PANCE/PANRE Review: Cardiovascular System Questions & Answers

1. A 52-year-old male with a history of stable angina presents complaining of substernal chest pain for the past 4 hours. He is also nauseous and diaphoretic. He took 2 sublingual nitroglycerin tablets without relief. Which of the following would best confirm the suspected diagnosis? a. ST segment depressions b. elevated troponin I c. elevated CK-MB d. elevated homocysteine

e. echocardiography Troponin is elevated between 4 and 6 hours after the onset of an acute myocardial infarction (MI). It is the most sensitive and specific diagnostic study to confirm myocardial infarction; level remain elevated for 5-7 days. CK-MB will also rise within 4-6 hours of an infarction but is less specific than troponin; however, CK-MB normalizes within 24 hours and is, therefore, more helpful in evaluating suspected re-infarction. Echocardiography is helpful in assessing wall function and valves but will not diagnose an MI. Answer: B 2. An 81-year-old male presents complaining of substernal chest pain X 1 hour. Blood pressure is 148/90. ECG demonstrates 3 mm ST-segment elevation in leads I and V1-V4. Medications include sildenafil (last dose yesterday). Which of the following is the preferred treatment? a. angioplasty with stenting b. coronary artery bypass surgery (CABG) c. sodium nitroprusside d. recombinant tissue plasminogen activator (tPA) The ECG changes indicate an acute MI. Recanalization therapy (percutaneous coronary intervention) is associated with the best outcomes if it is able to be completed within 90 minutes of presentation. Studies have shown that, whenever possible, recanalization results in less residual ischemia and recurrent infarction than thrombolysis. CABG is most appropriate for patients with high risk and have failed other

interventions or to treat multi-vessel disease. Nitrates should be avoided in patients who have taken phosphodiesterase inhibitors (i.e. sildenafil, vardenafil, tadalafil) within the last 24 hours. Answer: A 3. A 62-year-old post-menopausal woman describes three episodes of substernal chest pain which occurred during periods of exercise; each episode lasted 5 minutes and was relieved with rest. Resting ECG is normal. What is the next best diagnostic approach for this patient at this time? a. coronary angiography b. echocardiography c. pharmacologic stress testing d. treadmill exercise stress testing

e. cardiac MRI An exercise stress test is indicated to replicate the symptoms and observe for ECG changes indicating ischemia. Pharmacologic stress testing is indicated for patients who cannot tolerate exercise. Coronary angiography is an invasive procedure; it is reserved for very severe presentations or after non-invasive testing is completed and further evaluation is needed such as planning for recanalization. Echocardiography is especially useful to detect cardiac anatomical and mechanical abnormalities but not useful for detecting ischemia. An MRI with gadolinium combined with pharmacological stress testing will demonstrate perfusion status but is less specific than an exercise stress test; it is best used to assess myocardial fibrosis. Answer: D 4. A 68-year-old female with no significant past medical history presents complaining of acute, substernal chest pain that began at rest. It lasted 20 minutes and was relieved with nitroglycerin provided by the emergency providers. ECG and troponin levels are normal. What is the most likely diagnosis? a. acute myocardial infarction b. pericarditis c. aortic dissection d. unstable angina Acute myocardial infarction (MI) is defined as evidence of ischemia (symptoms, ECG changes or new Q waves) with a rise of cardiac biomarkers above the 90th percentile. Troponin is the most sensitive cardiac biomarker. By definition, unstable angina occurs at rest, lasts 15-30 minutes, and is very likely relieved by nitroglycerin. The pain of pericarditis is usually pleuritic in nature and not typically responsive to nitroglycerin. The

pain of aortic dissection is tearing and progressive and will not be relieved by nitroglycerin. Answer: D 5. A 25-year-old male with a history of Marfan syndrome presents for annual follow-up for pulmonic regurgitation. Which of the following will provide the most useful information? a. cardiac catheterization b. chest radiography c. echocardiography d. electrocardiography Echocardiography, especially when enhanced with colorflow Doppler, will best illustrate the presence and severity of pulmonic regurgitation. Chest x-ray may show an enlarged right ventricle; it is not specific enough to evaluate pulmonary regurgitation. ECG typically shows right bundle branch block (RBBB) and right axis deviation in more severe cases of Marfan but would not help evaluate the pulmonic regurgitation. Cardiac catheterization is generally unnecessary to evaluate pulmonary regurgitation because of the high correlation with echocardiographic data in pulmonic valve disease. Answer: C 6. A 46-year-old female presents for a routine checkup without complaints; this is her first office visit in over 25 years. Cardiac exam reveals a right ventricular lift, a III/VI systolic ejection murmur, and a widely split S2 that does not vary with breathing. What

is the most likely cause of these findings? a. aortic stenosis b. atrial septal defect c. mitral regurgitation d. ventricular septal defect This is a classic presentation for uncorrected atrial septal defect (ASD); symptoms are due to left to right shunting across the atrial septal defect. Most ventricular septal defects are diagnosed in childhood although very small VSDs may escape diagnosis; patients are generally asymptomatic. Mitral regurgitation results in a large apical impulse and left-sided heart enlargement; no splitting is present. Aortic stenosis is usually seen in older patients. Findings are related to the left ventricle and may include a palpable LV heave/thrill or a weak/absent aortic sound, or reversed splitting of the second heart sound. Answer: B

