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 FOURTH EDITION

™
LANGE Q&A

INTERNAL MEDICINE

Yashesh Patel, MD, MSc, FRCPC

Assistant Professor
University of Toronto
Division of General Internal Medicine
Mount Sinai Hospital
Toronto, Ontario
Canada

Barry J. Goldlist, MD, FRCPC, FACP

Professor and Head
Division of Geriatric Medicine
University of Toronto
Toronto, Ontario
Canada

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New Delhi San Juan Seoul Singapore Sydney Toronto
Copyright © 2007 by The McGraw-Hill Companies, Inc. All rights reserved. Manufactured in the United States of America. Except as permitted under the
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DOI: 10.1036/0071473645
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Contents

Preface ................................................................................................................................................................... v

Acknowledgments ............................................................................................................................................ vii

1. Cardiology ..................................................................................................................................................... 1
Questions ........................................................................................................................................................ 1
Answers and Explanations ........................................................................................................................ 23

2. Skin ............................................................................................................................................................... 35
Questions ...................................................................................................................................................... 35
Answers and Explanations ........................................................................................................................ 45

3. Endocrinology ............................................................................................................................................ 51
Questions ...................................................................................................................................................... 51
Answers and Explanations ........................................................................................................................ 68

4. Gastroenterology ........................................................................................................................................ 79
Questions ...................................................................................................................................................... 79
Answers and Explanations ........................................................................................................................ 92

5. Hematology ................................................................................................................................................. 99
Questions ...................................................................................................................................................... 99
Answers and Explanations ...................................................................................................................... 112

6. Oncology ..................................................................................................................................................... 119

Questions .................................................................................................................................................... 119
Answers and Explanations ...................................................................................................................... 129

7. Diseases of the Nervous System ........................................................................................................... 135

Questions .................................................................................................................................................... 135
Answers and Explanations ...................................................................................................................... 148

8. Kidneys ....................................................................................................................................................... 157

Questions .................................................................................................................................................... 157
Answers and Explanations ...................................................................................................................... 168

iii
iv Contents

9. Muscles and Joints ................................................................................................................................... 175

Questions .................................................................................................................................................... 175
Answers and Explanations ...................................................................................................................... 191

10. Infection ..................................................................................................................................................... 199

Questions .................................................................................................................................................... 199
Answers and Explanations ...................................................................................................................... 217

11. Immunology and Allergy ........................................................................................................................ 229

Questions .................................................................................................................................................... 229
Answers and Explanations ...................................................................................................................... 235

12. Diseases of the Respiratory System ...................................................................................................... 239

Questions .................................................................................................................................................... 239
Answers and Explanations ...................................................................................................................... 252

13. Clinical Pharmacology ............................................................................................................................. 259

Questions .................................................................................................................................................... 259
Answers and Explanations ...................................................................................................................... 267

14. Comprehensive Review ........................................................................................................................... 275

Questions .................................................................................................................................................... 275
Answers and Explanations ...................................................................................................................... 294

References ......................................................................................................................................................... 307

Index ................................................................................................................................................................... 309

 Preface

The practice of internal medicine requires both the USMLE, making it an ideal study guide for indi-
breadth and depth of knowledge. To acquire mas- viduals preparing for licensing examinations.
tery of the subject requires extensive reading and The questions and answers reflect the increas-
clinical experience. The knowledge base is also con- ing growth of knowledge in the field of internal
stantly expanding and changing as medicine enters medicine. As a result, reviewing the answers gives
the era of molecular biology and large randomized the reader a “mini review” of basic concepts and
clinical trials. This textbook provides a review of the pathophysiology in internal medicine, allowing the
major issues in internal medicine by presenting a reader to approach clinical problems in an appro-
wide variety of typical examination questions and priate manner.
referenced answers. Finally, since the last edition was published, the
The text is organized by topic to facilitate in- list of references has been expanded and updated to
depth review but contains a large comprehensive reflect current knowledge in the field of internal
test that mimics the typical examination format. medicine.
The content has been organized to reflect the areas
tested on Step 2 of the United States Medical Yashesh Patel, MD, MSc, FRCPC
Licensing Examination (USMLE Step 2). The format Barry J. Goldlist, MD, FRCPC, FACP
of the questions is modeled after the format used on

Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use.
This page intentionally left blank
 Acknowledgments

I would like to thank the countless medical students Goldlist for giving me the opportunity to work on
and residents who teach me and compel me to learn the latest edition of the book with him.
every day. Thanks to the patience of my family
and friends for putting up with my absences while Yashesh Patel, MD, MSc, FRCPC
I worked on the book. Finally, thanks to Barry

vii

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This page intentionally left blank
 CHAPTER 1

Cardiology
Questions

DIRECTIONS (Questions 1 through 61): Each of 3. A 42-year-old man develops shortness of breath
the numbered items in this section is followed by (SOB) and chest pain 7 days after an open
answers. Select the ONE lettered answer that is cholecystectomy. His blood pressure is 145/86
BEST in each case. mm Hg, pulse is 120/min, respirations 24/min,
and oxygen saturation of 97%. Pulmonary
embolism is clinically suspected. Which of the
1. A 62-year-old man with coronary artery dis-
following is the most common ECG finding of
ease (CAD) presents with presyncope. His
pulmonary embolism?
physical examination is normal except for
bradycardia (pulse 56 beats/min) and an irreg- (A) a deep S wave in lead I
ular pulse. The electrocardiogram (ECG) shows (B) depressed ST segments in leads I and II
Wenckebach’s type atrioventricular (AV) block. (C) prominent Q wave in lead I, and
Which of the following are you most likely to inversion of T wave in lead III
see on the ECG?
(D) sinus tachycardia
(A) progressive PR shortening (E) clockwise rotation in the precordial
(B) progressive lengthening of the PR interval leads
(C) tachycardia
(D) dropped beat after PR lengthening 4. A 63-year-old woman develops exertional
angina and has had two episodes of syncope.
(E) fixed 2:1 block
Examination shows a systolic ejection murmur
with radiation to the carotids and a soft S2. Which
2. A 72-year-old woman had a pacemaker
of the following is the most likely diagnosis?
inserted 4 years ago for symptomatic brady-
cardia because of AV nodal disease. She is clin- (A) mitral stenosis
ically feeling well and her ECG shows normal (B) mitral insufficiency
sinus rhythm at a rate of 68/min but no pace- (C) aortic stenosis
maker spikes. Her pacemaker only functions
(D) aortic insufficiency
when the ventricular rate falls below a preset
interval. Which of the following best describes (E) tricuspid stenosis
her pacemaker function?
(A) asynchronous
(B) atrial synchronous
(C) ventricular synchronous
(D) ventricular inhibited
(E) atrial sequential

Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use.
2 1: Cardiology

5. A 42-year-old man with known valvular heart (D) negatively chronotropic

disease develops a fever for 1 week. He appears (E) excitation contraction uncoupling
unwell; findings include a pansystolic murmur
at the apex that radiates to the axilla and a soft 9. A 22-year-old primagravida woman develops
S1 sound. He has petechiae on his conjunctival hypertension at 28 weeks. She is asymptomatic
sac, linear hemorrhages under a few finger- and the examination is normal except for 1+
nails, and painful, tender, and erythematous pedal edema. Her complete blood count, liver
nodules on some of the distal fingertips. Which enzymes, and electrolytes are normal. The uri-
of the following is the most responsible mech- nalysis is positive for proteinuria. Which of the
anism for these physical findings? following is true for this type of hypertension?
(A) direct bacterial invasion (A) improves in the third trimester
(B) immune response (B) leads to large-birth-weight babies
(C) vascular phenomena (C) should be controlled with medications
(D) valvular damage (D) spares the placenta
(E) preexisting cardiac dysfunction (E) spares maternal kidney function

6. Which of the following antiarrhythmic drugs 10. A 61-year-old man has a non-ST-elevation MI
mediates its effect by interfering with move- and is admitted to the coronary care unit. The
ment of calcium through the slow channel? following day, he develops bradycardia but no
(A) phenytoin symptoms. His blood pressure is 126/84 mm
Hg, pulse 50/min, and on examination, the
(B) verapamil
heart sounds are normal, with no extra sounds
(C) lidocaine or rubs. His ECG has changed. Which of the
(D) amiodarone following ECG findings is the best indication
(E) bretylium for this patient to receive a pacemaker?
(A) persistent bradycardia
7. A 67-year-old man presents with an anterior
myocardial infarction (MI) and receives throm- (B) second-degree AV block Mobitz type I
bolytic therapy. Three days later, he develops (C) first-degree AV block
chest pain that is exacerbated by lying down, (D) new right bundle branch block
and his physical findings are normal except for (E) left bundle branch block (LBBB) and
a friction rub. His ECG shows evolving second-degree AV block Mobitz type II
changes from the anterior infarction but new
PR-segment depression and 1-mm ST-segment 11. Auscultation of the heart of a 17-year-old boy
elevation in all the limb leads. Which of the reveals an increased intensity of the pulmonary
following is the most likely diagnosis? component of the second heart sound. He com-
(A) reinfarction plains of dyspnea on exertion but no other car-
diac or pulmonary symptoms. Which of the
(B) pulmonary embolus
following explanations is the most likely cause
(C) viral infection of his dyspnea? (See Fig. 1–1.)
(D) post-MI pericariditis
(A) pulmonary stenosis
(E) dissecting aneurysm
(B) aortic stenosis
8. Which of the following best describes the effect (C) MI
of calcium ions on the myocardium? (D) pulmonary hypertension
(A) positively inotropic (E) systemic hypertension
(B) negatively inotropic
(C) positively chronotropic
 Questions: 5–13 3

(A) sinus tachycardia

(B) paroxysmal atrial fibrillation
(C) paroxysmal atrial flutter
(D) paroxysmal supraventricular
tachycardia (PSVT)
(E) paroxysmal ventricular tachycardia

13. A 73-year-old man has angina pectoris on exer-

tion, but an angiogram reveals noncritical
stenosis of the coronary arteries. This occurs
most frequently with which of the following
valvular heart diseases?
(A) mitral stenosis
(B) mitral insufficiency
Figure 1–1. (C) pulmonary stenosis
(D) aortic stenosis
12. A 22-year-old woman complains of palpitations (E) aortic insufficiency
and has a regular heartbeat at a rate of 170/min,
with a blood pressure of 110/70 mm Hg. The
rate abruptly changes to 75/min after applying
carotid sinus pressure. Which of the following is
the most likely diagnosis? (See Fig. 1–2.)

Figure 1–2.
(Reproduced, with permission, from Fuster V, et al., Hurst’s the Heart, 11th ed. New York: McGraw-Hill, 2004:819.)
4 1: Cardiology

14. A patient with new-onset syncope has a blood 16. A 57-year-old man has an anterior MI. It is com-
pressure of 110/95 mm Hg and a harsh sys- plicated by the development of heart failure.
tolic ejection murmur at the base, radiating to Nitroglycerin would be a useful first medica-
both carotids. Auscultation of the second heart tion under which circumstances?
sound at the base might reveal which of the
(A) severe pulmonary congestion, blood
following findings?
pressure 80 mm Hg systolic
(A) it is accentuated (B) clear lungs, blood pressure 120 mm Hg
(B) it is diminished systolic
(C) it is normal in character (C) clear lungs, blood pressure 80 mm Hg
(D) it is widely split due to delayed systolic
ventricular ejection (D) clear lungs, blood pressure 160 mm Hg
(E) it shows fixed splitting systolic
(E) moderate pulmonary congestion, blood
15. A 69-year-old woman complains of easy fatigue pressure 130 mm Hg systolic
and one episode of presyncope. On examina-
tion of the jugular venous pressure (JVP), there 17. A 28-year-old man develops viridans group
are irregular large a waves. The ECG has fixed streptococci septicemia. Which of the follow-
PP and RR intervals but varying PR intervals. ing cardiac lesions has the highest risk of devel-
Which of the following conditions is this most oping endocarditis?
likely caused by? (See Fig. 1–3.)
(A) ventricular septal defect
(A) surgical removal of an atrium (B) atrial septal defect, secundum type
(B) independent beating of atria and (C) mitral valve prolapse with regurgitation
ventricles (D) pure mitral stenosis
(C) a reentry phenomenon (E) asymmetric septal hypertrophy
(D) a drug effect
(E) a heart rate under 60 beats/min 18. A 47-year-old woman has new-onset transient
right arm weakness and word finding diffi-
culty symptoms lasting 3 hours. She is also
experiencing exertional dyspnea, and had a

