Cardiology Practice Questions

Q: A 41-year-old man presents to his primary care provider because of chest pain with activity for the past 6 months. Past medical history is significant for appendectomy at age 12 and hypertension, and diabetes mellitus type 2 that is poorly controlled. He takes metformin and lisinopril but admits that he is bad at remembering to take them everyday. His father had a heart attack at 41 and 2 stents were placed in his heart. His mother is healthy. He drinks alcohol occasionally and smokes a half of a pack of cigarettes a day. He is a sales executive and describes his work as stressful. Today, the blood pressure is 142/85 and the body mass index (BMI) is 28.5 kg/m2. A coronary angiogram shows > 75% narrowing of the left anterior descending coronary artery. Which of the following is most significant in this patient?

Diabetes mellitus. ***Diabetes mellitus*** - **Diabetes mellitus** is a significant risk factor for **atherosclerosis** and contributes to accelerated progression of **coronary artery disease (CAD)**, often leading to more widespread and severe disease. - Poorly controlled diabetes can cause **endothelial dysfunction**, increasing oxidative stress and inflammation, which are key processes in **plaque formation** and destabilization. *Obesity* - **Obesity** (BMI 28.5 kg/m2) is a risk factor for **CAD** but often acts through associated conditions like **hypertension**, **diabetes**, and **dyslipidemia**. - While it contributes to overall cardiovascular risk, it is less directly pathogenic than diabetes which independently accelerates **atherosclerosis**. *Family history* - The patient's father had a **heart attack at 41**, which is a significant risk factor for **early-onset CAD**. - However, the patient has multiple modifiable risk factors (smoking, hypertension, diabetes) that are independently and more directly contributing to his current presentation. *Hypertension* - **Hypertension** (142/85 mmHg) is a major modifiable risk factor that causes **endothelial damage** and promotes **atherosclerosis**. - While important, the patient's **poorly controlled diabetes mellitus** often creates a more aggressive environment for plaque formation and progression compared to hypertension alone. *Smoking* - **Smoking** is a potent, modifiable risk factor that causes direct vascular injury, promotes **thrombogenesis**, and contributes to **atherosclerosis**. - Although highly detrimental, smoking is one of several significant risk factors; **diabetes mellitus**, with its systemic metabolic impact, can be considered more broadly influential in the severity and diffuse nature of **CAD**.

Q: A 75-year-old man is brought to the emergency room after being found unresponsive in his home. His medical history is unknown. On physical examination he does not demonstrate any spontaneous movement of his extremities and is unable to respond to voice or painful stimuli. You notice that he is able blink and move his eyes in the vertical plane. Based on these physical exam findings, you expect that magnetic resonance angiogram will most likely reveal an occlusion in which of the following vessels?

Basilar artery. ***Basilar artery*** - The patient's presentation with **quadriplegia**, inability to respond to stimuli, and preserved **vertical eye movements** and blinking is characteristic of **locked-in syndrome**. - **Locked-in syndrome** is most commonly caused by an **occlusion of the basilar artery**, leading to infarction of the ventral pons while sparing the tegmentum. *Anterior cerebral artery* - Occlusion of the **anterior cerebral artery** typically causes **contralateral leg weakness** and sensory loss, and sometimes **abulia** or urinary incontinence. - It does not explain the widespread motor paralysis affecting all four limbs or the preservation of vertical eye movements in an otherwise unresponsive patient. *Anterior spinal artery* - Occlusion of the **anterior spinal artery** causes an **anterior spinal cord syndrome**, characterized by bilateral weakness and loss of pain/temperature sensation below the lesion, with preserved proprioception and vibration sense. - This presentation does not include the characteristic signs of **brainstem dysfunction** seen in locked-in syndrome. *Posterior cerebral artery* - An occlusion in the **posterior cerebral artery** typically leads to **contralateral homonymous hemianopia**, and depending on the branch occluded, can also cause memory deficits or thalamic pain. - It does not account for the extensive motor paralysis or the pattern of preserved vertical eye movements seen in locked-in syndrome. *Anterior inferior cerebellar artery* - Occlusion of the **anterior inferior cerebellar artery (AICA)** typically results in **lateral pontine syndrome**, which includes ipsilateral facial weakness, hearing loss, cerebellar ataxia, and contralateral loss of pain and temperature sensation. - While it affects the pons, AICA occlusion does not typically cause the complete quadriplegia and preservation of vertical eye movements characteristic of locked-in syndrome.