7. A 76-year-old female with a history of surgically repaired tricuspid stenosis presents complaining of swollen ankles and abdominal discomfort for the past week. Which of the following would most likely be found on exam? a. delayed and diminished carotid pulse b. elevated diastolic blood pressure c. hepatomegaly and ascites d. periorbital edema Surgical valvuloplasty often results in tricuspid regurgitation which leads to right ventricular failure which is characterized by hepatomegaly, ascites, and dependent edema. The tricuspid valve has no effect on peripheral blood pressure readings. Periorbital edema is not commonly found in tricuspid stenosis; it is more commonly seen in renal failure. Delayed and diminished carotid pulses are associated with aortic stenosis.

Answer: C 8. A 78-year-old female with a history of untreated rheumatic fever as a child presents with complaints of dyspnea, fatigue and shortness of breath. A new murmur that is low-pitched, mid-diastolic and heard best at the apex is noted on cardiac auscultation. Which valve is most likely abnormal? a. aortic b. mitral c. pulmonic d. tricuspid This murmur is suggestive of mitral stenosis and the majority of acquired cases of mitral stenosis are attributed to rheumatic heart disease. The mitral valve alone is affected in 50-60% of all cases of valvular disease resulting from rheumatic fever. The aortic valve is involved concurrently in 20% of patients. The aortic valve is rarely affected alone. The tricuspid valve is involved in about 10% of all cases of rheumatic heart disease; it is more likely seen in injection drug users. The pulmonary valve is rarely affected in rheumatic heart disease. Answer: B 9. A 63-year-old female presents complaining of sudden onset of pain and paresthesia in her left leg that began 30 minutes ago. Physical exam reveals an irregularly irregular rhythm, as well as a cool, pale left leg and an absent left pedal pulse. What is the initial management? a. direct cardioversion

b. emergency embolectomy c. heparin administration d. immediate dialysis

e. intra-arterial thrombolysis The risk of emboli arising from the atrial appendage secondary to atrial fibrillation is very high. Cardioversion may be eventually attempted, but it is not the primary intervention in the setting of an acute emboli. IV heparin sodium should be given as soon as the diagnosis of acute arterial occlusion is made to help prevent clot propagation. Percutaneous catheters and/or open surgical procedures are indicated once heparin is administered. Although myoglobinuria and rhabdomyolysis may occur with acute arterial occlusion, dialysis is not always indicated, and should be deferred until needed. Answer: C 10. A 65-year-old female presents complaining of headache, scalp tenderness and jaw claudication. Lab values reveal a mildly elevated WBC, normal H&H, and an ESR of 115 mm/h. What is the treatment of choice? a. aspirin b. heparin c. prednisone d. coumadin

e. sumatriptan Immediate administration of 60 mg/d of prednisone should be given to reduce the risk of blindness associated with giant cell arteritis. Therapy should continue for at least one month before tapering. Low dose aspiring (ASA, 81 mg) may be added to prednisone in the treatment of giant cell (temporal) arteritis, but is not adequate if given alone. Heparin or coumadin is not indicated in this inflammatory vascular disease. Answer: C . 11. A 45-year-old male with no significant past medical history is being evaluated for new onset hypertension. He reports a 6 month history of recurrent spells of tachycardia, headache, diaphoresis, pallor, and anxiety. A 24 hour urine specimen reveals a metanephrine level that is two times the normal value. What is the most likely diagnosis? a. alcohol withdrawal b. primary hypertension c. Cushing's syndrome d. pheochromocytoma