Figure 1–3.
(Reproduced, with permission, from Fuster V, et al., Hurst’s the Heart, 11th ed. New York: McGraw-Hill, 2004:904.)
 Questions: 14–24 5

syncopal event 1 month ago. Her echocardio- (C) it is generally performed with
gram reveals a cardiac tumor in the left atrium, cardiopulmonary bypass
it is pendunculated and attached to the endo- (D) it may cause renal failure
cardium. Which of the following is the most (E) it requires carotid artery puncture
likely cause of this lesion?
(A) myxoma 22. A 23-year-old man develops sharp left-sided
(B) sarcoma chest pain, fever, and a friction rub heard at
the lower left sternal border, unaffected by res-
(C) rhabdomyoma
piration. The pain is also aggevated by lying
(D) fibroma down and relieved by sitting up. He is other-
(E) lipoma wise well with no other symptoms and the
remaining physical examination is normal.
19. A 72-year-old woman has new-onset atrial flut- Which of the following is the most likely cause
ter with a ventricular rate of 150/min. She is for his symptoms?
hemodynamically stable with a blood pressure
of 155/90 mm Hg, but is experiencing palpita- (A) rheumatic fever
tions. Which of the following drugs is the best (B) tuberculosis (TB)
intravenous choice for controlling the heart rate? (C) herpes simplex virus
(A) diltiazem (D) MI
(B) lidocaine (E) coxsackievirus
(C) aminophylline
23. A 72-year-old woman with angina undergoes
(D) magnesium cardiac catheterization. The pulmonary capil-
(E) atropine lary “wedge” pressure is an approximation of
the pressure in which of the following structures?
20. Several of the older patients in your practice
intend to pursue exercise programs. They have (A) pulmonary artery (PA)
no cardiac symptoms, but some do have vas- (B) pulmonary vein
cular risk factors such as diabetes or hyperten- (C) left atrium
sion. In these patients, which of the following (D) right atrium
is true about exercise electrocardiography? (E) vena cava
(A) it is an invasive procedure
(B) it is contraindicated in patients over 24. A 58-year-old man with hypertension is
65 years of age brought to the emergency room after sudden-
onset chest pain that radiates to his back and
(C) it detects latent disease
arms. He is in moderate distress with a blood
(D) it has a morbidity of approximately 5% pressure of 160/90 mm Hg in the left arm and
(E) it is used in pulmonary embolism 120/70 mm Hg in the right arm. Cardiac exam-
ination reveals a soft second heart sound and a
21. A 58-year-old man is undergoing cardiac murmur of aortic insufficiency. His ECG shows
catheterization for evaluation of chest pain sinus tachycardia but no acute ischemic changes,
symptoms. He is worried about the risks, and and the chest x-ray (CXR) is shown in Fig. 1–4.
as part of obtaining informed consent, you Which of the following is the most appropriate
advise him about the risks and benefits of the next step in confirming the diagnosis?
procedure. Which of the following aspects of
angiography is true? (A) coronary angiography
(B) transthoracic echocardiography
(A) it is contraindicated in the presence of
(C) computerized tomography (CT) chest
cyanosis
(D) exercise stress test
(B) it is considered noninvasive
(E) cardiac troponin level
6 1: Cardiology

(A) mitral stenosis

(B) mitral regurgitation
(C) aortic stenosis
(D) aortic regurgitation
(E) coarctation of the aorta

28. A 63-year-old woman on digitalis for chronic

atrial fibrillation experiences fatigue, nausea,
and anorexia. Her pulse is regular at 50
beats/min, and the heart sounds, chest, and
abdominal examinations are normal. On the
ECG, no P waves are visible and the QRS com-
plexes are narrow and regular. Which of the
following is the most appropriate management
Figure 1–4.
step? (See Fig. 1–5.)
(A) an increase in digitalis dose
25. A 17-year-old girl develops exertional dysp-
nea, but has no cough, sputum, or wheezing (B) complete cessation of digitalis
symptoms. On examination, she has a fixed (C) withdrawal of digitalis for one dose
splitting of her second heart sound and a 3/6 (D) addition of a beta-blocker
systolic ejection murmur heard best over the (E) addition of a calcium channel blocker
left sternal border. An echocardiogram con-
firms the condition. Which of the following 29. A 47-year-old man is found to have edema,
is the best physiologic explanation for her ascites, and hepatosplenomegaly. The exami-
condition? nation of his neck veins reveals elevated
venous pressure with a deep y descent. Heart
(A) pulmonary blood flow is greater than
size on x-ray is normal. Which of the following
systemic blood flow
etiologies is not a possible explanation for this
(B) pulmonary blood flow is less than
syndrome?
systemic blood flow
(C) pulmonary blood flow is equal to (A) rheumatic fever
systemic blood flow (B) TB
(D) the left ventricle is enlarged (C) unknown cause
(E) the systemic blood pressure is elevated (D) previous acute pericarditis
(E) neoplastic involvement of the pericardium
26. A 19-year-old man develops typical angina pec-
toris. There is no family history of premature 30. A 65-year-old man develops palpitations and
CAD. Which of the following is the most likely dizziness. His blood pressure is 80/50 mm Hg
diagnosis? and his pulse is regular at 150/min. His ECG
shows a “saw-toothed” pattern of P waves.
(A) mitral stenosis
Which of the following procedures is most
(B) coronary artery aneurysm
appropriate in converting him back to sinus
(C) coarctation rhythm? (See Fig. 1–6.)
(D) atrial septal defect
(A) carotid sinus pressure
(E) Werner’s syndrome
(B) gagging procedures
27. A 32-year-old asymptomatic woman has a (C) Valsalva maneuver
rapidly rising, forceful pulse that collapses (D) eyeball compression
quickly. Which of the following is the most (E) electrical cardioversion
likely diagnosis?
 Questions: 25–30 7

Figure 1–5.

aVR V1 V4

aVL V2 V5

aVF
V3 V6

25.0 mm/s 10.0 mm/mV 4 by 2.5s + 8 rhythm lds MACVU 003C 12SLLm v250

Figure 1–6.
(Reproduced, with permission, from Fuster V, et al., Hurst’s the Heart, 11th ed. New York: McGraw-Hill, 2004:843.)
8 1: Cardiology

31. A 63-year-old woman presents with symptoms (D) increased growth hormone
of palpitations and atrial flutter on the ECG. (E) decreased vasopressin
Which of the following is the most likely mech-
anism of this arrhythmia? 33. Three months after an anterior MI, a 73-year-
(A) atrial asystole old man has a follow-up ECG. He is clinically
feeling well with no further angina symptoms.
(B) atrial bigeminy
His ECG shows Q waves in the anterior leads
(C) right atrial macro-reentry with persistant ST-segment elevation. The cur-
(D) AV nodal reentry rent ECG is most compatible with which of the
(E) accessory pathway following diagnosis? (See Fig. 1–7.)
(A) ventricular aneurysm
32. A 62-year-old man has progressive symptoms
of dyspnea, and more recently noticed diffi- (B) hibernating myocardium
culty lying supine. Examination shows an ele- (C) acute infarction
vated JVP at 8 cm, with a third heart sound, (D) silent infarction
pedal edema, and bibasilar crackles on auscul- (E) early repolarization
tation. Which one of the following may be
implicated in fluid retention for this condition?
(A) decreased renin
(B) increased aldosterone
(C) increased estrogen

Figure 1–7.
 Questions: 31–41 9

34. A 79-year-old man presents with syncope. On 38. A 59-year-old woman presents for the first time
physical examination, he has a slow upstroke in with untreated congestive heart failure (CHF).
his carotid pulse and a diamond-shaped sys- Urinalysis and urine biochemistrty is most
tolic murmur at the base. His chest is clear. likely to show which of the following?
Which of the following findings is his CXR
(A) decreased urinary sodium content
most likely to reveal?
(B) low urine specific gravity
(A) right ventricular dilatation (C) increased urinary chloride content
(B) stenosis of the proximal ascending aorta (D) red blood cell (RBC) casts
(C) left atrial hypertrophy (E) proteinuria
(D) normal overall cardiac size
(E) displaced apex 39. A 60-year-old woman presents with symptoms
of weight loss, anxiety, and palpitations. On
35. A 49-year-old man has his serum lipids meas- examination, she has a thyoid goiter. Which of
ured. Which pattern suggests the lowest risk the following is the most likely cardiac finding?
for CAD?
(A) prolonged circulation time
(A) total cholesterol 215 mg/dL, high-density (B) decreased cardiac output
lipoprotein (HDL) cholesterol 28 mg/dL (C) paroxysmal atrial fibrillation
(B) total cholesterol 215 mg/dL, HDL (D) pericardial effusion
cholesterol 43 mg/dL
(E) aortic insufficiency
(C) total cholesterol 180 mg/dL, HDL
cholesterol 29 mg/dL 40. A 70-year-old woman is found to have an irreg-
(D) total cholesterol 202 mg/dL, HDL ular pulse rate on a routine visit. She is experi-
cholesterol 45 mg/dL encing no new symptoms at rest or on exertion.
(E) total cholesterol 225 mg/dL, HDL On the ECG, there are no P waves and an
cholesterol 40 mg/dL irregular RR interval at a rate of 70/min. On
her previous ECG from 4 years ago she was in
36. A 16-year-old boy is found to have hyperten- sinus rhythm. Which of the following is the
sion on routine evaluation. On examination, most appropriate next step in management?
the blood pressure in his arms is higher than in (See Fig. 1–8.)
his legs by more than 10 mm Hg. Which of the
(A) cardioversion
following is the most likely diagnosis?
(B) antiarrhythmic therapy
(A) aortic insufficiency (C) beta-blocker
(B) coarctation of the aorta (D) anticoagulation
(C) normal variant (E) aspirin
(D) ventricular aneurysm
(E) severe juvenile diabetes 41. A 47-year-old woman develops accelerated
hypertension (blood pressure 210/105 mm Hg)
37. A 79-year-old man with a 40-year history of but no clinical symptoms except frequent
hypertension and cardiomegaly on CXR is headaches. Which of the following findings
likely to show which of the following on his are most likely on examination of the fundii?
ECG? (See Fig. 1–9.)
(A) clockwise rotation of the electrical axis (A) retinitis obliterans
(B) rSR′ pattern in V1 (B) cotton wool spots
(C) right axis deviation (C) retinal detachment
(D) high-voltage QRS complexes in V5 and V6 (D) optic atrophy
(E) prolonged PR interval in the limb leads (E) foveal blindness
10 1: Cardiology

I aVR V1 V4

II
aVL V2 V5

III
aVF V3 V6

VI

II

Vs

Figure 1–8.

43. A 22-year-old woman develops idiopathic peri-

carditis, with a resultant pericardial effusion.
Which of the following features determines the
patient’s clinical course and prognosis?
(A) specific gravity of the fluid
(B) presence or absence of blood in the fluid
(C) presence or nature of any underlying
disease
(D) cellular count of the fluid
(E) viscosity of the fluid

44. A 65-year-old man complains of postural

Figure 1–9.
(Reproduced, with permission, from Kasper DL, et al.,
hypotension with dizziness. His blood pressure
Harrison’s Principles of Internal Medicine, 16th ed. New York: is 110/80 mm Hg supine and 85/70 mm Hg
McGraw-Hill, 2005:168.) standing (after 2 minutes), the pulse rate
42. A 32-year-old man presents for rountine evalu- remains the same at 80/min. Which of the fol-
ation. He has no symptoms but has noticed lowing is the most likely diagnosis?
some new “nodules” on his legs. Physical exam- (A) thyrotoxicosis
ination reveals lumps on his Achillis tendon, (B) diuretic therapy
yellow lesions around his eyes, and pigmenta-
(C) venous varicosities
tion of his iris. Which of the following is the
(D) possibility of diabetes mellitus (DM)
most likely diagnosis? (See Figs. 1–10 a and b.)
(E) essential hypotension
(A) familial hyperlipidemia
(B) diabetes
(C) myxedema
(D) chronic renal disease
(E) an inherited defect of glycogen utilization
 Questions: 42–46 11

Figure 1–10.
(Reproduced, with permission, from Wolff K and Johnson RA, Fitzpatrick’s Color Atlas &
Synopsis of Clinical Dermatology, 5th ed. New York: McGraw-Hill, 2005:447 & 449.)

