IM Cardiology

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IM Cardiology

All PYQ before 2020 (4th + 6th year)

ISCHEMIC HEART DISEASE


1) Which of the following features indicated a poorer prognosis in
acute myocardial infarction?
a) Atrial fibrillation at onset
b) Left ventricular ejection fraction 50%
c) Age over 75 years
d) Ventricular fibrillation occurring at day 5 post the infarction
e) Inferior rather than anterior infarction

Answer: D

Note: Most common cause of death post MI is ventricular


arrhythmias like ventricular fibrillation or ventricular tachycardia. Old
age (>75) and atrial fibrillation are also poor prognostic factors, but
ventricular arrhythmias are the worst prognostic factors.

2) Patient with anterior MI, suddenly he lost his consciousness, the


most likely cause is
a) +Ventricular fibrillation

3) Most common cause of early death after inferior MI:


a) +Ventricular fibrillation

Note: Most common cause of death in the first several days after a
myocardial infarction is ventricular arrhythmia (ventricular
tachycardia, ventricular fibrillation).

4) All the followings are poor prognostic indicators after ant. MI


except:
a) Age < 60 Years
b) HF
c) S3
d) Female sex
e) Male

Note: general poor prognostic factors after MI include old age (>75
years), female gender, presence of HF or severe left ventricular
dysfunction, and arrhythmias.
I think something in the question is wrong since both genders are
choices as well as age<60. Age and male sex are wrong choices.

5) One of the following is associated with bad prognosis in MI


a) +Sinus bradycardia

Note: The prognosis is worse for anterior than for inferior infarcts.
Bundle branch block and high cardiac marker levels both indicate
extensive myocardial damage. Old age, depression and social
isolation are also associated with a higher mortality.

6) Which of the following is false about myocardial infarction (MI)?


a) An anterior wall MI is more serious than an inferior wall MI
b) Annual mortality in a patient who had an MI is 20-30%
c) High troponin levels correlate with worse prognosis in ST
elevation MI
d) MI’s are more likely to present with vomiting than angina
e) Arrhythmias are more likely associated with MI’s than angina

Answer: D (not 100% sure)

7) A 62-year old woman received thrombolytic therapy for acute


anterior wall myocardial infarction. After 48 hours, she developed
severe shortness of breath and her oxygen saturation dropped to
85% on room air. Her blood pressure is 96/60 mmHg and heart rate
is 120 bpm. On examination, a new Pansystolic murmur, loudest at
the apex, and bilateral crackles on both lung fields up to the mid
zone are appreciated. What is the likely cause for her deterioration?
a) Acute ventricular septal defect (VSD)
b) Left ventricular wall rupture
c) Acute pericarditis
d) Papillary muscle rupture leading to mitral regurgitation
e) Left ventricular aneurysm
Answer: D

8) All of the following are complications of MI except :


a) Endocarditis
b) Atrial fibrillation.
c) Papillary Muscle Rupture.
d) HF

Answer: A

Note: Complications of acute MI include congestive heart failure,


arrhythmias, recurrent infarction, mechanical complications (free
wall rupture, papillary muscle rupture, and ventricular aneurysm),
acute pericarditis and Dressler syndrome.

9) A 45-year-old male complains of typical chest pain. A 12 lead ECG


show transient ST-segment elevation in V2-V4. Upon cardiac
catheterization coronaries appear normal. What is the most likely
diagnosis?
a) Unstable angina
b) Stable angina
c) Non ST elevation myocardial infraction
d) Prinzmetal’s angina
e) Pericarditis

Answer: D

Note: Vasospasm in coronary arteries may coexist with atheroma,


especially in unstable angina; in less than 1% of cases, vasospasm
may occur without angiographically detectable atheroma. This is
sometimes known as variant angina, and may be accompanied by
spontaneous and transient ST elevation on the ECG (Prinzmetal’s
angina). Calcium channel antagonists, nitrates and other coronary
vasodilators are the most useful therapeutic agents but may be
ineffective.

10) In MI, the earliest marker to rise is:


a) CK-MB
b) Troponin T
c) Troponin I
d) Myoglobin

Answer: D

11) Question about what is the first enzyme to raise after MI:
a) CPK-MB
b) Troponin l
c) Myoglobin

Answer: C

Note: CK-MB raises 4-6 hrs after symptom onset. Myoglobin rises
2-4 hours after onset of infarction. Troponin rises after 6-12 hrs of
onset of myocardial damage.

12) A patient presents with typical chest pain, his pain was relived
with nitroglycerin, ECG shows ST depression in v1 -v4
what is your next step?
a) Discharge him home
b) Gives him thrombolytic
c) Admission on B-blocker, ACE-I and aspirin
d) Stress test

Answer: C

13) Right ventricle infarction, which of the following you will not
see?
a) Congestion on the lungs (pulmonary edema)
b) Increase JVP
c) Occlusion or RCA
d) Low capillaries wedge pressure
e) Hypotension

Answer: A

14) All are absolute contraindications for thrombolytic thereby,


except:
a) Age more than 70
b) Stroke 3 weeks ago
c) Transurethral resection of the prostate 2 weeks ago
d) Bleeding from PUD one week ago

Answer: A

15) Post-MI with pansystolic murmur. What is the ause?


a) +Ruptured papillary cause MR

16) Long case. 65y male come to ER with severe retrosternal pain, BP
90/50, bradycardia, ST elevation in aVR, leads 2, 3, diagnosis:
a) Aortic dissection
b) Inferior MI
c) Right MI
d) Inferior MI with right

Answer: B

17) All the following are false about stable angina except:
a) Occur at rest
b) It is a new onset angina
c) Precipitated by eating
d) It is angina that increase in frequency and severity
e) Angina not relived by sublingual nitrate

Answer: C

Note: Characteristics of stable angina Provoking factors include


activities and situations that increase myocardial oxygen demand
including physical activity, cold, emotional stress, sexual
intercourse, meals or lying down (this increases venous return
which increases wall stress). Can usually be predicted and the pain
is usually similar to previous types of chest pain you've had Lasts a
short time, perhaps five minutes or less disappears sooner if you
rest or use your angina medication.

18) Case: patient complains from chest pain upon walking uphill,
lasting for 5 min , relieved by test , normal ECG and normal Echo :
a) +Stable Angina
19) Which is not related to unstable angina
a) Angina of recent onset
b) Post MI angina
c) Angina at rest
d) Predictable angina in some patients

Answer: D

Note: Unstable angina includes the following; new onset angina,


rest angina, early post MI angina, post-revascularization angina
and absence of significant coronary disease.

20) All the following conditions are considered contraindications to


exercise stress testing except:
a) Acute myocarditis
b) Unstable angina
c) Abdominal aortic aneurysm with transverse diameter of 4 cm
d) Symptomatic hypertrophic obstructive cardiomyopathy
e) Advanced aortic stenosis

Answer: C

Note: Absolute contraindications include:


 Acute MI (within 2 days)
 Unstable angina not previously stabilized by medical therapy
 Uncontrolled cardiac arrhythmias causing symptoms or
hemodynamic compromise
 Symptomatic severe aortic stenosis
 Uncontrolled symptomatic heart failure
 Acute pulmonary embolus or pulmonary infarction
 Acute myocarditis or pericarditis
 Acute aortic dissection

21) A 60 years old female patient, hypertensive, smoker, presented


to the ER with SOB, hx of EF of 35%, all of the following
investigations can be done in this case except:
a) Echo
b) ECG
c) PFT
d) CXR
e) Stress testing

Answer: E

22) Which one is the best definition of MI:


a) All MI patients will have chest pain
b) Chest pain may present with diaphoresis , vomiting
c) Chest pain in MI will change with movement , eating
d) Chest pain is infrequent finding
e) Chest pain is the definitive diagnosis of MI

Answer: B

23) The least likely condition to cause Unstable Angina:


a) Fever
b) Hypothyroidism

Answer: B

Note: Factors that increase myocardial oxygen demand and elicit


unstable angina; Arrhythmias, Fever, Hypertension, Cocaine use,
Aortic stenosis, AV shunts, Anemia, Thyrotoxicosis,
Pheochromocytoma and CHF.

24) Which of the following about the pain radiation in MI is


incorrect:
a) Jaw
b) Left scapula
c) Right shoulder
d) Epigastrium
e) Throat

Note: I think the answers will be more specific. According to


uptodate angina often radiates to the upper abdomen (epigastric),
shoulders, arms (upper and forearm), wrist, fingers, neck and
throat, lower jaw and teeth (but not upper jaw), and rarely to the
back (specifically the interscapular region).
25) MI radiated to all of following except:
a) +Upper Jaw

26) All of the following are sites for radiating MI, except :
a) Forehead
b) Intracellular
c) Left. Scapula

Answer: A
Note: no idea what intracellular is supposed to be.

27) All of the followings are risk factors for IHD except :
a) Homocystinemia
b) High LDL level
c) Low HDL level
d) Alcohol

Answer: D

Note: Moderate alcohol consumption is thought to be


cardioprotective for coronary heart disease.
Major risk factors of coronary heart disease include diabetes
(worst risk factor), elevated LDL, hypertension (most common risk
factor), smoking, age (>45 in males, >55 in females), family history
of premature coronary artery disease or MI in first degree relative
(<55 in males and <65 in females), low levels of HDL.

28) All of the following are precipitating factors for IHD except :
a) HTN
b) Smoking
c) Homocystenemia
d) Father who died because of MI, when he was 72 Years

Answer: D

29) One is not a risk factor of MI:


a) Increased HDL
b) Increased LDL
c) Obesity
d) Homocystenemia
Answer: A

30) A Healthy 38 year old man comes to cardiology clinic for routine
checkup; he is smoker, no HTN, no family history of DM or HTN.
Everything is normal. What will you do to complete his exam as a
screening tool?
a) FBG
b) Fasting lipid profile
c) CBC
d) Abdominal US
e) ECG

Answer: B
Note: Since everything is normal, and his age is above 35, this is
the age to screen for hyperlipidemia.
The U.S. Preventive Services Task Force (USPSTF) strongly
recommends screening men 35 years and older for lipid disorders.
The USPSTF recommends screening men 20 to 35 years of age for
lipid disorders if they are at increased risk of coronary heart
disease (CHD).

31) All of the following are risk factor of coronary artery disease
except:
a) Hyperlipoproteinemia
b) Increase LDL
c) Increase insulin
d) Increase estrogen
e) Increase homocystine

Answer: D

32) Patient with inferior MI, developed 3rd degree heart block, the
management of choice will be:
a) +Keep him on his medication, and observe

Note: Third degree AV block when it occurs in the setting of an


inferior MI, the block is usually at the level of the AV node. It
tends to be transient, although it may take up to 1 to 2 weeks to
resolve. As a result, IV atropine may be used initially and if
conduction is not restored a temporary pacemaker is appropriate.
When complete AV block occurs in the setting of an anterior MI,
the His-Purkinje system is usually involved. The block is usually
permanent, and a permanent pacemaker should be implanted.

33) Case of MI, developed hypotension , bradycardia, ST elevation in


aVR, Lead III, aVF, your dx :
a) Right ventricular MI
b) Inferior MI

Note: The answer is probably right ventricular MI (which is a


complication of inferior MI). The major clinical features of a
hemodynamically significant right ventricular MI (RVMI) include
hypotension, elevated jugular venous pressure, and clear lung
fields and an electrocardiogram with evidence of an acute inferior
MI (ST segment elevation in leads II, III, aVF).

