Cardiology lecture toIternal Medicine 21/10/2013


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  • {"85":"Multiple studies have validated the Duke criteria. When applied and reapplied over the entire evaluation, these criteria are sensitive and specific and very rarely erroneously reject a true endocarditis.\n"}
  • Cardiology lecture toIternal Medicine 21/10/2013

    1. 1. Cardiology Lecture to IM Board Exam oriented MCQS Picture Quiz Explanatory notes Dr Ihab Suliman 20/October 2013
    2. 2. Outline    MCQS Picture Quiz Explanatory notes
    3. 3. Old/Prior MI
    4. 4. Prognosis in AMI   Risk of dying is highest in first hour, one third of all MI deaths occur in first hour Many of these early deaths are due to arrhythmias, usually ventricular fibrillation (VF)
    5. 5. Introductory MCQs       The best BB associated with significant & proven Mortality benefit post MI ? a- Atenolol b- Propranolol c- Timolol d- carvedilol (Dilatrend) e-Metoprolol tartrate, Short acting
    6. 6.  d- carvedilol (Dilatrend)  Other Medications with mortality benefit post MI are Metoprolol succinate , bisoprolol ( Concor), ACEI, ARBs , Spironolactone, statins 
    7. 7. The pathophysiology of heart failure can best be described as: A. B. C. D. E. a failure of protective mechanisms activation of harmful pathways introduction of pathogenic influences inappropriate activation of normal mechanisms all of the above
    8. 8. Physiologic effects of Angiotensin II include: A. B. C. D. E. vasoconstriction activation of thirst sodium retention aldosterone release all of the above
    9. 9.  The following is a feature of the heart failure state: reduced circulating catecholamines B. increased left ventricular end diastolic pressure C. reduced plasma volume D. increased renal sodium excretion E. reduced pulmonary capillary wedge pressure A.
    10. 10. B increased left ventricular end diastolic pressure
    11. 11. All the following medications can precipitate heart failure in susceptible patient except: A. B. C. D. E. metoprolol spironolactone procainamide diltiazem rosiglitazone
    12. 12. The following are all adverse effects of beta blockers except: A. B. C. D. E. bronchospasm bradycardia hypotension depression anxiety
    13. 13. Q1       A 56 year old obese female presents for a routine physical examination. Her lipid profile  reveals a significantly elevated triglyceride level of 355 mg/dL. Which of the following medications can act to lower her triglyceride level by stimulating the synthesis of lipoprotein lipase? A) gemfibrozil B) rosuvastatin C) cholestyramine D) ezetimibe E) ketoconazole
    14. 14. A1  A) gemfibrozil  Gemfibrozil acts by stimulating the synthesis of lipoprotein lipase to degrade triglycerides  into fatty acids increasing their metabolism and lowering blood levels. Elevated triglyceride levels can lead to atherosclerosis and coronary artery disease. Rosuvastatin (B) is an HMG-CoA reductase inhibitor which can cause rhabdomyolysis or hepatic dysfunction (elevation in AST and ALT levels). Cholestyramine (C) is a bile acid binding resin used to treat elevated lowdensity lipoprotein levels (LDL). Ezetimibe (D) is also used to treat elevated LDL levels and acts by inhibiting cholesterol absorption at the brush border of the small intestine. Ketoconazole (E), an anti-fungal medication, significantly reduces LDL levels as well.  
    15. 15. Q2  A 19 year old boy with no past medical history passes out while running at a school evnt. He states that he was feeling a little dizzy prior to the event, but does not complains of chest pain or palpitations. His blood pressure is 120/85, heart rate 85/min, Respiratory Rate 12/min, and he is afebrile. His physical examination reveals normal lung sounds, a II/VI mid-sytolic creshendo-decreshndo murmur is heard at the right upper sternal border which increases in intensity with Valsalva, an S4 heart sound is also present. Laboratory studies are normal. What is the most appropriate treatment at this time?
    16. 16.      A) Start a Diuretic  B) Permanent Pacemaker Implantation  C) AICD Implantation  D) Observation  E) Start  Beta Blocker
    17. 17. A2  C) AICD Implantation
    18. 18. Q3   The commonest cardiovascular manifestation of the Coxsackie infective agent is a) cardiac tamponade b) congenital Pericardial Defects c) acute viral Pericarditis d) pericardial Cysts e) bronchogenic carcinoma
    19. 19. A3  c) acute viral Pericarditis
    20. 20. Q4   35 year old obese women develops painful leg on the 10th post operative day following emergency surgery for a ruptured ectopic pregnancy. She is likely to have ? a) thromboangitis obliterans  b) ruptured baker`s cyst  c) deep vein thrombosis of the lower limb  d) aortoiliac artery artherosclerosis  e) embolus
    21. 21. A4   c) deep vein thrombosis of the lower limb  Specially if she is homozygous or heterozygous for coagulopathy factor ?
    22. 22. Q 5  A 56 year old gardener complains of sudden pain with swelling behind the right knee. He also complains of associated pain and swelling in the calf. On examination a crescentic hematoma is noted below the medial malleolus of the ankle.  a) Acute hemarthrosis  b) Osteonecrosis  c) Baker’s cyst  d) pigmented villonodular synovitis  e) rheumatoid arthritis
    23. 23. A5  A Baker cyst is sometimes called a popliteal cyst. When an excess of knee joint fluid is compressed by the body weight between the bones of the knee joint, it can become trapped and separate from the joint to form the fluidfilled sac of a Baker cyst. The name of the cyst is in memory of the physician who originally described the condition, the British surgeon William Morrant Baker (1839-1896).
