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1 | |
A 60-year-old male patient on aspirin, nitrates, and a beta blocker, being followed for chronic stable angina, presents to the ER with a history of two to three episodes of more severe and long-lasting anginal chest pain each day over the past 3 days. His ECG and cardiac enzymes are normal. The best course of action of the following is to |
| | A) | Admit the patient and begin intravenous digoxin |
| | B) | Admit the patient and begin intravenous heparin |
| | C) | Admit the patient and give prophylactic thrombolytic therapy |
| | D) | Admit the patient for observation with no change in medication |
| | E) | Discharge the patient from the ER with increases in nitrates and beta blockers |
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2 | |
A 60-year-old white female presents with epigastric pain, nausea and vomiting, heart rate of 50, and pronounced first-degree AV block on ER cardiac monitor. Blood pressure is 130/80. The coronary artery most likely to be involved in this process is the |
| | A) | Right coronary |
| | B) | Left main |
| | C) | Left anterior descending |
| | D) | Circumflex |
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3 | |
You are seeing in your office a patient with the chief complaint of relatively sudden onset of shortness of breath and weakness but no chest pain. ECG shows nonspecific ST-T changes. You would be particularly attuned to the possibility of painless, or silent, myocardial infarction in the |
| | A) | Advanced coronary artery disease patient with unstable angina on multiple medications |
| | B) | Elderly diabetic |
| | C) | Premenopausal female |
| | D) | Inferior MI patient |
| | E) | MI patient with PVCs |
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4 | |
A 75-year-old African American female is admitted with acute myocardial infarction and congestive heart failure, then has an episode of ventricular tachycardia. She is prescribed multiple medications and soon develops confusion and slurred speech. The most likely cause of this confusion is |
| | A) | Captopril |
| | B) | Digoxin |
| | C) | Furosemide |
| | D) | Lidocaine |
| | E) | Nitroglycerin |
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5 | |
Two weeks after hospital discharge for documented myocardial infarction, a 65-year-old returns to your office very concerned about low-grade fever and pleuritic chest pain. There is no associated shortness of breath. Lungs are clear to auscultation and heart exam is free of significant murmurs, gallops, or rubs. ECG is unchanged from the last one in the hospital. The most effective therapy is likely |
| | A) | Antibiotics |
| | B) | Anticoagulation with warfarin (Coumadin) |
| | C) | An anti-inflammatory agent |
| | D) | An increase in antianginal medication |
| | E) | An antianxiety agent |
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6 | |
A 72-year-old male presents to the ER with the chief complaint of shortness of breath that awakens him at night and also night cough. Further questioning confirms recent dyspnea on exertion. As you pursue the diagnosis of congestive heart failure using the Framingham criteria, you note the physical exam findings below. Which of the findings is considered among the less specific minor criteria? |
| | A) | Neck vein distention |
| | B) | Rales |
| | C) | S3 gallop |
| | D) | Positive hepatojugular reflux |
| | E) | Extremity edema |
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7 | |
A 55-year-old patient presents to you with a history of having recently had a myocardial infarction with a 5-day hospital stay while away on a business trip. He reports being told he had mild congestive heart failure then, but is asymptomatic now with normal physical exam. You recommend which of the following medications? |
| | A) | An ACE inhibitor |
| | B) | Digoxin |
| | C) | Diltiazem |
| | D) | Furosemide (Lasix) |
| | E) | Hydralazine plus nitrates |
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8 | |
A 26-year-old female is referred to you from an OB-GYN colleague due to the onset of extreme fatigue and dyspnea on exertion 3 months after her second vaginal delivery. By history, physical, and echocardiogram, which shows systolic dysfunction, you make the diagnosis of postpartum cardiomyopathy. Which of the following is correct? |
| | A) | Postpartum cardiomyopathy may occur unexpectedly years after pregnancy and delivery |
| | B) | About half of all patients will recover completely |
| | C) | Since the condition is idiosyncratic, future pregnancy may be entered into with no greater than average risk |
| | D) | The postpartum state will require a different therapeutic approach than typical dilated cardiomyopathies |
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9 | |
Yesterday you admitted a 55-year-old white male to the hospital due to chest pain and ruled out MI. The patient tends to be anxious about his health. On admission, his lungs were clear, and his heart revealed a grade II/VI systolic crescendo-decrescendo murmur at the upper right sternal border; cardiac enzymes were normal, and resting ECG showed right bundle branch block with less than 1 mm ST segment depression. The idea of performing a routine Bruce protocol treadmill exercise test (stress test) to further assess coronary artery disease was considered, but rejected primarily due to which of the following? |
| | A) | Anticipated difficulty with the patient’s anxiety (i.e., he might falsely claim chest pain during the test) |
| | B) | Pulmonary embolus suspected as the primary diagnosis |
| | C) | Concern about the presence of aortic stenosis, a contraindication to stress testing |