34) Male with severe chest pain, distended jugulars, hypotensive. ST


elevation in I, II, aVF. Lungs were clear. What's the diagnosis?!
a) Right ventricular infarction
b) Cardiac rupture
c) Ventricular septal rupture
d) Left ventricular failure

Answer: A

35) Patient had MI and then was discharged, after 2 weeks


developed chest pain during inspiration, fever..Your dx is:
a) +Dressler syndrome

Explanation: Chest pain during inspiration (indicate pleuritic = chest


pain that is worsens during inspiration) and have fever (usually low
grade) pericarditis He had MI before so it could be one of the
complications of ACS because Secondary Pericarditis Dressler
Syndrome (late) is one of them.

The post-MI syndrome (Dressler’s syndrome) is characterized by


persistent fever, pericarditis and pleurisy, and is probably due to
autoimmunity. The symptoms tend to occur a few weeks or even
months after the infarct and often subside after a few days;
prolonged or severe symptoms may require treatment with high-
dose aspirin, NSAIDs or even corticosteroids.

36) Patient 50 years old had MI, after 4 weeks he developed pleuritic
chest pain aggravated by inspiration, your Dx:
a) Dressler syndrome
b) Another MI

Answer: A

37) A 55-year old man has had an acute myocardial infarction 2


months ago. He takes nitroglycerin as needed and aspirin daily.
Examination reveals normal heart sounds. Treatment with the beta
blocker metoprolol is most likely to improve his symptoms due to
which of the following mechanisms?
a) Dilating the coronary arteries
b) Preventing fibrin and platelet plugs
c) Peripheral vasodilation
d) Decreasing diastolic relaxation
e) Decreasing myocardial contractility

Answer: E

Note: Reducing contractility reduces oxygen demand which will


improve the symptoms.

38) Best regimen for treatment of unstable angina :


a) +Heparin, Aspirin, ACE-I

Explanation: Any patient coming to ER & after taking the vital


signs we start medical therapy:

1) Morphine: analgesic, reduce pain/anxiety—decrease


sympathetic tone, systemic vascular resistance and oxygen
demand. Careful with hypotension, hypovolemia, & respiratory
depression

2) Oxygen (2-4 liters/minute) (class I, level C)


Up to 70% of ACS patient demonstrate hypoxemia
May limit ischemic myocardial damage by increasing oxygen
delivery/reduce ST elevation.

3) Nitroglycerin: Coronary vasodilator, causes dilatation of


coronary arteries and reduces the pain (analgesic), and reduces
the preload & afterload.

4) Aspirin: One of the most important drugs that given in ACS


 Irreversible inhibition of platelet aggregation
 Stabilize plaque and arrest thrombus
 Reduce mortality in patients with STEMI
 All ACS patients given aspirin except those with active
bleeding

5) Beta-Blockers: (class I, level A)


 14% reduction in mortality risk
 Reduce the work load on the heart
 Not given to heart failure or heart block patients

6) ACE-Inhibitors/ARB:
 Start in patients with acute anterior MI & their BP is stable &
normal
 Start in the first 24 hrs
 Remember that this group may cause postural hypotension,
so make sure that the patient is stabilized.

7) Heparin: LMWH or UFH (low molecular weight or


unfractionated heparin)
 Indirect inhibitor of thrombin
 Adjunct to surgical revascularization and thrombolytic /
PCI reperfusion (additive agent)

 Mortality-lowering therapy includes dual antiplateletbtherapy


(DAPT) with aspirin and a P2Y12
inhibitor, heparin, and β-blockers.

39) Case of new onset MI discharge on all


the following except:
a) +Nefidipine
Note: Discharge Medications List after MI: Aspirin, Clopidogrel
after PCI for at least 1 Year, β-Blocker, ACE inhibitor, Lipid-
lowering agent (Statin), Nitroglycerin sublingual PRN for angina.

40) A patient presented to ER with chest pain, his ECG showed ST


segment elevation MI involving lateral leads. What is the initial
treatment?
a) +Form A : aspirin – alteplase – heparin
b) +Form B : aspirin – streptokinase

41) Inferior MI with ST elevation, BP < 90/60 u will give all except:
a) +IV nitroglycerin

Note: The treatment of hypotension in the patient with right


ventricular infarction in the sitting of inferior MI often requires
rapid intravascular volume repletion and inotropic agents (e.g.,
dobutamine). Diuretic and vasodilator (e.g., nitroglycerin) therapy
should be avoided because they may provoke hypotension in this
setting.

42) A long case ( which wasn’t important) which one of the following
ECG finding is an indication for thrombolysis:
a) +ST elevation in V4-V6 about 2 mm

Note: thrombolytic therapy is only indicated in STEMI.

43) A 58 year old man presents to the ER with sudden onset of


severe retrosternal chest pain associated with nausea, vomiting,
and diaphoresis. His ECG showing ST segment elevations in leads
aVL and I. The patient was treated with thrombolytic therapy in the
ER. His is known to have diabetes for the last 2 years and
hypertension for the last 3 years and is treated on enalapril and
insulin. Which of the following combination of medications has
been shown to reduce mortality (Best combination) after an acute
MI?
a) Magnesium, beta-blockers and aspirin
b) Oxygen, morphine, aspirin and nitrates
c) Aspirin, beta-blockers and ACE inhibitors
d) ACE inhibitors, nirates and beta-blockers
e) Nitrates, beta-blockers and aspirin

Answer: C

44) Patient with USA. Which one of the following cannot be given?
a) Aspirin
b) Heparin
c) Nitroglycerin
d) Streptokinase

Answer: D

45) Old male presented with retrosternal chest pain and diaphoresis.
ECG showed ST depression on leads II, III, aVF. All of the following
are part of the management, EXCEPT:
a) Streptokinase
b) Aspirin
c) Heparin
d) Beta-blockers
e) Nitrates

Answer: A

46) Note: Thrombolytic therapy is not beneficial in patients with a


non ST elevation acute coronary syndrome.

47) 39)All of the following drugs are considered for secondary


prophylaxis after a myocardial infarction except
a) ACE inhibitors
b) Nitrates
c) Statins
d) Aspirin
e) Beta-blockers

Answer: B
Note: Secondary prevention of post myocardial infarction
includes ABCDE:
A-Aspirin and anti-anginals
B- Beta blockers and blood pressure
C- Cholesterol and cigarettes
D- Diet and diabetes
E- Education and exercise
Long acting nitrates are reserved for patients with continuous and
frequent chest pain because tolerance may occur.

48) Not a contraindication for thrombolytics:


a) Pregnancy
b) ischemic stroke before 1 year
c) cholecystectomy before 2
weeks
d) active bleeding
e) high blood pressure
(something like 220/150)

Answer: B

Note: They’re all


contraindications; I think the
answers should be more
specific.

49) All of the following are contraindications to thrombolytic


therapy, EXCEPT
a) Pregnancy
b) BP 180/110
c) Proliferative diabetic retinopathy
d) CVA (thrombotic infarct) at any time
e) Aortic dissection

Answer: C

NOTE: Not exactly sure but all of these questions are dumb tbh.

50) Which of the following is an absolute contraindication to


thrombolysis therapy:
a) 40 years old pt with amenorrhea for three months and abdominal
distention
b) Eye surgery (laser photocoagulation)
c) History of ischemic stroke before 24 months
d) Elderly female with uncontrolled HTN and new onset diastolic
murmur at the left lower sternal border

Answer: D
Note: the pt in D is a case of suspected aortic dissection
(uncontrolled HTN and the aortic regurgitation murmur)!!

51) Absolute contraindication for thrombolytic therapy is:


a) BP > 180 over 100
b) +Something else

52) Definitive contraindication for thrombolytic therapy in acute


MI?
a) Age > 75
b) Acute severe asthma
c) Brain tumor
d) Previous ischemic stroke
e) Atrial fibrillation
f) Stroke before 9 years

Answer: C

NOTE: Brain tumor is an absolute contraindication so I think it is


the correct answer. It should be specified what kind of stroke it is
(if ischemic then it is NOT an ABSOLUTE contraindication).

53) 45)most common cause of cardiac death in patients >36 Years of


age is:
a) HOCM
b) Long QT associated with drugs
c) Long QT
d) ACS

Answer: D

54) All cause ST elevation EXCEPT :


a) LVH
b) MI
c) LV aneurysm
d) Hypokalemia

Answer: D
Note: Hypokalemia causes ST segment depression.

55) There was a question about NSTEMI and STEMI :


a) First 6 months higher mortality in STEMI
b) STEMI more in elderly and with more comorbidities
c) STEMI is more frequent

Answer: A

Note: According to uptodate, short-term mortality is lower in


patients with NSTEMI compared with patients with STEMI. In contrast
to the short-term outcomes, which are worse with STEMI, long-term
outcomes have been similar or worse with NSTEMI.

CONGESTIVE HEART FAILURE


56) The earliest sign of cardiogenic pulmonary edema on CXR is:
a) Alveolar infiltrates
b) Interstitial infiltrates
c) Upper lobe diversion (increased pulmonary flow to the upper
lobes)
d) Kerley B lines
e) Pleural effusion

Answer: C
Note: also known as "Cephalization of the pulmonary vessels".

57) Which of the following ancillary tests can be used to detect


pulmonary edema?**(Not sure of the question’s phrasing):
a) +Brain natriuretic peptide – more than 100pg/ml

Notes: also (ECG, Cath, Echocardiogram, Transesophageal Echo,


BUN, ABG, US, CT)
58) All may cause decompensated heart failure except?
a) NSAID
b) Anemia
c) Thyrotoxicosis
d) Pregnancy
e) Digoxin

Answer: E

59) Patient with S4 with picture suggestive of MI. What is the cause
of S4?
a) Increased ventricular compliance
b) Decreased ventricular compliance
c) Decreased ventricular contraction

Answer: B
Note: a low-frequency gallop sound that results from forceful
atrial contraction into a ventricle which cannot expand further.

60) One of the following is true:


a) +Bilateral basal lung crackles suggest left ventricle failure

61) What cannot be found in Left ventricular failure:


a) Dilated JVP
b) Pulmonary edema + pulmonary symptoms

Answer: A

62) All of the followings are signs of left ventricular heart failure
except:
a) S3 gallop
b) Basal crepitation
c) Dyspnea
d) Edema

Answer: D

63) All of these are signs of LHF except:


a) S4 gallop
b) Pulsus alternans
c) Sinus tachycardia
d) Lung crepitation
e) S3 gallop
Answer: A

Note: S4 is associated with any process that increases the stiffness of


the ventricle (hypertrophy, long standing hypertension).

Pulsus alternans is characterized by evenly spaced alternating strong


and weak peripheral pulses and if present, is pathognomonic of
severe left ventricular systolic failure.

64) Not precipitating factor of heart failure :


a) Venesection
b) Thyrotoxicosis
c) Volume overload
d) Anemia

Answer: A

65) All the following are true about complication of


HF except:
a) Pulmonary edema
b) DVT
c) Protein losing enteropathy

Answer: C

Note: Complications of heart failure include renal failure,


electrolyte imbalances (hypokalemia/ hyperkalemia,
hyponatremia), impaired liver function, thromboembolism, atrial
and ventricular arrhythmias, and sudden cardiac death (mostly
due to ventricular fibrillation).

66) All are complication of heart failure except:


a) +Endocarditis

67) One is specific sign for congestive heart failure:


a) Palpable liver
b) Pulmonary edema
c) Ankle edema
Note: The question is probably missing more choices.

68) Specific for congestive heart failure:


a) +S3

Note: S3 has a low sensitivity but a high specificity (up to 99%) for
clinical diagnosis of HF.