    24. 24. Rheumatoid Hands
    25. 25. Question 6      All of the following is correct about Atrial Fibrillation except ? A- The most common persistent arrhythmia. B- Incidence or prevalence increases with age. C- if hemodynamically unstable patient in ER should be cardioverted . D- Dabigatran( Pradaxa) new antithrombin associated with Decresed GI bleed compared to Warfarin
    26. 26. A6    D- Dabigatran new antithrombin associated with Decresed GI bleed compared to Warfarin The correct answer is Dabigatran (Oral Thrombin inhibitor) new antithrombin associated with INCREASED GI bleed compared to Warfarin
    27. 27. Atrial fibrillation is a common arrythmia • In the FHS, the lifetime risk of atrial fibrillation (AFib) for adults age 40 is 26% for men and 23% for women1 • Prevalence of AFib in the US is estimated > 2.2 million adults with an incidence > 70 000 2 • Prevalence increases steeply with age 2 1.Lloyd-Jones DM, et al. Circulation 2004;110:1042– 1046
    28. 28. AFib: a common but serious arrythmia  AFib increases the risk of stroke 5-fold1  The increase in risk of stroke is similar for paroxysmal, persistent and permanent AFib2  Strokes associated with AFib are usually more severe than those from other causes, conferring an increased risk of morbidity, mortality and poor functional outcome1 1. Savelieva et al. Ann Med 2007;39:371– 2. Hart R et al. JACC 2000; 35:183
    29. 29. Dabigatran etexilate – a new, reversible, oral DTI        Dabigatran etexilate is an oral prodrug, converted to dabigatran, a potent reversible DTI No interaction with food No participation with CYP450 Predictable anticoagulant effect Fixed dose No need for routine coagulation monitoring Very recently some genetic variation for response 36
    30. 30. Q7   A 68-year-old gentleman is admitted with an Anterior myocardial infarction (MI) and receives thrombolysis, aspirin, atenolol, atorvastatin and lisinopril. His ECG shows good ST segment resolution. The next day he develops some pain in the legs and a dusky discolouration of the lower limbs. On closer examination there is a diffuse petechial rash over the lower limbs, particularly the feet, but all peripheral pulses are palpable.  CBC showed elevated eosinophils
    31. 31. Q7       Which of the following is the most likely cause for his current situation? A)Polyarteritis Nodosa B)Aspirin Allergy C)Periphral Vascular Disease D)Cholesterol Emboli E)Post Thrombolysis Allergy
    32. 32. A7 D)Cholesterol Emboli The  above patient is an arteriopath as suggested by the acute Myocardial Infarction, and one day after thrombolysis he develops a petechial rash in the lower limbs with raised white cell count marked eosinophilia and raised IgE. This suggests cholesterol embolisation syndrome rather than allergy.  
    33. 33. Question 8  Catheter-delivered balloon expansion techniques are now the treatment of choice for which one of the following lesions in adults?  A. Valvular pulmonic stenosis.  B. Valvular aortic stenosis.  C. Coarctation of the aorta.  D. Ebstein's anomaly of the tricuspid valve.  E. Severe mitral stenosis with Significant regurgitation.
    34. 34. Answer to 8  Comment The correct answer is A.  Although catheter balloon valvuloplasty and aortoplasty have been attempted in all these conditions, only pulmonary valvotomy has achieved a success level consistent with being the treatment of choice in adults. Aortic stenosis responds initially to balloon expansion and may serve as a bridge to valve replacement surgery, but is associated with rapid restenosis. Success rates with coarctation and Ebstein's anomaly are not uniform enough to displace surgery except in selected patients. Mitral stenosis in the absence of severe subvalvular disease can be successfully treated by balloon valvuloplasty, but the presence of moderate to severe regurgitation is an indication for surgery.
    35. 35. Q9  A 72 year old female with a history of breast cancer and tobacco use complains of dizziness and dyspnea on exertion. Her heart sounds are distant and her systolic blood pressure is noted to markedly decrease with inspiration. Which of the following is the most likely diagnosis?  A) Constrictive cardiomyopathy B) Mitral valve Stenosis C) Congestive heart failure D) Pulmonary embolus E) Cardiac Tamponade    
    36. 36. A9  E) Cardiac Tamponade      Cancer is the most common cause of pericardial effusion and when enough fluid accumulates in the pericardial space, cardiac tamponade occurs. “Pulsus paradoxus” is when there is a decrease in systolic blood pressure during inspiration due to failure of the right ventricle to accept the normal increased venous return that occurs with inspiration. This also results in a “Kussmal’s sign” or elevated jugular venous distension during inspiration (normally the opposite occurs). Treatment is with emergent pericardiocentesis.
    37. 37. Q 10  In which of the following diseases is pregnancy difficult, but not highly risky to mother and fetus?  A. Eisenmenger's syndrome.  B. Primary pulmonary hypertension.  C. Hypertrophic obstructive cardiomyopathy.  D. Prior peripartum cardiomyopathy with heart failure.  E. The Marfan syndrome with dilated aortic root.
    38. 38. Answer to Q10   Comment The correct answer is C. The cardiovascular system must be able to handle a doubling of cardiac output during pregnancy. Thus, cardiopulmonary diseases that obstruct blood flow are usually contraindications to pregnancy because both the mother and fetus get inadequate blood flow. Thus, obstruction to pulmonary flow due to the Eisenmenger reaction or primary pulmonary hypertension fits into this category, but hypertrophic cardiomyopathy does not. The increased cardiac output increases venous return to the left heart resulting in left ventricular enlargement and less obstruction. In fact, during pregnancy the murmur of hypertrophic obstructive cardiomyopathy may lessen or even disappear, causing the diagnosis to be missed. Prior peripartum cardiomyopathy with heart failure is a contraindication to pregnancy because of the high incidence of recurrent failure and death. Hormonal changes during pregnancy alter vascular walls, making them more distensible. This is a normal mechanism to adapt to higher cardiac output; however, in the patient with the Marfan syndrome and an enlarged aortic root, it can lead to increased wall stress and aortic rupture or dissection.
    39. 39. Q 11  A 50 year old gentleman is admitted to the CCU with an acute Inferior wall infarction. Three hours after the admission his B.P is 90/50 mmHg. The heart rate is 38 beats per minute with sinus rhythm. Which of the following will be the most appropriate initial therapy?  A)Immediate insertion of temporary pacemaker B)Intravenous administration of of Isoproterenol 5 micrograms/min C)Intravenous administration of Dobutamine 0.35 mg/min D) Administration of Intravenous Normal saline, 300 ml over 15 mins E) Intravenous administration of atropine sulfate , 0.6 mg    
    40. 40. A 11  E) Intravenous administration of atropine sulfate , 0.6 mg
    41. 41. Q 12  A 50 year old gentleman with a history of hypertension and high cholesterol presents to the emergency department with pain in chest for one hour. He describes a substernal chest pressure associated with shortness of breath and sweating. His ECG shows ST elevations consistent with myocardial infarction. Which of the following laboratory results would be expected?  A) Elevated myoglobin, normal troponin I, and normal CK-MB  B)Normal myoglobin, elevated troponin I, and normal CK-MB  C)Normal myoglobin, normal troponin I, and elevated CK-MB  D)Normal myoglobin, normal troponin I, and normal CK-MB   
    42. 42. A 12    A) Elevated myoglobin, normal troponin I, and normal CK-MB Myoglobin is a heme protein found in skeletal and cardiac muscle that has attracted considerable interest as an early marker of MI. Its low molecular weight accounts for its early release profile: myoglobin typically rises1- 2hours after onset of infarction, peaks at 6-12 hours, and returns to normal within 24-36 hours.
