Cardiology Practice Questions

Q: A 34-year-old man presents to his primary care provider for evaluation of nocturnal cough and dyspnea. He has been a smoker for the past 15 years with a 7.5-pack-year smoking history. He has no significant medical history and takes no medications. His blood pressure is 118/76 mm Hg, the heart rate is 84/min, the respiratory rate is 15/min, and the temperature is 37.0°C (98.6°F). A sputum sample shows Charcot-Leyden crystals and Curschmann spirals. What is the most likely diagnosis?

Atopic asthma. ***Atopic asthma*** - The presence of **Charcot-Leyden crystals** and **Curschmann spirals** in the sputum is pathognomonic for asthma, indicating a chronic inflammatory airway process with eosinophilic infiltration and mucus plugging. - **Nocturnal cough** and **dyspnea** are classic symptoms of asthma, particularly when associated with airway hyper-responsiveness. *Chronic obstructive pulmonary disease* - While a 7.5-pack-year smoking history is notable, **Charcot-Leyden crystals** and **Curschmann spirals** are not typically seen in COPD sputum and are more characteristic of asthma. - COPD usually presents with persistent and progressive dyspnea and cough, which is continuously present in contrast to episodic nocturnal symptoms in asthma. *Pneumonia* - Pneumonia is an **acute infection** of the lungs, typically presenting with fever, productive cough with purulent sputum, and often systemic signs of infection, which are absent here. - Sputum microscopy in pneumonia usually shows bacteria, neutrophils, and inflammatory cells, not Charcot-Leyden crystals or Curschmann spirals. *Bronchiectasis* - Characterized by **permanent dilation of the bronchi** due to chronic inflammation and infection, leading to chronic cough with copious, purulent sputum. - While it can cause dyspnea, the sputum findings of Charcot-Leyden crystals and Curschmann spirals are not typical for bronchiectasis, which often features bacterial cultures. *Panacinar emphysema* - A type of COPD primarily affecting the **respiratory bronchioles and alveolar ducts and sacs**, often associated with alpha-1 antitrypsin deficiency or smoking. - While smoking is a risk factor, the sputum findings in this case are not consistent with emphysema, which primarily involves alveolar destruction and less sputum production, and not these specific crystalline and spiral formations.

Q: A 49-year-old woman presents to her primary care physician for a general check up. She has not seen a primary care physician for the past 20 years but states she has been healthy during this time frame. She had breast implants placed when she was 29 years old but otherwise has not had any surgeries. She is concerned about her risk for breast cancer given her friend was recently diagnosed. Her temperature is 97.0°F (36.1°C), blood pressure is 114/64 mmHg, pulse is 70/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is unremarkable. Which of the following is the most appropriate workup for breast cancer for this patient?

Mammography. ***Mammography*** - The patient is 49 years old, making regular screening **mammography** the most appropriate initial workup for breast cancer, as guidelines recommend screening for women over 40. - While breast implants can make mammograms more challenging, specialized techniques like **Eklund views** can be used to visualize breast tissue effectively. *No intervention indicated at this time* - This is incorrect because the patient's age (49) places her in the demographic for routine **breast cancer screening**. - Delaying screening in this age group would increase the risk of detecting cancer at a later, less treatable stage. *Sentinel node biopsy* - **Sentinel node biopsy** is a procedure typically performed after a breast cancer diagnosis to stage the disease and determine lymph node involvement. - It is not a screening tool and is therefore inappropriate as an initial workup in an asymptomatic patient without a known mass. *BRCA genetic testing* - **BRCA genetic testing** is indicated for individuals with a strong family history of breast or ovarian cancer, or those diagnosed with specific types of breast cancer at a young age. - This patient has no such risk factors mentioned, making genetic testing unnecessary as a first-line screening step. *Ultrasound* - **Ultrasound** is often used as a follow-up to an abnormal mammogram or to evaluate specific palpable masses, especially in younger women with dense breasts. - It is not typically recommended as a primary screening tool for breast cancer in a 49-year-old woman, especially without prior mammographic findings.