Q: A 78-year-old woman comes to the physician because of a 2-month history of right-sided headache and generalized fatigue. She also has pain, weakness, and stiffness of her shoulders and hips. The stiffness is worse in the morning and usually improves after 60–90 minutes of activity. Three months ago, she fell and hit her head on the kitchen countertop. Her temperature is 38.1°C (100.6°F). Examination shows normal muscle strength in bilateral upper and lower extremities; range of motion of the shoulder and hip is mildly limited by pain. Deep tendon reflexes are 2+ bilaterally. Her erythrocyte sedimentation rate is 68 mm/h and serum creatine kinase is 36 mg/dL. Which of the following is the most likely underlying cause of this patient's headache?

Large-vessel vasculitis. ***Large-vessel vasculitis*** - The patient's age (78 years), new-onset **right-sided headache**, and elevated **ESR** (68 mm/h) are highly suggestive of **giant cell arteritis (GCA)**, which is a form of large-vessel vasculitis. - The associated symptoms of **polymyalgia rheumatica** (pain, weakness, and stiffness in shoulders and hips, worse in the morning, improving with activity) further support this diagnosis. *Hyperthyroidism* - While hyperthyroidism can cause fatigue and muscle weakness, it is typically associated with **tachycardia**, **weight loss**, and **tremors**, which are not reported here. - An elevated **ESR** and localized headache would not be primary features of hyperthyroidism. *Cluster headache* - Characterized by **severe, unilateral periorbital or temporal pain**, often accompanied by ipsilateral **autonomic symptoms** (e.g., lacrimation, nasal congestion, ptosis). - It typically occurs in younger men and does not present with systemic symptoms like elevated ESR or polymyalgia rheumatica. *Tension headache* - Usually described as a **bilateral, pressing or tightening pain** of mild to moderate intensity, without associated systemic symptoms. - It is not associated with an elevated **ESR** or the symptoms of polymyalgia rheumatica. *Polyarteritis nodosa* - This is a **necrotizing vasculitis** primarily affecting medium-sized arteries, often presenting with symptoms like **skin lesions**, **neuropathy**, and **renal involvement**. - It does not typically cause headache from direct cranial artery inflammation or polymyalgia rheumatica, as seen in GCA.

Q: A 76-year-old woman comes in for a routine checkup with her doctor. She is concerned that she feels tired most days and has difficulty doing her household chores. She complains that she gets fatigued and breathless with mild exertion. Past medical history is significant for diabetes mellitus, chronic kidney disease from prolonged elevated blood sugar, and primary biliary cirrhosis. Medications include lisinopril, insulin, and metformin. Family medicine is noncontributory. She drinks one beer every day. Today, she has a heart rate of 98/min, respiratory rate of 17/min, blood pressure of 110/65 mm Hg, and a temperature of 37.0°C (98.6°F). General examination shows that she is pale and haggard looking. She has a heartbeat with a regular rate and rhythm and her lungs are clear to auscultation bilaterally. A complete blood count (CBC) is as follows: Leukocyte count: 12,000/mm3 Red blood cell count: 3.1 million/mm3 Hemoglobin: 11.0 g/dL MCV: 85 fL MCH: 27 pg/cell Platelet count: 450,000/mm3 Fecal occult blood test is negative. What is the most likely cause of her anemia?