| | D) | The presence of RBBB, with this baseline ECG change obscuring typical diagnostic ST-T changes |
| | E) | Concern that this represents the onset of unstable angina with unacceptable risk of MI with stress testing |
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10 | |
A 75-year-old patient presents to the ER after a sudden syncopal episode. He is again alert and in retrospect describes occasional substernal chest pressure and shortness of breath on exertion. His lungs have a few bibasilar rales, and his blood pressure is 110/80. On cardiac auscultation, the classic finding you expect to hear is |
| | A) | A harsh systolic crescendo-decrescendo murmur heard best at the upper right sternal border |
| | B) | A diastolic decrescendo murmur heard at the mid-left sternal border |
| | C) | A holosystolic murmur heard best at the apex |
| | D) | A midsystolic click |
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11 | |
A 72-year-old male comes to the office with intermittent symptoms of dyspnea on exertion, palpitations, and cough occasionally productive of blood. On cardiac auscultation, a low-pitched diastolic rumbling murmur is faintly heard toward the apex. The origin of the patient’s problem probably relates to |
| | A) | Rheumatic fever as a youth |
| | B) | Long-standing hypertension |
| | C) | Silent MI within the past year |
| | D) | Congenital origin |
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12 | |
You are helping with school sports physicals and see a 13-year-old boy who has had some trouble keeping up with his peers. He has a cardiac murmur, which you correctly diagnose as a ventricular septal defect based on which of the following auscultatory findings? |
| | A) | A systolic crescendo-decrescendo murmur heard best at the upper right sternal border with radiation to the carotids; the murmur is augmented with transient exercise |
| | B) | A systolic murmur at the pulmonic area and a diastolic rumble along the left sternal border |
| | C) | A holosystolic murmur at the mid-left sternal border |
| | D) | A diastolic decrescendo murmur at the mid-left sternal border |
| | E) | A continuous murmur through systole and diastole at the upper left sternal border |
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13 | |
A 40-year-old male presents to the office with a history of palpitations that last for a few seconds and occur two or three times a week. There are no other symptoms. ECG shows a rare single unifocal premature ventricular contraction (PVC). The most likely cause of this finding is |
| | A) | Underlying coronary artery disease |
| | B) | Valvular heart disease |
| | C) | Hypertension |
| | D) | Apathetic hyperthyroidism |
| | E) | Idiopathic or unknown |
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14 | |
Subsequent 24-h Holter monitoring in the preceding patient confirms occasional single unifocal PVCs plus occasional premature atrial contractions (PACs). The best antiarrhythmic management in this case is |
| | A) | Anxiolytics |
| | B) | Beta blocker therapy |
| | C) | Digoxin |
| | D) | Quinidine |
| | E) | Observation, no medication |
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15 | |
An active 78-year-old female has been followed for hypertension but presents with new onset of mild left hemiparesis and the finding of atrial fibrillation on ECG, which persists throughout the hospital stay. She had been in sinus rhythm 6 months earlier. Optimal treatment by the time of hospital discharge includes antihypertensives plus |
| | A) | Close observation |
| | B) | Permanent pacemaker |
| | C) | Aspirin |
| | D) | Warfarin (Coumadin) |
| | E) | Subcutaneous heparin |
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16 | |
A 36-year-old white female nurse comes to the ER due to a sensation of fast heart rate, slight dizziness, and vague chest fullness. Blood pressure is 110/70. The following rhythm strip is obtained, which shows |
| | A) | Atrial fibrillation |
| | B) | Atrial flutter |
| | C) | Supraventricular tachycardia |
| | D) | Ventricular tachycardia |
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17 | |
The initial pharmacologic therapy of choice in this stable patient is |
| | A) | Adenosine 6 mg rapid IV bolus |
| | B) | Verapamil 2.5 to 5 mg IV over 1 to 2 min |
| | C) | Diltiazem 0.25 mg/kg IV over 2 min |
| | D) | Digoxin 0.5 mg IV slowly |
| | E) | Lidocaine 1.5 mg/kg IV bolus |
| | F) | Electrical cardioversion at 50 joules |
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18 | |
A 65-year-old man with diabetes, on an oral hypoglycemic, presents to the ER with a sports-related right shoulder injury. His heart rate was noted to be irregular and the following ECG was obtained. The best immediate therapy is |
| | A) | Atropine |
| | B) | Isoproterenol |
| | C) | Pacemaker |
| | D) | Electrical cardioversion |
| | E) | Digoxin |
| | F) | Diltiazem |
| | G) | Observation |
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19 | |
While at the grocery store, you see an elderly lady slump to the floor. Going to her aid, your first step in Adult Basic Life Support (CPR) should be the following |
| | A) | Check for a carotid pulse |
| | B) | Assess breathing |
| | C) | Establish an airway |
| | D) | Determine responsiveness |
| | E) | Institute chest compression |
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20 | |
In the ICU, a patient suddenly becomes unresponsive, pulseless, and hypotensive, with cardiac monitor indicating ventricular tachycardia. The crash cart is immediately available. The first therapeutic step among the following should be |