    43. 43. Q13  A 60 year old man with a histoty of Diabetes, hypertension and congestive heart failure was brought to the ER after he complained of blurred vision and headache. He was found to have Blood Pressure of 220/90 mm Hg. The intern who examined her wanted to give her drug X, but the attending doctor rejects this choice because of its tendency to cause compensatory tachycardia and exacerbate fluid retention. The drug can also cause lupus like syndrome with long term use. What is the mechanism of action of Drug X?  A)Blocks Calcium Channels  B)Increases Production of cGMP  C)Decreases Production of cGMP  D)Inhibits Angiotensin Converting Enzyme  e)Inhibits carbonic Anhydrase
    44. 44. A 13     Hydralazine increases  (cGMP) levels, increasing the activity of protein kinase G (PKG). Active PKG adds an inhibitory phosphate to myosin light-chain kinase (MLCK) – a protein involved in the activation of cross-bridge cycling (i.e. contraction) in smooth muscle. This results in blood vessel relaxation. It dilates arterioles more than veins. Hydralazine requires the endothelium to provide NO) thus only provides the effects of NO in vivo with functional endothelium. It will not work to vasodilate in vitro in an isolated blood vessel. Activation of  has been suggested as a mechanism
    45. 45. Q 14  A 46 year old gentleman came to the Emergency department with c/o sudden dyspnea. Patient had similar episode of dyspnea two days earlier which was associated with profuse sweating. Patient is a reformed smoker and a social drinker. ECG is displayed below. Let`s interpret the ECG and decide the next step in the management.
    46. 46. Sinus; PVCs; LAD; anterior symmetric T wave inversion - and almost "Wellens"-like in V2,V3 - so patient will probably need cath in short order (looking for a tight LAD lesion ...).
    47. 47. Q 15  A 30 year old female with no significant past medical history is 42 weeks pregnant and labor has just begun. She begins to complain of difficulty in breathing which worsens throughout delivery to the point of requiring intubation. She had never previously complained of any shortness of breath or chest pain. Her temperature is 37.0, blood pressure 90/60, heart rate 135, respirations 25, and oxygen saturation 100% on 60% FiO2 on the ventilator. Physical examination reveals diffuse pulmonary rales, a II/IV early diastolic murmur, and no lower extremity edema. Laboratory studies are normal. ECG shows sinus tachycardia and left atrial enlargement. Her chest x-ray has pulmonary edema. Which of the following is the most likely diagnosis?  A) Aortic Dissection B)Dissection of Coronary Artery C)Aortic valve Stenosis D) Mitral Valve Stenosis   
    48. 48. A15  D) Mitral Valve Stenosis
    49. 49. Q 16  A 60 year old gentleman with a history of dyslipidemia, hypertension and CHF presents to the emergency department with acute onset swelling of the lips, eyes, and tongue causing airway obstruction and respiratory distress. He also has an urticarial rash. Which of the following medications is the likely culprit of his current symptoms?   A)Pindolol  B)Clonidine  C)Felodipine  D)Captopril  E)Methyldopa    
    50. 50. A 16   D)Captopril
    51. 51. Butter fly skin rash of SLE
    52. 52. Q 17       A 72 year old female with no significant past medical history passes out while exercising. She has intermittent exertional chest pains and dyspnea on exertion as well. Her physical examination reveals a III/VI late-peaking creshendo-decreshendo murmur at the right upper sternal border and a III/VI holosystolic murmur at the apex. Her S2 heart sound is very soft and her carotid upstroke is weak and delayed. Which of the following is most likely causing her symptoms? A) Aortic valve regurgitation B) Aortic valve stenosis C) Mitral valve regurgitation D) Mitral valve stenosis E) Mitral valve prolapse
    53. 53. A 17  Aortic valve stenosis (AS) presents with one of the classic triad: syncope (passing out), exertional angina, or exertional dyspnea (from heart failure).  Over the age of 70 the most likely cause is degenerative calcific aortic stenosis while under the age of 70 a bicuspid aortic valve is the likely culprit. Rheumatic heart disease is the third leading cause. Physical examination reveals a crescendo-decrescendo murmur at the aortic listening post (right upper sternal border) which radiates to the carotids. The more severe the aortic stenosis the later the peak of the murmur in systole and the softer the A2 component of the S2 heart sound. The murmur is depicted below:  “Pulses parvus et tardus” is present upon carotid artery examination. Remember parvus means weak and tardus means late. The murmur can radiate to the apex and sound holosystolic mimicking mitral regurgitation (this is known as the Galiverdin phenomenon). No medical treatment is available for aortic stenosis. Aortic valve replacement surgically is indicated for anyone who is symptomatic.
    54. 54. Q 18       A 56 year old African American female with a history of asthma is diagnosed with hypertension. Laboratory studies reveal a creatinine of 3.0 mg/dL and a potassium level of 5.1 mg/dL. Which of the following medications is appropriate to treat her hypertension? A) amlodipine B) hydrochlorothiazide C) enalapril D) propranolol E) spironolactone
    55. 55. Calcium channel blockers        Mechanism of Action Calcium channel blockers (CCB) are a group of medications that act to inhibit either central or peripheral calcium channels. This results in decreased calcium influx and smooth muscle relaxation. Dihydropyridine calcium channel blockers act predominantly in the periphery causing arterial vasodilation. Non-dihydropyridine calcium channel blockers act predominantly centrally to decreased heart rate (chronotropy) and contractility (inotropy). Indications Calcium channel blockers are used to treat hypertension and stable angina. The non-dihydropyridine calcium channel blockers are used to lower heart rate during tachyarrhythmias especially atrial fibrillation and atrial flutter as well as during acute coronary syndromes when beta-blockers are contraindicated. Verapamil has been studied to treat hypertrophic obstructive cardiomyopathy as well as multifocal atrial tachycardia.