Q: A 31-year-old female presents to the clinic with excessive anxiety and palpitations for a month. She also mentions loss of 2.72 kg (6 lb) of her weight over the last month. Her past medical history is insignificant. She does not smoke nor does she drink alcohol. Her temperature is 37°C (98.6°F), pulse is 81/min, respiratory rate is 23/min, and blood pressure is 129/88 mm Hg. On examination, mild exophthalmos is noted. Heart and lung examination is normal including cardiac auscultation. What is the most likely cause of her symptoms?

Thyroid stimulating antibodies. ***Thyroid stimulating antibodies*** - The patient's symptoms of **anxiety**, **palpitations**, **weight loss**, and **exophthalmos** are characteristic of **hyperthyroidism**, specifically **Graves' disease**. - **Graves' disease** is an autoimmune condition caused by **thyroid-stimulating immunoglobulins (TSI)**, which act as agonists at the TSH receptor, leading to excessive thyroid hormone production. *Inadequate iodine in her diet* - **Iodine deficiency** is a common cause of **hypothyroidism** and **goiter**, where the thyroid gland is unable to produce sufficient thyroid hormones. - This condition presents with symptoms such as **fatigue, weight gain, constipation**, and **cold intolerance**, which are opposite to the patient's presentation. *Lithium use* - **Lithium** is primarily used as a mood stabilizer and is known to cause **hypothyroidism** or, less commonly, euthyroid goiter due to its interference with thyroid hormone synthesis and release. - This would not explain the patient's hyperthyroid symptoms of anxiety, palpitations, and weight loss. *Use of propylthiouracil* - **Propylthiouracil (PTU)** is an **antithyroid medication** used to treat hyperthyroidism by inhibiting thyroid hormone synthesis. - Its use would lead to a reduction in thyroid hormone levels and would not be the cause of the patient's hyperthyroid symptoms. *Medullary carcinoma of the thyroid* - **Medullary thyroid carcinoma** is a neuroendocrine tumor that arises from parafollicular C cells and secretes **calcitonin**. - It typically presents as a thyroid nodule and usually does not cause symptoms of hyperthyroidism unless very advanced and aggressive.

Q: A 25-year old man comes to the physician because of fatigue over the past 6 months. He has been to the emergency room several times over the past 3 years for recurrent shoulder and patella dislocations. Physical examination shows abnormal joint hypermobility and skin hyperextensibility. A high-frequency mid-systolic click is heard on auscultation. Which of the following is most likely to result in an earlier onset of this patient’s auscultation finding?

Abrupt standing. ***Abrupt standing*** - Abrupt standing reduces **preload** (venous return), leading to a smaller left ventricle and earlier prolapse of the mitral valve, causing an **earlier systolic click**. - This maneuver decreases **left ventricular volume**, thereby reducing the tension on the chordae tendineae and facilitating earlier mitral valve billowing into the atrium. *Hand grip* - Hand grip is an **isometric exercise** that increases **afterload** and **left ventricular volume**. - Increased left ventricular volume would cause the mitral valve leaflets to become taut earlier in systole, thus **delaying** the click rather than making it earlier. *Rapid squatting* - Rapid squatting rapidly increases **venous return** and **systemic vascular resistance**, increasing **preload** and **afterload**. - This leads to increased left ventricular volume, which would **delay** the onset of the systolic click as the mitral valve takes longer to prolapse. *Leaning forward* - Leaning forward is typically used to accentuate the murmur of **aortic regurgitation** or **pericardial friction rubs**, not to alter the timing of a mitral valve prolapse click. - It can sometimes make heart sounds clearer by bringing the heart closer to the chest wall but does not directly affect cardiac preload or afterload significantly to change click timing. *Valsalva release phase* - The release phase of Valsalva maneuver is characterized by an **increase in venous return** and **cardiac output** after the initial decrease during straining. - This increase in left ventricular volume would **delay** the mitral valve prolapse click, as it increases the tension on the mitral valve apparatus.

