ca++ channel blockers are Class VI.
34. Scientific Concepts/Cardiology
In congestive heart failure the mechanism responsible for the
production of an S3 gallop is
Answers
A. contraction of atria in late diastole against a stiffened ventricle.
B. rapid ventricular filling during early diastole.
C. vibration of a partially closed mitral valve during mid to late
diastole.
D. secondary to closure of the mitral valve leaflets during systole.
Explanations
(u) A. Atrial contraction against a noncompliant ventricle i
the mechanism responsible for S4.
(c) B. Rapid ventricular filling during early diastole is the
mechanism responsible for the S3.
(u) C. Vibration of a partially closed mitral valve during m
to late diastole is the mechanism responsible for the
Austin-Flint murmur of aortic regurgitation.
(u) D. Closure of the mitral valve leaflets during systole is
the mechanism responsible for part of the S1 heart soun
35. Scientific Concepts/Cardiology
What is the most likely mechanism responsible for retinal
hemorrhages and neurologic complications in a patient with
infective endocarditis?
Answers
A. Metabolic acidosis
B. Systemic arterial embolization of vegetations
C. Hypotension and tachycardia
D. Activation of the immune system
Explanations
(u) A. See B for explanation.
(c) B. The vegetations that occur dur ing infective
endocarditis can become emboli and can be d ispersed
throughout the arterial system.
(u) C. See B for explanation.
(u) D. Glomerulonephr itis and arthritis result from
activation of the immune system.
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36. Scientific Concepts/Cardiology
During an inferior wall myocardial infarction the signs and symptoms
of nausea and vomiting, weakness and sinus bradycardia are a result
of what mechanism?
Answers
A. Increased sympathetic tone
B. Increased vagal tone
C. Activation of the renin-angiotensin system
D. Activation of the inflammatory and complement cascade system
Explanations
(u) A. See B for explanation.
(c) B. Increased vagal tone is common in inferior wall MI; i
the SA node is involved, bradycardia may develop.
(u) C. See B for explanation.
(u) D. See B for explanation.
37. Scientific Concepts/Cardiology
Which of the following is the most common cause of secondary
hypertension?
A. Renal parenchymal disease
B. Primary aldosteronism
C. Oral contraceptive use
D. Cushing's syndrome
Explanations
(c) A. Renal parenchymal disease is the most common
cause of secondary hypertension.
(u) B. Primary aldosteronism can cause secondary
hypertension, but it is not the most common cause.
(u) C. Oral contraceptives can cause small increases in
blood p ressure but considerable increases are much less
common.
(u) D. Cushing's disease is a less common cause of
secondary hypertension.
38.
Clinical Therapeutics/CardiologyWhich of the following medication c lasses is the treatment of choice
in a patient with variant or Prinzmetal's angina?
A. Calcium channel blockers
B. ACE inhibitors
C. Beta blockers
D. Angiotensin II receptor blockers
Explanations(c) A. Calcium channel blockers are effective
prophylactically to treat coronary vasospasm associated
with variant or Prinzmetal's angina.
(u) B. ACE inhibitors are n ot a treatment for coronary
vasospasm.
(h) C. Beta blockers have been n oted to exacerbate
coronary vasospasm potentially leading to worsening
ischemia.
(u) D. Angiotensin II receptor blockers are not a treatmen
for coronary vasospasm.
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39. Clinical Therapeutics/Cardiology
A 63 year-old female with history of diabetes mellitus presents for blood
pressure follow-up. At her last two visits her blood pressure was 150/92
and 152/96. Today in the office her blood pressure is 146/92. Recent
blood work shows a Sodium 140 mEq/L, Potassium 4.2 mEq/L, BUN of 23
mg/dL, and Creatinine of 1.1 mg/dL. Which of the following is the most
appropriate initial medication in this patient?
A. Terazosin (Hytrin)
B. Atenolol (Tenormin)C. Lisinopril (Zestril)
D. Hydrochlorothiazide (HCTZ)
Explanations
(u) A. Alpha blockers are not the treatment of choice in
diabetic with hypertension.
(u) B. Patients with hypertension and d iabetes may
require a Beta blocker, but it should be added to an
ACE inhibitor
if the ACE inhibitor is ineffective on its own.
(c) C. ACE inhibitors should be part of the initial
treatment of hypertension in d iabetics because of beneficial effects in
diabetic nephropathy and is the most appropriate init
medication.
(u) D. Patients with hyp ertension and d iabetes mellitu
may require a diuretic, but it should be add ed to an
ACE
inhibitor if the ACE inhibitor is ineffective on its own.
40. Diagnostic Studies/Cardiology
What is the EKG manifestation of cardiac end-organ damage due to
hypertension?
A. Right bundle branch block
B. Left ventricular hypertrophy
C. Right ventricular hypertrophy
D. ST segment elevation in lateral precordial leads
Explanations
(u) A. Right bundle branch block is caused by a delay i
the conduction system in the right ventricle. It may be
caused by right ventricular hypertrophy or conditions
with higher pulmonic resistance such as cor pulmonal
Hypertension, however, is likely to cause changes in th
left ventricle rather than the right ventricle.
(c) B. Long-standing hypertension can lead to left
ventricular hypertrophy with characteristic changes
noted on EKG.
(u)C. See A for explanation.
(u) D. ST segment elevation is a sign of acute myocardia
infarction n ot hypertension.
41. Health Maintenance/Cardiology
Annual blood pressure determinations should be obtained beginning at
the age of
A. 3 years.
B. 5 years.
C. 12 years.
D. 18 years.
Explanations
(c) A. Periodic measurements of blood pressure should
be part of routine preventive health assessments
beginning at the age of 3 years.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
42. History & Physical/Cardiology
Which of the following conditions would cause a positive Kussmaul's
sign on physical examination?
A. Left ventricular failure
B. Pulmonary edema
C. Coarctation of the aorta
D. Constrictive pericarditis
Explanations
(u) A. Left ventricular failure results in the back-up of
blood into the left atrium and then the pulmonary
system so it would not be associated with Kussmaul's
sign.