| | A) | Amiodarone 300 mg IV push |
| | B) | Lidocaine 1.5 mg/kg IV push |
| | C) | Epinephrine 1 mg IV push |
| | D) | Defibrillation at 200 joules |
| | E) | Defibrillation at 360 joules |
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21 | |
A 55-year-old African American female presents to the ER with lethargy and blood pressure of 250/150. Her family members indicate that she was complaining of severe headache and visual disturbance earlier in the day. They report a past history of asthma but no known kidney disease. On physical exam, papilledema and retinal hemorrhages are present. The best approach is |
| | A) | Intravenous labetalol therapy |
| | B) | Continuous-infusion nitroprusside |
| | C) | Clonidine by mouth to lower blood pressure slowly but surely |
| | D) | Nifedipine sublingually to lower blood pressure rapidly and remove the patient from danger |
| | E) | Further history about recent home antihypertensives before deciding current therapy |
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22 | |
A patient has been in the cardiac care unit with an acute anterior myocardial infarction. He develops the abnormal rhythm shown below. You should |
| | A) | Give digoxin |
| | B) | Consult for pacemaker |
| | C) | Perform cardioversion |
| | D) | Give propranolol |
| | E) | Give lidocaine |
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23 | |
A 48-year-old male with a history of hypercholesterolemia presents to the ER after 1 h of substernal chest pain, nausea, and sweating. His ECG is shown at right. There is no history of hypertension, stroke, or any other serious illness. Which of the following therapies is not appropriate? |
| | A) | Aspirin |
| | B) | Beta blocker |
| | C) | Morphine |
| | D) | Digoxin |
| | E) | Nitroglycerin |
| | F) | Thrombolytic agent |
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24 | |
A 55-year-old obese woman develops pressurelike substernal chest pain 1 h in duration. Her ECG is shown below. The most likely diagnosis is |
| | A) | Costochondritis |
| | B) | Acute anterior myocardial infarction |
| | C) | Acute inferior myocardial infarction |
| | D) | Pericarditis |
| | E) | Esophageal reflux |
| | F) | Cholecystitis |
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25 | |
A 50-year-old construction worker continues to have an elevated blood pressure of 160/95 even after a third agent is added to his antihypertensive regimen. Physical exam is normal, electrolytes are normal, and the patient is taking no over-the-counter medications. The next helpful step for this patient is to |
| | A) | Check pill count |
| | B) | Evaluate for Cushing syndrome |
| | C) | Check chest x-ray for coarctation of the aorta |
| | D) | Obtain a renal angiogram |
| | E) | Obtain an adrenal CT scan |
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26 | |
A 43-year-old woman with a 1-year history of episodic leg edema and dyspnea is noted to have clubbing of the fingers. Her ECG is shown below. The correct diagnosis is |
| | A) | Inferior wall myocardial infarction |
| | B) | Right bundle branch block |
| | C) | Acute pericarditis |
| | D) | Wolff-Parkinson-White syndrome |
| | E) | Cor pulmonale |
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27 | |
A 62-year-old male with underlying COPD develops a viral upper respiratory infection and begins taking an over-the-counter decongestant. Shortly thereafter he experiences palpitations and presents to the emergency room, where the following rhythm strip is obtained, demonstrating |
| | A) | Normal sinus rhythm |
| | B) | Junctional rhythm |
| | C) | Atrial flutter with 4:1 atrioventricular block |
| | D) | Paroxysmal atrial tachycardia with 2:1 atrioventricular block |
| | E) | Complete heart block with 2:1 atrioventricular block |
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28 | |
An asymptomatic 30-year-old female was noted by her gynecologist to have a cardiac murmur. She was referred for an echocardiogram, with results reported to her as showing mitral valve prolapse. The patient desires more information and now comes to you. Which of the following is true about her condition? |
| | A) | Echocardiography demonstrates displacement of one or both mitral valve leaflets posteriorly into the left atrium during systole |
| | B) | Migration of the systolic click and systolic murmur toward the first heart sound will occur during squatting |
| | C) | Prophylactic beta blocker therapy is indicated |
| | D) | Significant mitral regurgitation is likely to occur (>50% chance) sometime in her life |
| | E) | Restriction of exercise is advised to reduce the risk of sudden cardiac death |
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29 | |
You are reviewing a number of patients with congenital heart disease with specific attention to whether or not they need antibiotic prophylaxis for dental work. Which of the following cardiac conditions creates the lowest risk for development of infective endocarditis? |
| | A) | Coarctation of the aorta |
| | B) | Ventricular septal defect |
| | C) | Atrial septal defect |
| | D) | Patent ductus arteriosus |
| | E) | Prosthetic heart valve |
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30 | |
An 80-year-old with a past history of myocardial infarction is found to have left bundle branch block on ECG. He is asymptomatic with blood pressure 130/80, lungs clear to auscultation, and no leg edema. On cardiac auscultation, the most likely finding is |
| | A) | Fixed (wide) split S2 |
| | B) | Paradoxical (reversed) split S2 |
| | C) | S3 |
| | D) | S4 |
| | E) | Opening snap |
| | F) | Midsystolic click |
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