e. acute intermittent porphyria This is a classic presentation of pheochromocytoma which is a rare, catecholamine-secreting tumor that may precipitate life-threatening hypertension. Primary hypertension should not be the initial diagnosis in light of the presence of associated symptoms which point to a secondary cause (tachycardia episodes, headache, diaphoresis, anxiety). Acute porphyria is caused by a deficiency of enzymes in the heme production pathway; individuals present with abdominal pain, neuropathy, autonomic instability and psychosis. Alcohol withdrawal can mimic these symptoms, but patients have a history of chronic alcohol use and typically show sign of liver insufficiency (jaundice, ascites, caput medusa, spider angioma). Cushing's syndrome presents with moon facies, truncal obesity, buffalo hump, striae, hypertension, osteoporosis, decreased glucose tolerance and proximal muscle weakness; the course is progressive, not intermittent or recurrent cycles. Answer: D 12. A 65-year-old male with a BP of 250/150, confusion, and severe hypertensive retinopathy has a non-focal neurologic exam and leukoencephalopathy on CT scanning. Intravenous sodium nitroprusside is initiated. Which of the following represents the correct target rate for blood pressure control in this patient? a. lower blood pressure to a systolic BP of 130 mmHg within five hours b. lower blood pressure to a systolic BP of 170 mmHg within the first hour c. lower blood pressure to a systolic BP of 210 mmHg within the first hour d. lower blood pressure to a systolic BP of 225 mmHg within five hours In most hypertensive emergencies, the goal of parenteral therapy is to achieve a controlled and gradual lowering of blood pressure. A good rule of thumb is to lower the initially elevated arterial pressure by no more than 25% in the first 1-2 hours towards a target blood pressure of about 160/100 mm Hg by 2-6 hours. Answer: C 13. A 22-year-old asymptomatic male with known ventricular septal defect presents for a routine check-up. Which of the following findings would be expected on ECG? a. bilateral atrial enlargement b. normal ECG c. right axis deviation d. tachycardia Most adults with a small VSD (asymptomatic) have normal ECGs and CXRs. Evidence

of left or right atrial enlargement is only found in approximately 25% of patients with asymptomatic ventricular septal defect (VSD). Right axis deviation commonly results from right ventricular hypertrophy (RVH); RVH is usually not found with a small asymptomatic VSd. Elevated heart rate is usually associated with symptoms of heart failure or pulmonary hypertension; this patient is asymptomatic. Answer: B 14. Spontaneous superficial thrombophlebitis most commonly involves what vein? a. femoral b. greater saphenous c. posterior tibial d. small saphenous

e. iliac Spontaneous superficial thrombophlebitis most commonly involves the greater saphenous vein. Answer: B 15. A 43-year-old complains of dull pain in the lower thigh. Exam reveals linear erythema and tenderness along the lower medial aspect of the thigh. There is no palpable cord. She is afebrile; blood pressure is 110/70. What is the recommended management? a. antibiotics b. heparin therapy c. local heat and NSAIDs d. sclerotherapy The recommended management of superficial thrombophlebitis is local heat and NSAIDs. Heparin therapy would be warranted if a deep venous thrombophlebitis was suspected. Antibiotics would be needed if there was an infection; this patient does not have fever, chills, or throbbing pain. Sclerotherapy is an option for small tortuous varicose veins but not phlebitis. Answer: C 16. A 23-year-old female presents with chest pain that worsens with inspiration; she also describes symptoms of migratory polyarthritis. Exam reveals a temperature of 100.0F, a friction rub, and a scattered crescent-shaped macular rash on the trunk. Which of the following is most likely in this patient's history?

a. embedded tick bite b. excessive aspirin intake c. exposure to tuberculosis d. recent pharyngitis This patient fits the description of acute rheumatic fever which is a nonsuppurative sequelae of a streptococcal infection. Aspirin is a treatment for rheumatic fever, not a cause. Lyme disease presents with bulls-eye or crescent skin lesions, myalgias, and arthralgias but the pain is not typically migratory. Tuberculosis is a rare cause of pericarditis; when it occurs it is more likely present with other signs of tuberculosis and not a stand-alone finding. Answer: D 17. A 33-year-old complains of a racing heart. Each episode begins and ends abruptly, lasting 5-10 minutes. Holter monitor records three episodes of tachycardia; during episodes, the P waves are embedded within narrow QRS complexes. What is the most likely diagnosis? a. atrial fibrillation b. Lown-Ganong-Levine syndrome c. paroxysmal supraventricular tachycardia (PSVT) d. Wolf-Parkinson-White syndrome (WPW) PSVT abruptly starts and ends and manifests with embedded P waves within narrow QRS complexes. WPW displays a short PR interval and a delta wave. Lown-Ganong-Levine syndrome has short PR intervals and normal QRS complexes. Atrial fibrillation causes erratic disorganized atrial activity with discrete QRS complexes. Answer: C 18. A 55-year-old male presents to the emergency room with substernal chest pain without dyspnea. The pain is relieved by sitting and leaning forward. He was discharged 2 weeks ago following a mild anterolateral myocardial infarction (MI). He is currently on a beta-blocker and daily aspirin. BP is 112/80; pulse is 88. What is expected on ECG? a. diffuse ST segment depression b. diffuse ST segment elevation c. peaked T waves d. varied morphology of p waves Diffuse ST segment elevations are associated with pericarditis. This patient likely has