(u) B. Pulmonary edema primarily results in increased
pulmonary pressures rather than having effects on th
venous inflow into the heart.
(u) C. Coarctation of the aorta primarily affects outflow
from the heart du e to the stenosis resulting in delayed
and decreased femoral pulses; it has no effect on
causing Ku ssmaul's sign.
(c) D. Kussmaul's sign is an increase rather than the
normal decrease in the CVP during inspiration. It is mo
often caused by severe right-sided h eart failure; it is a
frequent finding in patients with constrictive pericardi
or right ventricular infarction.
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43. History & Physical/Cardiology
Which of the following physical findings is suggestive of atrial septal defect?
A. Fixed split S2
B. Increased pulse pressure
C. Continuous mechanical murmur
D. Difference in blood pressure between the left and right arm
Explanations
(c) A. An atrial septal defect will cause a shun
of blood from the left to the right atrium. Th
will result in an equalization in the amount o
blood entering b oth the left and right
ventricles which effectively eliminates the
normally wide splitting that inspiration
typically causes in h earts without an atrial
septal defect.(u) B. Pulse pressures reflect the difference
aortic and left ventricular volumes that occu
during ventricular systole Increased pulse
pressures are seen in aortic regurgitation
which is a different entity than atrial septal
defect.
(u) C. Continuous mechanical murmurs are
noted in patients with patent ductus
arteriosus.
(u) D. Differences in blood pressure betwee
the left and r ight arms are seen in condition
such as coarctation of theaorta.
44. Clinical Therapeutics/Cardiology
A 29 year-old male presents with complaint of substernal chest pain for 12 hours.
The patient states that the pain radiates to his shoulders and is relieved with
sitting forward. The patient admits to recent upper respiratory symptoms. On
examination vital signs are BP 126/68, HR 86, RR 20, temp 100.3 degrees F. There is
no JVD noted. Heart exam reveals regular rate and rhythm with no S3 or S4. There
is a friction rub noted. Lungs are clear to auscultation. EKG shows diffuse ST
segment elevation. What is the treatment of choice in this patient?
A. Pericardiocentesis
B. Nitroglycerin
C. Percutaneous coronary interventionD. Indomethacin (Indocin)
Explanations
(u) A. Pericardiocentesis is the treatment of
choice in a patient with a pericardial effusion
and cardiac tamponade, there is no evidenc
of either of these in this patient.
(u) B. Nitroglycerin is indicated in the
treatment of chest pain related to angina.
(u) C. Percutaneous coronory intervention i
the treatment of choice in a patient with an
acute myocardial infarction.
(c) D. Indomethacin, a nonsteroidal anti-inflammatory medication, is the treatment o
choice in a patient with acute
pericarditis.
45. Diagnosis/Cardiology
A 24 year-old male presents for routine physical examination. On physical
examination, you find that the patient's upper extremity blood pressure is higher
than the blood pressure in the lower extremity. Heart exam reveals a late systolic
murmur heard best posteriorly. What is the most likely diagnosis in this patient?
A. Hypertrophic obstructive cardiomyopathy
B. Patent foramen ovale
C. Coarctation of the aorta
D. Patent ductus arteriosus
Explanations
(u) A. Patients with hypertrophic obstructive
cardiomyopathy do not present with
hypertension or weak femoral pulses.
(u) B. The murmur associated with patent
foramen ovale is a systolic ejection murmur
heard in the second and third intercostal
spaces and patients do not present with
hypertension.(c) C . Coarctation of the aorta commonly
presents with higher systolic pressures in th
upper extremities than the lower extremitie
and absent or weak femoral pulses.
(u) D. Patent ductus arteriosus is rare in
adults and patients are noted to have a
continuous rough, machinery murmur.
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46. Diagnosis/Cardiology
A 63 year-old female presents with a complaint of chest pressure for one
hour, noticed upon awakening. She admits to associated nausea,
vomiting, and shortness of breath. 12 lead EKG reveals ST segment
elevation in leads II, III, and AVF. Which of the following is the most likely
diagnosis?
A. Aortic dissection
B. Inferior wall myocardial infarction
C. Acute pericarditisD. Pulmonary embolus
Explanations
(u) A. A patient with aortic dissection will complain of
tearing, ripping pain. EKG is often normal, but may
reveal left ventricular strain pattern.
(c) B. Myocardial infarction often presents with ches
pressure and associated nausea and vomiting. ST
segment elevation in leads II, I II , and AVF are classic
findings seen in acute inferior wall myocardial
infarction.(u) C. Acute pericarditis presents with atypical chest
pain and d iffuse ST segment elevation.
(u) D. Pulmonary embolism often presents with eith
no EKG changes or sinus tachycardia. Classically
described,
rarely seen findings include a large S wave in lead I,
Q wave with T wave inversion in lead I II , ST segmen
depression in lead II , T wave inversion in leads V1-V
and a transient right bundle branch block.
47. History & Physical/Cardiology
A 12 month-old child with tetralogy of Fallot is most likely to have which
of the following cl inical features?
A. Chest pain
B. Cyanosis
C. Convulsions
D. Palpitations
Explanations
(u) A. Chest pain is not a feature of tetralogy of Fallo
(c) B. Cyanosis is very common in tetralogy of Fallot.
(u) C. Convulsions are occasionally seen as p art of
severe hypoxic spells in infancy rather than a featu
of tetralogy
of Fallot.
(u) D. Palpitations are uncommon in tetralogy of
Fallot.
48. Diagnosis/Cardiology
A 23 year-old male presents with syncope. On physical examination you
note a medium-pitched, mid-systolic murmur that decreases with
squatting and increases with straining. Which of the following is the most
likely diagnosis?
A. Hypertrophic cardiomyopathy
B. Aortic stenosis
C. Mitral regurgitation
D. Pulmonic stenosis
Explanations
(c) A. Hypertrophic cardiomyopathy is characterized
by a medium- pitched, mid-systolic murmur that
decreases with squatting and increases with
straining.