    56. 56. Q 18       A 29 year old male with a history of ectopia lentis presents for a routine physical examination. He is noted to have pectus excavatum, pes planus, a high arched palate, and a positive wrist and thumb sign. Which of the following cardiac disorders is associated with his condition? A) Aortic valve stenosis B) Coarctation of the aorta C) Mitral valve prolapse D) Ventricular septal defect E) Ebstein’s anomaly
    57. 57. A 18    C) Mitral valve prolapse Marfan’s syndrome is associated with mitral valve prolapse and aortic aneurysms. Specifically, the ascending aorta may dilated and predispose patient’s to acute aortic dissection which can be fatal. Also, when the ascending aorta dilates, the aortic valve annulus stretches causing the valve leaflets to fail to coapt which results in aortic regurgitation. Aortic stenosis (A) is not associated with Marfan’s syndrome and is caused be either senile calcific degeneration of the valve or from a congenital bicuspid aortic valve . Coartaction of the aorta (B) is associated with Turner’s syndrome and presents with hypertension in the upper extremities and hypotension in the lower extremities. “Rib notching” is seen on the chest xray.  Ventricular septal defects  (D) and Ebstein’s anomaly  (E) are not associated with Marfan’s. 
    58. 58. Q19  In long-term follow-up of patients after surgical repair of tetralogy of Fallot, the most common dysrhythmia observed is:  A. Sinus bradycardia.  B. Atrial fibrillation.  C. Atrial tachycardia.  D. Ventricular tachycardia.  E. Junctional tachycardia.
    59. 59. Answer Q19  Comment The correct answer is D.  Complex ventricular arrhythmias often occur during long-term follow-up of patients with tetralogy of Fallot. The incidence correlates with age at repair and with higher residual postoperative right ventricular systolic and end-diastolic pressures. Sudden death accounts for a significant proportion of the late mortality among these patients. In patients with ventricular tachycardia, the site of origin is typically found to be in the right ventricular outflow tract related to the previous ventriculotomy and infundibular resection.
    60. 60. Question 20  A 42-year-old man is referred for evaluation of a systolic murmur. Your exam shows normal carotid pulses, a prominent apical impulse, an early systolic sound, and a grade III/VI mid-systolic murmur at the base. Respiration did not change the character of these auscultatory findings. After an extrasystole, the systolic murmur increased in intensity. Handgrip did not alter the systolic murmur. Valsalva decreased the intensity of the murmur, and it returned to baseline intensity after seven heart beats.  Which one of the following diagnoses is most likely?  A. Congenital pulmonic stenosis.  B. Innocent murmur.  C. Mitral valve prolapse.  D. Hypertrophic obstructive cardiomyopathy.  E. Bicuspid aortic valve.
    61. 61. Answer to Q 20  Comment The correct answer is E.  A systolic murmur that increases in intensity in the beat following an extrasystole is usually due to turbulent flow out of the ventricles. Mitral regurgitation is less likely because this murmur does not change following an extrasystole. The murmur of hypertrophic obstructive myopathy usually decreases with handgrip exercise. An innocent flow murmur is less likely because of the presence of an early systolic sound and grade III intensity. With pulmonic stenosis, there are characteristic changes in the intensity of the murmur and the ejection sound during respiration. The ejection sound establishes the diagnosis of an abnormal aortic valve, a bicuspid valve being the most common abnormality.
    62. 62. Q 21      Regarding the Renin-Angiotensin system, which if the following is false ? a. Chronic renal hypoperfusion leads to catecholamine release, hypertension, cardiac hypertrophy and salt and water retention b. Angiotensin Converting Enzyme (ACE) inhibitors work by inhibiting Angiotensinogen cleavage to Angiotensin I c. ACE-2 is not inhibited by Angiotensin Converting Enzyme (ACE) inhibitors d. Bradykinin is thought to mediate the cough associated with ACE inhibitors
    63. 63. Answer to Q 21  b. Angiotensin Converting Enzyme (ACE) inhibitors work by inhibiting Angiotensinogen cleavage to Angiotensin I
    64. 64. Q 22        Which of the following structures are not found in the right atrium? a. Tendon of Todaro b. Moderator band c. Koch's triangle d. Pectinate muscle c. Koch's triangle d. Pectinate muscle
    65. 65. Answer to Q 22    b. Moderator band The moderator band, located in the right ventricle, is a muscular bridge that connects the distal septum and the right ventricular free wall at the anterior papillary muscle. The tendon of Todaro is a fibrous band located between the valves of the inferior vena cava and coronary sinus in the right atrium.
    66. 66.  Koch's triangle is located in the lower medial portion of the right atrium, overlying the AV node and the proximal His bundle. Pectinate muscles arise from the crista terminalis and course as bands on the right atrial free wall.
    67. 67. 32 years old male came with fever and acute CVA Zoomed view at MV
    68. 68.  M V vegetations ( endocarditis)
    69. 69. Major Criteria  1. Positive blood culture  Typical organism from 2 separate cultures- Viridans streptococci, Strptococcus bovis, HACEK, S. aureus, enterococci OR  Persistently + blood culture- all of three/ majority 4 blood cultures OR  Single +ve blood culture for Coxiella or phase IgG > 1:800
    70. 70.  2. Evidence of endocardial involvement ECHO- oscillating intracardiac mass OR  Abscess OR  New partial deheiscence of prosthetic valve/ new regurgitation 
    71. 71. Minor criteria      Predisposing heart condition Fever > 100.4F Vascular- Emboli, pulmonary infarct, mycotic aneurysm, Janeway lesions Immune- Osler’s nodes, Roth spots, glomerulonephritis Microbiological evidence
    72. 72. Modified Duke Criteria  Definite IE       Microorganism (via culture or histology) in a valvular vegetation, embolized vegetation, or intracardiac abscess Histologic evidence of vegetation or intracardiac abscess 2 Major 1 Major + 3 minor 5 Minor Possible IE   1 major and 1 minor 3 minor
    73. 73. Janeway Lesions 1. 2. 3. 4. 5. More specific Erythematous, blanching macules Nonpainful Located on palms and soles Microabscess of the dermis with marked necrosis and inflammatory infiltrate not involving the epidermis.