Dressler's syndrome (post infarction syndrome). As the inflammation resolves with NSAIDs, the ST segment will return to baseline and T waves may invert. Diffuse ST segment depression is associated with ischemia. Peaked T waves are associated with hyperkalemia. Varied p wave morphology is associated with multifocal atrial tachycardia which is most commonly seen in patient with COPD. Answer: B 19. A 54-year-old male presents with dyspnea, fatigue and pedal edema. A myocardial biopsy confirms the diagnosis of amyloidosis. What is the most likely cause of his symptoms? a. acute rheumatic fever b. constrictive pericarditis c. hypertrophic cardiomyopathy d. restrictive cardiomyopathy Amyloidosis is the most common cause of restrictive cardiomyopathy. Acute rheumatic fever (ARF) presents with similar symptoms, but affects mitral and aortic valves; it does not require biopsy for diagnosis, and is not associated with amyloidosis. Constrictive pericarditis also causes dyspnea, fatigue and edema, but is not associated with amyloidosis. Hypertrophic cardiomyopathy is diagnosed by echocardiography and MRI; biopsy is not needed. Answer: D 20. A 38-year-old female is discharged after a 2-day hospital stay for a successful vaginal delivery. She presents two days later complaining of warmth, erythema and pain in her left antecubital fossa. Which of the following is the most likely diagnosis? a. chronic venous insufficiency b. malignant abscess c. nodular fibrositis d. superficial venous thrombophlebitis Superficial venous thrombophlebitis is most commonly associated with short term venous access, such as IVs. Lesions of chronic venous insufficiency are rarely warm or red; they are more likely to be dark and dusky. Abscesses have extreme, localized pain, and are not usually associated with IV sites. Nodular fibrositis is very rare and not usually associated with IV sites. Answer: D

21. A 68-year-old asymptomatic male with a history of hypertension and a 40 pack-year smoking history presents for his annual physical. Abdominal exam reveals a 5 cm pulsatile mass. What is the recommended next step? a. immediate surgical referral (today) b. lifestyle changes x 6 months c. refer for imaging and vascular studies d. watchful waiting; no additional care at this time Any patient with >4 cm pulsatile mass should be referred for further studies; abdominal aortic aneurysm is the most likely cause. Urgent referral is indicated if the patient has abdominal/back pain at the time of presentation. Lifestyle changes do not improve the prognosis of an abdominal aneurysm. Answer: C 22. A 68-year-old is admitted with an acute myocardial infarction (MI). Day 2, he exhibits an acute onset of ventricular tachycardia (VT) while on telemetry monitoring in the CCU. He denies symptoms and his vitals are stable. Which of the following is the preferred treatment? a. amiodarone b. atropine c. defibrillation d. implantable cardioverter-defibrillator (ICD) Amiodarone is a first line pharmacologic agent for VT with a pulse. Recurrence risk is high in patients with symptomatic or sustained VT without a reversible cause (i.e. acute MI, ischemia, electrolyte abnormality, etc.). If there is also significant left ventricle dysfunction, sudden death is common; the patient should be treated with an implantable cardioverter defibrillator (ICD). Atropine is used to increase heart rate. Defibrillation is used to treat V-fib in a pulseless patient. Answer: A 23. A 52-year-old female with a history of breast cancer presents with dyspnea and cough x 1 week. Physical exam reveals respirations at 24/min, heart rate 118 bpm, and a narrow pulse pressure. Lungs are clear. What additional finding on the physical exam would best support the most likely diagnosis? a. bisferins pulse b. elevated systolic blood pressure c. fever > 102 F d. pulsus paradoxus

Pulsus paradoxus is the classic finding associated with tamponade where the palpable pulse varies in amplitude/intensity due to the fluid surrounding the heart. Blood pressure in tamponade is usually normal, but may be low if shock is present. Tamponade is not an infectious process and rarely results in fever. Bisferins pulse (two strong systolic peaks with a midsystolic trough) is associated with aortic regurgitation and hypertrophic obstructive cardiomyopathy. Answer: D 24. A 23-year-old anxious female presents with new onset chest pain and palpitations occurring intermittently over the past 10 hours. Physical exam reveals a mid-systolic click. ECG is normal. What study will best confirm the most likely diagnosis? a. CT of the heart b. echocardiography c. exercise stress test d. MRI of the heart Echocardiography is inexpensive and non-invasive; it is excellent for diagnosing all types of valvular disorders. An exercise stress test would not provide any more information than the ECG in this case. CT is helpful to delineate aortic root disease, after echocardiography confirms the diagnosis. MRI is too costly and should not be ordered in this initial stage of diagnosis. Answer: B 25. A 55-year-old male smoker with no significant past medical history presents complaining of severe, cramping bilateral calf pain that occurs after walking 2 blocks. The pain is relieved after 5 minutes of rest. Which of the following treatment plans would best alleviate his symptoms? a. antiplatelet therapy b. smoking cessation and walking c. warfarin therapy d. weight loss and sodium restriction Smoking cessation and walking are the treatments of choice in early peripheral vascular disease. Antiplatelet agents may reduce cardiovascular mortality, but will not reduce symptoms. While weight loss and sodium restriction help reduce overall cardiovascular risk factors, but they may not alleviate his current symptoms. Answer: B