69) Pure diastolic dysfunction:


a) +Long standing hypertension

70) HF not good prognostic factor :


a) higher BMI
b) resting tachycardia

Answer: B

Note: Four major findings that suggest severity of the cardiac


dysfunction; resting sinus tachycardia, narrow pulse pressure,
diaphoresis and peripheral vasoconstriction.

71) All of the following conditions are associated with high output
heart failure, EXCEPT:
a) Paget’s disease of the bone
b) Iron overload
c) Hyperthyroidism
d) Thiamine deficiency
e) Large AV fistula

Answer: B

Note: Causes of high output HF include; chronic anemia,


pregnancy, hyperthyroidism, AV fistula, wet beriberi (thiamine
deficiency), Paget's disease of bone, MR, and aortic insufficiency.

72) All of the following steps or drugs are appropriate measures in


the treatment of acute pulmonary edema, EXCEPT:
a) Semi-sitting position
b) Intravenous digoxin
c) Intravenous morphine
d) Oxygen therapy
e) Intravenous loop diuretics

Answer: B

Note: Cardiogenic pulmonary edema (CPE) is defined as


pulmonary edema due to increased capillary hydrostatic pressure
secondary to elevated pulmonary venous pressure. CPE reflects
the accumulation of fluid with low-protein content in the lung
interstitium and alveoli as a result of cardiac dysfunction.

Treatment includes oxygenation and ventilatory assistance,


diuretics (furosemide) and nitrates (IV nitroglycerin) in patients
without hypotension. In case of persistent edema, inotropic
agents can be given (dobutamine) but digoxin takes several weeks
to work and is not indicated in an acute setting. Morphine and
ACE inhibitors can be given in specific situations (usually in the
setting of acute MI).

73) Which of the following is NOT part of management in pulmonary


edema?
a) IV nitroglycerin
b) IV morphine
c) O2
d) IV furosemide
e) IV digoxin

Answer: E

74) A case about a patient who is using aspirin and furosemide and
now he is starting to feel tired while walking uphill which one of the
following treatment is best to be added :
a) Spironolactone
b) Hydrochlorothiazide
c) Enalapril

Answer: C
Note: Initial therapy of systolic heart failure includes a
combination of diuretic therapy, an angiotensin system blocker
(ACE inhibitor or ARBs) and a beta blocker.
Enalapril is an ACE inhibitor and so it is the answer.

75) Patient long case of heart failure, admitted to the hospital 5 days
ago due to fluid overload, after that ABG was done:
PH = 7.49 PCO2 = 42 HCO3 = 32 …. What is the cause?
a) Diuretic drug
b) Shock
c) Respiratory muscle weakness

Answer: A

Note: a case of metabolic alkalosis seen in loop and thiazide


diuretics.

76) Heart failure with low ejection fraction :


a) Implantable cadiodefibllerator
b) Furosemide

Note: no idea what the question wants but implantable cardiac


defibrillator can be indicated for HF with reduced ejection fraction
as a means of prevention of sudden cardiac death (due to
ventricular arrhythmias) in high risk patients (<35% EF on optimal
medical therapy)..

77) Which of the following prolongs survival in patients with HFrEF


except:
a) ACEI
b) B blocker
c) ICD
d) Spironolactone
e) Furosemide

Answer: E

Note: The following all reduce rate of mortality; ACE Inhibitors


(like enalapril)/ARBs, cardioselective Beta blockers (carvedilol,
bisoprolol, metoprolol), Aldosterone antagonists (eplerenone,
spironolactone), Hydralazine and Nitrates (isosorbide dinitrate),
Neprilysin inhibitor (sacubitril/valsartan) and ICD. Digoxin does
NOT reduce mortality.

78) All of the following drugs or procedures can improve outcomes


and reduce mortality in heart failure except:
a) ICD implantation
b) Spironolactone
c) Carvedilol
d) Digoxin
e) ACE inhibitors

Answer: D
Note: this table is from Medstudy IM and it's very useful as reference
of when solving cardiology drugs drama.
79) All of the following increase survival in patients of heart failure,
EXCEPT:
a) Spironolactone
b) ICD
c) ACE inhibitors
d) High atrial natriuretic peptide (ANP)
e) High body mass index

Answer: E

Note: Neprilysin inhibitor increases ANP and is known to reduce


mortality.

80) All increase survival in systolic heart failure except:


a) Beta blockers
b) ACEI
c) Digoxin
d) Isosorbitedinitrate/ Hydralazine
e) Aldosterone antagonist

Answer: C

81) All of the following Doesn't affect mortality rate of heart failure
(increase survival in heart failure ) except :
a) Digoxin
b) IV nitroglycerin
c) IV propranolol
d) Defibrillator implant

Answer: A

Note: I think the choice B nitroglycerin would be with


HYDRALAZINE and as such would reduce mortality so that the
answer would be digoxin.

82) All of the following reduce mortality in a patient with heart


failure except
a) Implantable cardiac defibrillator
b) Spironolactone
c) Digoxin
d) Carvedilol
e) Enalapril

Answer: C

ECG CHANGES & ARRHYTHMIAS

83) Each of the following statements is true regarding electrolyte


abnormalities and ECG changes except:
a) Hypokalemia causes peaked T wave
b) Hyperkalemia causes QRS widening
c) Hypocalcemia results in prolongation of QT interval
d) Hypothermia and J waves (Osborn waves)
e) Hypomagnesemia is associated with polymorphic ventricular
tachycardia

Answer: A

Note: Hyperkalemia (not hypokalemia) causes peaked T wave


early on. What is meant by polymorphic ventricular tachycardia is
prolonged QT syndrome which can be caused by hypokalmeia,
hypomagnesenia and rarely hypocalcemia.

84) All of the following are true regarding chronic LBBB, EXCEPT:
a) QRS > 0.12 s
b) ST-T depression in leads I, aVL, V2-V6
c) ST-T elevation in V1,V2
d) Septal Q-waves in V5,V6

Answer: D
Note: in LBBB there will be absence of q wave in leads I, V5 and
V6.

85) LBBB all are true except.. ECG readings:

Note: Right bundle branch block (RBBB) can occur in healthy


people but left bundle branch block (LBBB) often signifies
important underlying heart disease. The left bundle branch divides
into an anterior and a posterior fascicle. Damage to the
conducting tissue at this point (hemiblock) does not broaden the
QRS complex but alters the mean direction of ventricular
depolarisation (mean QRS axis), causing left axis deviation in left
anterior hemiblock and right axis deviation in left posterior
hemiblock. The combination of right bundle branch block and left
anterior or posterior hemiblock is known as bifascicular block.

86) All of the following medications can cause QT segment


prolongation, EXCEPT:
a) Organophosphates
b) Cisapride
c) Erythromycin
d) Hypokalemia
e) Beta blockers

Answer: E

Note: QT (<50% of RR interval; corrected QT ≤0.44 s)


Prolonged: congenital, hypokalemia, hypocalcemia, drugs (e.g.,
class IA and class III antiarrhythmic, tricyclics).

TORSADES DE POINTES (TWISTING POINTS): This form of VT


complicates prolonged ventricular repolarisation (pro-longed QT
interval), which may be congenital or secondary to drugs (e.g.
class Ia and class III anti-arrhythmics, macrolide antibiotics,
tricyclic antidepressants, phenothiazines) or electrolyte
disturbance (↓Ca2+, ↓Mg2+, ↓K+).

87) All of the following cause prolonged QT interval except:


a) Digoxin
b) Hypocalcemia
c) Tricyclic antidepressants
d) Head injury (cerebral injury)
e) Amiodarone

Answer: A

88) All of the following are causes of prolonged QT except:


a) Levofloxacin
b) Digoxin
c) Erythromycin -as S/E
d) Quinidine – Antiarrhythmic IA

Answer: B

89) All are of the following ECG changes happen in hyperkalemia


except:
a) Peaked P-wave
b) Peaked T-wave
c) Wide QRS
d) Sine Wave
e) Prolonged P-R

Answer: A

Note: ECG changes associated with hyperkalemia are the


following:
 Tall peaked T waves
 Shortened QT interval
 Progressive lengthening of PR interval and QRS duration
 Absence of P wave
 Sine wave pattern

90) A 65-year-old diabetic with creatinine of 140mmol/l (normal up


to 115) was started on an angiotensin converting enzyme inhibitor
for hypertension. The patient presented to the emergency room
with weakness. His other medications include a statin for
hypercholesterolemia, a beta-blocker and spironolactone for heart
failure, insulin for diabetes, and aspirin. Laboratory examinations
shows: potassium: 7.2mmol/l (normal up to 5.0), creatinine:
180mmol/l, glucose: 400mg/dl. Which of the following is the most
important factor in determining the initial treatment of
hyperkalemia in this patient?
a) Age of the patient
b) The magnitude of the hyperkalemia
c) The presence of renal failure
d) Severity of weakness
e) The ECG changes
Answer: Most likely E (or B)

91) One of the followings does not cause RBBB:


a) Aortic stenosis
b) Normal in children
c) ASD
d) PE
e) Corpulmonale

Answer: A

Note: Aortic stenosis will cause LBBB not RBBB.

92) One can't be presented in the ECG in 3rd degree heart block:
a) +Absent P wave

93) Complete AV block one is wrong:


a) Regular P-P interval
b) +Something else

Explanation: ECG findings for 3rd degree heart block:


1) No relationship between P waves and QRS complexes,
2) Relatively constant PP intervals and RR intervals
3) Greater number of P waves than QRS

94) What is wrong concerning ECG:


a) Hypercalcemia : prolonged QT
b) Hyperkalemia : peaked T wave
c) Hypokalemia : U wave

Answer: A

95) Which of the following is the commonest ECG finding in a patient


with pulmonary embolism:
a) Sinus Tachycardia
b) S1Q3T3 pattern on an ECG
c) Right bundle branch block

Answer: A
Note: Sinus tachycardia is the most common ECG finding but
S1Q3T3 pattern is classic of PE.

96) One can't be presented in the ECG in hyperkalemia:


a) +Prolonged Q-T

97) A 22-year old female who is asymptomatic except for infrequent


short episodes of palpitations characterized by sudden onset of
regular quick heart beats. ECG shows narrow complex tachycardia
with a rate of 170 beats per minute. Blood pressure is 125/75. The
most appropriate treatment for this episode is:
a) Intravenous lignocaine bolus and infusion
b) Immediate cardioversion
c) Oral digoxin
d) Intravenous adenosine
e) Amiodarone infusion

Answer: D
Note: This is a case of SVT.

Management of paroxysmal SVT:


 Vagal maneuvers (carotid sinus massage, Valsalva maneuver,
breath holding, head immersion in cold water) delay AV
conduction and thus block the reentry mechanism.

 In case vagal maneuvers aren’t helpful, IV adenosine is the


initial drug of choice.

 If still not effective, IV non-dihydropyridine calcium channel


blockers (diltiazem or verapamil) and IV beta blockers
(metoprolol or esmolol) or digoxin are alternatives in patients
with preserved left ventricular function.

 Direct current cardioversion if drugs aren’t effective or patient


is unstable.

 As prevention therapy calcium channel blockers or beta


blockers can be used. Radiofrequency catheter ablation is used in
case episodes are recurrent and symptomatic.
98) All of the followings are managements of SVT (supra-ventricular
tachycardia) except:
a) Adenosine
b) Carotid massage
c) Verapamil
d) Diltiazem

Answer: All choices are correct, may be the answer choice is


missing.