Chronic kidney disease. ***Chronic kidney disease*** - **Chronic kidney disease (CKD)** is a common cause of **normocytic, normochromic anemia** due to decreased production of **erythropoietin** by the kidneys. - This patient's history of CKD, alongside her **normocytic anemia (MCV 85 fL)**, makes this the most likely cause. *Acute bleeding* - Acute bleeding would typically present with signs of **hypovolemia** (e.g., hypotension, tachycardia) and potentially a **reticulocytosis** as the bone marrow compensates, neither of which are seen here. - The **negative fecal occult blood test** and stable vital signs also argue against acute or chronic gastrointestinal bleeding. *Alcoholism* - Chronic alcoholism can lead to anemia, often **macrocytic** due to **folate deficiency**, or less commonly microcytic if associated with iron deficiency from GI bleeding. - While she drinks one beer daily, this amount is unlikely to directly cause significant anemia, especially given her **normocytic MCV**. *Liver disease* - **Primary biliary cirrhosis (PBC)** can cause anemia through various mechanisms, including **hemolysis**, **folate deficiency**, or bleeding from **portal hypertension**. - However, PBC-related anemia is often microcytic or macrocytic, and her **normocytic MCV** and the more direct link to CKD make it less likely to be the primary cause. *Colorectal cancer* - **Colorectal cancer** can cause anemia due to **chronic blood loss**, which would typically lead to **iron deficiency anemia** (microcytic anemia). - The patient has a **normocytic anemia (MCV 85 fL)** and a **negative fecal occult blood test**, making this diagnosis highly unlikely.

Q: A 27-year-old man presents to the emergency department with weakness and a fever for the past week. The patient is homeless and has a past medical history of alcohol and IV drug abuse. His temperature is 102°F (38.9°C), blood pressure is 107/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a tremulous patient with antecubital scars and a murmur over the left lower sternal border. Blood cultures are drawn and the patient is started on vancomycin and ceftriaxone and is admitted to the ICU. The patient's fever and symptoms do not improve despite antibiotic therapy for which the initial identified organism is susceptible. Cultures currently reveal MRSA as one of the infective organisms. Which of the following is the best next step in management?

Transesophageal echocardiography. ***Transesophageal echocardiography*** - The patient's history of **IV drug abuse**, **fever**, **new murmur**, and identification of **MRSA** strongly suggest **infective endocarditis**. - A Transesophageal echocardiography (TEE) is the **most sensitive and specific imaging modality** to detect vegetations, abscesses, or valvular damage, which is crucial for guiding further management. *Obtain new blood cultures* - While repeating blood cultures can be useful to confirm eradication or identify new pathogens, the initial blood cultures already revealed MRSA, which is a common cause of **endocarditis in IV drug users**. - The immediate priority given the lack of improvement and high suspicion of endocarditis is to visualize the heart valves for vegetations. *CT scan of the chest* - A CT scan of the chest would be useful to look for complications such as **septic emboli in the lungs** or other pulmonary pathologies. - However, it would not provide the detailed visualization of heart valves necessary to diagnose or rule out valvular vegetations characteristic of endocarditis. *Nafcillin and piperacillin-tazobactam* - **Nafcillin** is active against **methicillin-susceptible Staphylococcus aureus (MSSA)**, but the patient's cultures already identified **MRSA**. - **Piperacillin-tazobactam** is a broad-spectrum antibiotic but not a first-line treatment for MRSA infections and would not be appropriate given the identified pathogen. *Vancomycin and gentamicin* - The patient is already on **Vancomycin**, which is appropriate for MRSA, but adding **gentamicin** without clear indication would not be the best next step. - While gentamicin is sometimes used as an adjunct in specific endocarditis regimens (e.g., enterococcal), the primary concern here is the lack of clinical improvement despite appropriate MRSA coverage, pointing towards a structural cardiac issue.