26. A 55-year-old male smoker with no significant past medical history presents complaining of severe, cramping bilateral calf pain that occurs after walking 2 blocks. The pain is relieved after 5 minutes of rest. What is the initial diagnostic test? a. ankle-brachial index (ABI) b. electrocardiography c. magnetic resonance angiography (MRA) d. x-ray of lower extremities Intermittent claudication indicates arterial disease. The ABI will demonstrate restricted arterial flow in the lower extremities. MRA is an expensive test; it is reserved for symptomatic patients with confirmed severe peripheral vascular disease to aid in planning surgical intervention. ECG evaluates electrical activity of the heart only. X-rays will not assess vascular disease. Answer: A 27. A 79-year-old male presents after experiencing two separate syncopal episodes. Each occurred when moving from a sitting to standing position. Which of the following tests would best help diagnose the cause of his syncope? a. cardiac catheterization b. chest x-ray (CXR) c. electrophysiologic studies d. tilt-table testing Tilt-table testing is the recommended test for new onset syncope associated with positional changes. Electrophysiologic studies (EPS) may be needed in the future, but not initially. Cardiac catheterization is too invasive and costly for an initial study. CXR does not help with cardiac conduction disorders. Answer: D 28. A 33-year-old female presents complaining of intermittent palpitations x 2 days. The ECG demonstrates paroxysmal supraventricular tachycardia. BP is 128/80, pulse is 126; the patient is in no distress. What is the initial treatment of choice to interrupt this abnormal conduction? a. electrical defibrillation b. hyperventilation techniques c. synchronized cardioversion d. Valsalva maneuver

Vagal maneuvers (such as Valsalva, cough, face in cold water, etc.), are recommend as initial treatments for PSVT in a stable patient. Synchronized cardioversion is indicated in unstable patients in paroxysmal supraventricular tachycardia (PSVT) or after vagal maneuvers (Valsalva) and medications fail. Hyperventilation does not correct or change cardiac rhythm disturbances. Defibrillation is indicated for pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF) but never for atrial abnormalities. Answer: D 29. A 47-year-old female with a history of ischemic heart disease undergoes electrocardiography. Results show a QRS interval of 0.16 seconds and an RSR' pattern in leads V5 and V6. What is the most likely diagnosis? a. atrial enlargement b. left bundle branch block (LBBB) c. second-degree heart block d. Wolff-Parkinson-White syndrome (WPW) LBBB is evidenced by a wide QRS (>0.12 sec) and RSR' pattern in V5 and/or V6; ST segment depressions in leads I, AVF, V5, and V6 may also be present. Right atrial enlargement is evidenced by tall, peaked P waves in II, III, and AVF. Left atrial enlargement is evidenced by a biphasic P wave in V1. Second-degree heart block is evidenced by varying PR intervals and dropped QRS complex(es). WPW demonstrates a short PR interval (<.08) and a delta wave. Answer: B 30. A 72-year-old female with a history of hypothyroidism presents after 2 episodes of syncope. ECG shows a widened QRS complex with an atrial rate of 100 and a ventricular rate of 40 beats per minute. Where is the conduction delay most likely found? a. atrioventricular (AV) node b. bundle of His c. distal to the bundle of His d. sinoatrial (SA) node Complete (3rd degree) heart block is usually due to a block distal to the bundle of His. The atrial impulses are completely blocked and the ventricular pacemaker maintains a slow rate, usually <45; wide QRS complexes are noted on ECG. Mobitz type I (Wenckebach) is usually due to a block in the AV node; it manifests as a progressively lengthening PR interval until a beat is dropped. Mobitz type II is usually due to a block in the bundle of His; it manifests as intermittently non-conducted atrial beats. The SA node

is not affected in Types I, II or III heart block. Answer: C 31. A 68-year-old female presents with new headaches described as throbbing and continuous, localized to above the ears. She states it is painful to wear her reading glasses. Further questioning reveals two episodes of transient unilateral blurriness of vision and progressive jaw claudication. Which of the following is expected on exam? a. bounding carotid pulse b. nodular, tender temporal artery c. retinal cotton wool spots d. temporomandibular joint (TMJ) syndrome Jaw claudication (pain with chewing or other movement) is common in giant cell (temporal) arteritis. The temporal artery may be nodular, enlarged, tender, or pulseless on exam. The carotid pulse is tender in 15% of patients with giant cell arteritis; it would not be bounding. Cotton wool spots are characteristic of retinal artery or vein occlusion, not giant cell arteritis. TMJ is characterized by clicking, chronic pain, and reduced range of motion.