99) A chronic coffee drinker lady came to the ER complaining of


palpitation HR=180, she should be managed with
a) Adenosine
b) Amiodarone
c) Cardiovergin

Answer: A

100) 23 Year old female. 190HR-regular, BP 80/50, with 4 Years Hx of


palpitation, what to do :
a) Cardiovert
b) IV adenosine

Answer: A

Note: patient is hemodynamically unstable. Signs can include


hypotension, shortness of breath, chest pain suggestive of
coronary ischemia, shock and/or decreased level of
consciousness.

101) Which arrhythmia has regular pulse:


a) SVT
b) Atrial Fib

Answer: A
102) All are possible findings of ECG in patients with hyperkalemia,
except :
a) Prolong QT interval
b) Peaked T wave
c) Wide QRS complex
d) Prolonged PR interval
e) Absent P wave

Answer: A

103) Which of the following medication would cause QT


prolongation?
a) +Erythromycin

104) Digoxin best give in:


a) AF with rapid vent response
b) Congestive heart failure with diastolic dysfunction

Answer: A

105) Stable patient with rapid ventricle response AF, start by:
a) IV procainamide
b) IV amiodarone
c) IV metoprolol
d) Cardioversion

Answer: Mostly C

Note: Intravenous diltiazem or metoprolol are commonly used for


AF with a rapid ventricular response.

Management of new-onset AF includes:


 Assessing for rate versus rhythm control strategy
 Preventing systemic embolization

Hemodynamically unstable patient  emergency cardioversion


Stable patients can receive medical therapy (eg, B-blockers,
diltiazem, digoxin) to control the ventricular rate.

Rhythm control for maintaining sinus rhythm should be


considered in patients unable to achieve adequate heart rate
control or in those with recurrent symptomatic episodes (eg,
palpitations, lightheadedness, dyspnea, angina) or heart failure
symptoms in the setting of underlying left ventricular systolic
dysfunction.

Amiodarone has a class IIa recommendation from the 2014


American College of Cardiology (ACC)/American Heart Association
(AHA)/Heart Rhythm Society (HRS) for use as a rate-controlling
agent for patients who are intolerant of or unresponsive to other
agents, such as patients with congestive heart failure (CHF) who
may otherwise not tolerate diltiazem or metoprolol.

106) What is false about SVT:


a) Can be terminated by adenosine
b) Usually affects diseased heart

Answer: B

107) When adenosine is used:


a) Narrow complex tachycardia
b) Wide complex tachycardia
c) Narrow complex tachycardia with pre-excitation
d) Wide complex tachycardia with pre-excitation

Answer: A

108) A young female presented with palpitations (more than 30


minutes). BP 80/60, HR 190 bpm. She has recurrent similar
episodes. What is the first step in management?
a) IV adenosine
b) IV verapamil
c) Carotid message
d) DC shock
Answer: D

109) Ventricular tachycardia and wide QRS treatment:


a) +Amiodarone

Explanation: Management of VT
Prompt action to restore sinus rhythm is required and should
usually be followed by prophylactic therapy. Synchronized DC
cardioversion is the treatment of choice if systolic BP is less than
90 mmHg. If the arrhythmia is well tolerated, intravenous
amiodarone may be given as a bolus, followed by a continuous
infusion.

110) What is the treatment of unstable ventricular tachycardia?


a) +DC cardioversion

111) Which of the following is the most common arrhythmia


occurring in patients over 75 years?
a) Atrial fibrillation
b) Complete heart block
c) Pre excitation arrhythmias
d) Sinus bradycardia
e) Sinus tachycardia

Answer: A

112) A 59 year old male patient presented with left upper abdominal
pain and a CT scan of the abdomen showed a splenic infarction.
Which of the following is the most likely cause of her condition
a) Aplastic anemia
b) Gilbert’s disease
c) Idiopathic pulmonary fibrosis
d) Atrial fibrillation
e) Idiopathic thrombocytopenic purpura

Answer: A

Note: Splenic and renal infarctions are common manifestations of


cardiac thromboembolism which occurs in atrial fibrillation.
113) All of the following are causes of atrial fibrillation except:
a) Hypertension
b) Aortic insufficiency
c) Mitral stenosis
d) Other

Answer: D

114) All are causes of atrial fibrillation except:


a) +Uncontrolled DM

Note: the answer is wrong since:


CHRONIC DISEASE ASSOCIATIONS WITH A FIB
 Hypertensive heart disease
 Coronary disease
 AF as a presentation of ACS
 Valvular heart disease
 Heart failure
 Hypertrophic cardiomyopathy
 Congenital heart disease
 Venous thromboembolic disease
 Other types of cardiopulmonary disease
 Obesity
 Diabetes
 Metabolic syndrome
 Chronic kidney disease
{UpToDate}

115) One of the followings does not cause AF?


a) VSD
b) Sick sinus syndrome
c) Thyrrotoxicosis
d) HTN

Answer: A

116) What is the effect of atrial fibrillation on S4:


a) No effect
b) It will cause absence of S4
c) It will cause presence of S4
d) It will cause increase in its pressure
e) It will cause decrease in its pressure

Answer: B

Note: S4 is the sound when atria contract to force blood into LF. In
atrial fib, contraction of left atrium is lost and so the sound S4
cannot be present.

117) What is not a complication of Atrial fibrillation:


a) Heart failure
b) Pulmonary embolism
c) Mesenteric ischemia

Answer: B
Note: AF can cause stroke. But recent study shows that A-Fib does
not increase the probability of PE
(http://www.ncbi.nlm.nih.gov/pubmed/22212132)

118) Which an indication of ICD (implantable cardioverter


defibrillator):
a) Complete heart block
b) First degree HB
c) 2nd degree HB

Answer: A

119) Wechenbach AV block in a regular runner treatment:


a) +Reassurance

120) All are presentations of WPW syndrome :


a) Ventricular fibrillation.
b) Atrial fibrillation
c) 2nd degree HB
d) AVRT

Answer: C
Note: Arrhythmias associated with WPW Syndrome include AVRT,
AVNRT, Atrial fibrillation, Atrial flutter, Ventricular tachycardia,
Ventricular fibrillation and sudden death.

121) Multifocal atrial tachycardia best treatment :


a) +Treat underlying cause

122) Which of the following will "not" lead to Sinus Tachycardia:


a) +Hypothyroidism

CARDIOMYOPATHY
123) All of the following are bad prognostic features in HOCM
(Hypertrophic Obstructive Cardiomyopathy) except:
a) Non-sustained VT at 24-hrs Holter ECG monitoring
b) High LVOT (Left Ventricular Outflow Tract) gradient
c) History of recurrent syncope during exercise
d) Family history of sudden death at young age
e) Excessive septal hypertrophy (more than 30 mm as measured by
echocardiography)

Answer: B

Note: Risk factors for sudden cardiac death in hypertrophic


cardiomyopathy:
 A history of previous cardiac arrest or sustained ventricular
tachycardia
 Recurrent syncope
 An adverse genotype and/or family history
 Exercise-induced hypotension
 Non-sustained ventricular tachycardia on ambulatory ECG
monitoring
 Marked increase in left ventricular wall thickness

124) About hypertrophic obstructive cardiomyopathy (HOCM), all


indicate poor prognosis except:
a) Non sustained Ventricular tachycardia
b) History of recurrent syncope on exercise
c) History of a family member died suddenly at a young age
d) Large pressure gradient
e) LV thickness greater than 30 mm measured by echocardiography

Answer: D

125) All increases the obstruction , thus increases the intensity of the
murmur in HOCM ) Hypertrophic cardiomyopathy ( except:
a) Squatting
b) Standing
c) Valsalva maneuver
d) Exercise

Answer: A

126) All are true about hypertrophic cardiomyopathy except:


a) Autosomal dominant in 50%
b) Exertional dyspnea is the commonest symptom
c) Echocardiogram is diagnostic
d) It is a systolic dysfunction
e) Jerky carotid pulse is found on examination
Answer: D

Note: The main pathophysiologic abnormalities seen in HCM are


left ventricular outflow obstruction, diastolic dysfunction, mitral
regurgitation, and arrhythmias.

127) Which of the following drug is not contraindicated in HOCM :


a) +B-blockers

128) Which drug not used in HOCM :


a) Verapamil
b) Enalapril
c) B-blocker

Answer: B

HOCM Management: Beta blockers are considered first-line agents in


treatment of HOCM, as they can slow down the heart rate and decrease
the likelihood of ectopic beats. For patients who cannot tolerate beta
blockers or do not have good control of symptoms with beta blockers,
nondihydropyridine Calcium Channel Blockers such as Verapamil can
be used. Disopyramide can be added to either B-blockers or CCB to
improve symptoms.

129) One of the following chemotherapeutic agents is cardiotoxic :


a) +Doxorubicin

Note: A very well known cause of dilated cardiomyopathy is the


chemotherapeutic agent Anthracyclines, most commonly
DOXORUBICIN (Adriamycin) or Daunpmycin.

130) The most serious side effect of the chemotherapeutic group of


anthracyclines is:
a) Cardiomyopathies
b) Thrombocytopenia
c) Lung Fibrosis
d) Hemorrhagic Cystitis
Answer: A

131) Anthracycline -like drugs ( S/E):


a) +Cardiotoxicity

132) Which of the following chemotherapeutic agents causes


cardiomyopathy?
a) Adriamycin
b) Chlorambucil
c) Melphalan

Answer: A

133) A 35 years old female with 37 weeks gestation. She has lower
limb edema, lower bilateral crackles, JVP 13 cm and hypertensive
(previously normotensive). There was diffuse apical sound with S3
gallop and holosystolic murmur heard at apex. What is your
diagnosis?
a) Peripartum cardiomyopathy
b) Severe tricuspid regurgitation

Answer: A

Note: In a patient with PPCM, signs of heart failure are the same
as in patients with systolic dysfunction who are not pregnant.
Tachycardia and decreased pulse oximetry (should be ≥ 97% at sea
level) are present.

Blood pressure may be normal. Elevated blood pressures (systolic


>140 mm Hg and/or diastolic >90 mm Hg) and hyperreflexia with
clonus suggest preeclampsia.

Physical findings of PPCM include elevated jugular venous


pressure, cardiomegaly, third heart sound, loud pulmonic
component of the second heart sound, mitral or tricuspid
regurgitation, and pulmonary rales, worsening of peripheral
edema, ascites, arrhythmias, embolic phenomenon, and
hepatomegaly.
134) Many symptoms (dilated cardiomyopathy) what is the diagnosis:
a) Amyloid
b) +Something else

Note: Amyloidosis causes restrictive cardiomyopathy.

Causes of Dilated cardiomyopathy include the following:


 Ischemic cardiomyopathy
 Stress-induced cardiomyopathy (Takotsubo cardiomyopathy)
 Infectious cardiomyopathy (viral/HIV/Chagas disease/Lyme
disease)
 Genetic causes
 Toxic cardiomyopathy (alcohol/cocaine/medications)
 Peripartum cardiomyopathy
 Tachycardia-mediated cardiomyopathy
 Sarcoidosis
 End-stage kidney disease
 Autoimmunity (SLE)
 Hyper or hypothyroidism

135) All of the followings are causes of dilated cardiomyopathy


except:
a) Viral myocarditis
b) Aortic regurgitation
c) Mitral stenosis
d) Peripartum

Answer: C

136) In dilated cardiomyopathy , one is false:


a) +Echo is normal

137) Which of the following is a possible cause of restrictive


cardiomyopathy
a) TB pericarditis
b) Amyloidosis
c) Hypertension

Answer: B
Note: causes of restrictive cardiomyopathy are amyloidosis,
sarcoidosis, hemochromatosis, scleroderma, carcinoid syndrome,
chemotherapy or radiation induced, idiopathic.