(u) B. Straining decreases the intensity of the
murmur associated with aortic stenosis and squattin
increases the intensity.
(u) C. Mitral regurgitation is characterized by a
blowing systolic murmur that radiates to the axilla, it
not often associated with syncope.
(u) D. Pulmonic stenosis is a harsh systolic murmur
with a widely split S2, and no change with
maneuvers.
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49. Health Maintenance/Cardiology
A patient with which of the following is at highest risk for
coronary artery disease?
A. Congenital heart disease
B. Polycystic ovary syndrome
C. Acute renal failure
D. Diabetes mellitus
Explanations
(u) A. Congenital heart disease is not an established r isk factor for
coronary artery disease.
(u) B. While patients with polycystic ovary syndrome have
hyperinsulimemia, they do not have the same poor
prognosis for coronary artery disease as patients with diabetes
mellitus.
(u) C. Patients with acute renal failure are not at risk for coronary
artery disease, although patients with d iabetes andchronic renal disease do have this risk.
(c) D. Patients with diabetes mellitus are in the same risk category for
coronary artery disease as those patients with
established atherosclerotic disease.
50. Clinical Therapeutics/Cardiology
Acute rebound hypertensive episodes have been reported
to occur with the sudden withdrawal of
A. verapamil (Calan).
B. l isinopril (Prinivil).
C. clonidine (Catapres).
D. hydrochlorothiazide (HCTZ)
Explanations
(u) A. Verapamil is a calcium channel blocker and there is no
associated rebound hyp ertension after withdrawal.
(u) B. Lisinopril is an ACE inhibitor, which is not associated with
rebound hypertension.
(c) C. Clonidine (Catapres) is a central alpha agonist and abrupt
withdrawal may produce a rebound hypertensive
crisis.
(u) D. Hydrochlorothiazide is a thiazide diuretic, which is not
associated with rebound hypertension.
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51. Diagnosis/Cardiology
A 38 year-old female with history of coarctation of the aorta repair at the age of two presents with fevers
for four weeks. The patient states that she has felt fatigued and achy during this time. Maximum
temperature has been 102.1 degrees F. She denies cough, congestion, or other associated symptoms.
Physical examination reveals a pale tired appearing female in no acute distress. Heart reveals a new grade
III-IV/VI systolic ejection border at the apex, and a II/VI diastolic murmur at the right sternal border.
What is the most likely diagnosis?
A. Acute myocardial infarction
B. Bacterial endocarditisC. Acute pericarditis
D. Restrictive cardiomyopathy
Explanations
(u) A. Acute MI
presents with
complaint of chest
pain, SOB, not with
fever and myalgias
(c) B. Bacterial
endocarditis
presents as febrileillness lasting sever
days to weeks,
commonly with
nonspecific
symptoms,
echocardiogram
often reveals
vegetations on
affected valves.
(u) C. Pericarditis
does not present
with systolic ordiastolic murmur o
vegetation, more
commonly
pericardial friction
rub would be note
(u) D. Restrictive
cardiomyopathy w
show impaired
diastolic filling on
echocardiogram an
is not associated wi
fever.
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52. Diagnostic Studies/Cardiology
A 23 year-old female with history of palpitations presents for evaluation. She
admits to acute onset of rapid heart beating lasting seconds to minutes with
associated shortness of breath and chest pain. The patient states she can
relieve her symptoms with valsalva. Which of the following is the most
appropriate diagnostic study to establish a definitive diagnosis in this patient?
A. Cardiac catheterization
B. Cardiac MRI
C. Chest CT scanD. Electrophysiology study
Explanations
(u) A. Card iac catheterization evaluates coronar
arteries but has no role in the diagnosis of
supraventricular tachycardia.
(u) B. Cardiac MRI cannot diagnose and define
pathway of supraventricular tachycardia.
(u) C. Chest CT scan will not establish definitive
diagnosis of supraventricular tachycardia.
(c) D . Electrophysiology study is useful inestablishing the diagnosis and pathway of
complex arrh ythmias such as
supraventricular tachycardia.
53. Clinical Therapeutics/Cardiology
Which of the following is the chief adverse effect of thiazide diuretics?
A. Hypokalemia
B. Hypernatremia
C. Hypocalcemia
D. Hypermagnesemia
Explanations
(c) A. Thiazide diuretics can induce electrolyte
changes. Principle among those is hypokalemia
(u) B. Hyponatremia, not hypernatremia may b
a complication of thiazide diuretics.
(u) C. Thiazide diuretics cause the retention of
calcium and would not cause hypocalcemia.
(u) D. Thiazide diuretics cause the retention of
calcium and do not readily affect magnesium
levels.
54. Clinical Intervention/Cardiology
A 25 year-old male with history of syncope presents for evaluation. The patient
admits to intermittent episodes of rapid heart beating that resolve
spontaneously. 12 Lead EKG shows delta waves and a short PR interval. Which
of the following is the treatment of choice in this patient?
A. Radiofrequency catheter ablation
B. Verapamil (Calan)
C. Percutaneous coronary intervention
D. Digoxin (Lanoxin)
Explanations
(c) A. Radiofrequency catheter ablation is the
treatment of choice on patients with accessory
pathways, such as Wolff-Parkinson-White
Syndrome.
(h) B. Calcium channel blockers such as
verapamil decrease refractoriness of the
accessory pathway or increase that of the AV
node leading to faster ventricular rates,
therefore calcium channel blockers should be
avoided in patients with WPW.
(u) C. Percutaneous coronary intervention is
indicated in the treatment of coronary artery
disease, not preexcitation syndromes.
(h) D. Digoxin decreases refractoriness of the
accessory pathway and increases that of the AV
node leading to faster ventricular rates. It shou
therefore be avoided in patients with WPW.
55. History & Physical/Cardiology
A patient presents for a follow-up visit for chronic hypertension. Which of the
following findings may be noted on the fundoscopic examination of this
patient?