Answer: B 32. A 38-year-old male with no significant past medical history presents with pleuritic substernal chest pain for the last 2 days. He states he feels better when he sits up and worse when lying down. He had flu-like symptoms two weeks ago that resolved without treatment. What is expected on physical exam? a. peripheral edema b. muffled heart sounds c. pericardial friction rub d. systolic ejection murmur

e. carotid bruit Pericarditis may be inflammatory or infectious. Post-viral illness pericarditis manifests with chest pain that is relieved with sitting forward; a pericardial friction rub is characteristic. Peripheral edema is not typical in the presentation of acute pericarditis. Muffled heart sounds and murmurs are not seen in acute pericarditis but may be noted with pericardial effusion.

Answer: C 33. A 33-year-old male presents for a routine physical. He states he has a small ventricular septal defect (VSD) that has not caused him any problems. What is

expected to be found on cardiac auscultation? a. harsh holosystolic murmur b. opening snap c. S3 gallop d. systolic ejection murmur A harsh holosystolic murmur is characteristic of small shunts associated with VSD; it is due to right to left shunting. An opening snap is characteristic of mitral valve stenosis. An S3 gallop is typically seen in patients with heart failure. A systolic ejection murmur is seen in patients with aortic stenosis. Answer: A 34. A 48-year-old male presents for a routine physical. He is 6 feet 2 inches and weighs 182 lbs. BP is 130/88. Which of the following should be suggested at this time? a. adopting a DASH diet b. increase dietary potassium c. increase red wine intake d. weight reduction In patients with prehypertension (systolic blood pressure 120-139 mmHg or diastolic blood pressure 80-89 mmHg), lifestyle modification (weight reduction, DASH diet, reducing sodium in diet, increasing physical activity and moderating alcohol consumption) should be encouraged. Weight reduction is a recommended course of action but this patient is of normal body weight (BMI=23.8).

Answer: A 35. A 58-year-old male with a history of hypertension x 15 years presents concerned about episodes of chest pain. The first episode occurred 3 weeks ago after shoveling snow. He felt the same pain 2 times since, once after sexual activity and once after walking up 1 flight of stairs. The pain subsides after 10-15 minutes of rest. Which of the following should be suggested to prevent further episodes of pain? a. avoiding any activity that would cause these symptoms b. begin taking a cholesterol lowering medication c. sublingual nitroglycerin 5 minutes before precipitating activity d. weight loss and increased cardio workouts The patient is describing symptoms of stable angina. He should undergo initial blood work, ECG and a chest radiograph. In the meantime, sublingual nitroglycerin is an effective and convenient treatment. Avoiding activities that provoke angina is possible but not always practical. Treating the underlying problem is more appropriate. Weight

loss and exercise should be recommended for risk reduction but would not be the treatment for the actual chest pain. Beginning a cholesterol lowering program would be indicated after he has had the appropriate blood tests to direct therapy. Answer: C 36. A 42-year-old male with a history of dilated cardiomyopathy presents with 2 episodes of syncope in the past week. 24-hour monitoring reveals 3 episodes of ventricular tachycardia, 1 of which was symptomatic. What is the appropriate long term treatment? a. amiodarone b. implantable cardioverter defibrillator c. procainamide d. radiofrequency ablation

e. coronary artery bypass grafting (CABG) Patients with symptomatic ventricular tachycardia in the absence of a reversible precipitating cause (acute MI, ischemia, electrolyte imbalance or drug toxicity) are at high risk for recurrence and, therefore, are best treated with an implantable cardioverter defibrillator. If the patient is tolerating the rhythm and currently in ventricular tachycardia, amiodarone would be an appropriate treatment. Procainamide may be tried in a stable patient with recurrent acute ventricular tachycardia despite amiodarone. Radiofrequency ablation (catheter ablation) is a palliative option with recurrent tachycardia and ICD activations despite treatment with antiarrhythmics. CABG is indicated in coronary occlusive disease, not electrical pathologies. Answer: B 37. A 53-year-old female with a history of diabetes x 13 years presents with dyspnea and muscle aches x 3 days. On exam, temperature is 38.2C (100.7F); petechiae are noted on the palate and painless erythematous lesions are noted on the soles of her feet. A new II/VI pansystolic murmur is heard at the apex. Blood cultures have been sent. What is the recommended initial empiric treatment for this patient? a. ceftriaxone IM given alone b. oxacillin IV given alone c. penicillin and gentamicin d. vancomycin and ceftriaxone Empiric regimens for endocarditis while culture results are pending should include agents active against Staphylococcus, Streptococcus, and Enterococci. Vancomycin 1 gram every 12 hours and ceftriaxone 2 grams every 24 hours is recommended for appropriate coverage. The other antibiotic choices are appropriate for specifically