    74. 74. The most common infecting organism in patients with right sided endocarditis: A. B. C. D. E. Staph epidermidis Staph aureus Strep viridans Strep faecalis Enterococci
    75. 75. Q 23      2. Which of the following statements about the pericardium is false? a. The pericardium contains 80 to 90 mL of pericardial fluid. b. It is connected to the diaphragm, sternum, and pleurae. c. It encloses the entire main pulmonary artery. d. The ligament of Marshall is a pericardial fold that contains the remnant of the embryonic left superior vena cava.
    76. 76. Answer Q 23   a. The pericardium contains 80 to 90 mL of pericardial fluid. The Correct answer is 10—50 mls
    77. 77. Q 24       A 45 year old female with a history of hypertension previously controlled with diet and lifestyle modifications presents to here primary care physician with increasing headaches. Her blood pressure is 160/90. She is diagnosed with worsening migraine headaches. Which of the following medications is appropriate to treat her hypertension and headaches simultaneously? A) hydrochlorothiazide B) metoprolol C) clonidine D) methyldopa E) lisinopril
    78. 78. A 24  Metoprolol is a lipid soluble beta-blocker which can cross the blood-brain barrier easily and have been shown to be effective in the prophylaxis of migraine headaches as well as the treatment of hypertension. They have slight sedating effects and therefore can also be used for stage freight or panic attacks as well.
    79. 79. Q 25      5. Which of the following statements about the tricuspid valve is true? a. It has three leaflets: anterior, lateral, and posterior. b. It is the largest heart valve. c. It is the most anterior heart valve. d. The posterior leaflet is the largest and most mobile
    80. 80. Dimeter of Valves  AV:  TRICUSPID 13 cm  MITRAL 11 cm  SEMILUNAR:  PULMONIC 8 cm  AORTIC 6 cm
    81. 81.   Answer is b: The tricuspid valve is the largest heart, whereas the pulmonic valve is the most anterior. The tricuspid valve consists of three leaflets, anterior, septal, and posterior. The anterior leaflet is the largest and most mobile. The posterior leaflet is the smallest, whereas the septal leaflet is the least mobile and occasionally absent.
    82. 82. Q 26       1. Which of the following statements about the assessment of the severity of a valvular abnormality are not true? a. Severe acute aortic regurgitation results in a holodiastolic murmur. b. Severe aortic stenosis results in a long-duration and latepeaking systolic ejection murumur. c. An S2-OS interval of less than 70 milliseconds is consistent with severe mitral stenosis with normal heart rates and absence of other left-sided valve disease. d. Severe aortic stenosis may be present with a soft murmur. e. The duration of a tricuspid stenosis murmur correlates with the severity of stenosis
    83. 83. Answer to Q 26  The answer is a: The severity of AS is best determined by the duration and time to peak of the murmur. Longduration and late peaking are consistent with severe AS. The intensity of an AS murmur is dependent on the stroke volume, so a soft murmur may occur with severe AS and LV dysfunction. Similarly, the duration of TS or MS murmurs are helpful in determining severity, as is the duration of the S2-OS interval. However, the S2-OS interval is also affected by heart rate and other valvular lesions that affect LA and LV pressure. Severe
    84. 84. Q 27       A 67 year old male suffers a large myocardial infarction complicated by sustained ventricular tachycardia. He is started on a lidocaine infusion. He subsequently develops shock liver from hypotension during the ventricular tachycardia and his serum lidocaine levels become significantly elevated. Which of the following is a manifestation of lidocaine toxicity? A) Stroke B) Seizures C) Renal failure D) Congestive heart failure E) Hyperkalemia
    85. 85. A 27  B) Seizures  Lidocaine which is used to treat ventricular arrhythmias such as ventricular tachycardia or ventricular fibrillation, can easily reach toxic levels and can cause seizures and may progress to coma and death. Lidocaine at high levels first inhibits the inhibitory neurons in the brain resulting in seizures. Eventually all neurons are inhibited and coma ensues. No specific treatment or antidote exists. 
    86. 86. Q 28       A 62 year old female with a history of hypertension presents with increasing shortness of breath, abdominal pain, and diarrhea. Computed tomography reveals a mass in the appendix and multiple nodules in the liver. Chest x-ray is normal. Serum 5hydroxyindoleacetic acid levels are elevated. Which of the following cardiac disorders is she likely to have? A) Aortic valve stenosis B) Aortic valve regurgitation C) Mitral valve stenosis D) Mitral valve regurgitation E) Tricuspid valve stenosis
    87. 87. A 28    E) Tricuspid valve stenosis This patient has carcinoid syndrome which consists of diarrhea, facial flushing, reactive airways causing shortness of breath, and cardiac valvular disease specifically of right-sided heart valves since the toxins produced by the tumor are filtered by the lungs and never reach the left sided heart valves (unless pulmonary metastasis are present). Others are all left-sided heart valves which would not be affected in carcinoid syndrome unless pulmonary metastasis are present (which is rare).
    88. 88. Q 29      A 29 year old male with no past medical history has been experiencing headaches for the past few months. His blood pressure is noted to be 210/110. Physical examination reveals an S4 heart sound and reduced femoral pulses. Which of the following is associated with his condition? A) Atrial septal defect B) Wolff-Parkinson-White syndrome C) Bicuspid aortic valve D) Mitral valve regurgitation
    89. 89. A 29    C) Bicuspid aortic valve Coarctation of the aorta occurs when the congenital narrowing of the aorta occurs. About two thirds of patients with coarctation of the aorta have a bicuspid aortic valve as well. Depending on the location of the narrowing differing presentations may occur. Infantile coarctation of the aorta presents when the stenosis is proximal or next to the ductus arteriosus. When the ductus arteriosus closes (as it should in normal infants), a severe increase in afterload occurs resulting in congestive heart failure (since blood was normally able to traverse the patent ductus arteriosus resulting in lower resistance, then suddenly is unable to).
    90. 90. Q 30       Which of the following will not cause a continuous murmur? a. An right coronary sinus to the right atrial fistula. b. A stenotic and regurgitant aortic valve. c. A venous hum. d. An aorta-to-pulmonary artery connection. e. A high-grade coarctation of the aorta.