A. cherry-red fovea
B. boxcar segmentation of retinal veins
C. papilledema
D. arteriovenous nicking
Explanations
(u) A. Cherry-red fovea and boxcar
segmentation of the retinal veins are findings
seen in central retinal artery occlusion.
(u) B. See letter A for explanation.
(u) C. Papilledema is noted in conditions causing
increased intracranial pressure.
(c) D . Arteriovenous nicking is common in chron
hypertension.
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56. Diagnostic Studies/Cardiology
Which of the following diagnostic tests should be ordered initially to evaluate for
suspected deep venous thrombosis of the leg?
A. Venogram
B. Arteriogram
C. Duplex ultrasound
D. Impedance plethysmography
Explanations
(u) A. Venogram has been replaced by
noninvasive tests due to discomfort, co
technical difficulties, and complications
such as phlebitis.
56
(h) B. Thrombophlebitis is a venous
problem, not an arterial one. Any
unnecessary invasive procedure ispotentially harmful.
(c) C. Ultrasound is the technique of
choice to detect deep venous thrombos
in the leg.
(a) D. Impedance plethysmography is
equivalent to ultrasound in detecting
thrombi of the femoral and popliteal
veins,
but it may miss early, nonocclusive
thrombi.
57. Diagnosis/Cardiology
A 36 year-old patient with cardiomyopathy secondary to viral myocarditis develops
fatigue, increasing dyspnea, and lower extremity edema over the past 3 days. He
denies fever. A chest x-ray shows no significant increase in heart size, but reveals
prominence of the superior pulmonary vessels. Based on these clinical findings, which
of the following is the most likely diagnosis?
A. Heart failure
B. Subacute bacterial endocarditis
C. Pulmonary embolus
D. Pneumonia
Explanations
(c) A. Given the presence of
cardiomyopathy, the patient's heart ha
decreased functional reserve. The
symptoms and chest x-ray findings are
typical of congestive heart failure.
(u) B. Endocarditis occurs as a result of
infection that primarily occurs in the
blood stream. Endocarditis would
present with signs of infection or seedin
rather than signs of heart failure.
(u) C. Pulmonary embolus usually
presents with an acute onset of chest
pain, severe dyspnea, and anxiety.(u) D. Pneumonia is less likely since the
is no fever and edema is not usually
associated with pneumonia.
58. Clinical Intervention/Cardiology
Which of the following is first-line treatment for symptomatic bradyarrhythmias due
to sick sinus syndrome (SSS)?
A. Permanent pacemaker
B. Radiofrequency ablation
C. Antiarrhythmics
D. Anticoagulation therapy
Explanations
(c) A. Permanent pacemakers are the
therapy of choice in patients with
symptomatic bradyarrhythmias in sick
sinus syndrome.
(u) B. Radiofrequency ablation is used
for the treatment of accessory pathway
in the heart. (u) C. See A for explanatio
(u) D. See A for explanation.
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59. History & Physical/Cardiology
What type of chest pain is most commonly associated with a dissecting aortic aneurysm?
A. Squeezing
B. Dull, aching
C. Ripping, tearing
D. Burning
Explanations
(u) A. Squeezing pain is more
characteristic of angina or
esophageal pain.
(u) B. Dull, aching pain is more
characteristic of chest wall pain,
possibly angina, or anxiety.
(c) C. A dissecting aortic aneurysm
often presents with a very severeripping, tearing-like pain.
(u) D. Burning pain is more
characteristic of esophageal reflux
esophagitis, or tracheobronchitis.
60. Health Maintenance/Cardiology
A 52 year-old obese female with a history of hypertension, tobacco abuse, and
hyperlipidemia presents for routine follow-up. Which of her risk factors for coronary
atherosclerosis is not modifiable?
A. Age
B. High LDL
C. Hypertension
D. Obesity
Explanations
(c) A. Age is a non modifiable risk
factor, as is family h istory of
premature coronary heart disease
(u) B. High LDL is a modifiable risk
factor, as is Hypertension, low HD
obesity, tobacco abuse, physical
inactivity
(u) C. See B for explanation.
(u) D. See B for explanation.
61. Diagnosis/Cardiology
An 8 year-old boy is brought to a health care provider complaining of dyspnea and fatigue.
On physical examination, a continuous machinery murmur is heard best in the second left
intercostal space and is widely transmitted over the precordium. The most likely diagnosis
is
A. ventricular septal defect.
B. atrial septal defect.
C. congenital aortic stenosis.
D. patent ductus arteriosus.
Explanations
(u) A. Ventricular septal defect
causes a holosystolic murmur
rather than a continuous
machinery-like murmur.
(u) B. Atrial septal defect causes a
fixed split S2 rather than a
continuous systolic heart murmur
(u) C. Congenital aortic stenosis
causes a crescendo-decrescendo
systolic murmur heard best in the
second
intercostal space.
(c) D. Patent ductus arteriosus is
classically described in children as
continuous machinery-type
murmur that is
widely transmitted across the
precordium.
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65. Clinical Therapeutics/Cardiology
Which of the following medications used in the treatment of
supraventricular tachycardia is able to cause sinus arrest and
asystole for a few seconds while it breaks the paroxysmal
supraventricular tachycardia?
A. Digoxin (Lanoxin)
B. Adenosine (Adenocard)
C. Verapamil (Calan)
D. Quinidine (Quinaglute)
Explanations
(u) A. Digoxin is not used for the acute termination of
supraventricular tachycardia.
(c) B. Adenosine is an endogenous nucleoside that results in
profound (although transient) slowing of the AV
conduction and sinus node discharge rate. This agent has a very
short half-life of 6 seconds.
(u) C. Although verapamil may be used for the termination of
acute supraventricular tachycardia, it does not lead tosinus arrest in therapeutic doses.
(u) D. Quinidine is rarely used today and is not indicated for the
termination of supraventricular tachycardia.