45. The echocardiogram of a 22-year-old woman ness, and anxiety. His pulse is 150/min, and his
reveals mitral valve prolapse. Which of the blood pressure is 124/70 mm Hg. Heart sounds
following is the most common physical finding are normal. Carotid sinus pressure gradually
in this condition? changes the rate to 75/min, but when released,
the pulse rate returns to 150/min. Which of the
(A) diastolic rumble
following is the most likely diagnosis?
(B) absent first heart sound
(C) diastolic click (A) atrial flutter with 2:1 block
(D) aortic regurgitation (B) paroxysmal atrial tachycardia with 2:1
block
(E) late systolic murmur
(C) sinus arrhythmia
46. A 36-year-old man is seen because of palpita- (D) atrial fibrillation
tions. He admits to precordial discomfort, weak- (E) nodal tachycardia
12 1: Cardiology

47. A 25-year-old man complains of left precordial

chest pain that radiates to the left shoulder but not
down the left arm. The pain is accentuated by
inspiration and relieved by sitting up. The pain is
accompanied by fever and chills. His blood pres-
sure is 105/75 mm Hg, pulse 110/min and regu-
lar, and temperature 37.5°C. Aside from the
tachycardia, there are no abnormal physical find-
ings in the heart or lungs. The ECG shows ST-
segment elevation in all leads except aVR and VI.
On the third hospital day, the patient’s blood pres-
sure falls, JVP rises, and he goes into CHF. Which
of the following is the most likely diagnosis?
(A) a second pulmonary embolus
Figure 1–11.
(B) extension of a myocardial infarct
(C) cardiac tamponade
(D) secondary bacterial infection 49. A 68-year-woman with hypertension and dys-
(E) rupture of a chordae tendineae lipidemia presents with 30 minutes of ret-
rosternal chest pain radiating to her neck. She
48. A 80-year-old man with Type II diabetes and is diaphoretic and in moderate distress. The
hypertension presents with increasing dysp- ECG shows ST-segment elevation in the infe-
nea. He appears short of breath, blood pres- rior leads. Which of the following mechanisms
sure is 170/95 mm Hg, pulse 100/min and is the most likely cause of her condition? (See
regular. The JVP is at 7 cm; there is a loud Fig. 1–12.)
second heart sound and a systolic ejection (A) coronary plaque rupture
murmur at the right sternal border, which does
(B) aortic inflammation
not radiate. The lungs have bibasilar crakles
(C) pericardial inflammation
up to the scapula. The CXR has bilateral infil-
trates and vascular redistribution. His echocar- (D) vasculitis
diogram reports aortic sclerosis, concentric left (E) myocarditis
ventricular hypertrophy (LVH), and normal
ejection fraction. Which of the following is the 50. A 62-year-old man with a prosthetic aortic
most likely mechanism for this condition? (See valve develops fevers and malaise. His valve
Fig. 1–11.) was replaced 5 years ago because of aortic
stenosis from a bicuspid valve. He has a sys-
(A) valvular heart disease tolic ejection murmur but no other abnormali-
(B) diastolic dysfunction ties on examination. Blood cultures are most
(C) systolic dysfunction likely to grow which of the following?
(D) hibernating myocardium
(A) fungi
(E) hypertrophic obstructive cardiomyopathy
(B) bartonella
(HOCM)
(C) diptheroids
(D) Staphylococcus epidermidis
(E) Streptococcus bovis
 Questions: 47–52 13

Figure 1–12.
(Reproduced, with permission, from Fuster V, et al., Hurst’s the Heart, 11th ed.
New York: McGraw-Hill, 2004:1356.)

51. A 58-year-old man with no prior cardiac his- (A) Cushing’s syndrome
tory presents with retrosternal chest pain start- (B) primary aldosteronism
ing at rest and lasting 30 minutes. The pain (C) essential hypertension
radiates to the left arm and is associated with
(D) pyelonephritis
diaphoresis and dyspnea. His blood pressure is
150/90 mm Hg, pulse 100/min, the heart (E) bilateral renal artery stenosis
sounds are normal, and the lungs are clear to
auscultation. Which of the following is the next
most appropriate investigation?
TABLE 1–1. LABORATORY INVESTIGATIONS
(A) CT scan—chest
Urinalysis
(B) CXR
(C) cardiac troponin pH 5.2
Albumin Negative to trace
(D) ECG Serum Na 140 mEq/L
(E) myocardial perfusion imaging K 3.5 mEq/L
Cl 100 mEq/L
CO2 25 mEq/L
52. The laboratory results shown in Table 1–1 are Creatinine 1.0 mg/100 mL
obtained from the investigation of a 37-year-old Fasting sugar 90 mg/100 mL
Calcium 9.0 mg/100 mL
African-American woman who has a blood Uric acid 5.0 mg/100 mL
pressure at rest of 140/100 mm Hg. Which of
the following is the most likely diagnosis?
14 1: Cardiology

53. Figure 1–13 is the x-ray and MR of an 8-year-old

boy who had easy fatigability and a soft, con-
tinuous murmur in the upper back. ECG
revealed minimal LVH. What is your diagnosis?
(A) aortic stenosis
(B) patent ductus arteriosus
(C) coarctation of the aorta
(D) pulmonary valvular stenosis
(E) peripheral pulmonary stenosis

54. Figure 1–14 is an x-ray of an asymptomatic 64-

year-old male executive coming in for his reg-
ular annual medical checkup. He had an
anterior Q wave MI 4 years ago. What is your
diagnosis?
(A) calcific pericarditis
(B) left ventricular aneurysm Figure 1–14.
(C) hydatid cyst
(D) pleuropericarditis
(E) normal

Figure 1–13.
 Questions: 53–58 15

55. A 70-year-old man has dyspnea, orthopnea,

and paroxysmal nocturnal dyspnea. He has
generalized cardiomegaly and pulmonary and
systemic venous hypertension. The ECG is
Figure 1–16.
shown in Fig. 1–15. What is the cardiac rhythm?
(A) ectopic atrial tachycardia 57. A 42-year-old woman has anterior chest pain of
(B) atrial flutter with 2:1 AV conduction a somewhat atypical nature for many years.
(C) sinus tachycardia The patient’s pain has been present and rela-
(D) supraventricular tachycardia tively stable for a number of years, and the
(E) atrial fibrillation with rapid ventricular ECG shown in Fig. 1–17 is a stable one. What is
response the diagnosis?
(A) inferior wall infarction
(B) anterior wall infarction
(C) ventricular aneurysm
(D) nonspecific changes
(E) pericarditis

Figure 1–17.

58. The ECG shown in Fig. 1–18 was obtained

during the initial stages of an acute MI. The
patient had just received thrombolytic therapy.
What is the rhythm?
Figure 1–15.
(A) atrial fibrillation
(B) atrial flutter
56. A 77-year-old woman comes to the emergency
(C) second-degree heart block
department because of feeling “light-headed
and dizzy.” Except for the irregular pulse, her (D) Wenckebach phenomenon
physical examination is normal. What is the (E) nonsustained ventricular tachycardia
rhythm in the lead tracing shown in Fig. 1–16?
(A) first-degree heart block
(B) second-degree heart block
(C) third-degree heart block
(D) premature ventricular beats
(E) premature atrial beats
Figure 1–18.
16 1: Cardiology

59. A 78-year-old man with advanced renal dis- Questions 62 through 64

ease has the ECG shown in Fig. 1–19 (lead II).
(A) shortened PR interval
What is the diagnosis?
(B) lengthened PR interval
(A) hyperkalemia (C) lengthened QU interval
(B) hypercalcemia (D) shortening of the QT interval
(C) hypernatremia (E) shortening of the QU interval
(D) pericarditis (F) broad-based (>0.20 second) peaked
(E) ventricular aneurysm T wave
(G) narrow-based (<0.20 second) peaked
T wave
(H) widened QRS
(I) flattened P waves

For each of the following patients, select the char-

Figure 1–19.
acteristic ECG findings.

60. A 58-year-old man whom you have followed 62. A 80-year-old man presents with nausea, vom-
dies suddenly, spurring you into doing some iting, and decreased urine output. He has a his-
research on sudden death. Which of the follow- tory of hypertension and chronic renal failure
ing is the most likely cause for this individual? (Stage 3, GFR [glomerular filtration rate] 50
(A) extensive coronary atherosclerosis mL/min). He is taking spironolactone and
nifedipine for treatment of hypertension.
(B) electrolyte disturbance
(SELECT FOUR)
(C) pulmonary embolism
(D) acute stroke 63. A 52-year-old woman presents with polyuria,
(E) CHF polydypsia, constipation, and fatigue. She has
no significant past medical history, and she is not
61. You have a large number of patients in your on any medications. She was recently diagnosed
practice with hypertension. If the diagnosis in with hyperparathyroidism. (SELECT ONE)
an individual is essential hypertension, which
of the following statements is correct? 64. A 64-year-old man with heart failure is recently
started on 80 mg/day of furosemide. He now
(A) over 95% of patients are salt-sensitive
feels weak and tired, but notes that his heart
(B) it comprises about 90% of hypertensives failure symptoms have improved. There is no
in general population change in his urine output and he gets a good
(C) renin levels are invariably high diuretic response every time he takes his
(D) women have a poorer prognosis furosemide. (SELECT ONE)
(E) alcohol reduces risk
Questions 65 through 68
DIRECTIONS (Questions 62 through 121): Each set (A) low right atrial pressure
of matching questions in this section consists of a
(B) normal right atrial pressure
list of lettered options followed by several num-
bered items. For each numbered item, select the (C) high right atrial pressure
appropriate lettered option(s). Each lettered option (D) normal or elevated gradient between PA
may be selected once, more than once, or not at all. diastolic pressure and wedge pressure
EACH ITEM WILL STATE THE NUMBER OF (E) low PA wedge pressure
OPTIONS TO SELECT. CHOOSE EXACTLY THIS (F) normal or high PA wedge pressure
NUMBER. (G) low cardiac output
 Questions: 59–73 17

(H) normal or high cardiac output (C) rapid decompensation with pulmonary
(I) low systemic vascular resistance edema
(J) normal or high systemic vascular (D) diminished S1
resistance (E) may be tolerated without loss of cardiac
(K) normal or high PA diastolic pressure reserve for years
(F) diminished forward stroke volume
For the following patients, select the hemodynamic
parameters that are most likely to apply. Select the typical auscultation findings for the fol-
lowing patients.
65. A 52-year-old man with alcoholic cirrhosis
develops a variceal bleed with hypotension. 69. An asymptomatic 19-year-old student with a
His blood pressure is 85/60 mm Hg, pulse murmur is found to have mitral regurgitation
120/min, and heart sounds are normal. The on echocardiogram. The physical findings
JVP is not visible, the lungs are clear, and his might include (SELECT THREE)
extremities are pale, cool, and clammy. Central
hemodynamic monitoring would reveal 70. A 60-year-old man with an acute myocardial
(SELECT FOUR) infarct develops a new murmur. Echocardiogram
reveals acute MR. The findings might include
66. A 73-year-old man has an inferior infarct with (SELECT THREE)
ST elevation documented on right-sided pre-
cordial leads. He is hypotensive (blood pres- Questions 71 through 75
sure 90/70 mm Hg) and tachycardic. The JVP
(A) prolonged PR interval
is 10 cm, the heart sounds are normal, lungs are
clear, and his extremitites are cool. Central (B) broad-notched P wave in lead II
hemodynamic monitoring would reveal (C) short QT interval
(SELECT SIX) (D) short PR interval
(E) LVH
67. A 20-year-old man is being treated for acute
lymphoblastic leukemia. While neutropenic, For each of the following patients, select the char-
he becomes severely hypotensive with a tem- acteristic ECG finding.
perature of 38.5°C. His blood pressure is 80/60
mm Hg, pulse 120/min, and heart sounds are
normal. The JVP is below the sternal angle, 71. A 25-year-old woman develops exertional dys-
lungs are clear, and his extremities are warm pnea and fatigue. Her past history is significant
and flushed. Central hemodynamic monitoring for rheumatic fever as a child. Auscultation of
would reveal (SELECT SIX) the heart reveals a loud first heart sound and a
low-pitched middiastolic sound. (SELECT ONE)
68. A 78-year-old woman has an acute anterior
wall MI with hypotension and pulmonary con- 72. A 70-year-old man with a prior anterior MI
gestion. Her blood pressure is 90/70 mm Hg, comes for his routine evaluation. He feels well
pulse 110/min, JVP at 8 cm, and the heart and has no symptoms. He is taking metoprolol
sounds are normal. The lungs have bibasilar 100 mg bid, aspirin 81 mg od, enalapril 10 mg
crackles, and her extremities are cool and bid, and simvastatin 40 mg od for secondary
diaphoretic. Hemodynamic monitoring would prevention. (SELECT ONE)
reveal (SELECT FIVE)
73. A 20-year-old woman develops palpitations
Questions 69 and 70 and dizziness. Her blood pressure is 100/70
mm Hg, pulse 140/min, and heart sounds are
(A) high-pitched holosystolic murmur normal. She has had symptoms of palpitations
(B) early and midsystolic murmur for many years. (SELECT ONE)
18 1: Cardiology