    91. 91. Answer to Q 30  The answer is b: A continuous murmur must extend uninterrupted through S2. An aortapulmonary connection such as a PDA, a coronary sinus-to-RA connection such as with a ruptured sinus of Valsalva, a severe coarctation, and a venous hum all result in continuous murmurs. The combination of a systolic and diastolic murmur of AS and AR is not considered a continuous murmur.
    92. 92. Q 31       An 82 year old male with a history of long standing atrial fibrillation and hypertension presents with increasing dyspnea on exertion. Chest x-ray shows a honeycoming pattern and pulmonary function testing shows a severe restrictive defect. Which of the following is likely causing his symptoms? A) Congestive heart failure B) amiodarone C) ramipril D) sotalol E) diltiazem
    93. 93. A 31        B) amiodarone C) ramipril D) sotalol E) diltiazem Amiodarone used to treat atrial fibrillation and ventricular arrhythmias, can cause pulmonary fibrosis after long-term use. Amiodarone also causes hypothyroidism, hyperthyroidism, and on rare occasion liver failure. Remember to check PFTs (pulmonary function tests), LFTs (liver function tests), and TFTs (thyroid function tests) on all patients on amiodarone. Blue man syndrome can occur as well due to deposition of amiodarone metabolites in the skin resulting in a blue hue.
    94. 94. Q 32      Which of the following about differentiating AS from HCM on examination is true? a. The murmur of AS decreases and the murmur of HCM increases with amyl nitrite. b. Post-PVC, the pulse pressure of HCM decreases and that of AS increases. c. The murmur of AS and HCM decrease with standing. d. With Valsalva, the murmur of AS and HCM decrease.
    95. 95. Answer to Q 32  The answer is b: Amyl nitrite results in an increase in the murmur of AS and HOCM. Valsalva (straining phase) and standing result in an increase of the murmur of HOCM and decreases the murmur of AS. Post-PVC, the murmur of AS and HOCM increases but the pulse pressure of HOCM decreases (Brockenbrough phenomenon) while that of AS increases.
    96. 96. Q 33  A 52 year old female is experiencing difficulty hearing. Which of the following drugs may be the cause?  A) bumetinide  B) clonidine C) minoxidil D) triamterene  
    97. 97. A 33   A) bumetinide Ototoxicity occurs with high dose loop diuretics such as furosemide, bumetinide, or torsemide. Aminoglycosides can cause similar hearing loss (also nephrotoxicity). Remember that congenital ear malformations are associated with congenital kidney problems to help remember the connection between medications that act on the kidney and cause hearing loss such as loop diuretics.
    98. 98. Q 34       Regarding cardiac myxoma, all of the following statements are true except: a. It can arise anywhere within the heart. b. It is the most common primary cardiac tumor. c. Approximately 75% occur in the left atrium. d. Most are familial. e. Myxomas may be associated with syncope, TIA, or stroke
    99. 99. Q 34  Answer is d: Cardiac myxoma is the most common primary cardiac tumor, accounting for 50% of primary cardiac tumors in adults. Though it can be found anywhere in the heart, the most common location is the left atrium attached
    100. 100. Q 35       What of the following malignancies has the highest likelihood of cardiac metastasis? a. Lung cancer b. Renal cell carcinoma c. Melanoma d. Breast cancer e. Colon cancer
    101. 101. Answer to Q 35  Answer is C : The malignancy with the highest likelihood of cardiac metastasis is melanoma, though in absolute numbers, cardiac metastases are more common, with lung and breast cancers reflecting the higher incidence of these cancers.
    102. 102. Q 36      A 55 year old female with a history of congestive heart failure is found to have breast cancer requiring chemotherapy. Which of the following chemotherapeutic agents should be avoided? A) doxorubicin B) bleomycin C) paclitaxel D) cyclophosphamide
    103. 103. A 36  A) doxorubicin  Doxorubicin and daunorubicin are anthracycline chemotherapeutic agents that are well known to cause systolic congestive heart failure especially at higher doses and should be avoided if pre-existing heart failure is present. Bleomycin (B) can cause pulmonary fibrosis. Paclitaxel (C) also causes pulmonary toxicity. Cyclophosphamide (D) can cause hemorrhagic cystitis (resulting in hematuria and bladder pain).   
    104. 104. Q 37       Digitalis is a cardiac glycoside that does all of the following except: a. indirectly activates a Na+/Ca++ exchanger found in the cardiac cell membrane b. inhibits the Na+/K+ ATPase found in the cardiac cell membrane c. increases chronotropy by increasing intracellular Ca+ + d. leads to a sodium gradient across the cardiac cell membrane that is favorable for Ca++ influx e. increases parasympathetic tone
    105. 105. Answer to Q 37   Answer is c: Digitalis inhibits the Na+/K+ ATPase found in the cardiac cell membrane which maintains a high intracellular K+ concentration and high extracellular Na+ concentration. Ca2+ is removed from the cytosol into the extracellular fluid by a sodium-calcium exchange pump driven by the pre-existing Na+ gradient. Inhibiting the Na+/K+ ATPase promotes enhanced Na+/Ca2+ exchange ultimately leading to increased intracellular Ca2+ available to the contractile apparatus increasing myocardial contractility. Chronotropy would not be increased with digitalis and in fact it is often used for the opposite effect of heart rate control in patients with atrial fibrillation.
    106. 106. Pic Quiz 45 years old with recent MI, This Skin lesion was noted on his Leg
    107. 107. Answer 2 pic quiz  Necrobiosis lipoidica of DM  How is it treated ?
    108. 108. Q 38       All of the following are class III recommendations in the treatment of unstable coronary syndromes, except: a. Use of fibrinolytic therapy for non-ST-elevation acute coronary syndromes b. Use of abciximab for conservatively managed high-risk patients who continue to have ischemic symptoms c. The use of a low-molecular-weight heparin instead of unfractionated heparin for conservatively managed unstable coronary syndromes d. Use of nitroglycerin within 24 hours of sildenafil (Viagra) e. Invasive therapy in low-risk patients who present with a chest pain syndrome
    109. 109. Answer to Q 38  Answer is c: There may be a marginal benefit of low-molecularweight heparin over unfractionated heparin for conservatively managed patients, and this strategy is a class IIa recommendation. Nitroglycerin should not be used within 24 hours from the last dose of sildenafil. Fibrinolytics should only be used for ST-elevation myocardial infarctions. Ideally, high-risk patients should be managed invasively, but for high-risk individuals who defer invasive therapy or who have extensive comorbidities and continue to have ischemic symptoms, the use of a glycoprotein IIb/IIIa inhibitor is a class IIa recommdation. However, eptifibitide or tirofiban should be used in this setting, while abciximab should be used only during invasive management.