66. Diagnosis/Cardiology
An elderly female presents for evaluation of exertional
syncope, dyspnea, and angina. She admits that previous to
these symptoms she had insidious progression of fatigue that
caused her to curtail her activities. Which of the following is
the most likely diagnosis?
A. Aortic stenosis
B. Aortic regurgitation
C. Mitral stenosis
D. Mitral valve prolapse
Explanations
(c) A. The major symptoms of aortic stenosis are exertional syncop
dyspnea, and angina. Symptoms do not become apparent for a
number of years and usually are not present until the valve is
narrowed to less than 0.5 cm to 2 cm of valve surface area.
(u) B. Patients with aortic regurgitation are likely to complain of an
uncomfortable awareness of their heart, especially when lying
down. These patients develop sinus tachycardia with exertion an
complain of palpitations and head pounding with activity.
(u) C. The symptoms related to mitral stenosis are related to
increased pulmonary pressure after the left atrium can no longe
overcome the outflow obstruction.
(u) D. Patients with mitral valve prolapse are typ ically
asymptomatic throughout their lives, although a wide range of
symptoms is possible. When symptoms do occur, p alpitations from
arrhythmias are most common along with lightheadedness.
Syncope is not part of this disease process.
67. History & Physical/Cardiology
Which of the following would you expect on physical
examination in a patient with mitral valve stenosis?
A. Systolic blowing murmur
B. Opening snap
C. Mid-systolic click
D. Paradoxically split S2
Explanations
(u) A. Mitral stenosis is a diastolic, not a systolic murmur.
(c) B. Mitral stenosis is characterized by a mid-diastolic opening
snap.
(u) C. Mid-systolic clicks are noted in mitral valve prolapse, not
mitral stenosis.
(u) D. Paradoxical splitting of S2 occurs in aortic stenosis not mitra
stenosis.
68. Scientific Concepts/Cardiology
Which of the following is the most common cause for acute
myocardial infarction?
A. Occlusion caused by coronary microemboli
B. Thrombus development at a site of vascular injury
C. Congenital abnormalities
D. Severe coronary artery spasm
Explanations
(u) A. Coronary microemboli occlusion is a rare cause of acute
myocardial infarction.
(c) B. Acute myocardial infarction occurs when a coronary artery
thrombus develops rapidly at a site of vascular
injury. In most cases, infarction occurs when an atherosclerotic
plaque fissures, ruptures, or ulcerates and when conditions favo
thrombogenesis, so that a mural thrombus forms at the site of
rupture and leads to coronary artery occlusion.
(u) C. Congenital abnormalities are rare causes of acute MI.
(u) D. Severe coronary artery spasm is more likely to result in
Prinzmetal's angina rather than true infarction.
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69. Health Maintenance/Cardiology
A 78 year-old male with history of coronary artery disease status post CABG and ischemic cardiomyopathy
presents with complaint of progressive dyspnea and orthopnea. He also complains of lower extremity
edema. The patient denies fever, chest pain, or cough. On physical examination, vital signs are BP 120/68,
HR 75 and regular, RR 22, afebrile. You note the patient to have an S3 heart sound, jugular venous
distention, and 2+ lower extremity edema. The patient is admitted and treated. Upon discharge from the
hospital, the patient should be educated to monitor which of the following at home?
A. Daily weights
B. Daily spirometryC. Daily blood glucose
D. Daily fat intake
Explanations
(c) A. Home
monitoring of dail
weights can alert
the health care
provider to the
early recognition o
worsening heart
failure.(u) B. Spirometry
monitoring is
important in a
patient with
asthma, not heart
failure.
(u) C. Daily blood
glucose monitorin
is important in a
patient with
diabetes, not hea
failure.(u) D. Daily fat
intake is importan
but will not impro
his heart failure
management.
70. Scientific Concepts/Cardiology
Which of the following is the most common cause of arterial embolization?
A. Rheumatic heart disease
B. Myxoma
C. Atrial fibrillation
D. Venous thrombosis
Explanations
(u) A. Rheumatic
heart disease is a
rare cause of
embolization
(u) B. Myxoma is a
rare cause of embolization.
(c) C. Atrial
fibrillation is
present in 60-70%
of patients with
arterial emboli an
is associated with
left atrial
appendage
thrombus.
(u) D. Venous
thrombosis may ba cause of
embolization
paradoxically, bu t
uncommon.
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71. Scientific Concepts/Cardiology
The most common arrhythmia encountered in patients with mitral stenosis is
A. atrial flutter.
B. atrial fibrillation.
C. paroxysmal atrial tachycardia.
D. atrio-ventricular dissociation.
Explanations
(u) A. See B for explanation.
(c) B. Mitral stenosis leads to enlargement of
the left atrium, which is the major
predisposing risk factor for the
development of atrial fibrillation.
(u) C. See B for explanation.
(u) D. See B for explanation.
72. Clinical Therapeutics/Cardiology
Long term use of which of the following drugs may cause a drug-induced lupus-
type eruption?
A. prednisone
B. tetracycline
C. procainamide
D. oral contraceptives
Explanations
(u) A. Prednisone is not implicated in drug-
induced skin reactions.
(u) B. Tetracycline and sulfonamides are
known to cause a photosensitive rash on su
exposed areas of the skin.
(c) C. Procainamide and hydralazine are the
most common drugs that may cause a lupu
like eruption.
(u) D. Oral contraceptives may induce
erythema nodosum.
73.
Scientific Concepts/CardiologyWhich of the following is a cause of high output heart failure?
A. myocardial ischemia
B. complete heart block
C. aortic stenosis
D. thyrotoxicosis
Explanations(u) A. Low output heart failure occurs
secondary to ischemic heart disease,
hypertension, dilated cardiomyopathy,
valvular and pericardial disease, and
arrhythmia.
(u) B. See A for explanation.
(u) C. See A for explanation.
(c) D. High output heart failure occurs in
patients with reduced systemic vascular
resistance. Examples include: thyrotoxicosis
anemia, pregnancy, beriberi and Paget's
disease. Patients with high output heart
failure usually have normal pump function
but it is not adequate to meet the high
metabolic demands.