Q: A 41-year-old woman presents to urgent care with complaints of a new rash. On review of systems, she endorses ankle pain bilaterally. Otherwise, she has no additional localized complaints. Physical examination reveals numerous red subcutaneous nodules overlying her shins, bilaterally. Complete blood count shows leukocytes 7,300, Hct 42.0%, Hgb 14.0 g/dL, mean corpuscular volume (MCV) 88 fL, and platelets 209. Chest radiography demonstrates bilateral hilar adenopathy with clear lungs. Which of the following is the most likely diagnosis?

Sarcoidosis. ***Sarcoidosis*** - The combination of **erythema nodosum** (red subcutaneous nodules on shins), **bilateral hilar adenopathy**, and **ankle arthralgia** (ankle pain) in a young woman is highly characteristic of **Lofgren's syndrome**, a common acute presentation of sarcoidosis. - While other conditions can cause hilar adenopathy or erythema nodosum, the triad presented makes sarcoidosis the most likely diagnosis. *Yersiniosis* - Can cause **erythema nodosum** and arthralgia, but **bilateral hilar adenopathy** is not a typical feature of *Yersinia* infection. - Often associated with **gastrointestinal symptoms** (e.g., diarrhea) which are not mentioned here. *Coccidioidomycosis* - Can cause **erythema nodosum** and affect the lungs, but typically presents with **pulmonary infiltrates** or **nodules**, not just isolated bilateral hilar adenopathy. - Endemic to specific geographic regions (e.g., southwestern US), which is not specified but relevant for exposure. *Histoplasmosis* - Can cause **hilar adenopathy** and **erythema nodosum**, especially in acute disseminated forms. - However, it's more common in individuals exposed to **bird or bat droppings** (Ohio and Mississippi River valleys), and a fungal infection would likely present with more systemic symptoms or specific lung findings beyond just hilar adenopathy. *Chlamydophila pneumoniae* - This atypical bacterial infection can cause respiratory symptoms and, rarely, reactive arthritis or erythema nodosum. - However, **bilateral hilar adenopathy** is not a typical prominent feature of *Chlamydophila pneumoniae* infection.

Q: A 37-year-old man presents to the clinic for evaluation of a chronic cough that has increased in frequency and severity for the past 2 days. His cough began 2 weeks ago but was not as bothersome as now. He states that he can hardly get to sleep because he is coughing all the time. Upon further questioning, he says that he had a low-grade fever, runny nose, and fatigue. However, everything resolved except for his cough. He has a history of hyperlipidemia and takes simvastatin. His vital signs are within normal limits. On physical examination, the patient is in no apparent distress and is alert and oriented. His head is normocephalic with non-tender sinuses. Sclerae are not jaundiced and there are no signs of conjunctivitis. Nares are clear without erythema. Examination of the pharynx shows erythematous mucosa without exudate. Lungs are clear to auscultation bilaterally. Posteroanterior chest X-ray shows no regions of consolidation, hypervascularity or effusion. Which of the following is the next best step in the management of this patient?