isolated bacterial causes of endocarditis. IM ceftriaxone alone is appropriate for Streptococcal viridans or HACEK organisms. IV oxacillin is effective against methicillin-susceptible Staphylococcus aureus endocarditis. Enterococcal endocarditis is treated with penicillin plus either gentamicin or streptomycin; this combination is also effective against Streptococcus viridans. Answer: D 38. A 48-year-old otherwise healthy female presents for the third time this year for a blood pressure check. Her BP is 142/90 which is similar to the past 2 readings. She has implemented lifestyle changes, including weight loss and avoidance of salt, but has not seen a change in her blood pressure. What is the recommended initial treatment for her elevated blood pressure? a. atenolol b. captopril c. eprosartan d. hydrochlorothiazide The Joint National Commission 8 (JNC 8) states that the different among anti-hypertensive choices is negligible. First line treatment may be a thiazide diuretic, calcium channel blocker, angiotensin converting enzyme inhibitor, or an angiotensin receptor blocker. However, diuretics administered alone control blood pressure in 50% of patients with mild to moderate hypertension and have a less severe side effect profile.

Answer: D 39. A 36-year-old female with no significant past medical history presents with pleuritic substernal chest pain for the last 2 days. She states the pain is worse when lying down. On exam a friction rub is noted and she has a temperature of 100.8F. What is the most appropriate treatment? a. ceftriaxone b. dialysis c. ibuprofen d. prednisone NSAIDs and aspirin are first-line agents for uncomplicated acute pericarditis. Ibuprofen is a recommended treatment for viral pericarditis which is the most likely cause of this patient's symptoms. Prednisone can be helpful with severe symptoms or in those unresponsive to non-steroidal agents. Dialysis would be the appropriate treatment if the cause was uremic pericarditis but, since this patient has no history of renal insufficiency, it is unlikely a contributing factor. Ceftriaxone would not be appropriate as the cause is most likely viral.

Answer: C 40. A 26-year-old female with no significant past medical history presents with rapid heart rate and SOb. ECG reveals a regular rhythm with a rate of 160 and narrow QRS complexes. Physical exam is otherwise normal. After multiple unsuccessful attempts to break the rhythm, including carotid massage, which of the following should be recommended? a. cardioversion b. intravenous adenosine c. intravenous procainamide d. sublingual nifedipine IV adenosine is recommended in patients with paroxysmal supraventricular tachycardia (PSVT) who have failed mechanical measures such as carotid massage or Valsalva maneuvers IV procainamide may be used but is not usually given until after a calcium channel blocker or beta-blocker have been administered and tachycardia continues. Cardioversion can be used in patients with PSVT if they are hemodynamically unstable or if adenosine, beta-blockers, and verapamil are contraindicated or ineffective. Sublingual nifedipine is not used in the acute treatment of PSVT, although IV verapamil or diltiazem are appropriate treatment choices. Answer: B 41. A 71-year-old female with a history of hypertension and diabetes presents with SOB and swollen ankles. Physical exam reveals BP 138/84, HR 108, SaO2 90% and rales throughout both lung fields. She also has 2+ pitting edema of both lower extremities. Which of the following is recommended as initial treatment? a. amlodipine b. digitalis c. furosemide d. warfarin Loop diuretics are highly effective in congestive heart failure (CHF). A combination of a diuretic and an ACE inhibitor should be the initial therapy in most cases. Digoxin should be used in patients who remain symptomatic despite diuretic and ACE inhibitor treatment and for rate control in patients with heart failure and atrial fibrillation. Amlodipine has been shown to be safe in patients with CHF but not superior to placebo and is only used in cases with associated hypertension or angina. Anticoagulation is not warranted in patients with heart failure unless there is a history of prior embolic events or mobile left ventricular thrombi.