    110. 110. Q 39       Which of the following are causes of secondary angina OR Type 2 MI (Type 1 Sontaneous)? a. An anemic patient from a gastrointestinal bleed b. A dialysis patient with an arterio-venous fistula c. A dyspneic patient with underlying emphysema d. a and c e. a, b, and c
    111. 111. Answer to Q 39  Answer is e: Anemia, anterior-venous shunting, and hypoxemia can all cause demand ischemia. Note that a left-arm arterio-venous fistula can produce shunting as well as subclavian steal in patients with a previous left internal mammary artery graft.
    112. 112. Q 40       Which of the following is not included in the differential diagnosis for electrocardiographic ST elevations? a. ST-elevation myocardial infarction b. Left ventricular aneurysm c. Hypokalemia d. Pericarditis e. Left ventricular hypertrophy
    113. 113. Answer to Q 40  Answer is C: Among the electrolyte abnormalities, hyperkalemia, not hypokalemia can cause ST elevations that mimic ST-elevation myocardial infarctions.
    114. 114. Q 41       Risk factors for intracranial hemorrhage during administration of fibrinolytics include all of the following except: a. Uncontrolled hypertension b. Advanced age c. Female gender d. Preexisting coagulopathy e. Morbid obesity
    115. 115. Answer to Q 41  Answer is E: Low body weight, not morbid obesity, is a risk factor for intracranial hemorrhage.
    116. 116. Q 42       Digoxin toxicity may present with all the following except? a- Color visual defect b-GI upset c- Bidirectional VT d-headache e –all of the above
    117. 117. Answer to Q 42  E –all of the above
    118. 118. Q 43       Digoxin toxicity is more found except a-young men b- elederly females. c-Renal impairement. d-Liver impairment e- a,d
    119. 119. A 43  E- a,d
    120. 120. Q 44       All of the following clinical findings are consistent with severe mitral stenosis except A. atrial fibrillation B. opening snap late after S2 C. pulmonary vascular congestion D. pulsatile liver E. right-ventricular heave
    121. 121. Answer to Q 44  B. opening snap late after S2
    122. 122. Q 45       A patient is found to have a holosystolic murmur on physical examination.With deep inspiration, the intensity of the murmur increases.This is consistent with which of the following? A. Atrial-septal defect B. Austin Flint murmur C. Carvallo’s sign D. Chronic mitral regurgitation E. Gallavardin effect
    123. 123. Answer to Q 45  C. Carvallo’s sign of TR  Carvallo's sign is a clinical sign found in patients with tricuspid regurgitation. The pansystolic murmur found in this condition becomes louder during inspiration this sign enables it to be distinguished from mitral regurgitation 
    124. 124.   Pectus excavatum Associated Marfan Syndrome
    125. 125. 77 years old male with CHF,CRF
    126. 126. Q 46       Which of the following findings would be suggestive of critical ischemia of the right foot? A. Ankle-brachial index <0.3 B. Ankle-brachial index <0.9 C. Ankle-brachial index >1.2 D. Lack of palpable dorsalis pedis pulse E. Presence of pitting edema of the extremities
    127. 127. Answer to Q 46  A. Ankle-brachial index <0.3
    128. 128. Q 47       All the following electrocardiogram (ECG) findings re suggestive of left ventricular hypertrophy except A. (S in V1 + R in V5 or V6) >35 mm B. R in aVL >11 mm C. R in aVF >20 mm D. (R in I + S in III) >25 mm E. R in aVR >8 mm
    129. 129. Answer to Q47  E. R in aVR >8 mm
    130. 130. Q 48       55 years old saudi male , investigated for recent onset of exertional syncope , found to have AS , the most likely aetiology is ? A. Age-related degeneration B. Dyslipidemia C. Glucose intolerance D. Hypertension E. Obesity
    131. 131. Answer to Q 48  A. Age-related degeneration
    132. 132. Q 49      In peripartum cardiomyopathy Which of the following factors is the most valuable predictor of mortality with subsequent pregnancies? A. Age >30 years B. African ancestry C. Interpartum left ventricular function D. Male child
    133. 133. Answer to Q 49  C. Interpartum left ventricular function
    134. 134. 55 Years old lady with SOB & fatigability ECG & ECHO done
    135. 135. 55 Years old lady with SOB & fatigability ECG & ECHO done NSR , Low Voltage ECG
    136. 136. Moderate Size Pericardial effusion
    137. 137.  Myxedema in Hypothyroidism  Atrial fibrillation might be the sole presentation of thyrotoxicosis. Atrial fibrillation may occur with Hypothyroidism Both Hypo-or Hyperthyroidism may cause Cardiomyopathy, wait for 3- 6 months before repeating ECHO after treament .  
    138. 138. Q 50       HMG-CoA reductase inhibitor reduces coronary events. This Medication will exert all the following beneficial effects except? A. direct action on atheroma progression B. improvement in endothelial-dependent vasomotion C. long-term reduction of serum LDL D. regression of existing coronary stenosis E. stabilization of existing atherosclerotic lesions
    139. 139. Answer to Q 50  D. Regression of existing coronary stenosis
    140. 140.  Tendon xanthomas at the wrists, knees, and achilles, With ostial RCA
    141. 141.  Haemorrhagic herpes zoster
    142. 142. Q 51    Which vein has the highest oxygen saturation? Which vein has the lowest oxygen saturation? In which situation is coronary sinus saturation elevated?
    143. 143. Answer to Q 51  Renal vein has the highest oxygen saturation. Hence the inferior vena caval (IVC) blood is more saturated than superior vena caval blood. The saturation is higher in the inferior vena cava above the renal veins (high IVC) than the low IVC.