Supportive treatment. ***Supportive treatment*** - This patient likely has a **post-viral cough**, which is a self-limiting condition that typically resolves on its own without specific medication. His history of a recent common cold and the absence of bacterial infection signs (normal vital signs, clear chest X-ray, no purulent sputum) support this. - Management involves **symptomatic relief** with measures like cough suppressants, lozenges, and hydration, rather than antibiotics which are ineffective against viral infections. *Azithromycin* - Azithromycin is an **antibiotic** used to treat bacterial infections, particularly atypical respiratory pathogens. - There is no clinical or radiological evidence suggesting a bacterial infection (e.g., fever, crackles, consolidation on X-ray) in this patient, making antibiotic therapy inappropriate. *Amoxicillin* - Amoxicillin is a **beta-lactam antibiotic** primarily used for common bacterial respiratory infections like strep throat or sinusitis. - The patient's symptoms are inconsistent with a bacterial infection requiring amoxicillin; his cough is likely viral in origin and there are no signs of bacterial sinusitis or pneumonia. *Levofloxacin* - Levofloxacin is a **fluoroquinolone antibiotic** typically reserved for more severe bacterial infections or when resistance to other antibiotics is suspected. - Using a broad-spectrum antibiotic like levofloxacin without clear evidence of a bacterial infection is inappropriate and contributes to **antibiotic resistance**. *Azithromycin with amoxicillin-clavulanate* - This combination represents broad-spectrum antibiotic coverage, often indicated for atypical and typical bacterial co-infections. - Prescribing multiple antibiotics without any indication of a bacterial infection is **unnecessary** and carries risks of side effects and promoting antibiotic resistance.

Q: A 75-year-old man comes to the physician because of fatigue and decreased urine output for 1 week. He takes ibuprofen as needed for lower back pain and docusate for constipation. Physical examination shows tenderness to palpation over the lumbar spine. There is pedal edema. Laboratory studies show a hemoglobin concentration of 8.7 g/dL, a serum creatinine concentration of 2.3 mg/dL, and a serum calcium concentration of 12.6 mg/dL. Urine dipstick is negative for blood and protein. Which of the following is the most likely underlying cause of this patient's symptoms?

Immunoglobulin light chains. ***Immunoglobulin light chains*** - The patient's symptoms (fatigue, decreased urine output, **anemia**, **hypercalcemia**, **elevated creatinine**, and **lumbar spine tenderness**) are highly suggestive of **multiple myeloma**. - **Immunoglobulin light chains** (**Bence Jones proteins**) are overproduced in multiple myeloma and are nephrotoxic, leading to **cast nephropathy** and acute kidney injury. *Hypersensitivity reaction* - A hypersensitivity reaction involving the kidneys typically presents as **acute interstitial nephritis** with fever, rash, and eosinophilia, which are absent in this patient. - While NSAIDs can cause interstitial nephritis, the presence of **hypercalcemia** and **anemia** points away from this as the primary cause. *Antiglomerular basement membrane antibodies* - These antibodies cause **Goodpasture syndrome**, characterized by rapidly progressive glomerulonephritis, often with pulmonary hemorrhage. - The urine dipstick negative for blood and protein makes glomerulonephritis less likely, and the co-occurrence of **hypercalcemia** and **anemia** does not fit. *Anti double-stranded DNA antibodies* - These antibodies are characteristic of **systemic lupus erythematosus (SLE)**, which can cause **lupus nephritis**. - While SLE can cause kidney dysfunction and anemia, the prominent **hypercalcemia** and specific bone pain are not typical features of SLE-related kidney disease. *Renal deposition of AL amyloid* - **AL amyloidosis** can present with kidney dysfunction and fatigue. However, significant **hypercalcemia** and a hemoglobin of 8.7 g/dL without other signs of chronic disease are less typical of amyloidosis alone. - The combination of **anemia, hypercalcemia, renal failure**, and bone pain points more specifically to **multiple myeloma**.

Q: A 42-year-old woman presents with complaints of a sharp, stabbing pain in her chest upon coughing and inhalation. She says that the pain started acutely 2 days ago and has progressively worsened. Her past medical history is significant for a rash on her face, joint pains, and fatigue for the past few weeks. The patient is afebrile and her vital signs are within normal limits. On physical examination, there is a malar macular rash that spares the nasolabial folds. There is a friction rub at the cardiac apex that does not vary with respiration. Which of the following additional physical examination signs would most likely be present in this patient?