74. Diagnosis/Cardiology
A 46 year-old male with no past medical history presents complaining of chest
pain for four hours. The patient admits to feeling very poorly over the past two
weeks with fever and upper respiratory symptoms. The patient denies shortness
of breath or diaphoresis. On examination the patient appears fatigued. Vital signs
reveal a BP of 130/80, HR 90 and regular, RR 14. The patient is afebrile. Labs reveal a
Troponin I of 10.33 ug/L (0-0.4ug/L). Cardiac catheterization shows normal
coronary arteries and an ejection fraction of 40% with global hypokinesis. Which
of the following is the most likely diagnosis?
A. myocarditis
B. pericarditis
C. hypertrophic cardiomyopathy
D. coronary artery disease
Explanations
(c) A. Myocarditis often occurs secondary to
acute viral illness and causes cardiac
dysfunction. Patients will commonly have a
history of a recent febrile illness. Chest pain
may mimic that of a myocardial infarction an
Troponin I levels maybe elevated in one-
third of patients. Contractile dysfunction is
seen on catheterization and/or
echocardiogram.
(u) B. Pericarditis does not typically cause
ventricular dysfunction and cardiac enzym
are usually n ormal.
(u) C. Hypertrophic cardiomyopathy is
associated with ventricular hypercontractili
(u) D. This patient had normal coronary
arteries on cardiac catheterization, no signs
coronary artery disease.
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75. Clinical Therapeutics/Cardiology
Which of the following antihypertensive agents is considered to have both
alpha- and beta-blocker activities?
A. carvedilol (Coreg)
B. hydralazine (Apresoline)
C. minoxidil (Loniten)
D. spironolactone (Aldactone)
Explanations
(c) A. Carvedilol has both alpha- and b eta-
blocker activities.
(u) B. Hydralazine and minoxidil are
considered vasodilators.
(u) C. See B for explanation.
(u) D. Spironolactone is a potassium-sparing
diuretic.
76. Diagnosis/Cardiology
A 12 year-old boy presents to the office with pain in his legs with activity
gradually becoming worse over the past month. He is unable to ride a bicycle
with his friends due to the pain in his legs. Examination of the heart reveals an
ejection click and accentuation of the second heart sound. Femoral pulses are
weak and delayed compared to the brachial pulses. Blood pressure obtained in
both arms is elevated. Chest x-ray reveals rib notching. Which of the following is
the most likely diagnosis?
A. abdominal aortic aneurysm
B. pheochromocytoma
C. coarctation of the aorta
D. thoracic outlet syndrome
Explanations
(u) A. Abdominal aortic aneurysm is usually
asymptomatic until the patient has dissection
or rupture. I t is uncommon in a child.
(u) B. Pheochromocytoma classically causes
paroxysms of hyp ertension due to
catecholamine release from the adrenal
medulla, but does not cause variations in bloo
pressure in the upper and lower extremities.
(c) C. Coarctation is a discrete or long segment
of narrowing adjacent to the left subclavian
artery. As a result of the coarctation, systemic
collaterals develop. X-ray findings occur from
the d ilated and pulsatile intercostal arteries
and the "3" is due to the coarctation site with
proximal and distal dilations.
(u) D. Thoracic outlet syndrome occurs when
the brachial plexus, subclavian artery , or
subclavian vein becomes compressed in the
region of the thoracic outlet. It is the most
common cause of acute arterial occlusion in th
upper extremity of adults under 40 years old
77. Clinical Therapeutics/Cardiology
According to the recent JNC VII guidelines, a 34 year-old male who has type 1
diabetes mellitus and hypertension should be started on which type of
antihypertensive agent?
A. beta-blocker
B. loop diuretic
C. ACE inhibitor
D. thiazide diuretic
Explanations
(u) A. Beta blockers could potentially be
harmful in a patient with diabetes mellitus. Us
a cardioselective beta- blocker to reduce the
incidence of hypoglycemia.
(u) B. See C for explanation.
(c) C. ACE inhibitors are effective in young
patients. They are capable of providing
protection to the kidney especially in diabete
mellitus.
(u) D. See C for explanation.
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78. Scientific Concepts/Cardiology
A patient presents with moderate mitral stenosis. Which of the
following complications is associated with an increased risk of
systemic embolization in this patient?
A. atrial fibrillation
B. pulmonary hypertension
C. increased left atrial pressure
D. left ventricular dilatation
Explanations
(c) A. 50-80% of patients with mitral stenosis will develop
paroxysmal or chronic atrial fibrillation; 20-30% of patients with
atrial fibrillation will hav e systemic embolization.
(u) B. Pulmonary hypertension can occur in patients with sever
mitral stenosis with symptoms of low cardiac output and right
sided heart failure. Pulmonary hypertension does not cause
systemic embolization.
(u) C. Patients with mitral stenosis can have increased left atrialpressures relative to the left ventricular diastolic pressures; this
does not usually cause systemic embolization.
(u) D. Left ventricular dilatation is more common in aortic valve
disease than mitral valve disease.
79. Diagnostic Studies/Cardiology
A 19 year-old female presents with complaint of palpitations.
On examination you note the patient to have particularly long
arms and fingers and a pectus excavatum. She has a history of
joint dislocation and a recent ophthalmologic examination
revealed ectopic lentis. Which of the following echocardiogram
findings would be most consistent with this patient's physical
features?
A. right atrial enlargement B. aortic root dilation
C. pulmonic stenosis
D. ventricular septal defect
Explanations
(u) A. Patients with Marfan's syndrome commonly have mitral
valve p rolapse and possibly aortic regurgitation. Right atrial
enlargement, pulmonic stenosis and ventricular septal defect a
not commonly seen.
(c) B. This patient has the signs and symptoms consistent with
Marfan's syndrome. Ectopia lentis, aortic root dilation and aortic
dissection are major criteria for the diagnosis of the disease.
(u) C. See A for explanation. (u) D. See A for explanation.