74. A 64-year-old woman with metastatic breast For each of the following statements, select
cancer presents with fatigue and malaise. She whether it is applicable to any or all of the above
recently started noticing polyuria and poly- medications.
dypsia. On examination, her JVP is below the
sternal angle, heart sounds are normal, and she
80. Direct action on vascular smooth muscle
has tenderness over her thoracic spine. (SELECT
(SELECT FOUR)
ONE)
81. Inhibition of angiotensin converting enzyme I
75. A 78-year-old man develops recent-onset chest
(ACE I) (SELECT ONE)
pain and dyspnea on exertion. His blood pres-
sure is 150/90 mm Hg, pulse 90/min, and a
82. Myocardial stimulant (SELECT ONE)
systolic ejection murmur at the right sternal
border that radiates to the carotids. His carotid
83. Used for primary pulmonary hypertension
pulse is also diminished. (SELECT ONE)
(SELECT ONE)
Questions 76 through 79
84. May decrease mortality by direct myocardial
(A) true of metoprolol but not captopril protective action against catecholamines
(B) true of captopril but not metoprolol (SELECT ONE)
(C) true of both captopril and metoprolol
Questions 85 through 89
(D) true of neither captopril nor metoprolol
(A) pulsus tardus
For each of the following statements, select whether (B) pulsus paradoxus
it is applicable to metoprolol and/or captopril. (C) hyperkinetic pulse
(D) bisferiens pulse
76. Useful in heart failure (SELECT ONE) (E) dicrotic pulse
(F) pulsus alternans
77. The effects on the heart result in a prominent
(G) delayed femoral pulse
negative inotropic effect (SELECT ONE)
(H) pulsus bigeminus
78. The treatment of chronic atrial fibrillation
(SELECT ONE) For each of the following patients, select the char-
acteristic arterial pulse finding.
79. Mechanism of action is calcium blockade
(SELECT ONE) 85. A 75-year-old woman with hypertension devel-
ops fatigue and dyspnea on exertion. Her blood
Questions 80 through 84 pressure is 160/60 mm Hg and pulse 80/min.
(A) hydralazine The second heart sound is diminished and
there is an early diastolic murmur that radi-
(B) enalapril
ates from the right sternal border to the apex.
(C) spironolactone Your clinical diagnosis is aortic regurgitation.
(D) metoprolol (SELECT ONE)
(E) nifedipine
(F) digoxin 86. A 64-year-old man with two previous MIs
(G) furosemide develops SOB at rest and has difficulty lying
down. His blood pressure is 95/70 mm Hg,
(H) metolazone
pulse 100/min, and JVP is 8 cm. The cardiac
(I) amlodipine apex is dilated and displaced laterally, heart
(J) nitrates sounds are normal, but there is a soft third
 Questions: 74–98 19

heart sound. Your clinical diagnosis is ischemic 93. Right-sided heart failure (SELECT ONE)
cardiomyopathy. (SELECT ONE)
94. Complete heart block (SELECT ONE)
87. A 18-year-old man notices occasional light-
headedness when standing up quickly. He also Questions 95 through 99
has difficulty playing sports because of easy
(A) aortic stenosis
fatigue and SOB. Examination shows normal
heart sounds, but a loud systolic ejection (B) HOCM
murmur at the right sternal border. The (C) mitral regurgitation (chronic)
murmur decreases with elevating the legs and (D) tricuspid regurgitation
increases in the standing position. Your clinical (E) mitral valve prolapse
diagnosis is hypertrophic cardiomyopathy (F) pulmonary stenosis
(HOCM). (SELECT ONE)
For each patient with a systolic murmur, select the
88. A 76-year-old woman presents with new-onset most likely diagnosis.
syncope. She has also noticed early fatigue on
exertion for the past year. On examination, there
is a systolic ejection murmur at the right sternal 95. A 25-year-old woman is found to have a
border that radiates to the carotids. Your clini- midsystolic murmur on routine evaluation.
cal diagnosis is aortic stenosis. (SELECT ONE) The murmur does not radiate but it does
increase with standing. She otherwise feels
89. A 62-year-old man with a 40-pack/year his- well and the rest of the examination is normal.
tory of smoking presents with increased (SELECT ONE)
sputum production and marked SOB. On
examination, he is using accessory muscles of 96. A 75-year-old man is bought to the hospital
respiration, and breath sounds are diminished because of a syncopal episode. There was no
with expiratory wheezes. Your clinical diagno- incontinence or post-event confusion. On exam-
sis is chronic obstructive pulmonary disease ination, his blood pressure is 140/80 mm Hg,
(COPD) exacerbation. (SELECT ONE) pulse 72/min with no postural changes. His
second heart sound is diminished and there is
Questions 90 through 94 a systolic ejection murmur that radiates to the
carotids. With the Valsalva maneuver, the
(A) Cannon a wave murmur decreases in length and intensity.
(B) prominent x descent (SELECT ONE)
(C) Kussmaul’s sign
(D) slow y descent 97. A 22-year-old woman with no past medical his-
(E) prominent v waves tory is found to have a systolic ejection murmur
on routine physical examination. She has no
(F) positive abdominojugular reflux
symptoms and feels well. The murmur is heard
along the right and left sternal borders and it
For each of the following cardiac abnormalities,
decreases with handgrip exercises. (SELECT
select the characteristic JVP finding.
ONE)

90. Tricuspid regurgitation (SELECT ONE) 98. A 45-year-old woman has developed increasing
SOB on exertion and fatigue. She has a loud
91. Right atrial myxoma (SELECT ONE) systolic ejection murmur heard best at the left
sternal border, and the murmur increases with
92. Right ventricular infarction (SELECT ONE) standing. A double apical impulse is also felt.
(SELECT ONE)
20 1: Cardiology

99. A 65-year-old man with a previous history of the CXR shows a normal cardiac silhouette.
an anterior MI comes for follow-up. On exam- (SELECT ONE)
ination, he has a systolic murmur heard best at
the apex and radiating to the axilla. Transient 103. A 55-year-old woman with metastatic lung
external compression of both arms with blood cancer presents with dyspnea and pedal
pressure cuffs 20 mm Hg over peak systolic edema. On examination, the JVP is at 10 cm,
pressure increases the murmur. (SELECT ONE) with a negative Kussmaul’s sign. The heart
sounds are diminished and the lungs have
Questions 100 through 105 bibasilar crackles. The ECG shows QRS com-
plexes of variable height. (SELECT ONE)
(A) cardiac tamponade
(B) constrictive pericarditis 104. A 64-year-old presents with dyspnea and
(C) restrictive cardiomyopathy edema. He had previous coronary bypass sur-
(D) right ventricle myocardial infarction gery 5 years ago, which was uncomplicated.
(RVMI) Since then he has had no further chest pain.
On examination, his JVP is at 8 cm, with promi-
For each patient with SOB and pheripheral edema, nent Kussmaul’s sign. The heart sounds are
select the most likely diagnosis. easily heard but there is an early diastolic fill-
ing sound (pericardial knock). (SELECT ONE)
100. A 56-year-old man presents with SOB, fatigue,
105. A 55-year-old woman is recently diagnosed
and edema. He has also noticed weight gain,
with amyloidosis. She is now noticing increas-
abdominal discomfort, and distension. He has
ing SOB, fatigue, and edema. On examination,
a prior history of lung cancer treated with
the JVP is at 10 cm with a negative Kussmaul’s
radiotherapy to the chest. There is no history of
sign but prominent x and y descent. The blood
liver or cardiac disease in the past. On exami-
pressure is 90/70 mm Hg, no pulsus para-
nation, he has an elvated JVP, prominent y
doxus, pulse 100/min with low volume, and
descent of neck veins, and positive Kussmaul’s
normal heart sounds. (SELECT ONE)
sign. The heart sounds are normal. The CXR
shows a normal cardiac silhouette and the ECG
Questions 106 through 110
has low voltages. (SELECT ONE)
(A) focal myocardial necrosis
101. A 28-year-old woman recently developed symp- (B) proximal aortitis
toms of chest pain that changed with position- (C) endothelial plaques
ing. It was worse when lying down and relieved
(D) systolic scratchy sound
when sitting up. The pain is better now but she
notices increasing dyspnea and edema. On (E) restrictive cardiomyopathy
examination, the blood pressure is 85/60 mm
Hg with a positive pulsus paradoxus, low For each patient with systemic disease, select the
volume pulse at 110/min, and the heart sounds typical cardiovascular involvement.
are distant. The JVP is at 7 cm with a negative
Kussmaul’s sign. There are low voltages on the 106. A 45-year-old man develops new symptoms of
ECG, and a large cardiac silhouette on the CXR. sudden-onset flushing involving his head and
(SELECT ONE) neck lasting a few minutes. He also notices
watery diarrhea and abdominal pain when the
102. A 69-year-old woman complains of some atyp- flushing occurs. Serotonin and its metabolites are
ical chest pain 2 days prior to presentation. On elevated in his urine and serum. (SELECT ONE)
examination, the JVP is at 8 cm, positive
Kussmaul’s sign, and normal heart sounds. 107. A 25-year-old man has noticed increasing lower-
The lungs are clear. The ECG is abnormal, and back and gluteal pain. It is dull and associated
 Questions: 99–114 21

with morning stiffness lasting 1 hour, and then (E) lifestyle modification
it improves after activity. On examination, there (F) estrogens (Premarin, estradiol)
are no active inflammatory joints but he has
limited forward and lateral flexion of the lumbar For each patient with dyslipidemia, select the
spine, as well as decreased chest expansion. X- most appropriate treatment.
rays of his pelvis and lumbar spine show
changes of sacroilitis. (SELECT ONE)
111. A 63-year-old woman with Type II diabetes is
108. A 31-year-old woman has new-onset headaches seen for follow-up after a fasting lipid profile.
and blood pressure elevation. She also notices She has no other medical conditions and feels
that the symptoms come episodically and con- well. Her diabetes is well-controlled and the last
sist of palpitations, headache, anxiety, and hemoglobin A1C value was 6.5%. Her total cho-
marked blood pressure elevation. She under- lesterol (T-chol) is 240 mg/dL, HDL 50 mg/dL,
goes a workup for secondary causes of hyper- low-density lipoprotein (LDL) 160 mg/dL, and
tension, and is found to have elevated free triglycerides 150 mg/dL. (SELECT TWO)
catecholamines in her urine. (SELECT ONE)
112. A 42-year-old woman, who is an executive at a
109. A 22-year-old university student notices unin- large company, is seen for her annual evalua-
tentional weight loss and palpitations for tion. She is concerned about her risk for future
1 month. She also complains of sweating and cardiac events since a collegue was just diag-
feeling hot all the time. On examination, her nosed with angina. She has no other medical
pulse is regular at 110/min, blood pressure illness and is a lifetime nonsmoker. Her fasting
96/60 mm Hg; she has a diffuse enlargement of lipid profile is T-chol 240 mg/dL, HDL 55
the thyroid gland. Her thyroid-stimulating hor- mg/dL, LDL 160 mg/dL, and triglycerides 140
mone (TSH) is low and free T3 and T4 are ele- mg/dL. (SELECT ONE)
vated. (SELECT ONE)
113. A 57-year-old man comes to see you for follow-
110. A 60-year-old man presents with SOB, increas- up 4 weeks after being discharged from hospi-
ing abdominal distention, and lower leg edema. tal for unstable angina. His coronary
He has no prior history of cardiac, renal, or liver angiogram showed moderate nonstenotic dis-
disease. On examination, the JVP is at 8 cm with ease in two vessels. The cardiologist asks you
a negative Kussmaul’s sign but prominent x and to follow up on his fasting lipid profile since it
y descent. The blood pressure is 95/75 mm Hg, no was not checked in the hospital. His T-chol is
pulsus paradoxus, pulse 100/min with low 240 mg/dL, LDL 120 mg/dL, HDL 50 mg/dL,
volume, and normal heart sounds. There is and triglycerides 130 mg/dL. (SELECT TWO)
shifting dullness of the abdomen and pedal
edema. His blood glucose and hemoglobin A1C 114. A 58-year-old woman is admitted to hospital
are elevated. (SELECT ONE) with left-sided hemiparesis. She is diagnosed
with an ischemic right cortical stroke, and
Questions 111 through 116 started on aminosalicylic acid (ASA) for sec-
ondary prevention. Her carotid ultrasound
(A) fibric acid derivatives (clofibrate, reveals no arterial stenosis. She has no other sig-
gemfibrozil) nificant past medical history but she does smoke
(B) nicotinic acid half pack a day. Her fasting lipid profile is T-chol
(C) bile acid-binding resins (cholestyramine, 240 mg/dL, HDL 50 mg/dL, LDL 160 mg/dL,
colestipol) and triglycerides 130 mg/dL. (SELECT TWO)
(D) hepatic hydroxymethylglutaryl-
coenzyme A (HMG-CoA) reductase
inhibitors (lovastatin, simvastatin,
pravastatin)
22 1: Cardiology

115. A 56-year-old man is diagnosed with the meta- 150/90 mm Hg. He has complications of phe-
bolic syndrome, which consists of hypertension, ripheral neuropathy and a urinalysis is positive
insulin resistance, dyslipidemia, and abdominal for microalbuminuria. (SELECT ONE)
obesity. He has no prior history of cardiac or
vascular disease and is otherwise well. His fast- 118. A 60-year-old woman with no past medical his-
ing T-chol is 270 mg/dL, HDL 50 mg/dL, LDL tory has an elevated blood pressure of 165/80
150 mg/dL, and triglycerides 150 mg/dL. mm Hg on routine evaluation. Repeated meas-
(SELECT TWO) urements over the next month confirm the ele-
vated pressure. Physical examination, routine
116. A 60-year-old woman is concerned about her blood count, and biochemistry are all normal.
risk for cardiovascular disease since she is post- (SELECT ONE)
menopausal now. She has no symptoms of car-
diac or vascular disease and her only cardiac 119. A 26-year-old woman develops new-onset
risk factor is hypertension for the past 5 years, hypertension. She has no other medical prob-
which is well-controlled. Her fasting T-chol is lems and is not taking any medications. She
240 mg/dL, HDL 55 mg/dL, LDL 160 mg/dL, undergoes an evaluation for secondary hyper-
and triglycerides 140 mg/dL. (SELECT ONE) tension and is found to have unilateral renal
artery stenosis. (SELECT ONE)
Questions 117 through 121
120. A 70-year-old man has isolated systolic hyper-
(A) thiazides
tension. On examination, his blood pressure is
(B) spironolactone 170/80 mm Hg, heart and lungs are normal. He
(C) clonidine has no other medical conditions. (SELECT ONE)
(D) prazosin
(E) beta-blockers 121. A 57-year-old man has a blood pressure of
(F) hydralazine 155/90 mm Hg on routine evaluation. He had
coronary artery bypass grafting 4 years earlier,
(G) ACE inhibitors
after which he has had no further chest pain.
(H) calcium channel blockers
The rest of the examination is normal, and the
elevated blood pressure is confirmed on two
For each patient with high blood pressure, select repeat visits. (SELECT ONE)
the most appropriate medication.