138) A lady who was previously treated from breast cancer by


chemotherapy presented now with progressive SOB and dyspnea.
On examination she has hypotension (85/55), raised JVP, and
abdominal distention. What is your most likely diagnosis?
a) Congestive Heart Failure
b) Cardiac Tamponade
c) Infective Endocarditis
d) Restrictive Endocarditis

Answer: D
Note: Previous chemotherapy treatment is the clue to reach
diagnosis.

PERICARDIAL DISEASE

139) Case of pericarditis what is the least valuable diagnostic tool:


a) +Cardiac cath

140) A 39-year-old smoker has sharp stabbing chest pain which is


made worse by inspiration and by lying flat. His temperature is 38.2
C and you can hear coarse rub at the left sternal edge. His ECG
shows diffuse ST elevation. What is the most appropriate initial
treatment for him?
a) Corticosteroids
b) Non steroid anti-inflammatory drugs
c) Low molecular weight heparin
d) Aspirin
e) rTPA ( recombinant tissue plasminogen activator)

Answer: B

Note: this is a case of acute pericarditis.


For nearly all patients with acute idiopathic or viral pericarditis
(most common causes), we recommend NSAIDs (in combination
with colchicine) as the initial treatment. {Uptodate}

141) Pericarditis question, all of the following are true, except?


a) Happens post MI
b) We use anticoagulant
c) We use steroids
d) Relieved by leaning forward

Answer: B

142) Which of the following is most likely to be found in a patient


with long standing history of constrictive pericarditis?
a) A rise in systolic pressure on inspiration
b) Ascites
c) A wide pulse pressure
d) Pulsus alternans
e) A fall in venous pressure on inspiration

Answer: B

Explanation: Signs of constrictive pericarditis are jugular venous


distension, Kussmaul sign (JVP paradoxically increases during
inspiration), pericardial knock, ascites and dependant edema.

143) Constrictive pericarditis causes all the following except:


a) Ascites
b) Pulmonary edema
c) Pericardial knock (early s3)
d) Raised JVP
e) Hepatomegaly

Answer: B

Note: There is prominent right heart failure in constrictive


pericarditis.

144) Which sign indicates significant in pericardial effusion?


a) +Pulses paradoxsus

Note: The end result of pericardial effusion is often cardiac


tamponade. Pulsus paradoxus often precedes severe
hemodynamic deterioration. Therefore, nearly all patients with
cardiac tamponade who have pulsus paradoxus should be
evaluated for urgent or emergent pericardial fluid drainage.
{Uptodate}

145) A female patient complaining of dyspnea upon exercise. On


examination, she was hypotensive and had raised JVP. ECG showed
small QRS complexes. The most likely diagnosis is:
a) Constrictive pericarditis
b) Pericardial tamponade
c) Pericarditis

Answer: B
Note: Signs of classical cardiac tamponade include three signs, known
as Beck's triad. Low blood pressure occurs because of decreased stroke
volume, jugular-venous distension due to impaired venous return to the
heart, and muffled heart sounds due to fluid buildup inside the
pericardium.
Other signs of tamponade include pulsus paradoxus (a drop of >10
mmHg in arterial blood pressure with inspiration),narrow pulse
pressure(due to decreased stroke volume) and ST segment changes on
the electrocardiogram, which may also show low voltage QRS
complexes, as well as general signs and symptoms of shock (such as fast
heart rate, shortness of breath and decreasing level of consciousness) .
Acute myocardial regurgitation causes (causenl or increase systolic
pressure).

146) Patient with dyspnea and dizziness for few days. Presented later
with hypotension and distended jugulars and S3 on apex. There was
significant decrease of systolic pressure on inspiration. What is the
diagnosis?!
a) Restrictive cardiomyopathy
b) Cardiac tamponade
c) Acute myocardial regurgitation
d) Cardiac tamponade

Answer: D

147) All the following are classic signs for cardiac tamponade EXCEPT:
a) Tachycardia
b) Muffled heart sounds
c) Wide pulse pressure
d) Raised JVP
e) Hypotension

Answer: C

148) Which one of the following causes pulsus paradoxus :


a) +Cardiac tamponade

149) In pericardial tamponade, one is false:


a) +Frank pulmonary edema is common

150) All might be associated with cardiac tamponade, except:


a) Pulmonary edema
b) increased JVP

Answer: A

151) A patient having cardiac tamponade (hypotension, distended


JVP, soft heart sounds) what investigation should be done for the
diagnosis:
a) +Echocardiography

Note: Whenever cardiac tamponade is suspected, an echo must


be performed and is usually diagnostic.

152) A patient presented to the ER with SOB, found to be


hypotensive. ECG findings: low voltage & electrical alternans . chest
Xray showed large cardiac shadow , how to manage ?
a) +Pericardiocentesis
Note: This is a case of cardiac tamponade with hemodynamic
instability and the treatment goes as follows.
If hemodynamically stable: close monitoring
If hemodynamically unstable: pericardiocentesis.

VALVULAR HEART DISEASE


and Heart Sounds
153) An innocent murmur is:
a) Early systolic
b) Pansystolic
c) Mid-diastolic

Answer: A

154) What is wrong concerning murmurs:


a) Soft S1 in first degree
b) S3 is associated with HOCM
c) S4 is found in systemic hypertension

Answer:  (all are true)

155) All of these cause wide splitting of the second heart sound
except:
a) Pulmonary embolism
b) RBBB
c) LBBB
d) Ventricular ectopic beat
e) Left ventricular pacemaker

Answer: C

Note: RBBB is the most common cause of the persistence of


audible expiratory splitting of S2. Other causes of persistent
expiratory splitting on standing may be due either to a delay in
pulmonic valve closure or to early closure of the aortic valve.

A delay in P2 may be secondary to the following:


 Delayed electrical activation of the right ventricle (e.g., left
ventricular ectopic or paced beats, Wolff-Parkinson-White
syndrome, and RBBB).

 Decreased impedance of the pulmonary vascular bed (e.g., atrial


septal defect, partial anomalous pulmonary venous return, and
idiopathic dilatation of the pulmonary artery).

 Right ventricular pressures overload lesions (e.g., pulmonary


hypertension with right heart failure, moderate to severe valvular
pulmonic stenosis, and acute massive pulmonary embolus).

156) All of these cause collapsing pulse except:


a) Aortic regurgitation
b) Mitral stenosis
c) Thyrotoxicosis
d) Anemia
e) PDA

Answer: B

Note: Physiological causes of collapsing pulse include fever,


exercise and pregnancy. Hyperdynamic circulatory states include
thyrotoxicosis, anemia, systolic hypertension, cor pulmonale.
Cardiac lesions include aortic regurgitation, PDA, truncus
arteriosus, mitral regurgitation, complete heart block.

157) One is matched incorrectly :


a) Mitral stenosis – mid systolic murmur
b) ASD – reversed splitting
c) Aortic stenosis – slow rising pulse

Answer: Both A & B

Note: mitral stenosis  mid-diastolic murmur. ASD  wide fixed


splitting of S2.

158) All of the following statements are true regarding cardiac


auscultatory findings EXCEPT:
a) Loud first heart sound (S1) is heard in mitral regurgitation
b) Fourth heart sound (S4) reflects forceful atrial contraction
c) Third heart sound (S3) reflects rapid ventricular filling.
d) Fixed splitting of S2 in atrial septal defect
e) Variable intensity of S1 in atrial fibrillation

Answer: A

Note: The first heart sound (S1) is diminished in mitral


regurgitation.

159) Which one of the following will present with pansystolic


murmur:
a) Mitral stenosis
b) Tricuspid stenosis
c) Aortic regurgitation
d) VSD
e) PDA

Answer: D

160) All are seen with mitral stenosis except:


a) S3 gallop
b) A-fib
c) Systemic embolization
d) Malar flush
e) Hymoptysis

Answer: A

161) What is wrong in mitral stenosis:


a) The patient is mostly asymptomatic
b) A diastolic murmur
c) Loud S1
d) It's the most common cause of death in IE

Answer: D

Note: HF (more commonly due to aortic valve involvement) is the


most common cause of death in IE in the modern era.
162) Which one of these is seen in mitral stenosis:
a) +Straightening of the left heart border on X-ray

Note: we can see this finding in patients with mitral stenosis


because of the enlarged left atrium.

163) Which of the following valve abnormality is associated with an


accentuated S1 heart sound:
a) +Mitral stenosis

Notes: add to it Tricuspid V. stenosis, WPW, Sinus Tachycardia.

164) Case aortic stenosis, diagnostic test:


A- ECG
B- Echo

Answer: B

165) All the following causes aortic regurgitation except?


a) MI
b) Aortic dissection
c) Bicuspid aortic valve
d) Marfan syndrome
e) Infective endocarditis

Answer: A

166) Young female with mid-systolic click, followed by a late systolic


murmur heard best at the apex. Increase when standing. Which of
the following is the cause?
a) Mitral valve prolapse
b) Aortic stenosis
c) Mitral stenosis

Answer: A

167) A 42-year-old male admitted with dyspnea was noted to have a


murmur suggestive of mitral stenosis. The presence of which of the
following signs suggest that the mitral valve is mobile?
a) S4
b) Soft S1
c) Loud S2
d) Opening snap
e) S3

Answer: D

Note: The physical signs of mitral stenosis are often found before
symptoms develop and their recognition is of particular importance
in pregnancy. The forces that open and close the mitral valve increase
as left atrial pressure rises. The first heart sound (S1) is therefore loud
and can be palpable (tapping apex beat). An opening snap may be
audible and moves closer to the second sound (S2) as the stenosis
becomes more severe and left atrial pressure rises. However, the first
heart sound and opening snap may be inaudible if the valve is heavily
calcified. (Opening snap, which due to leaflets tension).

168) All of the following are causes of Collapsing Pulse except:


a) +Mitral Stenosis

Note: Causes of collapsing pulse include aortic regurgitation and


mitral regurgitation.

169) Case about a patient who has vegetations in the mitral valve and
was dx of mitral (stenosis?), he underwent Trans thoracic Echo,
what else do you want to do?
a) Cath
b) transesophageal
c) Colonoscopy

Answer: A

Note: The diagnosis of rheumatic MS is suspected in a patient with


demographics consistent with risk of rheumatic heart disease and
signs or symptoms suggestive of MS.

Although the physical examination can be diagnostic, findings are


often subtle. Thus, resting transthoracic echocardiography is used to
confirm the diagnosis. If there is a discrepancy between resting
echocardiography and clinical symptoms or signs, exercise stress
echocardiography is suggested to evaluate changes in mean mitral
gradient and pulmonary artery pressure. Cardiac catheterization is
not generally required for diagnosis of MS but is indicated if
echocardiography is nondiagnostic or conflicts with clinical findings.
{Uptodate}

170) Diastolic murmur, cardiac apex, (the question also said loud S2
and then low sound after S2 I think):
a) Mitral stenosis
b) Aortic regurge
c) Mitral regurge

Answer: A

171) Which of the following associated with early systolic murmur


with syncope and radiated to carotid after?
a) +Aortic stenosis

172) A 76-year old woman presents with history of syncope. On


echocardiography, she is found to have severe aortic valve stenosis.
Which of the following is most likely to be found on physical
examination?
a) Widely split second heart sound
b) Pansystolic murmur
c) Pulsus bisferiens
d) Thrill over the right second intercostal space
e) Wide pulse pressure

Answer: D

173) Wrong about bicuspid aortic valve:


a) +Calcification is rare

174) A 40 year old male pt present with exertional chest pain,


exertional SOB and syncopal attacks, what do you expect to find on
examination :
a) Opening snap and early systolic murmur
b) Collapsing pulse
c) Blowing murmur below the clavicle
Answer: A

Note: a case of Aortic stenosis


Aortic stenosis results in a harsh crescendo-decrescendo systolic
murmur and a soft S2 that may be single. S4 heart sound can also
be heard.
An aortic ejection click can be heard with a congenital bicuspid
valve (no such thing as opening snap in aortic stenosis).