80. Diagnosis/Cardiology
A patient presents with chest pain. ECG done in the emergency
department reveals ST segment elevation in leads II, III, and
AVF. This is most consistent with a myocardial infarction in
which of the following areas?
A. anterior wall
B. inferior wall
C. posterior wall
D. lateral wall
Explanations
(u) A. Anterior wall myocardial infarction is characterized by ST
segment elevation in 1 or more of the precordial (V1- V6) leads.
(c) B. Inferior wall myocardial infarction is characterized by ST
segment elevation in leads II , III , and AVF.
(u) C. Posterior wall myocardial infarction is characterized by ST
segment depression in leads V1-V3 and a large R wave in leads
V1-V3.
(u) D. Lateral wall myocardial infarction is characterized by ST
segment elevation in leads I and AVL.
81. Clinical Therapeutics/Cardiology
Which of the following is an absolute contraindication to
thrombolytic therapy in a patient with an acute ST segment
elevation myocardial infarction?
A. history of severe hypertension presently controlled B.
current use of anticoagulation therapy
C. previous hemorrhagic stroke
D. active peptic ulcer disease
Explanations
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C . Absolute contraindications to thrombolytic therapy includ
a previous hemorrhagic stroke, a stroke within one year, a
known intracranial neoplasm, active internal bleeding, and a
suspected aortic dissection. Severe, but controlled hypertensio
use of anticoagulation, and active peptic ulcer disease are relati
contraindications in which the risk/benefit ratio must be weighe
in each patient.
(u) D. See C for explanation.
82. Health Maintenance/Cardiology
A postmenopausal woman is at greatest risk of death from
which of the following?
A. stroke
B. heart disease
C. ovarian cancer
D. breast cancer
Explanations
(u) A. See B for explanation.
(c) B. Although women tend to be concerned about dy ing from
breast cancer, heart disease is the number one k iller of
postmenopausal women.
(u) C. See B for explanation.
(u) D. See B for explanation.
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83. Diagnosis/Cardiology
A 46 year-old female is being evaluated for a new-onset hypertension that was
discovered on screening at her workplace. The patient had several readings
revealing systolic and diastolic hypertension. Patient is currently on no
medications. Physical examination is unremarkable. A complete laboratory
evaluation revealed hypokalemia as the only abnormality. Which of the
following is the most likely diagnosis for this patient?
A. pheochromocytoma
B. renal artery stenosisC. coarctation of the aorta
D. primary aldosteronism
Explanations
(u) A. Pheochromocytoma will result in an
increase in the production and release of
catecholamines, which results in an increase in
urinary metanephrines on testing.
(u) B. Renal artery stenosis is identified by an
abnormal radionuclide uptake on the affected
kidney.
(u) C. Coarctation of the aorta is identified bydelayed and weakened femoral pulses along
with a blood pressure in the lower extremities
significantly lower than in the upper extremitie
(c) D. Primary aldosteronism has an increased
aldosterone secretion, which causes the
retention of sodium and the loss of potassium.
This should be the primary consideration for th
patient.
84. Clinical Intervention/Cardiology
A 54 year-old female who has diabetes presents with rubor, absence of hair,
and brittle nails of her left foot. She complains of leg pain that awakens her at
night. Examination reveals a femoral bruit with diminished popliteal and
pedal pulses on the left side. The most appropriate therapy would be
A. vasodilator therapy.
B. bypass surgery.
C. exercise program.
D. embolectomy.
Explanations
(u) A. Vasodilator therapy is not indicated.
(c) B. Bypass surgery is indicated in the presen
of rest pain and provides relief of symptoms in
80 to 90% of patients.
(u) C. While an exercise program is appropriate
with claudication, rest pain is a surgical
indication.
(u) D. Embolectomy is used for acute arterial
occlusion.
85. Clinical Therapeutics/Cardiology
Which electrolyte abnormality is associated with an increase in the risk for
digoxin toxicity?]
A. hypercalcemia
B. hypokalemia
C. hypermagnesemia
D. hyponatremia
Explanations
(u) A. See B for explanation.
(c) B. Decreased concentration of potassium
results in the increased activity of cardiac
glycosides by increasing tissue b inding and
decreasing renal excretion of digoxin. Potassiu
loss is the only significant electrolyte abnormali
that significantly affects digoxin metabolism.
(u) C. See B for explanation.
(u) D. See B for explanation.
86. Health Maintenance/Cardiology
A 56 year-old male, status post myocardial infarction, is noted to have left
ventricular hypertrophy and an ejection fraction of 38%. Which of the
following medications should be prescribed to prevent the development of
heart failure symptoms?
A. amlodipine (Norvasc)
B. furosemide (Lasix)
C. hydrochlorothiazide (HCTZ)
D. lisinopril (Zestril)
Explanations
(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. ACE inhibitors have been shown to
markedly improve survival and are also
recommended for prevention of symptoms in
patients at risk for heart failure.
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87. Health Maintenance/Cardiology
A 74 year-old patient presents with signs and symptoms of heart failure. EKG shows the
patient to be in atrial fibrillation at a rate of 80 bpm. Blood pressure is 120/76. The
patient denies complaint of palpitations, chest pain, or syncope. Which of the
following is the most important long term therapy in this patient?
A. verapamil (Calan)
B. amiodarone (Cordarone)
C. furosemide (Lasix)
D. warfarin (Coumadin)
Explanations
(u) A. Calcium channel blockers are
utilized in rate control of atrial
fibrillation. This patient's rate is
controlled at 80bpm presently.
(u) B. Antiarrhythmic therapy may be
considered in patients with atrial
fibrillation; however anticoagulation
therapy must occur first.(u) C. Diuretics may be indicated in th
acute treatment of heart failure;
however they may not be needed lon
term.
(c) D . Patients with atrial fibrillation ha
an increased r isk for stroke, therefore
these patients need anticoagulation
with warfarin to an INR of 2.0-3.0.
88. Diagnostic Studies/Cardiology
Which of the following ECG findings is consistent with hyperkalemia?