117. A 54-year-old man with diabetes has a per-

sistently elevated blood pressure averaging
 Answers and Explanations

1. (D) Wenckebach, or type I second-degree AV a result of a transient ventricular tachyarrhyth-

block, is characterized on ECG by progressive mia. (Fuster, pp. 1645–1647)
lengthening of the PR interval until there is a
nonconducted P wave. The magnitude of PR 5. (C) Common findings in infective endocarditis
lengthening declines with each beat, so the RR include petechiae, Roth’s spots, Osler’s nodes,
intervals characteristically shorten prior to the Janeway lesions, splinter hemorrhages, stroke,
dropped beat. It is almost always caused by and infarction of viscera, or extremities.
abnormal conduction across the AV node, and Many of the complications are thought to
the QRS complex is usually of normal dura- be embolic but may include vasculitis. Autopsy
tion. (Fuster, p. 901) studies reveal that many systemic emboli go
unrecognized. Brain, lung, coronary arteries,
2. (D) The ventricular inhibited (VVI) pacemaker spleen, extremities, gut, and eyes are common
functions when the heart rate falls below a locations for emboli. (Fuster, pp. 2010–2011)
preset interval. If a QRS is detected, the pace-
maker is inhibited. If a QRS is not sensed, the 6. (B) The slow channel for calcium assumes con-
pacing stimulus is not inhibited and the ven- siderable importance in the region of the sinus
tricle is stimulated. (Fuster, p. 909) node and AV node. For verapamil, this results
in both antiarrhythmic and negative inotropic
3. (D) Sinus tachycardia is the most common ECG effects. Different classes of calcium channel
finding in pulmonary embolism. The specific blockers have differential effects on these slow
ECG signs of pulmonary embolism such as the channels, explaining the different clinical prop-
S1, Q3, T3 are rarely seen except in cases of erties of the various calcium channel blocking
massive pulmonary embolism. In submassive drugs. (Fuster, pp. 950)
pulmonary emboli, the ECG may show non-
specific ST changes and sinus tachycardia. 7. (D) Pericarditis secondary to transmural infarc-
On occasion, pulmonary embolism can tion is very common and most cases appear
precipitate atrial flutter or fibrillation. One of within 4 days. The most common manifestation
the most useful roles of the ECG is to rule out of pericarditis is a friction rub along the left ster-
MI when a massive embolism is present. nal border. It is evanescent, lasting only a few
(Fuster, pp. 1596–1597) days. The pain is usually perceived by the patient
to be different than that of the infarct. It is wors-
4. (C) Aortic stenosis is most likely to be associ- ened by inspiration, swallowing, coughing, or
ated with angina pectoris, syncope, and exer- lying down. It frequently is associated with a
tional dyspnea. Exertional syncope is caused by low-grade fever. (Fuster, p. 1980, 1995–1996)
either systemic vasodilation in the presence of
fixed or inadequate cardiac output, an arrhyth- 8. (A) Positively inotropic is the best description of
mia, or both. Syncope at rest is most frequently the effect of calcium ions on the myocardium.

23
24 1: Cardiology

Calcium plays a role in excitation– (parasympathetic) which decreases AV nodal

contraction coupling, and in possible drug conduction and terminates AV node re-entry
effects and heart failure. (Fuster, p. 129) arrhythmias. Sinus tachycardia differs from
PSVT tachycardia in that it does not start or
9. (C) In the past, there was concern that rigorous stop abruptly. In PSVT, the QRS is usually
drug treatment would harm the fetus. narrow without clearly discernible P waves.
Studies now show benefit in controlling A wide QRS in PSVT can result from a preex-
pressure with drugs, but ACE inhibitors are isting bundle branch block, or a functional
contraindicated because they might cause bundle branch block secondary to the tachy-
renal abnormalities in the fetus. Women who cardia. This can make the distinction from a
develop hypertension during pregnancy have ventricular arrhythmia quite difficult. (Fuster,
a higher risk of developing hypertension in pp. 845–847)
later life. (Fuster, p. 2217)
13. (D) In the absence of critical CAD, angina pec-
10. (E) There is a possible indication (but not an toris occurs most frequently with aortic stenosis.
obligation) to insert a temporary pacemaker if AMI is usually due to associated atherosclerotic
a new LBBB occurs. If LBBB and a Mobitz coronary occlusion. (Fuster, p. 1645)
type II AV block occur, there is general agree-
ment on the usefulness of pacing. Temporary 14. (B) In aortic stenosis, the first sound is usually
pacemaker is not required for first-degree block. normal; the second sound is characteristically
For second-degree block of the Wencke- diminished because of the increased ventricular
bach type (usually with an inferior infarction), pressure and the stenotic valve is less mobile.
pacing is only required if symptoms of brady- There can be a single S2 either because A2 and
cardia and hypotension cannot be controlled P2 are superimposed or A2 is absent or very
medically. The necessity for temporary pacing soft. Severe aortic stenosis may be accompanied
during an acute myocardial infarction (AMI) by paradoxical splitting of S2. (Fuster, p. 1646)
does not necessarily indicate that permanent
pacing will be required. (Fuster, pp. 1323–1324) 15. (B) AV dissociation is the independent beating
of atria and ventricles and is recognized on the
11. (D) Pulmonary hypertension is associated with ECG by fixed PP and RR intervals but variable
an increased intensity of the second heart PR intervals.
sound, which coincides with the end of the T AV block is one cause of AV dissociation.
wave on ECG. It is the pulmonic component of (Fuster, pp. 904–905)
the second heart sound that is increased.
Pulmonary stenosis can cause dyspnea on exer- 16. (E) Nitroglycerine is usually used in the set-
tion but auscultation will reveal a systolic ting of severe pulmonary congestion with ade-
murmur and decreased second heart sound quate blood pressure. With significant
(pulmonic component). hypotension, inotropic agents are generally
As well, there may be prominent a waves administered prior to nitroglycerine. (Fuster, pp.
in the jugular venous pulse, a right ventricu- 1316–1317)
lar heave, an ejection click, and a right ven-
tricular fourth heart sound. When signs and 17. (A) A ventricular septal defect is considered a rel-
symptoms are apparent, the pulmonary atively high-risk lesion for infective endocarditis.
hypertension is usually moderate to severe. Mitral valve prolapse with regurgitation,
(Fuster, pp. 1586–1587) asymmetric septal hypertrophy, and pure
mitral stenosis are considered an intermediate
12. (D) The patient most likely has PSVT, since risk. Atrial septal defects of the secundum
the tachycardia terminates after carotid sinus type are considered low risk. (Fuster, p. 2003)
massage (CSM). CSM increases vagal tone
 Answers: 9–28 25

18. (A) The myxoma is a solitary globular or poly- cause pericarditis, they are unlikely in this case.
poid tumor varying in size from that of a (Fuster, p. 1979)
cherry to a peach. About 75% are found in the
left atrium, and most of the remainder in the 23. (C) Left-heart catheterization is a more accurate
right atrium. The clinical presentation is with measurement, but involves a slightly increased
one or more of the classical triad of constitu- risk. End-expiratory PA diastolic pressure is
tion symptoms (fatigue, fever, anemia), very close (2–4 mm) to wedge pressure as well.
embolic events, or obstruction of the valve A discordance between wedge pressure and
orifice. (Fuster, pp. 2081–2082) PA diastolic pressure suggests the presence of
pulmonary hypertension. (Fuster, p. 512)
19. (A) Diltiazem and verapamil may be of help in
both acute paroxysms of atrial flutter and 24. (C) Aortic dissection is a medical emergency
chronic management. The other choices have requiring prompt attention. Other cardiac and
no effect on the AV node to slow down flutter, pulmonary causes of chest pain can be quickly
and atropine accelerates AV conduction. At ruled out with ECG and CXR. CT scan of the
times, catheter ablation of the flutter pathway chest is sensitive (93–100%) in ruling out dis-
is required in chronic atrial flutter. Surgical section. Transesophageal echocardiography is
ablation is reserved for cases where other sur- equally as sensitive but not a transthoracic
gical interventions are required. (Fuster, p. 844) echo. (Fuster, pp. 2312–2313)

20. (C) Exercise electrocardiography represents an 25. (A) This is characteristic of an atrial septal
increasingly popular noninvasive method for defect. Pulmonary blood flow is greater
early detection of latent ischemic heart disease. because of increased blood flow from the right
As with other diagnostic tests, the exercise ECG atrium, which receives blood from the vena
is of most clinical value when the pretest prob- cava and left atrium. (Fuster, pp. 1797–1798)
ability of disease is moderate (i.e., 30–70%). In
men over 40 and women over 50 who plan to 26. (B) Angina or infarction in young patients
start vigorous exercise, use of exercise ECG is should prompt the physician to consider con-
possibly, but not definitely, supported by the genital coronary artery anomaly or congenital
evidence (class IIb). (Fuster, pp. 477–478) coronary artery aneurysm. Acquired coronary
artery aneurysm can be caused by atheroscle-
21. (D) Contrast media used in cardiac catheteri- rosis, trauma, angioplasty, atherectomy, vas-
zation may result in renal impairment. The culitis, mycotic emboli, Kawasaki syndrome,
group at highest risk includes diabetics with or arterial dissection. (Fuster, p. 1178)
renal disease and those with preexisting renal
failure. Good hydration is essential. Other man- 27. (D) This pulse is seen in aortic regurgitation.
ifestations of contrast media include nausea The pressure in diastole is usually 50 mm
and vomiting (common), and anaphylactoid Hg or lower. This is known as a water ham-
reactions characterized by low-grade fever, mer or Corrigan’s pulse. A bisferiens pulse (in
hives, itching, angioedema, bronchospasm, and the bisferiens wave form there are two pres-
even shock. Side effects are reduced with the sure peaks) may be present as well. Systolic
use of new low osmolality contrast media. blood pressure is elevated. (Fuster, p. 1654)
(Fuster, p. 489)
28. (B) Digoxin toxicity may cause any dysrhyth-
22. (E) Pericarditis in clinical practice is commonly mia. Classically, dysrhythmias that are associ-
idiopathic and frequently assumed to be of pos- ated with increased automaticity and decreased
sible viral origin. Coxsackieviruses are a AV conduction occur (i.e., paroxysmal atrial
common cause, but herpesviruses are not. tachycardia with 2:1 block, accelerated junc-
Although TB, rheumatic fever, and MI can tional rhythm, or bidirectional ventricular tachy-
cardia [torsade de pointes]). Sinus bradycardia
26 1: Cardiology

and other bradyarrhythmias are very common. 33. (A) ST elevation persisting 2 weeks after an
Slow atrial fibrillation with very little variation infarct, an abnormal pericardial impulse, and a
in the ventricular rate (regularization of the R- bulge on the left ventricular border on x-ray are
R interval) may occur. This arrhythmia is likely characteristic of an aneurysm. Ventricular
slow atrial fibrillation. Symptoms of digitalis aneurysms are most often a result of a large
toxicity include anorexia, nausea, fatigue, dizzi- anterior infarct. The poor prognosis associated
ness, and visual disturbances. The presence of with these aneurysms is due to the associated
hypokalemia increases the likelihood of digi- left ventricular dysfunction, rather than to the
talis toxicity. (Fuster, p. 795) aneurysm itself. (Fuster, pp. 1321–1322)