Q: A 61-year-old white man presents to the emergency department because of progressive fatigue and shortness of breath on exertion and while lying down. He has had type 2 diabetes mellitus for 25 years and hypertension for 15 years. He is taking metformin and captopril for his diabetes and hypertension. He has smoked 10 cigarettes per day for the past 12 years and drinks alcohol occasionally. His temperature is 36.7°C (98.0°F) and blood pressure is 130/60 mm Hg. On physical examination, his arterial pulse shows a rapid rise and a quick collapse. An early diastolic murmur is audible over the left upper sternal border. Echocardiography shows severe chronic aortic regurgitation with a left ventricular ejection fraction of 55%–60% and mild left ventricular hypertrophy. Which of the following is an indication for aortic valve replacement in this patient?

Presence of symptoms of left ventricular dysfunction. ***Presence of symptoms of left ventricular dysfunction*** - The patient's symptoms of **progressive fatigue**, **shortness of breath on exertion**, and **orthopnea** (shortness of breath while lying down) are clear indicators of **left ventricular dysfunction** due to severe aortic regurgitation. - In patients with **severe chronic aortic regurgitation**, the development of symptoms is a Class I indication for **aortic valve replacement**, regardless of the ejection fraction. *Old age* - While age can influence surgical risk, it is **not an independent indication** for aortic valve replacement in the absence of severe symptoms or significant ventricular dysfunction. - The decision for surgery is primarily based on **symptom status** and objective measures of cardiac function. *Ejection fraction > 55%* - An ejection fraction of 55%-60% is considered **normal** or mildly reduced, indicating that the left ventricle still effectively pumps blood. - Aortic valve replacement is typically indicated when the **ejection fraction falls below 50%**, even in asymptomatic patients, or with symptoms. *Long history of diabetes mellitus* - A long history of diabetes mellitus is a significant **comorbidity** that increases surgical risk and cardiovascular complications but is **not an independent indication** for valve replacement itself. - The decision to operate is based on valve disease severity and its impact on cardiac function, not the duration of other chronic illnesses. *Long history of systemic hypertension* - Similar to diabetes, hypertension is a significant **comorbidity** that can exacerbate cardiac disease and increase surgical risk but does **not directly indicate** the need for aortic valve replacement. - Hypertension management is crucial, but the primary indication for surgery stems from the **severity of aortic regurgitation** and its symptomatic consequences.

Question 1

A 41-year-old man presents to his primary care provider because of chest pain with activity for the past 6 months. Past medical history is significant for appendectomy at age 12 and hypertension, and diabetes mellitus type 2 that is poorly controlled. He takes metformin and lisinopril but admits that he is bad at remembering to take them everyday. His father had a heart attack at 41 and 2 stents were placed in his heart. His mother is healthy. He drinks alcohol occasionally and smokes a half of a pack of cigarettes a day. He is a sales executive and describes his work as stressful. Today, the blood pressure is 142/85 and the body mass index (BMI) is 28.5 kg/m2. A coronary angiogram shows > 75% narrowing of the left anterior descending coronary artery. Which of the following is most significant in this patient?

Accepted Answer

Diabetes mellitus

Answer

Obesity

Answer

Family history

Answer

Hypertension

Answer

Smoking

Question 2

A 46-year-old Caucasian male with past medical history of HIV (CD4: 77/mm^3), hypertension, hyperlipidemia, and osteoarthritis presents to the emergency department with sudden weakness of his right hand. He reports that the weakness has gradually been getting worse and that this morning he dropped his cup of coffee. He has never had anything like this happen to him before, although he was hospitalized last year for pneumonia. He reports inconsistent adherence to his home medications, which include raltegravir, tenofovir, emtricitabine, TMP-SMX, hydrochlorothiazide, pravastatin, and occasional ibuprofen. His father died of a myocardial infarction at the age of 60, and his mother suffered a stroke at the age of 72. The patient's temperature is 102.6°F (39.2°C), blood pressure is 156/92 mmHg, pulse is 88/min, and respirations are 18/min. On neurological exam, he has 3/5 strength in the distal muscles of the right extremity with preserved sensation. His neurological exam is normal in all other extremities.