A. prolonged QT interval
B. delta wave
C. peaked T waves
D. prominent U waves
Explanations
(u) A. Prolonged QT interval is seen in
hypocalcemia.
(u) B. Delta wave is a sign of ventricula
preexcitation seen in Wolf-Parkinson-
White (WPW) Syndrome.
(c) C. Narrowing and peaking of T
waves are the beginning EKG change
associated with hyperkalemia.
(u) D. Prominent U waves are a sign of
prolonged ventricular repolarization
seen in hypokalemia.
89. History & Physical/Cardiology
A 58 year-old male presents with chest pain. Vital signs include blood pressure of
210/175, pulse 80, RR 20. Which of the following would you expect to find on physical
examination?
A. papilledema
B. carotid bruit
C. diastolic murmur
D. absent peripheral pulses
Explanations
(c) A. Malignant hypertension is
characterized by marked blood
pressure elevation with papilledema,
often with encephalopathy or
nephropathy.
(u) B. Carotid bruits are associated wit
carotid artery stenosis.
(u) C. Diastolic murmurs are associated
with valvular heart disease such as
aortic regurgitation and mitral stenosi
(u) D. Peripheral pulses are absent in
acute arterial occlusion or severe
periph eral arterial disease.
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90. Clinical Therapeutics/Cardiology
A 55 year-old diabetic female presents for a 3 month blood pressure follow-
up. At the last visit the BP was 160/90 for the third consecutive visit. She was
placed on an ACE inhibitor and educated regarding lifestyle modifications. At
today's visit the patient complains of persistent annoying dry cough that has
been going on since the last visit. BP today is 120/70. What is the best
recommendation to control her BP?
A. add a diuretic
B. stop the ACE inhibitor and continue lifestyle modificationsC. switch patient to an Angiotensin II Receptor Blocker (ARB)
D. do nothing and recheck BP in 3 months
Explanations
(u) A. This patient's blood pressure is controlled;
there is no indication at this time to add an
additional drug.
(u) B. This patient's chronic dry cough is likely
secondary to the ACE inhibitor, the medication
should be stopped, however the patient needs
something for blood pressure control.
(c) C. This patient's chronic dry cough is likelysecondary to the ACE inhibitor, the medication
should be stopped. Angiotensin II Receptor
Blockers (ARBs) are similar to ACE inhibitors for B
control, but do not cause cough.
(u) D. This patient's chronic dry cough is likely
secondary to the ACE inhibitor, the medication
should be stopped to encourage compliance.
91. Diagnosis/Cardiology
A newborn is seen for an initial two week visit. Physical examination reveals a
thrill and a continuous machinery murmur in the left second intercostal
space. Which of the following is the most likely diagnosis?
A. patent ductus arteriosus
B. ventricular septal defect
C. tetralogy of Fallot
D. coarctation of the aorta
Explanations
(c) A. Patent ductus arteriosus is characterized by
a classic harsh, machinery-like murmur that is
continuous through systole and diastole. This is
heard best at the left second interspace and is
commonly associated with a thrill.
(u) B. Ventricular septal defect is characterized by
a holosystolic murmur at the lower left sternal
border.
(u) C. Tetralogy of Fallot is characterized by a
systolic thrill at the left sternal border with a
systolic ejection murmur that may or may not ha
an associated systolic click.
(u) D. Coarctation of the aorta is associated with a
systolic ejection click or a short systolic murmur a
the left sternal border.
92. History & Physical/Cardiology
A patient had an acute inferior, transmural myocardial infarction 4 days ago.
A new murmur raises the suspicion of mitral regurgitation due to papillary
muscle rupture. Which of the following murmur descriptions describes this
condition?
A. A grade III/VI diastolic murmur heard best at the apex without radiation.
B. A grade IV/VI systolic ejection murmur heard best at the base with
radiation to the left clavicle.
C. A grade II/VI systolic murmur heard best at the apex preceded by a click
and without radiation.
D. A grade IV/VI systolic murmur heard best at the apex with radiation to the
left axilla.
Explanations
(u) A. This is a classic description of mitral stenosi
(u) B. This is a classic description for pulmonic
stenosis.
(u) C. This is a classic description for mitral valve
prolapse.
(c) D. This is a classic description of mitral
regurgitation. The papillary muscle rupture is a
complication of an acute inferior transmural
myocardial infarction, and results in a failure of
the mitral valve leaflets to close. The direction of
regurgitant flow of blood is toward the left axilla.
93. Clinical Intervention/Cardiology
A 58 year-old male who is otherwise healthy presents with chest pain and is
found to have left main coronary artery stenosis of 75%. The most important
aspect of his management now is
A. daily aspirin to prevent MI.
B. nitrate therapy for the angina.
C. aggressive risk factor reduction.
D. referral for coronary artery revascularization.
Explanations
(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. Although medical therapy is important,
revascularization is indicated when stenosis of th
left main coronary artery is greater than 50%.
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94. Diagnostic Studies/Cardiology
A 17 year-old woman presents to the office with recurrent episodes of
palpitations and near syncope. Initial ECG was normal. She is concerned about
these episodes since they can occur at any time. Which of the following is the
most appropriate step to pursue in her evaluation?
A. cardiac catheterization
B. tilt table testing
C. echocardiogram
D. Holter monitoring
Explanations
(u) A. A cardiac catheterization will not be
useful since the patient is at low risk for actua
coronary artery disease.
(u) B. Tilt table testing is useful only in trying t
determine vasodepressor syncope that is
related to position.
(u) C. An echocardiogram shows valves and le
ventricle function, not pathways of conductio(c) D. Holter monitoring will identify the heart
rhythm; an event recorder may also be usefu
in this setting if the Holter monitor is not
diagnostic.
95. Health Maintenance/Cardiology
A 37 year-old female with history of Turner's syndrome and coarctation of the
aorta repaired at the age of 3 presents for routine examination. The patient is
without complaints of chest pain, dyspnea, palpitations, or syncope. On
exam