29. (A) Commonly, no cause is found for constric- 34. (D) In aortic stenosis, there is normal overall
tive pericarditis. Some patients do give a history cardiac size, but dilatation of the proximal
of previous acute pericarditis. TB is now an ascending aorta and blunt rounding of the
uncommon cause. Cancer can cause constric- lower left cardiac contour. Calcification of the
tion but is uncommon. Rheumatic fever does valve is often difficult to determine on plain
not cause pericarditis. (Fuster, pp. 1989–1991) films. Although left atrial enlargement can
occur, its presence on the CXR should raise
30. (E) The maneuvers listed increase the block and other diagnostic possibilities, such as mitral
are useful for diagnosis, but not for converting valve disease. (Fuster, p. 1647)
the atrial flutter to a sinus rhythm. Electrical
cardioversion is the method of choice in patients 35. (D) This combination, although the total cho-
who are hemodynamically unstable. Often very lesterol is borderline, has high HDL cholesterol,
low amounts of energy during cardioversion which is protective. Nevertheless, a level this
will convert atrial flutter. (Fuster, p. 844) high would likely require treatment. (Fuster,
pp. 1099–1100)
31. (C) Atrial flutter is characterized by regular
atrial activation with an atrial rate of >240 beats/ 36. (B) Besides coarctation of the aorta, aortic
min. The ventricular response depends on the occlusive disease, dissection of the aorta, and
conduction of the AV node, usually there is 2:1 abdominal aneurysm may lead to differential
or 3:1 conduction. It is now known that the pre- blood pressure in arms and legs. Coarctation is
dominant mechanism for atrial flutter is right the third most common form of congenital car-
atrial macroreentry with circular activation. diac disease. One-third of the patients will be
Atrial flutter typically originates from the right hypertensive. The femoral pulses are weak,
atrium and most often involves a large circuit delayed, and even absent. (Fuster, p. 1809)
that travels around the area of the tricuspid
valve. This type of atrial flutter is referred to as 37. (D) He likely has LVH.
typical atrial flutter. Less commonly, atrial flut- Signs include left axis deviation, high-
ter can result from circuits in other areas of the voltage QRS complexes in V5 and V6, deep S
right or left atrium. (Fuster, pp. 841–842) in V1 and V2, and prolonged QRS in the left
precordial leads. Age, orientation of the heart
32. (B) Retention of fluid is complex and not due to in the chest, and noncardiac factors make the
any one factor, however, hormones may con- ECG an imperfect tool for diagnosing or
tribute. Growth hormone does not have fluid- excluding LVH. The ECG is more accurate
retaining properties. The exact mechanisms and better for following progression or regres-
that initiate renal conservation of salt and water sion of LVH. (Fuster, pp. 311–312)
are not precisely understood, but may include
arterial volume receptors sensing a decrease in 38. (A) High urinary specific gravity, nocturia, and
the effective arterial blood volume. Aldosterone, daytime oliguria occur in addition to low uri-
renin, and vasopressin are generally increased nary sodium content in untreated CHF. These
in heart failure. (Fuster, p. 713) changes are the result of the activation of the
 Answers: 29–51 27

renin-angiotensin-aldosterone system. (Fuster, 45. (E) In mitral valve prolapse, the first heart
pp. 713–714) sound is usually preserved followed by a sys-
tolic click and late systolic murmur. The click is
39. (C) Thyroid disease may affect the heart muscle actually the most common finding. General
directly or there may be excessive sympathetic physical examination may reveal scoliosis,
stimulation. Common symptoms of thyrotoxic pectus excavatum, straightened thoracic spine,
heart disease include palpitations, exertional or narrow anteroposterior diameter of chest.
dyspnea, and worsening angina. Atrial fibril- (Fuster, p. 1698)
lation is particularly common in older individ-
uals. (Fuster, p. 827) 46. (A) The symptoms and signs are like any
sudden paroxysmal tachycardia, but the ven-
40. (D) Since the duration of atrial fibrillation is tricular rate is the clue, after carotid pressure, to
not known, it is presumed to be chronic. There the diagnosis of atrial flutter with 2:1 block.
is an increased risk of cardioembolic events if (Fuster, pp. 841–842)
restoration of sinus rhythm is attempted before
anticoagulating the patient for 3–4 weeks. 47. (C) Management of acute viral or idiopathic
Aspirin is only modestly effective in reducing pericarditis includes analgesia (usually aspirin
cardioembolic events and not the first choice. every 3–4 hours initially) and rest if the pain
Beta-blockers are not indicated since the rate is is severe. Occasionally, nonsteroidal anti-
controlled. (Fuster, pp. 833–834) inflammatory drugs (NSAIDs) are required
(e.g., ibuprofen or indomethacin). Careful
41. (B) Cotton wool spots, hemorrhage, and observation for increasing effusion and tam-
papilledema are common. Fibrinoid necrosis ponade are essential. The classic findings of
occurs on the arterioles of many organs. Earlier cardiac tamponade include arterial hypoten-
manifestations of arteriosclerosis include thick- sion and pulsus paradoxus. (Fuster, p. 1985)
ening of the vessel wall. This is manifested by
obscuring of the venous column at arterial 48. (B) Diastolic dysfunction is an important cause
crossings. (Fuster, p. 1541, 1543) of heart failure in the elderly. It is commonly
associated with a history of hypertension and
42. (A) Early atherosclerosis with tendon xan- diabetes. Normal ejection fraction and aortic
thomas, xanthelasma, and arcus senilis are sclerosis rule out either systolic or valvular
characteristics of familial hypercholesterolemia. heart disease as causes. In HOCM there is
The disorder is inherited in an autosomal dom- nonconcentric hypertrophy. (Fuster, pp. 710,
inant manner. (Fuster, pp. 236–237) 2276–2277)

43. (C) Acute pericarditis is most often idiopathic 49. (A) Acute rupture of an atherosclerotic plaque
and is typically self-limited (usually within is now recognized as the most common cause
2–6 weeks). While small effusions are common, of ST-elevation MI. Pericarditis has diffuse ST
tamponade is unusual, as are heart failure and elevation in multiple leads and aortic stenosis
constriction. Other diseases causing pericardi- does cause angina but not ST elevation.
tis should be searched for, and may influence (Fuster, p. 1226)
the prognosis. (Fuster, p. 1982)
50. (D) S. epidermidis is still the most frequent early
44. (D) Orthostatic hypotension (systolic dropping and late cause of endocarditis in patients with
by 20 mm or more) is particularly common in prosthetic heart valves. The other organisms
the elderly and in diabetics because of auto- are seen less frequently in late prosthetic valve
nomic neuropathy. Management includes endocarditis. (Fuster, pp. 2004–2005)
avoidance of precipitating factors, simple adap-
tive maneuvers, volume expansion, and phar- 51. (D) This man has acute coronary syndrome
macologic agents. (Fuster, pp. 1036–1037) (ACS) until proven otherwise. The ECG is the
28 1: Cardiology

most useful initial investigation since it identifies When this type of heart block develops, either
individuals with ST-segment elevation who may de novo or in the course of an AMI, a cardiac
be candidates for either thrombolysis or primary pacemaker is usually recommended, as the
angioplasty (PCI). The troponins are important incidence of complete heart block is high in
in diagnosing myocardial necrosis. The other this situation. (Fuster, pp. 901–903)
investigations may be important in looking for
alternate causes of chest pain once ST-elevation 57. (D) The ST is depressed in leads II, III, aVF, and
MI has been ruled out. (Fuster, pp. 1252, 1256) V4–V6. These nonspecific abnormalities do not
indicate significant coronary heart disease,
52. (C) Essential hypertension is the most likely especially in an apprehensive young patient.
diagnosis. A secondary cause for hypertension Further evaluations should be guided by clin-
is found in only 10% of patients, with 90% ical circumstances. (Fuster, pp. 304–305)
labeled as essential. Current recommendations
for initial workup of a hypertensive patient 58. (E) The underlying rhythm is a regular sinus
include serum chemistry (glucose, potassium, rhythm with a rate of 85 beats/min. The sinus
creatinine), urinalysis, and ECG. (Fuster, p. 1545) rhythm is interrupted frequently by bursts of
irregular ventricular, premature beats. The sinus
53. (C) Coarctation of the aorta is the diagnosis. rhythm is uninterrupted as can be determined
There is a reverse 3 deformity of the by plotting the PP intervals, which are regular.
esophagus, the belly of which represents the The rhythm may be termed a chaotic ven-
dilated aorta after the coarctation. The border tricular arrhythmia or ventricular tachycardia. Its
of the descending aorta shows a medial inden- gross irregularity is unusual. Antiarrhythmic
tation called the 3 or tuck sign, the belly of the therapy is usually not indicated for nonsus-
3 representing the poststenotic dilation and tained VT in the setting of thrombolytic treat-
the upper portion by the dilated subclavian ment. (Fuster, pp. 876–877)
artery and small transverse aortic arch. (Fuster,
p. 1809) 59. (A) No atrial activity is detected. The ventricu-
lar rate is slightly irregular. Beat number 4 is
54. (B) Note the abnormal humped contour of the a ventricular premature contraction. The T
left ventricular border, with a curvilinear calci- waves are tall and markedly peaked. This type
fication following the abnormal cardiac con- of T wave is characteristic of hyperkalemia, as
tour. The presence of calcification in the is absence of visible atrial activity.
ventricular wall and the abnormal left ventric- The potassium level was 8.2 mmol/L.
ular contour alerts one to the consideration of (Fuster, p. 313)
a ventricular aneurysm. (Fuster, pp. 1321–1322)
60. (A) Sudden death, defined as death within 1 hour
55. (B) The cardiac rhythm is atrial flutter with 2:1 of onset of symptoms, is usually caused by car-
AV conduction. QRS complexes occur with diac disease in middle-aged and elderly
perfect regularity at a rate of about 150/min. patients, but in younger age groups noncar-
Their normal contour and duration indicate diac causes predominate. There is a bimodal
that ventricular activation occurs normally via distribution in the population, with the first
the AV junction-His-Purkinje system. (Fuster, peak before 6 months of age (sudden infant
pp. 841–842) death syndrome). The most common coronary
artery finding is extensive chronic coronary
56. (B) The PR interval of the first two complexes atherosclerosis, although acute syndromes do
is normal at 0.20 seconds. The QRS duration is occur. (Fuster, p. 1057)
0.16 seconds. The third P wave is noncon-
ducted. This cycle recurs in the remainder of 61. (B) Over 90% of hypertensives in the general
the strip. This is second-degree heart block of population have essential hypertension. Only
the Mobitz type II variety. Note the wide QRS.
 Answers: 52–72 29

about 60% of hypertensives are very sensi- increased. Systemic vascular resistance is usu-
tive to salt. About 20% of hypertensives have ally normal. (Kasper, p. 1615)
low-renin essential hypertension. This is more
common in Blacks. Male sex, Black race, youth, 67. (A, D, E, H, I, K) In septic shock, right atrial
smoking, DM, excess alcohol ingestion, hyper- wedge pressures, and systemic vascular resist-
cholesterolemia, more severe hypertension, ance are low. PA diastolic pressure is usually
and evidence of end-organ damage are among normal or high, therefore, resulting in an
the factors that suggest a poor prognosis. increased gradient between PA diastolic and
(Kasper, pp. 1463–1464) wedge pressures. Cardiac output can be
normal or high in early sepsis. (Kasper, p. 1615)
62. (B, G, H, I) In renal impairment, potassium-
sparing diuretics can cause life-threatening 68. (C, F, G, J, K) Cardiogenic shock is character-
hyperkalemia. The characteristic findings of ized by high right atrial pressure (although it
hyperkalemia are a narrow-based, peaked T can be normal at times), high PA wedge pres-
wave in conjunction with a widened QRS com- sure, high PA diastolic pressure, high systemic
plex. Other causes of widened QRS complexes vascular resistance, and low cardiac output.
do not coexist with a narrow-peak T wave. (Kasper, p. 1615)
Also, the PR interval prolongs and the P wave
flattens with hyperkalemia. (Fuster, p. 313) 69. (A, D, E) In chronic, compensated mitral regur-
gitation, there is a holosystolic murmur, which
63. (D) With severe hypercalcemia, the QT interval starts with S1 and extends to or past the aortic
is markedly shortened. There is a correlation component of S2. The S1 is diminished, and
between the length of QT interval and the there is increased splitting of S2.
degree of hypercalcemia. (Fuster, p. 314) This condition is often tolerated for years
before symptoms develop. (Fuster, p. 1686)
64. (C) Hypokalemia results in prolongation of the
QU interval. The delayed repolarization in 70. (B, C, F) CAD is the most common cause of
hypokalemia is best expressed at QU rather acute mitral regurgitation in the United States.
than QT prolongation since it can be difficult to The murmur is often midsystolic early on, and
separate the T wave from the U wave. In severe a thrill may be present. The apex is usually
cases, the ST segments become depressed. hyperdynamic but actual forward stroke
Quinidine, even in therapeutic doses, can cause volume is usually diminished. The presenta-
similar ECG findings. This is felt to be a risk tion is usually dominated by acute pulmonary
factor for ventricular arrhythmias, including edema and occurs most often 2–7 days post-MI.
Torsades des pointes. (Fuster, p. 314) (Fuster, pp. 1680–1682)

65. (A, E, G, J) Hypovolemic shock is characterized 71. (B) ECG changes in mitral stenosis are due to
by a low cardiac output with normal or high enlargement and hypertrophy of the left atrium
systemic vascular resistance. The low right and asynchronous atrial activation.
atrial filling pressure and low PA wedge pres- The notched P wave is most prominent in
sure reflect the inadequate venous return. lead II. In lead V1, the P wave has a negative
(Kasper, p. 1615) terminal deflection. (Fuster, p. 1673)

66. (C, D, F, G, J, K) This man has a right ventric- 72. (A) A prolonged PR interval is a common find-
ular MI. Primary right ventricular failure is ing in asymptomatic elderly patients that have
characterized by a disproportionately high age-related degeneration of the AV node. Drugs
right atrial pressure with normal or high wedge such as beta-blockers (metoprolol) may exac-
pressure. The PA diastolic pressure is normal or erbate the condition or even cause PR prolon-
elevated and the gradient between PA diastolic gation in excessive doses. (Fuster, p. 901)
pressure and wedge pressure is usually
30 1: Cardiology