Which of the following is the best next step in management?

Accepted Answer

Head CT

Answer

Serology for Toxoplasma-specific IgG antibodies

Answer

Empiric treatment with pyrimethamine-sulfadiazine

Answer

Empiric treatment with itraconazole

Answer

Lumbar puncture

Question 3

A 61-year-old man comes to the emergency department because of a 3-hour history of pain and redness of both eyes. He has new blurry vision and difficulty opening his eyes in bright surroundings. He has not had any recent trauma. He uses contact lenses daily. He had surgery on his left eye 6 months ago after a penetrative trauma caused by a splinter. His vital signs are within normal limits. Physical examination shows congestion of the perilimbal conjunctivae bilaterally. Visual acuity is decreased bilaterally. Ocular movements are normal. Slit-lamp examination shows a cornea with normal contours and leukocytes in the anterior chambers of both eyes. The eyelids, eyelashes, and lacrimal ducts show no abnormalities. Which of the following is the most likely cause of this patient's condition?

Accepted Answer

Autoimmune reaction against retinal antigens

Answer

Impaired drainage of aqueous humor

Answer

Age-related denaturation of lens proteins

Answer

Reactivation of herpes zoster virus

Answer

Corneal infection with Pseudomonas aeruginosa

Question 4

A 45-year-old man presents to his primary care physician complaining of increasingly frequent headaches. He also reports that his hats and wedding ring do not fit anymore. His temperature is 99°F (37.2°C), blood pressure is 145/80 mmHg, pulse is 85/min, and respirations are 16/min. Physical examination is notable for frontal bossing, a prominent jaw, and an enlarged tongue. A chest radiograph reveals mild cardiomegaly. Serum insulin-like growth factor 1 levels are significantly elevated. Which of the following complications is this patient most likely to develop?

Accepted Answer

Carpal tunnel syndrome

Answer

Medullary thyroid carcinoma

Answer

Pheochromocytoma

Answer

Osteoid osteoma

Answer

Osteosarcoma

Question 5

A 75-year-old man is brought to the emergency room after being found unresponsive in his home. His medical history is unknown. On physical examination he does not demonstrate any spontaneous movement of his extremities and is unable to respond to voice or painful stimuli. You notice that he is able blink and move his eyes in the vertical plane. Based on these physical exam findings, you expect that magnetic resonance angiogram will most likely reveal an occlusion in which of the following vessels?

Accepted Answer

Basilar artery

Answer

Anterior cerebral artery

Answer

Anterior spinal artery

Answer

Posterior cerebral artery

Answer

Anterior inferior cerebellar artery

Question 6

A 78-year-old woman comes to the physician because of a 2-month history of right-sided headache and generalized fatigue. She also has pain, weakness, and stiffness of her shoulders and hips. The stiffness is worse in the morning and usually improves after 60–90 minutes of activity. Three months ago, she fell and hit her head on the kitchen countertop. Her temperature is 38.1°C (100.6°F). Examination shows normal muscle strength in bilateral upper and lower extremities; range of motion of the shoulder and hip is mildly limited by pain. Deep tendon reflexes are 2+ bilaterally. Her erythrocyte sedimentation rate is 68 mm/h and serum creatine kinase is 36 mg/dL. Which of the following is the most likely underlying cause of this patient's headache?

