Medicine 4th Le Ay 2011-12

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2013A MEDICINE 4 LE: CARDIOLOGY MODULE 1. Which of the ff. statements correctly === the surface projection of the heart and the great vessel?

13. Rapid y descent of the jugular venous pulsation is a finding in:

A: In supine patients, diameter of the PMI is approximately 1-2.5

A: Tricuspid regurgitation

2. Paradoxical splitting of the 2

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14. Wall stress is increased in: heart sound is:

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A: Splitting of the 2 heart sound during expiration [physiological/normal splitting = inspiration] 3. Which of the ff. statements is correctly === relation of auscultatory findings to the chest wall? A: Murmurs arising from the aortic valve may be heard anywhere from the right segment of the costal space to the apex

A: Dilatation [Law of Laplace] 15. True statement regarding heart failure: A: Volume overload causes diastolic wall stress 16. Diastolic heart failure is predominant in decompensated: A: Hypertrophic cardiomyopathy [dilated, ischemic = systolic]

4. What is v wave in a jugular venous pulsation? A: The rise in the right atrial pressure as it fills up with blood while the tricuspid valve is closed st

17. A 46-year old male…easy fatigability for the past 3 months, complains of associated orthopnea…previous hospitalization for myocardial infarction…What is the…predisposition of this patient?

5. Loud 1 heard sound is heard in: A: Coronary artery disease A: Mitral stenosis [not heard if MS is very severe]

A: Atrial fibrillation with varying AV block [almost always AF]

For Q’s 18-20: A 26-year old male consulted you for pre-employment clearance for work in Saudi Arabia. He is asymptomatic cardiopulmonary-wise but admits to not being a very athletic person. He has a first cousin who died in his early 20’s while training to be a policeman. Upon examination, you noted a 3/6 mid to late systolic murmur over the apical area which becomes louder upon Valsalva maneuver, there was no S3.

8. Cyanosis is a physical finding in:

18. The murmur in this patient is probably due to:

A: Tetralogy of Fallot

A: Systolic anterior motion of the anterior mitral valve leaflet due to Venturi effect [murmur over apical area = MV; Dx: HCM especially if patient is young, athletic, suddenly dies]

6. Characteristics of carotid pulsation include: A: A vigorous thrust with single outward component 7. Irregularly irregular heart rhythm is observed in:

9. Differential cyanosis is a physical finding in: A: Patent Ductus Arteriosus with pulmonary hypertension [most especially if with Eisenmenger syndrome]

19. The best diagnostic tool for this patient is: A: 2D Echo

10. Which of the ff. valvular lesions will most likely be symptomatic with moderate exercise: A: moderate --- [NOT in mild (usually no symptoms) or chronic (has adapted) disease]

20. Advice for this patient: A: May work abroad but avoid vigorous physical activity and dehydration [dehydration will decrease preload and worsen condition]

11. Left ventricular hypertrophy is likely to be found in: A: [not read but answer is probably Aortic Stenosis; ASD = right, MS = LA, Acute AR = none] 12. Acute mitral regurgitation is likely to be seen in: A: Angina pectoris [MV prolapse, dilated LV due to ischemia, MR d/t RHD = chronic]

For Q’s 21-22 A 56-year old male went to you for consult, he was seen by another doctor due to shortness of breath associated with orthopnea and bipedal edema, is a known diabetic, poorly compliant to his medication, his 2D Echo was with him and findings were left ventricle end-diastolic volume of 260cc and systolic volume of 200cc, his BP…HR…distended neck veins…

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21. [Q not read] A: The patient’s --- is…depressed [EF is a function of systolic]

32. What is the hemodynamic hallmark of tricuspid stenosis? A: Diastolic pressure gradient between the right atrium and right ventricle [MS = left side]

22. Computed ejection fraction is: A: 23% For Q’s 23-24 A 56-year old…uncontrolled hypertension for the past 7 years, is symptomatic.