73. (D) In Wolff-Parkinson-White syndrome, the PR angina. Calcium channel blockers are not gen-
interval is short, the QRS is widened, and there erally used in CHF, because of their negative
is slurring of the upstroke of the R wave. The inotropic effect. However, amlodipine can be
shortened PR interval reflects faster than normal used for concurrent treatment of angina or
conduction through an accessory pathway. The hypertension. (Fuster, pp. 730–738)
ventricular complex represents a fusion beat.
The blurred upstroke of the QRS (delta wave) 81. (B) Enalapril may exert its effect by inhibiting
represents ventricular activation via the acces- formation of angiotensin II. This lowers sys-
sory pathway. The normal end portion of the temic vascular resistance. In addition, ACE
QRS represents activation via the normal route inhibitors have a natriuretic effect by inhibition
through the AV node. (Fuster, p. 865) of aldosterone secretion. They have been shown
to improve mortality and decrease hospitaliza-
74. (C) Hypercalcemia may prolong the QRS and tion in patients with CHF. (Fuster, pp. 730–738)
shorten the ST and QT intervals. Serious
arrhythmias rarely occur with hypercalcemia. 82. (F) Digoxin is a direct inotropic agent, but is
(Fuster, p. 314) usually reserved for patients who are sympto-
matic after treatment with ACE inhibitors and
75. (E) The ECG in severe aortic stenosis shows diuretics. It can be used for rate control in atrial
LVH, but is not perfectly sensitive and is not fibrillation, although beta-blockers might be
specific. Bundle branch blocks and ST-T preferred. (Fuster, p. 741)
changes can occur, but some patients have a
normal ECG. (Fuster, p. 1647) 83. (E) Long-acting nifedipine has been a useful
adjunct to the treatment of primary pulmonary
76. (C) Beta-blockers and ACE inhibitors are both hypertension, but great care must be used as
indicated in the treatment of heart failure even low doses of vasodilators can cause unto-
patients with systolic dysfunction. (Fuster, p. 729) ward reactions in patients with pulmonary
hypertension. Lung transplants have provided
77. (A) Beta-blockers have a negative inotropic a major therapeutic modality for managing
effect on the heart. Despite this they improve severe pulmonary hypertension.
survival in patients with left ventricular dys- ACE inhibitors and hydralazine have been
function and heart failure (Fuster, p. 733) tried, but are not effective. (Fuster, p. 1788)

78. (A) In chronic atrial flutter, control of ventricu- 84. (D) There are numerous potential mechanisms
lar rate is the goal of therapy. Beta-blockers, that might explain the beneficial effects of beta-
Ca2+ calcium channel blockers, and digoxin blockers in left ventricular dysfunction, and
are drugs commonly used. (Fuster, pp. 836–837) post-MI. The benefit is additive to that pro-
vided by ACE inhibitors. (Fuster, p. 733)
79. (D) Neither ACE inhibitors or beta-blockers
mediate their effects by calcium channel block- 85. (C) A hyperkinetic pulse occurs in the setting of
ade. (Brunton, pp. 272, 800) an elevated stroke volume (anemia, fever, anx-
iety) or an abnormally rapid runoff from the
80. (A, E, I, J) Hydralazine has a greater dilator arterial system (aortic regurgitation, patent
effect on arterioles than on veins, the opposite ductus arteriosus, arteriovenous fistula). (Fuster,
is true for nitrates. Combined therapy with p. 244)
hydralazine and nitrates has been shown to
reduce mortality in patients with heart failure, 86. (E) A dicrotic pulse has a peak in systole and
but not reduce hospitalization for heart failure. another in diastole. It occurs in patients with
Reflex tachycardia with hydralazine is common very low stroke volume, especially dilated car-
in patients with hypertension, but less so in diomyopathy. (Fuster, p. 244)
heart failure. Tachycardia may precipitate
 Answers: 73–101 31

87. (D) The bisferiens pulse, two systolic peaks, ventricular systole (Cannon a waves) in
occurs in HOCM and aortic regurgitation. In complete heart block or other arrhythmias.
aortic regurgitation, the bisferiens pulse can (Fuster, p. 248)
occur both in the presence or absence of aortic
stenosis. (Fuster, p. 224) 95. (E) With standing, most murmurs diminish.
The two exceptions are HOCM, which becomes
88. (A) The pulsus tardus of aortic stenosis is the louder, and mitral valve prolapse, which
result of mechanical obstruction to left ventric- becomes longer and louder. (Kasper, pp.
ular ejection and often has an accompanying 1308–1310)
thrill. The characteristic feel of the pulse is
caused by a delayed systolic peak. (Fuster, p. 244) 96. (A) With the Valsalva maneuver, most mur-
murs will decrease. The exceptions are the mur-
89. (B) Pulsus paradoxus, a drop of >10 mm Hg in murs of HOCM and mitral valve prolapse,
systolic blood pressure during inspiration, is which increase.
caused by pericardial tamponade, airway After release of the Valsalva maneuver,
obstruction, or superior vena cava obstruction. right-sided murmurs tend to return to base-
At times, the peripheral pulse may disappear line more rapidly. (Kasper, pp. 1308–1310)
completely during inspiration. (Fuster, p. 245)
97. (B) The murmur of HOCM often decreases
90. (E) Tricuspid regurgitation increases the size with submaximal isometric exercise (hand-
of the v wave. When tricuspid regurgitation grip). Murmurs across normal or obstructed
becomes severe, the combination of a promi- valves will be increased.
nent v wave and obliteration of the x descent Handgrip can also accentuate an S3 or S4.
results in a single, large, positive systolic wave. (Kasper, pp. 1308–1310)
(Fuster, p. 248)
98. (B) HOCM often has a bisferiens pulse. It can
91. (D) Right atrial myxoma, or tricuspid stenosis, also be found in pure aortic regurgitation or
will slow the y descent by obstructing right combined aortic regurgitation and aortic steno-
ventricular filling. The y descent of the JVP is sis. (Kasper, pp. 1308–1310)
produced mainly by the tricuspid valve open-
ing and the subsequent rapid inflow of blood 99. (C) This maneuver will increase the murmurs
into the right ventricle. (Fuster, p. 248) of mitral regurgitation, ventricular septal
defect, and aortic regurgitation. Other mur-
92. (C) Right ventricular infarction and constrictive murs are not affected. (Kasper, pp. 1308–1310)
pericarditis frequently result in an increase in
JVP during inspiration (Kussmaul’s sign). 100. (B) Constrictive pericarditis is characterized by
Severe right-sided failure can also be a cause. a prominent y descent of the neck veins and
(Fuster, p. 247) low voltage on ECG. The presence of a positive
Kussmaul’s sign helps differentiate the syn-
93. (F) Right-sided heart failure is the most drome from cor pulmonale and restrictive car-
common cause of a positive abdominojugular diomyopathies. (Fuster, p. 1990)
reflux (normal JVP at rest, increases during
10 seconds of firm midabdominal compression, 101. (A) Cardiac tamponade can occur with as little
and only drops when pressure is released). as 200 mL of fluid if the accumulation is rapid.
(Fuster, p. 247) Physical examination reveals a pulsus para-
doxus (>10 mm Hg inspiratory decline in sys-
94. (A) Large a waves occur with increased resist- tolic arterial pressure), a prominent x descent of
ance to filling (tricuspid stenosis, pulmonary the jugular veins, but no Kussmaul’s sign. The
hypertension) or when the right atrium con- ECG may show low voltage. (Fuster, p. 1985)
tracts against a tricuspid valve closed by right
32 1: Cardiology

102. (D) RVMI is characterized by high neck veins, Hypertension can further impair left ven-
ECG abnormalities, and often a right-sided S3. tricular function. (Kasper, p. 1424)
The low cardiac output associated with RVMI
can often be treated by volume expansion. 109. (D) The Means-Lerman scratch, a systolic
Although a third of patients with inferoposterior scratchy sound heard at the left second inter-
infarctions have some degree of right ventricu- costal space during expiration, is thought to
lar necrosis, extensive RVMI is uncommon. result from the rubbing of the hyperdynamic
(Fuster, p. 1281) pericardium against the pleura. Palpitations,
atrial fibrillation, hypertension, angina, and
103. (A) Electrical alternans (a beat-to-beat alterna- heart failure are more common cardiac mani-
tion in one or more component of the ECG festations of hyperthyroidism. (Kasper, p. 1423)
signal) can occur in pericardial effusion and
numerous other conditions. Total electrical 110. (E) DM can result in a restrictive cardiomyopa-
alternans (P-QRS-T) and sinus tachycardia is thy in the absence of large-vessel CAD.
relatively specific for pericardial effusion (often Histology reveals increased collagen, glycopro-
with tamponade). (Fuster, p. 1985) tein, triglycerides, and cholesterol in the myocar-
dial interstitium. Abnormalities may be present
104. (B) A pericardial knock is characteristic of con- in small intramural arteries. (Kasper, p. 1422)
strictive pericarditis. It is in fact an early S3,
occurring 0.06–0.12 seconds after aortic closure. 111. (D, E) Patients with diabetes have the same
S1 and S2 are frequently distant. (Fuster, p. 1990) rates of coronary heart disease events as
patients with established CAD. Therefore dia-
105. (C) The combination of absent pulsus and betes is now considered a coronary heart dis-
absent Kussmaul’s sign with prominent x ease, equivalent when assessing risk even if
descent favors a restrictive cardiomyopathy. the patient has not had any previous cardiac
Unlike constrictive pericarditis, restric- symptoms. The current guidelines support risk
tive cardiomyopathies frequently present reduction efforts (both lifestyle and drug ther-
with an enlarged heart, orthopnea, LVH, and apy) in patients with diabetes similar to those
bundle branch blocks. (Fuster, pp. 1937–1938) recommended for patients with CAD (secondary
prevention). The goal for LDL is <100 mg/dL
106. (C) The cardiac lesions of gastrointestinal car- in patients with diabetes and secondary goals
cinoids are almost exclusively in the right side include considering fibrates for those with high
of the heart and occur only when there are triglycerides and nicotinic acid for low HDL
hepatic metastases. Fibrous plaques are found cholesterol. Lifestyle modification is recom-
on the endothelium of the cardiac chambers, mended for everyone irrespective of risk.
valves, and great vessels. These plaques can (Kasper, pp. 1430–1433)
distort cardiac valves; tricuspid regurgitation
and pulmonic stenosis are the most common 112. (E) When assessing patients for cardiovascular
valvular problems. (Kasper, pp. 1423–1424) risk, it is always important to consider recom-
mendations in light of their risk level. For pri-
107. (B) The proximal aortitis of seronegative arthri- mary prevention (no known symptomatic
tis (ankylosing spondylitis, Reiter syndrome, CAD), there are risk calculators available to
psoriatic arthritis, or associated with inflam- estimate an individual’s future risk (see
matory bowel disease) can result in aortic http://www.nhlbi.nih.gov/guidelines/cholesterol/ for
regurgitation and AV block. (Kasper, p. 1424) a risk calculator based on the Framingham
database). The treatment recommendations
108. (A) Focal myocardial necrosis and inflamma- and goals should match the patient’s risk level.
tory cell infiltration caused by high circulating In this individual, she has no risk factors for
levels of catecholamines are seen in about 50% CAD and her 10-year risk for cardiovascular
of patients who die with pheochromocytoma. events is low. The goals for LDL in her are
 Answers: 102–119 33

<160 mg/dL, and drug therapy should be only recommending estrogen therapy to lower car-
considered if her LDL >190 mg/dL. For her, diovascular risk in postmenopausal women.
the best advice is lifestyle modification such as Recently two large randomized clinical trials
dietary modification, exercise, and weight loss have shown no benefit with estrogen replace-
if indicated since these changes will lower ment in postmenopausal women as a means of
triglycerides, raise HDL, and lower LDL. reducing cardiovascular risk. With this evi-
Repeat screening is recommended every 5 years. dence, estrogen replacement is not recom-
(Kasper, pp. 1430–1433) mended for cardiac risk modification, and is
only indicated to treat the symptoms of
113. (D, E) For patients with established CAD, their menopause. For postmenopausal women at
future risk for further cardiovascular events is increased risk of cardiac disease, statins are
high (10-year risk >20%). In such individuals, considered first-line therapy in modifying risk
the goals of LDL level are adjusted lower to since there are randomized trial data from mul-
match the increased risk. For secondary preven- tiple trials supporting their effectiveness in
tion, the LDL level target is <100 mg/dL. For all women. Since this patient has only one risk
individuals at increased risk-lifestyle modifica- factor her future 10-year risk is low (<10%) and
tion is stressed as a key component therapy. In lifestyle modification is the best advice. She
this patient given, the recent diagnosis of CAD will require follow-up lipid risk assessment in
and the elevated LDL level treatment with a 5 years. (Kasper, pp. 1430–1433)
“statin” is also indicated. (Kasper, pp. 1430–1433)
117. (G) ACE inhibitors have no adverse effects on
114. (D, E) Recent evidence has suggested that lipid glucose or lipid metabolism and minimize the
modification for patients with ischemic stroke development of diabetic nephropathy by
(that is not cardioembolic in origin) by lower- reducing renal vascular resistance and renal
ing LDL level with statins is beneficial in reduc- perfusion pressure. The goal for blood pres-
ing future stroke risk. This evidence comes sure control in diabetics is set at 130/80 mm Hg
from the analysis of cardiovascular statin trials which is lower than in nondiabetics. This lower
that have a lower rate of ischemic strokes in pressure is important in preventing progres-
patients taking the medication as compared to sion of renal disease and other end-organ
the placebo group. In addition, lifestyle modi- damage. (Kasper, p. 1479)
fication is important for this individual espe-
cially smoking cessation. (Kasper, pp. 1430–1433) 118. (A) Thiazides have been a cornerstone in most
trials of antihypertensive therapy. Their
115. (D, E) The metabolic syndrome is frequently adverse metabolic consequences include renal
identified among individuals given the increas- potassium loss leading to hypokalemia, hype-
ing rates of obesity and diabetes in Western ruricemia from uric acid retention, carbohy-
society. This individual has multiple athero- drate intolerance, and hyperlipidemia. The
genic risk factors (obesity, hypertension, current U.S. Joint National Committee (JNC-7)
increased LDL) and his 10-year risk for cardiac guidelines suggest starting with thiazide
events is approximated at 10–20% by the risk diuretics because of their proven efficacy in
calculator. At this risk level, the LDL goal is lowering mortality and morbidity in large clin-
<130 mg/dL and treatment threshold for ical trials. Other agents are considered if there
starting drug therapy is >130 mg/dL. As are comorbidities such as diabetes or CAD.
well lifestyle modification is an important (Kasper, pp. 1472, 1478)
component of the overall treatment. (Kasper,
pp. 1430–1433) 119. (G) Although contraindicated in bilateral
stenosis, ACE inhibitors are the drug of choice
116. (E) Many observational studies have verified in unilateral renal artery stenosis.
the increased risk of CAD in women after When ACE inhibitors are used in
menopause, and this formed the basis for patients with impaired renal function, renal
34 1: Cardiology

function should be monitored twice a week for treatment is a blood pressure of 140/90 mm
for the first 3 weeks. (Kasper, p. 1479) Hg. (Kasper, pp. 1471, 1480)