175) Regarding symptomatic aortic stenosis is false:


a) Degenerative heart disease is the most common cause in elderly
pt
b) Vigorous exercise is best avoided
c) Heart failure is the worst presentation
d) Vasodilators improve the presentation
e) Causes muffled S2

Answer: D
Note: We need to be careful when using vasodilators in aortic
stenosis since then can cause life-threatening hypotension.
Generally speaking, medical therapy is of limited value in aortic
stenosis.

176) One of the following is mismatched regarding murmurs of the


heart:
a) +Aortic stenosis –early diastolic murmur

177) A 47-year old man is brought to the emergency department 2


hours after the sudden onset of shortness of breath, crushing chest
pain, and sweating. He has no history of similar symptoms. He has
hypertension treated with hydrochlorothiazide. His pulse is
120/min, respirations are 24/min, blood pressure is 110/50 mm Hg.
A grade 3/6, diastolic blowing murmur is heard over the left sternal
border and radiates to the right sternal border. Femoral pulses are
decreased bilaterally. An ECG shows only left ventricular
hypertrophy. Which of the following Is the most likely diagnosis?
a) Acute myocardial infarction
b) Mitral valve prolapse
c) Esophageal rupture
d) Pulmonary embolism
e) Aortic dissection

Answer: E

Explanation: Aortic dissection can present with stabbing chest


pain, diaphoresis, hypertension, pulse or BP asymmetry between
limbs and aortic regurgitation.

178) Blowing diastolic murmur in upper right sternal border:


a) Aortic regurgitation
b) Aortic stenosis
c) Tricuspid regurgitation
d) Tricuspid stenosis

Answer: A

179) Where do u find collapsing pulse:


a) Aortic regurgitation
b) Mitral stenosis
c) Aortic stenosis

Answer: A

180) Which one of the following isn’t a risk factor for aortic valve
regurgitation:
a) Rheumatic fever
b) Infective endocarditis
c) Cardiomyopathy
d) Bicuspid valve

Answer: C

181) Decrescendo low pitched s2 heard on the left 3rd sternal border:
a) Aortic regurgitation

182) A 57-year old male is evaluated for a 6-month progressive


dyspnea on exertion. Physical exam reveals an elevated JVP, a
holosystolic murmur at the apex that radiates to the axilla and does
not vary with inspiration, a loud pulmonary component of the
second heart sound, crackles at the bases of both lungs, and
moderate bilateral lower limb pitting edema. CXR shows
cardiomegaly and pulmonary congestion. What is the most likely
diagnosis?
a) Tricuspid regurgitation
b) Aortic regurgitation
c) Mitral regurgitation
d) Aortic stenosis
e) Mitral stenosis

Answer: C

183) What is wrong about mitral regurgitation (MR):


a) Loud S1
b) Pansystolic murmur
c) Dilated atrium
d) Left ventricular hypertrophy

Answer: A

Note: On auscultation, S1 may be diminished in acute MR and


chronic severe MR with defective valve leaflets, and wide splitting
of S2 may occur due to early closure of the aortic valve and late
closure of pulmonic valve. S3 may be present due to LV
dysfunction or as a result of increased blood flow across the mitral
valve.

184) One of the following conditions causes PanSystolic Murmur:


a) +Mitral Regurgitation

185) All of the following are true about mitral regurgitation except:
a) Wide pulse pressure
b) Hemoptysis  diffuse alveolar Hemorrhage Syndrome in silent MR
c) Atrial dilation
d) Pulmonary hypertension " edema "

Answer: A
186) All of these causes mitral regurgitation except:
a) PDA
b) MI
c) Papillary muscle injury

Answer: A

187) All of the following diseases can cause mitral regurgitation


EXCEPT:
a) Infective endocarditis
b) Marfan’s syndrome
c) Papillary muscle rupture
d) Rheumatic fever
e) Acute pericarditis

Answer: E

Note: Causes of mitral regurgitation:


Acute: Causes include Infective Endocarditis, IHD complication
after 1 week could cause papillary muscle rupture, mitral valve
prolapse (chordal rupture) and chest trauma after RTA.

Chronic: Causes include Infective endocarditis, rheumatic heart


disease, also IHD (most common) that results in papillary muscle
malfunction (not rupture), mitral valve prolapse, prosthetic valve,
heart failure.

188) One of the following is not true about mitral valve prolapse:
a) Low risk of infective endocarditis
b) Increased risk of regurgitation with thick, redundant leaflets
c) Complications are more common in females
d) Regurgitation is associated with worse prognosis
e) Most cases are asymptomatic

Answer: A

Note: Potential complications of MVP include infective


endocarditis and arrhythmias.
189) Mitral Valve prolapse most common presentation:
a) +Incidental

190) Tricuspid regurgitation most common cause:


a) Carcinoid
b) LVHF
c) Flail or prolapse
d) Rheumatic fever

Answer: B

Note: Tricuspid regurgitation can either be primary (the leaflets


themselves are affected) or secondary where right ventricular
failure is the cause (leaflets themselves are normal).
Secondary TR is more common and the most common cause of
secondary TR is left ventricular heart failure, whereas the most
common cause of PRIMARY TR is rheumatic fever.

191) Pansystolic murmur that's present in left lower sternal angle and
increases with inspiration is:
a) Regurgitation tricuspid
b) Mitral regurgitation
c) Aortic regurgitation

Answer: A

Note: tricuspid regurgitation murmur is more audible in


inspiration because of the increased venous return to the right
side.

192) Which one is wrong about Pulmonary Artery stenosis:


a) +Absent a waves in JVP

Note: The principal finding on examination is an ejection systolic


murmur, loudest at the left upper sternum and radiating towards
the left shoulder. There may be a thrill, best felt when the patient
leans forward and breathes out. The murmur is often preceded by
an ejection sound (click).
Delay in right ventricular ejection may cause wide splitting of the
second heart sound. Severe pulmonary stenosis is characterized
by a loud harsh murmur, an inaudible pulmonary closure sound
(P2), an increased right ventricular heave, prominent a waves in
the jugular pulse, ECG evidence of right ventricular hypertrophy,
and post-stenotic dilatation in the pulmonary artery on the chest
X-ray. Doppler echocardiography is the definitive investigation.

193) All the following are indicators of non-functioning mechanical


mitral valve, except:
a) Signs of heart failure
b) Absence of metallic click
c) Hemolytic anemia
d) Pansystolic murmur
e) Early diastolic murmur

Answer: C

194) All the following are true regarding heart murmurs and their
associated pathological conditions except:
a) Pansystolic murmur – Tricuspid regurgitation
b) Mid-diastolic murmur – Aortic regurgitation
c) Late diastolic murmur – Complete heart block
d) Pansystolic murmur – Mitral regurgitation
e) Ejection systolic murmur – Aortic stenosis

Answer: B

Note: In complete heart block, short, crescendo-decrescendo


presystolic murmurs are occasionally heard when atrial
contraction falls in late diastole. Aortic regurgitation causes an
early diastolic murmur
RHD & INFECTIVE ENDOCARDITIS

195) All of the followings are considered as part Jones major criteria
except:
a) Erythema multiforme
b) Migratory polyarthritis
c) subcutaneous nodule
d) Sydenham chorea

Answer: A

196) Which one of these is not in the major criteria of rheumatic heart
disease
a) Polyarthritis
b) Sydenham's chorea
c) Erythema marginatum
d) Severe arthralgia
e) SC nodules

Answer: D

197) All are true regarding rheumatic fever except:


a) Carditis is the most common criteria
b) Arthritis is self-limiting and non-erosive
c) Sydenham's chorea is a late manifestation
d) Prolonged PR interval is a minor criteria
e) Salicylates are useful for arthritis but not for carditis

Answer: A
Note: Arthritis is the most common criteria.

198) In rheumatic heart disease, the cause is:


a) +Immunological response
199) In infective endocarditis u may find all of these except:
a) Hematuria
b) Arthritis
c) Osler's nodes
d) Gottron's papules
e) Roths spots

Answer: D
Note: Gottron's papules found in Dermatomyositis

200) Least to find in infective endocarditis:


a) Duputryn contracture
b) Clubbing
Answer: A

201) Which of the following isn’t present in a patient with infective


endocarditis:
a) Splinter hemorrhages
b) Roth spots
c) Deputryen’s contracture
d) Clubbing
e) Osler’s nodes

Answer: C

Notes: Janeway lesions  (Non-tender, macular lesions on sloes


& palms)

202) All of the followings are recognized features of infective


endocarditis, EXCEPT:
a) Splinter hemorrhages
b) Duputryn’s contracture
c) Roth spots in the retina
d) Finger clubbing
e) Splenomegaly
Answer: B

203) The most common pathogens that cause bacterial infective


endocarditis in native valve is
a) Staph. Aureus
b) Enterococci
c) Strep. viridans
d) Strep. pneumonia

Answer: C

204) Which one of the following has the highest risk of infective
endocarditis :
a) Presence of the prosthetic valve
b) Mitral valve prolapse with regurgitation

Answer: B
Note: not sure as they’re both risk factors.

205) In infective endocarditis, one of the following is false:


a) Streptococcus viridans is most common cause of native valve
endocarditis
b) Staph species is the cause of prosthetic valve endocarditis
c) The cause of negative culture is partial treatment with antibiotics
d) 3 negative serial blood cultures exclude the diagnosis.
e) The sensitivity of transesophageal Echocardiography is much more
than the transthoracic

Answer: D

206) A 60-year old man presents with general malaise, fever, and
night sweats. He has a history of rheumatic heart disease. On
physical examination, there is evidence of a new onset Pansystolic
murmur. All the following are true about his condition except:
a) Prior antibiotic use is a common cause for blood-culture-negative
endocarditis
b) Prophylactic antibiotic is indicated in this patient before any
dental extraction
c) Normal transthoracic echocardiography does not rule out
infective endocarditis
d) The most common microorganism is Streptococcus viridans
e) The presence of prosthetic valve is not an indication for surgical
valve replacement

Answer: B

207) One of the following is an indication for infective endocarditis


prophylaxis:
a) ASD secundum before dental extraction
b) Coarctation of aorta before cardiac catheterization

Answer: A

Note: indications for prophylaxis in infective endocarditis include


both a qualifying cardiac indication AND procedure to warrant
antibiotic prophylaxis.

Cardiac indications: 1. Prosthetic heart valves 2. History of IE 3.