33. A 45-year old male came to you for heart murmur. The patient is asymptomatic and very active. On examination, a continuous murmur at the left upper sternal border…What is your diagnosis? A: Patent Ductus Arteriosus

23. What is the patient’s heart failure classification? A: Stage B [Stage A = asymptomatic but with risk factors]

34. The most common congenital anomaly associated with Down’s Syndrome? A: Atrio-Ventricular Septal Defect

24. The best choice of medication for this patient is: A: ACE-inhibitor 25. Long-term effect of compensatory mechanism in heart failure include:

35. What is the most common…of Coarctation of the Aorta? A: Bicuspid

A: Left ventricular remodeling

36. A 70-year old male presents to you with the ff. findings: differential hypertension…

26. True of dilated cardiomyopathy:

A: Rib notching [Dx: Coarctation of the Aorta]

A: Clinically presents as systolic heart failure [hypertrophic = diastolic HF]

37. A 32-year old female came for consult complaining of difficulty of breathing and shortness of breath. On PE, S1 is soft…

27. Which of the ff. will be most likely in a patient with chronic severe mitral regurgitation? rd

A: Ventricular Septal Defect

A: 3 heart sound

38. Calf pain on walking relieved by rest is:

28. Which of the ff. statements about the natural history of severe aortic regurgitation is true?

A: Intermittent claudication

A: [not read] 29. A 53-year old man complains of a heart murmur. He is completely asymptomatic and active. He sought consult at the correctional hospital near Global where…carotid delay, single S2 and 3/6…

39. The recommended initial screening test for peripheral artery disease is: A: Ankle:Brachial Index [normal ratio: 0.9] 40. 0.75…which of the following… A: Moderate

A: Severe aortic stenosis [delayed A2/no normal splitting because of delayed closure of AoV] 30. Aling Gloria, a 62-year old woman, presents to you with shortness of breath, no history of heart murmur…no history of rheumatic fever…2/6 holosystolic murmur at the apex…

41. Treadmill exercise test is used to provoke clinically unapparent: A: Peripheral Arterial Disease 42. The most fatal complication of Deep Vein Thrombosis is:

A: Mild mitral stenosis and mitral regurgitation A: Pulmonary embolism 31. Rapidly rising water hammer pulse: A: Rapid descent in late systole and diastole

43. Outcomes of cardiac rehab training include which of the ff? A: AOTA: improved quality of life, control of symptoms, improved exercise tolerance [but you cannot improve survival / mortality rate still the same]

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44. Cardiac rehab is indicated in which of the ff:

55. The mechanism on how PET Scan detects myocardial perfusion abnormality:

A: AOTA: chronic stable angina pectoris, underwent post-coronary bypass surgery, post-transplant surgery [not an indication in acute decompensated HF]

A. Permits the detection and quantification of exogenous glucose utilization in areas of hypoperfused myocardium

45. Parameters that should be assessed prior to start of symptom-limited exercise testing:

56. The best imaging modality to rule out aortic dissection:

A: AOTA 46. The current mainstay in the diagnosis of deep vein thrombosis is: A: [not read but answer is probably Venous Duplex Scan; Segmental Pressure Study is for PAD] 47. Lifestyle modification and drug-therapy is indicated among patients with BP of: A: [not read but answer is probably 140/90mmHg] 48. After initiating lipid-lowering drugs, lipid determination should be done: A: After 2 months 49. Virchow’s triad includes abnormalities of the vessel wall, changes in the formed and soluble elements of the blood, and blood stasis. This is seen in:

a. 2D echo [too short to view the entire heart] b. chest xray [you only see the silhouette, cannot see the dissection] c. nuclear perfusion scan [you see perfusion] d. CT angiogram (GOLD STANDARD) 57. What type of cardiac catheterization… A: Coronary angiogram 58. The method of pressure and O2 saturation measurement to screen for intracardiac shunts using Pick’s principle is done at the: A: Right heart 59. The method where the catheter is advanced with fluoroscopic guidance in the central aorta is: A: Coronary angiogram

A: Deep Vein Thrombosis

60. Evaluates the rapidity of coronary flow … rush of capillary filling into the myocardium … is:

50. The most common cause of acute limb ischemia is:

A: Angiogram

A: Atherosclerosis

61. The surgical procedure performed to relieve the angina and reduce death due to coronary artery disease using arteries or veins as grafts is:

51. Primary imaging modality for assessment of left ventricle cavity size, systolic function and wall thickness:

A: Coronary artery bypass graft A: 2D Echo 62. Functions of the pericardium include: 52. A 25-ear old female came to you for pre-employment evaluation. She had a previous history of Rheumatic Fever. She’s still on Pen G. On PE you notice a 3/6 systolic murmur. You suspect rheumatic valvular heart disease. What would be the best diagnostic modality to validate your suspicion? A: 2D Echo 53. A 43-year old hypertensive female came to you due to vague, effort-related chest pain. You think that she falls into intermediate pre-test probability of having coronary artery disease. What would be the best modality to validate your suspicion? A: Exercise SESTAMIBI (nuclear myocardial perfusion imaging)