    144. 144. Answer Q 51  Coronary sinus has the lowest oxygen saturation as the oxygen extraction is maximum in the coronary circulation. Coronary sinus saturation does not fall with exercise as the extraction reserve is fully utilized in the coronary circulation and increase in oxygen consumption can occur only by increasing the flow
    145. 145. Q 52   Janeway lesion: a) Tender b) Nodular c) Most common in trunk d) Blanches on pressure
    146. 146. A 52   Answer: d) Blanches on pressure Nodular and tender lesions are Osler’s nodes. Janeway lesions are seen on the palms and soles. They are non tender, macular lesions. These are lesions seen in infective endocarditis
    147. 147. Q 53   HACEK organisms causing endocarditis includes: a) Cardiobacterium b) Acinetobacter c) E. coli d) Klebsiella
    148. 148. A 53   Answer: a) Cardiobacterium HACEK is an acronym for a group of gram-negative bacilli: Haemophilus species (Haemophilus parainfluenzae, Haemophilus aphrophilus, Haemophilus paraphrophilus), Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella species. They have a higher potential to produce endocarditis and is responsible for about three percent of native valve endocarditis
    149. 149. Q 54      Which of the following statements about infective endocarditis is wrong? a) Splenomegaly is more common in acute than sub acute infective endocarditis b) Disease manifestation occurs within two weeks of the cause of bacteremia c) Cerebral embolism is more common in the middle cerebral artery territory d) 5% chance of intracranial hemorrhage
    150. 150. A 54  a) Splenomegaly is more common in acute than sub acute infective endocarditis
    151. 151. Q55   Gene defective in Marfan syndrome: a) Collagen b) Fibrillin c) Elastin d) Cathepsin
    152. 152. A 55   b) Fibrillin Marfan syndrome is caused by defects in a gene called fibrillin-1 (FBN1), located on chromosome 15.
    153. 153. Q 56   For blood pressure measurement, least important is: a) Arm cuff at heart level b) Manometer at heart level c) Arm cuff >80% arm circumference d) Manometer should be vertical
    154. 154. A 56  b) Manometer at heart level Manometer need not be at heart level as the difference involved will be only the weight of the air column in the tubing, which is negligible compared to that of mercury. But the mercury level should be at the level of your eye to avoid parallax error. A slanting mercury column will increase the reading. Position of arm cuff is important as level difference will alter the recorded pressure which will depend on the column of blood in the vessel above or below the heart level. Cuffs which are shorter will not provide adequate compression during inflation and is likely to record falsely elevated pressures
    155. 155. Q 57   QT interval shortens in: a) Hypothermia b) Hypokalemia c) Hypocalcemia d) Acidosis
    156. 156. A57   Answer: d) Acidosis Acidosis is associated with shift of potassium out of the cells and hyperkalemia. QT prolongation in hypocalcemia is due to ST segment prolongation. Digitalis and congenital short QT syndrome are other causes of a short QT interval.
    157. 157. 60 years old male with CHF
    158. 158.  Acromegally
    159. 159. Q 58   According to BMI (body mass index), the cut off for obesity is: a) 25 Kg/m2 b) 30 Kg/m2 c) 35 Kg/m2 d) 40 Kg/m2
    160. 160. A58       Answer: b) 30 Kg/m2 The International Classification of adult underweight, overweight and obesity according to BMI (World Health Organization) is as follows: Underweight <18.50 Normal range 18.50 – 24.99 Overweight ≥25.00 Pre-obese 25.00 – 29.99 Obese ≥30.00 Obese class I: 30.00 – 34.99 Obese class II: 35.00 – 39.99 Obese class III: ≥40.00
    161. 161. Q 59
    162. 162. A 59 Tamponade can be acute or subacute, depending on the etiology: Acute: Rapid accumulation (usually blood) within a stiff, noncompliant pericardium Subacute: Gradual increase of a preexisting effusion, with limited accommodative pericardial stretch
    163. 163. Q 60
    164. 164. A60
    165. 165. Q 61
    166. 166. A 61
    167. 167. Q 62
    168. 168. A 62  D- VMA
    169. 169. Q 63 ???????
    170. 170. Q 63
    171. 171. A 63  Dextrocardia Associated with situs inversus and kartageners syndrome.  Sometimes polysplenism 
    172. 172. Q 64 ?????????? 25 years old with Flu
    173. 173. A 64       Diffuse ST elevation with PR segment depression Inferior Leads.This is Acute Pericarditis. Treatment First Line A- High dose ASA 2- grams per day B- Paracetamol C-Cholchicine Avoid NSAIDs and steroids at least as first line , in post MI.
    174. 174. Q 65 ?????? 60 male with CAD Where is the delta waves
    175. 175. WPW syndrome with pseudo inferior MI pattern
    176. 176. A 65       WPW Next step is Echo is needed because of increased incidence of associated structural heart disease with WPW. Treatment A- Asymptomatic Leave Alone B- Symptomatic offer EPS + ablation C- found and difficult to ablate in Ebstein anomaly
    177. 177. Q 66
    178. 178. A 66  Atrial Flutter with 2:1 Block.
    179. 179. B
    180. 180.   25 year old female has a butterfly rash on her face, photosensitivity and oral ulcers. She is diagnosed with SLE. Which of the following is another characteristic of SLE? a) polyuria  b) polydipsia  c) polyphagia  d) pericarditis  e) Philadelphia chromosom
    181. 181.  d) pericarditis 
    182. 182.   You are reviewing a patient in the intensive care unit with acute renal failure. Which antimicrobial agent is LEAST likely to require a dose adjustment in renal failure? a) gentamicin b) amitriptyline c) carbonic anhydrase inhibitors d) streptomycin e) erythromycin
    183. 183.  e) erythromycin
    184. 184.   A 44 year old woman with a long history of multiple sclerosis complains of severe pain on the right side of her face. The most likely pathology is in the a) the right facial nerve b) the right long thoracic nerve c) the right trigeminal nerve d) the left trigeminal nerve e) the right recurrent laryngeal nerve
    185. 185. Correct Answer: C Pain typical of trigeminal neuralgia occasionally affects patients with lesions in the brain stem as a result of multiple sclerosis. They may also occur with vasculitis involving the descending root of the fifth cranial nerve. Trigeminal neuralgia usually occurs after other symptoms of MS. Of all patients with MS, however, about 10% have facial pain as a presentation, and other symptoms of MS may not appear for 6 yea 
    186. 186. Thank much you very