120. (A) Thiazides seem to work particularly well in 121. (E) Beta-blockers are the most appropriate
Blacks and the elderly. Younger individuals and choice for the treatment of hypertension in
Whites respond well to beta-blockers, ACE patients with CAD. They lower mortality in
inhibitors, and calcium channel antagonists. patients with CAD as well as hypertension.
Isolated systolic hypertension is a common ACE inhibitors can also be used, especially if
occurance in the elderly. It is due to arterioscle- there is left ventricular dysfunction, or the
rosis of the large arteries. Treatment of isolated patient has multiple cardiovascular risk factors
systolic hypertension with low-dose thiazides such as diabetes or dyslipidemia. (Kasper, p. 1479)
results in lower stroke rates and death. The goal
 CHAPTER 2

Skin
Questions

DIRECTIONS (Questions 1 through 5): Each set of Questions 3 through 5

matching questions in this section consists of a list
(A) rarely involves border of scalp
of lettered options followed by several numbered
items. For each numbered item, select the appro- (B) discoloration of upper eyelids
priate lettered option(s). Each lettered option may (C) skin atrophy
be selected once, more than once, or not at all. (D) never a permanent effect on skin
EACH ITEM WILL STATE THE NUMBER OF (E) potentially aggravated by contact
OPTIONS TO SELECT. CHOOSE EXACTLY with the skin
THIS NUMBER. (F) drop-shaped lesions
(G) exacerbated by exposure to light
Questions 1 and 2 (H) worse on weekends
(A) psoriasis (I) high likelihood of malingering
(B) eczema (J) associated with squamous cell cancer
(C) hypersensitivity reactions (K) extensive large plaques
(D) lichen planus (L) pitting of the nails
(E) toxic erythemas (M) lesions at various stages (progression
of lesions)
(F) lichen planus
(G) Kaposi sarcoma
For each patient, select the associated skin and
(H) melanotic nodules clinical findings.
(I) maculopapular rash
(J) serum-filled bullae
3. A diagnosis of psoriasis, never previously
treated, is made on a 22-year-old man. Findings
For each patient with a skin lesion, select the most
may include (SELECT THREE)
likely diagnosis.
4. A 63-year-old woman develops skin lesions,
1. A 19-year-old man develops new lesions at the and difficulty getting out of a chair. A clinical
sites of skin trauma. The lesions appear as diagnosis of dermatomyositis is made. Finding
sharply marginated erythematous papules may include (SELECT THREE)
with silvery-white scales. (SELECT ONE)
5. A 43-year-old woman develops a rash on her
2. A 32-year-old man with human immunodefi- arms and hands after starting a new job in a
ciency virus (HIV) infection develops skin factory. The lesions have well-demarcated ery-
tumors and patches on the legs with some on thema and edema with superimposed closely
the face. They are palpable, firm, and appear spaced vesicles and papules. Findings might
violaceous with some nodules appearing include (SELECT ONE)
purple brownish. (SELECT ONE)

35

Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use.
36 2: Skin

DIRECTIONS (Questions 6 through 21): Each of 8. A 85-year-old woman has large blistering
the numbered items in this section is followed by lesions on the abdomen and thighs that come
answers. Select the ONE lettered answer that is and go without therapy. Nikolsky’s sign is neg-
BEST in each case. ative. Which of the following is the most likely
diagnosis? (See Fig. 2–2.)
6. A 19-year-old woman with asthma has a (A) pemphigus vulgaris (PV)
chronic rash with distribution on her hands, (B) dermatitis herpetiformis (DH)
neck, and elbow creases. It is very itchy, and the (C) bullous pemphigoid
skin appears thickened with increased skin
(D) herpes gestationis
markings. There are some areas of fissures in
the skin at the elbow creases and hands. Which (E) erythema multiforme
of the following is the most appropriate advice?
(See Fig. 2–1.)
(A) psychoanalysis
(B) warm clothing
(C) dry environment
(D) environmental manipulation
(E) vigorous exercise

Figure 2–2.

Figure 2–1.

9. A 69-year-old woman develops dark, velvety

pigmentation in her axillae. She has noticed
7. A 74-year-old man develops a new single
10 lb weight loss over the past 3 months with
1.5 cm lesion on his face. It is firm and nodular
heartburn and early satiety. She notices no
with a dome shape and central keratotic plug.
other symptoms. Which of the following
Excisional biopsy confirms keratoacanthoma.
conditions should she be studied for? (See
Which of the following best characterizes this
Fig. 2–3.)
lesion?
(A) a visceral carcinoma
(A) rapid growth
(B) lymphoma
(B) distinct pathology
(C) diabetes mellitus
(C) usual occurrence on the trunk
(D) sarcoidosis
(D) a malignant potential
(E) an allergy
(E) a dark brown color
 Questions: 6–14 37

12. A 27-year-old man develops warts on his hand.

Which of the following is a correct statement
concerning these skin lesions?
(A) are viral in etiology
(B) may be premalignant lesions
(C) are found mainly in patients with
lymphoma
(D) are contagious in children only
(E) may be treated with griseofulvin

13. A 27-year-old man develops a painless 1 cm

sore on his penis. It appears ulcerated with a
raised margin and minimal serous exudates.
Which of the following is the most appropriate
next step in the diagnosis? (See Fig. 2–4.)
(A) biopsy
(B) Gram stain
(C) serology
(D) ultrasound
Figure 2–3. (E) skin test
(Reproduced, with permission, from Wolff K and
Johnson RA, Fitzpatrick’s Color Atlas & Synopsis
of Clinical Dermatology, 5th ed. New York: 14. A 64-year-old woman notices bullous-type
McGraw-Hill, 2005:87.) lesions over her thighs and axilla. They are
itchy, but not painful, and she has no other
10. A 22-year-old woman develops an acute con- symptoms. On examination, there are large
tact dermatitis to a household-cleaning agent. tense, serous-filled bullae on the affected areas.
Which of the following treatments is most A biopsy confirms the diagnosis of bullous
appropriate during the bullous, oozing stage? pemphigoid. Which of the following histologic
features is typical of this condition?
(A) wet dressings
(A) nonspecific changes
(B) systemic corticosteroids
(B) immunoglobulin A (IgA) deposits
(C) topical anesthetics
(C) lesions within the epidermis
(D) systemic antibiotics
(acantholysis)
(E) antihistamines
(D) basement membrane lesions
11. Which of the following is a characteristic of (E) immunoglobulin M (IgM) deposits.
ringworm of the scalp as compared with other
dermatophytoses?
(A) more frequent occurrence in childhood
(B) high degree of contagiousness
(C) ability to invade the dermis
(D) sensitivity to penicillin
(E) ability to spread to other organs
38 2: Skin

Figure 2–4.
(Reproduced, with permission, from Wolff K and Johnson RA, Fitzpatrick’s Color Atlas &
Synopsis of Clinical Dermatology, 5th ed. New York: McGraw-Hill, 2005:915.)

15. A 27-year-old woman has a 1-year history of

loosely formed bowel movements associated
with some blood and abdominal pain. She
develops multiple painful erythematous nod-
ules on her lower legs. Which of the following
is the most likely diagnosis? (See Fig. 2–5.)
(A) erythema multiforme
(B) erythema migrans
(C) erythema nodosum
(D) cutaneous lymphoma
(E) necrobiosis lipoidica

16. Which of the following best describes mycosis

fungoides?
(A) fungal infection of the epidermis
(B) benign skin lesion
(C) cutaneous lymphoma
(D) dermatitis
(E) form of eczema

Figure 2–5.
(Reproduced, with permission, from Wolff K and
Johnson RA, Fitzpatrick’s Color Atlas & Synopsis of
Clinical Dermatology, 5th ed. New York: McGraw-Hill,
2005:149.)
 Questions: 15–21 39

17. A 58-year-old man complains of an enlarged, 19. A 70-year-old man develops multiple pruritic
pitted nose, and a facial rash that “flushes” in skin lesions and bullae mostly in the axillae
response to drinking hot liquids or alcohol. The and around the medial aspects of his groin and
rash is on both cheeks, and it is red and flushed thighs. There are some lesions on his forearms
in appearance, with some telangiectatica and and on his lower legs (first appeared in this
small papules. Which of the following is the location), and moderately painful oral lesions.
most likely diagnosis? (See Fig. 2–6.) Nikolsky’s sign is negative. There is no eye
involvement. Which of the following is the
(A) acne vulgaris
most likely diagnosis?
(B) pemphigus
(C) rosacea (A) dermatitis herpetiformis (DH)
(D) psoriasis (B) pemphigus vulgaris (PV)
(E) seborrheic dermatitis (C) bullous pemphigoid
(D) cicatricial pemphigoid
(E) epidermolysis bullosa (EB)

20. A man presents with bullous lesions on his

face, armpit, and chest. He initially had them
only in his mouth. They appear round and oval
with serous fluid and some are “flabby.” When
pressure is applied to the lesion the fluid
spreads laterally. A clinical diagnosis of pem-
phigus vulgaris (PV) is made. Which of the fol-
lowing is the usual age of onset for this
condition? (See Fig. 2–7.)
(A) under 10 years of age
(B) 10–20 years of age
(C) 20–40 years of age
(D) 40–60 years of age
(E) 60–80 years of age

21. Which of the following is the most likely drug

to cause pemphigus vulgaris (PV)?
(A) captopril
Figure 2–6.
(Reproduced, with permission, from Wolff K and (B) D-penicillamine
Johnson RA, Fitzpatrick’s Color Atlas &
(C) sulfonamides
Synopsis of Clinical Dermatology, 5th ed. New
York: McGraw-Hill, 2005:11.) (D) hydralazine
(E) quinidine
18. A 81-year-old man presents with pallor, glos-
sitis, cheilitis, and vitiligo. Which of the fol-
lowing is the most likely diagnosis?
(A) sickle cell anemia
(B) cold agglutinin syndrome
(C) methemoglobinemia
(D) pernicious anemia
(E) polycythemia
40 2: Skin

Figure 2–7.
(Reproduced, with permission, from Wolff K and Johnson RA, Fitzpatrick’s Color Atlas & Synopsis of
Clinical Dermatology, 5th ed. New York: McGraw-Hill, 2005:104.)

DIRECTIONS (Questions 22 through 28): Each set (G) neural tumors most frequently appear
of matching questions in this section consists of a during old age
list of lettered options followed by several num- (H) multiple neural tumors
bered items. For each numbered item, select the
appropriate lettered option(s). Each lettered For each patient with a skin lesion, select the most
option may be selected once, more than once, or common associated features.
not at all. EACH ITEM WILL STATE THE NUM-
BER OF OPTIONS TO SELECT. CHOOSE
EXACTLY THIS NUMBER. 22. A young child is found to have axillary freck-
ling. The lesions appear light brown with sharp
margination and are of variable size from small
Questions 22 and 23 tiny “freckle”-like macules to larger patches.
(A) other areas of skin pigmentation Other characteristics of this disorder include
(SELECT THREE)
(B) associated with adenocarcinoma
(C) autosomal dominant inheritance 23. A 68-year-old woman develops grayish-brown,
(D) insulin resistance thickened skin in the axillae. Examination
(E) viral etiology shows increased pigmentation, with accentu-
(F) adenocarcinoma ated skin lines and the skin appears “dirty.”
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