Accepted Answer

Large-vessel vasculitis

Answer

Hyperthyroidism

Answer

Cluster headache

Answer

Tension headache

Answer

Polyarteritis nodosa

Question 7

A 76-year-old woman comes in for a routine checkup with her doctor. She is concerned that she feels tired most days and has difficulty doing her household chores. She complains that she gets fatigued and breathless with mild exertion. Past medical history is significant for diabetes mellitus, chronic kidney disease from prolonged elevated blood sugar, and primary biliary cirrhosis. Medications include lisinopril, insulin, and metformin. Family medicine is noncontributory. She drinks one beer every day. Today, she has a heart rate of 98/min, respiratory rate of 17/min, blood pressure of 110/65 mm Hg, and a temperature of 37.0°C (98.6°F). General examination shows that she is pale and haggard looking. She has a heartbeat with a regular rate and rhythm and her lungs are clear to auscultation bilaterally. A complete blood count (CBC) is as follows:
Leukocyte count: 12,000/mm3
Red blood cell count: 3.1 million/mm3
Hemoglobin: 11.0 g/dL
MCV: 85 fL
MCH: 27 pg/cell
Platelet count: 450,000/mm3
Fecal occult blood test is negative. What is the most likely cause of her anemia?

Accepted Answer

Chronic kidney disease

Answer

Acute bleeding

Answer

Alcoholism

Answer

Liver disease

Answer

Colorectal cancer

Question 8

A 27-year-old man presents to the emergency department with weakness and a fever for the past week. The patient is homeless and has a past medical history of alcohol and IV drug abuse. His temperature is 102°F (38.9°C), blood pressure is 107/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a tremulous patient with antecubital scars and a murmur over the left lower sternal border. Blood cultures are drawn and the patient is started on vancomycin and ceftriaxone and is admitted to the ICU. The patient's fever and symptoms do not improve despite antibiotic therapy for which the initial identified organism is susceptible. Cultures currently reveal MRSA as one of the infective organisms. Which of the following is the best next step in management?

Accepted Answer

Transesophageal echocardiography

Answer

Obtain new blood cultures

Answer

CT scan of the chest

Answer

Nafcillin and piperacillin-tazobactam

Answer

Vancomycin and gentamicin

Question 9

A 61-year-old white man presents to the emergency department because of progressive fatigue and shortness of breath on exertion and while lying down. He has had type 2 diabetes mellitus for 25 years and hypertension for 15 years. He is taking metformin and captopril for his diabetes and hypertension. He has smoked 10 cigarettes per day for the past 12 years and drinks alcohol occasionally. His temperature is 36.7°C (98.0°F) and blood pressure is 130/60 mm Hg. On physical examination, his arterial pulse shows a rapid rise and a quick collapse. An early diastolic murmur is audible over the left upper sternal border. Echocardiography shows severe chronic aortic regurgitation with a left ventricular ejection fraction of 55%–60% and mild left ventricular hypertrophy. Which of the following is an indication for aortic valve replacement in this patient?

Accepted Answer

Presence of symptoms of left ventricular dysfunction

Answer

Old age

Answer

Ejection fraction > 55%

Answer

Long history of diabetes mellitus

Answer

Long history of systemic hypertension

Question 10

A 38-year-old man is brought to the emergency department after losing consciousness upon rising from his chair at work. The patient has had progressive cough, shortness of breath, fever, and chills for 6 days but did not seek medical attention for these symptoms. He appears distressed, flushed, and diaphoretic. He is 170 cm (5 ft 7 in) tall and weighs 120 kg (265 lbs); BMI is 41.5 kg/m2. His temperature is 39.4°C (102.9°F), pulse is 129/min, respirations are 22/min, and blood pressure is 91/50 mm Hg when supine. Crackles and bronchial breath sounds are heard over the right posterior hemithorax. A 2/6 midsystolic blowing murmur is heard along the left upper sternal border. Examination shows diffuse diaphoresis, flushed extremities, and dullness to percussion over the right posterior hemithorax. The abdomen is soft and nontender. Multiple nurses and physicians have been unable to attain intravenous access. A large-bore central venous catheter is inserted into the right internal jugular vein by standard sterile procedure. Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

Administer intravenous levofloxacin

Answer

Bronchoscopy

Answer

Chest X-ray

Answer

CT scan of the chest

Answer

Echocardiogram

Cardiology — MCQs

Cardiology — MCQs

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