Congenital heart disease 4. Cardiac transplant with valvulopathy

Procedures: 1. Dental procedures involving manipulation of


gingival mucosa or periapical region of teeth 2. Procedures
involving biopsy or incision of respiratory mucosa 3. Procedures
involving infected skin or musculoskeletal tissue

NOT indications for prophylaxis : 1. native mitral valve


prolapse/stenosis 2.Routine GI or GU procedures

208) All of these are indications for prophylaxis against infective


endocarditis except:
a) Previous hx of infective endocarditis
b) Atrial septum defect (secundum)
c) Hypertrophic CMP
d) VSD
e) Mitral valve prolapsed
Answer: E

209) Which is not an indication for prophylaxis for infective


endocarditis:
a) Pacemaker
b) VSD
c) Previous history of IE
d) Prosthetic valve

Answer: A

210) One of the following doesn't require prophylaxis in infective


endocarditis:
a) +Permanent pacemaker

211) All should be given prophylaxis against Infective endocarditis


Except:
a) Post CABG patients
b) VSD
c) Mitral regurgitation

Answer: C

212) Patient had history of URTI after a while he started to feel chest
pain and dyspnea, by CXR cardiomegaly was found, what is the best
finding?
a) +Pericardial rub

Explanation: I think this case is about Acute Rheumatic Fever with


Carditis manifestation.

A ‘Pancarditis’ involves the endocardium, myocardium and


pericardium to varying degrees. Its incidence declines with
increasing age. It may manifest as breathlessness due to heart
failure or pericardial effusion, palpitations or chest pain (usually
due to pericarditis or pancarditis).

Other features include tachycardia, cardiac enlargement and new


or changed murmurs (soft systolic murmur mitral regurgitation is
very common, a soft mid-diastolic murmur (the Carey Coombs
murmur) is typically due to valvulitis, with nodules forming on the
mitral valve leaflets). Aortic regurgitation (50% of cases) but the
tricuspid and pulmonary valves are rare. Pericarditis may cause
chest pain, a pericardial friction rub and precordial tenderness.

CONGENITAL HEART DISEASE

213) The most common congenital heart disease is:


a) Pulmonary stenosis
b) Aortic stenosis
c) Mitral regurgitation
d) Aortic regurgitation

Note: the most common congenital heart valve disease is bicuspid


aortic valve, and the most common congenital heart disease in
general is VSD.

214) Most common congenital heart disease in adults


a) Ventricular Septal Defect
b) Bicuspid aortic disease
c) Coarctation of aorta

Answer: A

215) Regarding ASD, one is false:


a) +Surgical treatment is indicated in pulmonary hypertension

Note: Significant pulmonary hypertension is a contraindication to


ASD closure.

216) What is wrong about ASD:


a) Paradoxical split of S2
b) Ejection systolic murmur
c) Right axis deviation
Answer: A

Note: ASD is associated with fixed splitting of S2, systolic ejection


murmur across pulmonic valve, diastolic flow murmur across
tricuspid valve due to increased flow and right bundle branch
block as well as right axis deviation on ECG. If severe enough can
cause RV failure.

217) A 23 year old male patient presented with peripheral cyanosis


and clubbing involving only his lower limbs with no upper limb
involvement. What is the most likely abnormality causing this?
a) Patent ductus arteriosus
b) Tetralogy of Fallot
c) Coarctation of Aorta

Answer: A
218) Which of the following congenital heart diseases causes
cyanosis?
a) HOCM
b) TOF
c) VSD

Answer: B

219) Regarding coarctation of the aorta, least common association:


a) Subarachnoid hemorrhage
b) Increased risk of dissection
c) Hypertension
d) Rib notching
e) Bicuspid aortic valve

Answer: D

Note: all are associated with coarctation of the aorta, but the
least common is "rib notching" as dr Mohammad al Jarrah
answered this Q after the exam!!

220) Regarding coarctation of the aorta, one is false:


a) +The most common site is between the left internal carotid and
brachiocephalic trunk

Note: the most common site is distal to left subclavian artery

221) Coarctaition of the aorta least probable finding:


a) +The most common site is proximal to the Lf subclavian artery

222) What is true about coarctation of aorta:


a) Associated with bicuspid valve
b) Heart cannot increase cardiac output during exercise
c) Different BP between right and left arms

Answer: A

HYPERTENSION

223) A 66-year old obese man is evaluated for poorly controlled


hypertension. He has obstructive sleep apnea but finds it difficult to
use his CPAP. His medications include Lisinopril 40 mg daily,
amlodipine 10 mg daily, and hydrochlorothiazide 25 mg daily.
Physical examination shows a BMI of 37 kg/m2, BP of 165/95 mm
Hg, and a pulse rate of 68/min. the remainder of his examination is
unremarkable. In addition to lifestyle modification, which of the
following is the most effective intervention to lower BP and
improve his nocturnal BP pattern?
a) Increase the dose of Lisinopril to 80 mg daily
b) Extensive work-up for secondary hypertension
c) Regular use of his CPAP during sleep
d) Nocturnal oxygen supplementation
e) Sleep in a semi-sitting position

Answer: C

224) Hypertensive patient with minimal symptomatic BPH, which of


the following would benefit the patient over the long term survival
benefit?
a) Terazosin
b) B blocker
c) Dexazosin
d) ACE- I

Answer: D

225) You prescribe thiazide to hypertensive pt. which statement


indicates that the patient understood your instructions:
a) I should eat high potassium diet
b) I should regularly check my blood glucose, because the drug might
mask hypoglycemia symptoms
c) I will take it when I want
d) I Will stop taking it when my BP normalize

Answer: A

226) Long case about hypertensive patient takes Furosemide 40g


came complaining of fatigue and muscle weakness. what is the
cause :
a) Hypercalcemia
b) Hyperkalemia
c) Hypernatremia
d) Hyponatremia
e) Hypokalemia

Answer: E

227) Which of the following isn't a risk factor for hypertension


a) Increased LDL
b) Increased HDL
c) Increased homocysteine

Answer: B

Note: low HDL is a risk factor for HTN (LANGE Current Medical
Diagnosis and Treatment 2013)
228) Previously healthy female 35 years with family history of HTN,
her blood pressure recently starts to increase gradually within few
months now presented with Bp 155/95. What's most appropriate?
a) Kidney MRI
b) Start with thiazide it is essential HTN
c) Start with b blocker & ACEI
d) Reassure her with follow after 1y or 3 month can't remember if
exactly was its as I wrote

Answer: C

229) A patient presented to you with pulmonary edema which is


secondary to acute HTN. Which of the following is NOT part of
management?
a) IV nitroglycerin
b) IV morphine
c) O2 mask
d) IV furosemide
e) None of the above

Note: If the patient was not in pain, then the answer would most
likely be B. IV morphine.

230) Which one of the following is considered as irreversible


hypertension complication:
a) MI
b) Papillodema
c) Hypertensive encephalopathy

Answer: A

231) A known case of uncontrolled HTN , presented with SOB on


exertion , Echo was done and showed LVH , what is going on with
this patient :
a) +Diastolic dysfunction

232) All of the following are complications of HTN except:


a) Retinopathy
b) Nephropathy
c) Neuropathy
d) ICH

Answer: C

233) Which of the following is not a complication of hypertension


a) Peripheral neuropathy
b) Cerebrovascular accidents
c) Retinopathy
d) Nephropathy

Answer: A

234) All of the following are known complications of systemic


hypertension, EXCEPT:
a) Deep vein thrombosis
b) Grade 3 retinopathy (soft exudates and flame shape
hemorrhages)
c) Left ventricular hypertrophy
d) Intra-cerebral hemorrhage
e) Left atrial enlargement

Answer: A

235) All the following anti-hypertensive medications match


appropriately with their side effects except:
a) Calcium channel blockers - Peripheral edema
b) Beta blockers – Bronchospasm
c) Furosemide – hypercalcemia
d) ACE-inhibitors – Cough
e) Thiazide – hyperglycemia

Answer: C

Note: Furosemide increases renal calcium excretion.

236) A hypertensive patient came to ER complaining of chronic dry


cough, he was recently given antihypertensive drugs, what could it
be?
a) Fosinopril
b) Ca channel blockers
c) Hydralazine

Answer: A
Note: Common adverse drug reactions of ACEI include:
hypotension, cough, hyperkalemia, headache, dizziness, fatigue,
nausea, and renal impairment.

237) A 37-year old male presented with headache, vomiting, and


blurred vision. His blood pressure was 200/135 mmHg. Fundoscopy
showed flame shaped hemorrhages and cotton wool exudates. His
serum creatinine is elevated. The most appropriate immediate step
in management is:
a) Urgently reduce BP to 120/80
b) Reducing BP smoothly with oral antihypertensive medications
over few days
c) Intravenous steroids
d) Urgently reduce the diastolic pressure to 95-100 mmHg
e) Perform immediate hemodialysis to improve the renal failure

Answer: D

Note: In hypertensive emergencies, IV antihypertensives should


be used not oral. In hypertensive emergencies we reduce mean
arterial pressure by 25% in 1 to 2 hours. The goal is not to
immediately achieve normal BP, but to get the patient out of
danger, then reduce BP gradually.

238) In hypertension all of the following are suggestive of secondary


cause except:
a) Low plasma renin activity
b) Hypochloremia
c) Red blood cell cast in the urine
d) Metabolic alkalosis
e) Hypokalemia

Answer: B

239) Doesn't go with secondary hypertension:


a) Retinal hemorrhage
b) Hypernatremia
c) Hypokalemia
d) Active urine sediment

Answer: A

Note: Retinal hemorrhage occurs as a complication of long


standing hypertension. Hypernatremia and hypokalemia directs us
to aldosteronism, while active urine sediment could be caused by
renal parenchymal disease as a cause of secondary hypertension.

240) All can indicate secondary cause for HTN except:


a) Hyponatremia
b) Hypokalemia

Answer: A

241) Which of the following isn't a cause of secondary hypertension:


a) +Hypoparathyroidism

Note: hyperparathyroidism is endocrine cause of HTN (Oxford


Handbook of Clinical Medicine 6th edition).

242) Amlodipine side effect?


a) +lower limb edema

243) What to keep in mind while managing elderly patients with


secondary hypertension:
a) Renovascular disease
b) Obstructive sleeping apnea
c) Pheochromocytoma

Answer: A

Note: renovascular disease is suspected cause of secondary HTN


for elderly patient >50 years old (CMDT 2013).

244) A 16 Year old female presented with HTN and hypokalemia , all
of these are causes of that presentation, except:
a) Renal artery stenosis
b) Hyperaldosteronism
c) +Something else

Note: RAS is one cause of secondary hyperaldosteronism, so both


causes HTN and hypokalemia

245) Wrong mismatch in 2nd HTN


a) Cons/ Hypernatremia
b) Coarctation of the aorta / murmur in back
c) Abdominal striae / cushing
d) Abdominal bruit / renal stenosis
e) All are true

Answer: E

246) Which of the following doesn’t go with a cause of secondary


hypertension:
a) Strong family history of hypertension
b) Age <25 or >55
c) Rapidly developing
d) Poor response to standard medical therapy
e) certain physical signs like mooning of the face and abdominal
striae

Answer: A

247) All of the following diseases can lead to elevated blood pressure
EXCEPT:
a) Renal artery stenosis
b) Primary hyperaldosteronism
c) Cushing’s syndrome
d) Polycystic kidney disease
e) Acute pyelonephritis

Answer: E

248) You will look for 2dry cause of HTN in all except:
a) LVH
b) Age<25
c) Active urinary sedimentation
d) Hypokalemia

Answer: A

249) Not a complication of secondary HTN?


a) DVT
b) Intracerebral hemorrhage
c) LVH
d) MI
e) Encephalopathy

Answer: A

DRUGS

250) All of these cause Bradycardia except:


a) Valsalva maneuver
b) B2 agonist

Answer: B

Note: B2 agonist causes tachycardia.

251) All of these drugs cause vasodilatation except:


a) Digoxin
b) Furosemide
c) ACE inhibitor
d) Nitroprusside

Answer: A

252) Uses of B-blocker except:


a) Asthma
b) heart failure
c) Hypertension
d) Anxiety
e) Migraine

Answer: A

Note1: Beta blockers are contraindicated in ACUTE heart failure.