Answer: C 42. A 62-year-old male presents with substernal chest pain that radiates to his jaw. The pain has been present for the past 30 minutes. He had a similar episode 1 week ago that was relieved with rest. ECG shows normal sinus rhythm. The pain is relieved with 1 sublingual nitroglycerin. What is the best diagnosis at this time? a. acute myocardial infarction (MI) b. pancreatitis c. perforated ulcer d. unstable angina Unstable angina is part of the spectrum of acute coronary syndrome. It is defined as chest pain that occurs at rest, is different than previous episodes of chest pain, or chest pain without release of cardiac enzymes. It often presents in the manner described above but a non-ST segment elevation MI cannot be ruled out until serial cardiac enzymes and ECGs are assessed. Acute MI would most likely show ST segment elevations on the ECG and is less likely to be relieved by nitroglycerin however, it cannot be entirely ruled out until cardiac enzymes are done. Pancreatitis usually presents with subxiphoid pain that radiates to the back; it would not improve with nitroglycerin. A perforated ulcer usually presents as sudden, severe generalized abdominal pain. Answer: D 43. A 32-year-old pregnant female presents with exertional dyspnea. Cardiac exam reveals an opening snap and a diastolic murmur heard best at the apex. What is the most likely diagnosis? a. mitral regurgitation b. mitral stenosis c. tricuspid regurgitation d. tricuspid stenosis Mitral stenosis is characterized by an opening snap and a diastolic murmur heard best at the apex. Findings often increase during pregnancy. Mitral regurgitation is characterized by a pansystolic murmur maximal at the apex and radiating to the axilla; mid-systolic clicks are common. Tricuspid regurgitation is characterized by a holosystolic murmur heard best along the left sternal border; the murmur increases on inspiration. Tricuspid stenosis is characterized by a diastolic rumble heard best along the left sternal border that increases on inspiration. Answer: B

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44. A 56-year-old male is 2 days post myocardial infarction (MI). He now complains of palpitations and dyspnea; the following rhythm appears on the telemetry monitor. What is the rhythm? a. atrial fibrillation b. supraventricular tachycardia (SVT) c. ventricular fibrillation (V-fib) d. ventricular tachycardia (V-tach) V-tach is essentially regular with wide QRS complexes. It occurs commonly after an acute MI. V-fib is very irregular in appearance and rhythm. Atrial fibrillation is a supraventricular rhythm which presents with narrow QRS complexes and an irregularly irregular rhythm. SVT presents with narrow QRS complexes. Answer: D http://media.mycme.com/images/2016/01/13/cardq45_899230.png

45. A 38-year-old female presents with occasional palpitations. ECG reveals the above rhythm strip. An exercise stress test revealed only sinus rhythm and sinus tachycardia. What is the recommended management? a. cardiac catheterization b. electrophysiology studies c. pacemaker implantation d. no further testing or treatment is necessary Isolated premature beats that disappear with exercise are considered normal; no further

testing or treatment is warranted at this time. Occasional PVCs by themselves are not an indication for cardiac catheterization. Electrophysiology studies (EPS) are usually reserved for atrial arrhythmias that are not controlled with medical management. Pacemakers are not indicated in the treatment of occasional PVCs. Answer: D

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46.

A routine ECG on a 57-year-old male with COPD reveals the above. What is the diagnosis? a. atrial fibrillation b. atrial flutter with variable block c. second degree A-V block d. third degree A-V block

Atrial flutter has classic 'saw tooth'/flutter waves; in this case with a variable block of the ventricular response. Atrial fibrillation has no distinct flutter or p waves. Second degree A-V block is identified with either progressively lengthening PR interval until a QRS is dropped (Wenckebach) or intermittent spontaneous dropping of a QRS (Mobitz). Third degree A-V block demonstrates p waves and QRS complexes occurring independently of each other. Answer: B http://media.mycme.com/images/2016/01/13/cardq47_899251.png

47.

A 48-year-old female presents for an initial history and physical exam. Which of the following conduction abnormalities is shown on her ECG? a. first degree A-V block b. second degree Wenckeback block (type 1) c. second degree Mobitz block (type 2) d. third degree A-V block Second degree Wenckebach block (type 1) demonstrates progressively lengthening PR intervals until a QRS is dropped as shown in this rhythm strip. First degree A-V block is defined as a PR interval > 0.2 sec. Second degree Mobitz block (type 2) does not show lengthening of the PR interval; it is characterized by intermittently dropped QRS complexes. Third degree A-V block shows a separate atrial and ventricular (usually slower) rhythm, usually with wide QRS complexes. Answer: B http://media.mycme.com/images/2016/01/13/cardq48_899258.png

48. An 82-year-old female presents for a routine exam. ECG rhythm strip is shown here. Chronic prophylaxis is indicated to reduce the risk of which of the following conditions? a. angina b. myocardial infarction c. stroke d. sudden cardiac death Chronic anticoagulation is indicated to prevent the incidence of stroke in atrial fibrillation. Atrial fibrillation alone does not predispose to angina or myocardial infarction. Sudden cardiac death is associated with ventricular, not atrial, fibrillation. Answer: C <img alt=""

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