A: AOTA: mediates interventricular coupling, serves as barrier to prevent spread of local infection, reduce friction between the heart the surrounding mediastinal structures 63. An exaggerated arterial fall in arterial pressure of more than 10 mmHg is (as seen in tamponade): A: Pulsus paradoxus 64. The diagnostic tool in pericardial effusion or tamponade is: A: AOTA: ECG [electrical alternans due to its swinging in pericardial fluid], 2D echo, etc.

54. The ff. is/are the isotopes being used for myocardial perfusion scintigraphy: A: Technitium & Thallium [MRI: Gadolinium]

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65. The clinical findings in cardiogenic shock is: a. S3 gallop [diastolic event which is abnormal; usually seen in acute heart failure] b. elevated JVP [RA and RV are overloaded due to congestion due to left-sided heart failure] c. hypotension [decreased CO and SV means HF] d. … 66. Chronic inflammation causing fibrosis and … is: A: Pericardium 67. Most common primary benign tumor of the heart in adult is:

78. Angina pectoris is best diagnosed by: A: History only [angina is only a symptom] 79. Which of the following is best for showing perfusion defects due to ischemia? A: PET or Nuclear scan 80. What is the probability that a 38-year old female who has pain that is intermittent, lasting for a few seconds and occurring even at rest has ischemia?

A: Myxoma

A: Low Risk [the patient is still in her reproductive years (usually older patients will have present with this symptom) and pain due to ischemia happens during activity, not at rest]

68. Most common primary valvular tumor of the heart in adult is:

81. In the secondary progression of a coronary artery disease, which of the following goals is desirable?

A: Papillary fibroblastoma

A: Waist:hip ratio should be 0.9 in females, 1.0 in males

69. Most common location of myxoma is: A: Left atrium

82. 58-year old male has acute onset of moderate to severe chest pain an hour prior to consult related to ischemia. Which of the following is an appropriate test?

70. Most common malignant tumor of the heart in adult is: A: Angiosaroma 71. Most common adult tumor of the heart is…: A: Secondary 72. Which of the following best defines the anatomic characteristic of an arteriosclerotic disease? a. ECG [electrical properties] b. 2D echo [peripheral] c. angiogram [lumen} d. intravascular ultrasound [defines the walls of the arteries] 73. Of the following lipoproteins…:

A: Treadmill exercise [males at 40 y/o have an increased risk for CAD] 83. In instances where non-surgical procedures are preferred for patients with MI, which of the following is recommended? A: Streptokinase [reperfuse patient with streptokinase as heparin, statins and aspirin can only prevent plaque rupture] 84. What is the pathophysiology of coronary artery disease? A: Plaque rupture 85. ECG criteria for left ventricle hypertrophy with wide QRS complex:

A: HDL [good while LDL is bad] 74. [Q & A not read]

A: Bundle branch block [this condition delays the impulses to the ventricles which causes widening of the QRS complex]

75. Lipid-lowering with statins may reduce plaque formation through which of the following?

86. First degree AV block is diagnosed with…

A: Decrease in macrophage

A: [not read]

76. [Q not read]

87. Sinus bradycardia may be due to the following drugs:

A: Plaque vulnerability

A: Beta-blockers

77. Which of the following is true?

88. Old myocardial infarction is diagnosed using p waves in which of the following…

A: 35% of the patients have atherosclerosis A: [not read]

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89. Tracing: Ischemia? A: a and b: [ST wave depression] 90. Tracing: What is the HR? A: >100 bpm 91. Tracing: Rhythm? A: Sinus rhythm [normal, P followed by QRS, regular RR interval and P wave is upright] 92. Tracing: A: Sinus tachycardia 93. Tracing: A: Skip beats 94. Tracing: What is the origin? A: Ventricular 95. Tracing: What do the arrows point at? … A: [not read] 96-98. Tracings: A: [not read] 99. Collapsed during walking: A: Ventricular fibrillation 100. Student was brought to ER after alcoholic binge. What is the ECG find? A: Atrial fibrillation/bradycardic [Holiday heart syndrome]

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