Cardioselective beta blockers can be given in asthma patients.
Beta blockers can also be given in hypertension, anxiety and
migraine. The most accurate answer would be asthma since they
didn’t specify cardioselective beta blockers.

Note2: Beta blocker with antioxidant and alpha blocking effects =


carvedilol.

Note3: B blockers used in CHF to Decrease deleterious effect of


sympathetic nervous system on the heart Dec the risk of
arrhythmias.

253) Which of the following increases digitalis toxicity


a) Hypokalemia
b) Hyponatremia
c) Hyperglycemia
d) Amlodipine
e) Aspirin

Answer: A

254) Digoxin can lead to all of the following ECG abnormalities except:
a) Increase in number of premature ventricular beats
b) ST segment depression in lateral chest leads (V4, V5 and V6)
c) Ventricular tachycardia
d) Prolongation of the PR interval
e) Complete heart block
Answer:  (All of the above choices are possibly caused by
digoxin)

255) Not used in digoxin toxicity:


a) Quinidine
b) Potassium
c) Digi-bind

Answer: A

Note: quinidine, verapamil, amiodarone, diltiazem, thiazide and


furosemide spironolactone, increase Digoxin effect.
And the treatment of toxicity is by: stopping the drug, potassium
administration (if needed), lidocaine, phenytoin, and Digi-bind for
the acute overdose.

256) All of the following drug interactions are matched except:


a) ACE inhibitors  cough
b) Statins  Lung fibrosis
c) Angiotensin receptor blockers  hyperkalemia

Answer: B

257) Which of the following is not matched with its side effect:
a) Thiazide  thrombocytosis
b) Digoxin  3rd degree heart block
c) Spironolactone  gynecomastia

Answer: A

258) One association of the followings is wrong:


a) Thiazide  thrombocytosis
b) Diazoxide  hyperglycemia
c) Nifidipine  ankle swelling

Answer: A

Note: Major Side Effects of thiazides:


 Hypokalemia
 Hypomagnesemia
 Hypercalcemia
 Hyperuricemia
 Hyperglycemia
 Increases in LDL cholesterol
 Gynecomastia

Relative Contraindications: Diabetes, gout, hyperlipidemia.

Nifedipine Major Side Effects of Ca Channel blockers:


 Peripheral edema
 Constipation
 Heart block
 Reflex tachycardia

Relative Contraindications: Atrioventricular conduction defects,


congestive heart failure from systolic dysfunction.

Diazoxide suspension is a glucose-elevating agent. It works by


blocking the release of insulin from the pancreas, which helps to
increase blood sugar.

259) All of the following are side effects of Thiazides except:


a) +Hypocalcemia

260) What isn't a Side Effect of Ca channel blockers:


a) Flushing
b) Leg swelling
c) Cough

Answer: C

261) Mechanism of action for Clopidogrel:


a) Inhibits GpIIb/IIIa receptors
b) Inhibits ADP receptors

Answer: B

262) Amiodarone Side Effect, what is wrong?


a) Hyperkalemia
b) Corneal deposits
c) Hyperthyroidism
d) Hypothyroidism
e) Increase Warfarin

Answer: A

263) All are associated with chronic amiodarone use except:


a) Corneal deposits
b) Hypothyroidism
c) Hyperthyroidism
d) Lung fibrosis
e) Hepatitis

Answer: E

Note: Side effects of amiodarone are the following:


 Hyper and hypothyroidism
 Increased LFTs (however usually asymptomatic and mild)
 Skin sensitivity to sun
 Blue-gray discoloration
 Corneal deposits
 Pulmonary fibrosis (most common cause of death)
 Potentiates warfarin

264) What is wrong in this matching, drug and its indication:


a) SVT  Adenosine IV
b) Chronic AF  Amiodarone IV
c) HOCM  Digoxin
d) Prolonged QT  propranolol

Answer: C
Note: in HOCM we use Beta-blockers or verapamil.

265) Which of the following doesn't cause hyperkalemia:


a) +Salbutamol
Note: high dose of salbutamol causes hypokalemia.
RANDOM & MIXED

266) One of the followings is not a risk factor for Aortic dissection:
a) Hypothyroidism
b) Pregnancy
c) HTN
d) Bicuspid value

Answer: A

Note: Risk factors of aortic dissection are long-standing HTN,


cocaine use, trauma, connective tissue diseases, bicuspid aortic
valve, coarctation of aorta, third trimester of pregnancy.

267) A patient present with a crushing chest pain radiating to the


back, his upper limb blood pressure 170/110 while his lower limbs
110/60 which one of the following is the most like presentation:
a) +Notching of the lower border of the ribs

268) Incorrectly matched:


a) Rheumatic fever  erythema nodosum
b) Mitral stenosis  opening snap
c) ASD  wide fixed splitting

Answer: A
269) All the following conditions will cause peripheral cyanosis
except?
a) DVT
b) Peripheral vascular disease
c) Raynaud phenomena
d) Cold

Answer: All answers are correct


Note: Causes include:
 Too tight clothing or jewelry
 Deep Vein Thrombosis (DVT)
 Venous Insufficiency
 Raynaud’s phenomenon
 Lymphedema
 Heart failure
 Arterial insufficiency
 Severe hypotension
 Hypovolemia
 Hypothermia

270) A patient with history of hypertension and abdominal bruit,


underwent cardiac catheterization, and presented after 2 weeks
complaining of pancreatitis, renal failure, and loss of vision on one
side. What is your diagnosis:
a) Cholesterol embolization syndrome
b) Contrast induced acute renal failure
c) Polyarteritis nodosa
d) Ruptured aortic aneurysm

Answer: A
Explanation: Cholesterol embolism syndrome should be
suspected in a patient who develops worsening renal function,
hypertension, distal ischemia, or acute multisystem dysfunction
after an invasive arterial procedure. Atheroemboli may also occur
spontaneously.

271) Female 60y with Heart failure, cardiomyopathy, ejection f<25%,


present with fever, productive cough 3 days, on exam decrease
tactile vocal, dullness on left side, x ray with left pleural effusion,
which is true:
a) All pleural effusion should be drain
b) Normal because her heart problem
c) Thoracocentesis must done because it's new finding
d) Can't remember the rest

Answer: 
Note: Generally speaking pleural effusion is very common in
congestive heart failure, and should resolve with treatment of
congestive heart failure. However, refractory, recurrent, massive
or significant pleural effusions warrant treatment by pleural
drainage.

272) One of the following is not associated with increased JVP :


a) Liver cirrhosis
b) Corpulmonale
c) Right ventricular infarction
d) Constrictive pericarditis
e) Cardiac tamponade

Answer: A

273) Causes of raised JVP include all of the followings except:


a) Mediastinal lymphoma
b) Mediastinal irradiation
c) ST elevation in lead rV4 and chest pain
d) Liver cirrhosis
e) Atrialization of the right ventricle

Answer: D

274) False about JVP?


a) +Can be measured in right clavicle level.

275) Echo finding pedunculated mass in left atrium, on exam opening


snap and mid diastolic murmur, right sided hemiparesis. next step:
a) Blood culture
b) Anticoagulants
c) Cardiac catheterization
d) Radionuclear study
e) Immediate surgical intervention

Answer: B (not sure)

Note: This is a case of atrial myxoma which usually presents with


constitutional symptoms (fever, weight loss) and symptoms of
mitral valve prolapse since they usually originate in the left
atrium. They also tend to present with emboli. Auscultatory
findings include a low-pitched diastolic murmur. Mainstay of
treatment is surgical resection only AFTER evaluation due to risks
of embolization or cardiovascular complications like sudden
death. So most likely the answer is anticoagulants.

276) Wide pulse pressure is seen in all, except:


a) Dilated cardiomyopathy
b) Thyrotoxicosis
c) Pregnancy
d) Aortic regurgitation
e) AV malformation

Answer: A

Explanation: Pulse pressure is the difference between the systolic


and diastolic pressure reading.
Pulse pressure above 40mmHg = widened pulse pressure.
Causes: It is normal to have widened blood pressure after or
during exercise.

 Thyrotoxicosis
 Severe anemia
 Pregnancy
 Thiamine deficiency (wet beriberi)
 AV fistula
 Volume depletion
 Sympathetic overdrive
 Aortic regurgitation

277) All are features f metabolic syndrome except:


a) +Proteinuria

Note: Clinical manifestations of metabolic syndrome include the


following:
 Hypertension
 Hyperglycemia
 Hypertriglyceridemia
 Reduced HDL
 Abdominal obesity
 Chest pain or SOB
 Acanthosis nigricans
 Hirsutism
 Peripheral neuropathy
 Retinopathy: in patients with insulin resistance and
hyperglycemia or with DM
 Xanthomas or xanthelasma: in patients with severe dyslipidemia

278) 6 months progressive dyspnea, what is not a cause :


a) Pneumothorax
b) IHD
c) Cardiomyopathy

Answer: A

279) One is not a contraindication for pregnancy:


a) MVP
b) Esinmenger syndrome
c) Pulmonary hypertension

Answer: A

Note: Avoid pregnancy and sometimes even consider


termination of pregnancy if it occurs, such as:
 Pulmonary hypertension
 Dilated cardiomyopathy
 Ejection fraction <40%
 Symptomatic obstructive lesions (Aortic stenosis, Mitral
stenosis, pulmonary stenosis, Coarctation of the aorta)
 Marfan syndrome with aortic root >40 mm
 Cyanotic lesions
 Mechanical prosthetic valves

 Women with symptomatic MVP often find that their symptoms


decrease in frequency and severity during pregnancy.

280) All are true for DiGeorge syndrome EXCEPT:


a) Congenital heart disease
b) Hypoparathyroidism
c) Susceptibility for extracellular bacteria and viruses
d) Thymus abnormality
Answer: C

Note: All choices are actually correct but this is the closest to what
they want I guess.

281) Mismatch:
a) Folate  Cord degeneration
b) S1 loud  Mitral regurgitation
c) 70 years  Syncope
d) Systolic murmur  AS

Answer: B

282) Which one of the following isn’t a known cause of left ventricular
hypertrophy :
a) Old age
b) Obstructive hypertrophic cardiomyopathy
c) Aortic stenosis
d) Mitral stenosis
e) HTN

Answer: D

283) A 75 y/o female patient with recurrent fainting pulse 32 bpm


and normal blood, pressure, the most likely condition is:
a) Aortic valve obstruction
b) Heart
c) Complete Heart Block
d) Stroke

Answer: A

284) The least likely condition to present with pain:


a) Pericarditis
b) Aortic Dissection
c) Angina
d) MI
e) Left Ventricular Hypertrophy

Answer: E

285) Cardiac syncope characteristics?


a) Gradual onset
b) Warning symptoms
c) Rapid recovery

Answer: C

Note: Cardiovascular syncope is a brief loss of consciousness


(from a few seconds to a few minutes), that is characterized by
rapid onset and spontaneous recovery. It is caused by decreased
blood flow to the brain.

286) Inferior vena cava filter:


a) +DVT with active bleeding faithless

287) Woman after 10 hours flight:


a) +DVT case

288) Case of DVT, D dimer was done, the next diagnostic test is:
a) +Doppler Ultrasound

289) False about PE:


a) +Bradycardia

290) Case: female complaining from sudden left ant. chest pain, SOB,
she was cold cyanotic :
a) +I think acute pulmonary edema due to MI

Done by: Salam Mustafa

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