Chest pain that improves with leaning forward. ***Chest pain that improves with leaning forward*** - The patient's symptoms (malar rash, joint pains, fatigue, chest pain worse with coughing/inhalation, and an apical friction rub) are highly suggestive of **pericarditis secondary to Systemic Lupus Erythematosus (SLE)**. - Pain from pericarditis is classically **relieved by leaning forward** as this position decreases the pressure on the inflamed pericardium. *Mid-systolic click* - A mid-systolic click is characteristic of **mitral valve prolapse**, which is not directly indicated by the patient's presenting symptoms or primary diagnosis of pericarditis. - While SLE can be associated with various cardiac manifestations, a mid-systolic click is not a direct presentation of acute pericarditis. *Displaced apical impulse* - A displaced apical impulse typically suggests **ventricular enlargement** or conditions that shift the heart, such as a large **pericardial effusion**. - While pericarditis can lead to effusion, the presence of a friction rub and acute onset does not immediately imply a significant enough effusion to displace the apical impulse. *High-pitched diastolic murmur* - A high-pitched diastolic murmur is characteristic of **aortic regurgitation** or, less commonly, **pulmonic regurgitation**. - These are valvular abnormalities not directly linked to the acute pericarditis described in the patient's presentation. *Pain improvement with inspiration* - **Pleuritic chest pain**, often seen in conditions like pleurisy or pulmonary embolism, *worsens* with inspiration, not improves. - The patient's pain worsening with inhalation rules out improvement with inspiration as a likely sign.

Question 1

A 32-year-old woman is supposed to undergo tooth extraction surgery. Physical examination is unremarkable, and she has a blood pressure of 126/84 mm Hg and regular pulse of 72/min. She takes no medications. Which of the following cardiac conditions would warrant antibiotic prophylaxis to prevent infective endocarditis in this patient?

Accepted Answer

Past history of infective endocarditis

Answer

Hypertrophic obstructive cardiomyopathy (HOCM)

Answer

Mitral regurgitation

Answer

Ventricular septal defect (VSD)

Answer

Implantable cardioverter defibrillator (ICD)

Question 2

A 34-year-old man presents to his primary care provider for evaluation of nocturnal cough and dyspnea. He has been a smoker for the past 15 years with a 7.5-pack-year smoking history. He has no significant medical history and takes no medications. His blood pressure is 118/76 mm Hg, the heart rate is 84/min, the respiratory rate is 15/min, and the temperature is 37.0°C (98.6°F). A sputum sample shows Charcot-Leyden crystals and Curschmann spirals. What is the most likely diagnosis?

Accepted Answer

Atopic asthma

Answer

Chronic obstructive pulmonary disease

Answer

Pneumonia

Answer

Bronchiectasis

Answer

Panacinar emphysema

Question 3

A 49-year-old woman presents to her primary care physician for a general check up. She has not seen a primary care physician for the past 20 years but states she has been healthy during this time frame. She had breast implants placed when she was 29 years old but otherwise has not had any surgeries. She is concerned about her risk for breast cancer given her friend was recently diagnosed. Her temperature is 97.0°F (36.1°C), blood pressure is 114/64 mmHg, pulse is 70/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is unremarkable. Which of the following is the most appropriate workup for breast cancer for this patient?

Accepted Answer

Mammography

Answer

No intervention indicated at this time

Answer

Sentinel node biopsy

Answer

BRCA genetic testing

Answer

Ultrasound

Question 4

A 31-year-old female presents to the clinic with excessive anxiety and palpitations for a month. She also mentions loss of 2.72 kg (6 lb) of her weight over the last month. Her past medical history is insignificant. She does not smoke nor does she drink alcohol. Her temperature is 37°C (98.6°F), pulse is 81/min, respiratory rate is 23/min, and blood pressure is 129/88 mm Hg. On examination, mild exophthalmos is noted. Heart and lung examination is normal including cardiac auscultation. What is the most likely cause of her symptoms?

Accepted Answer

Thyroid stimulating antibodies

Answer

Inadequate iodine in her diet

Answer

Lithium use

Answer

Use of propylthiouracil

Answer

Medullary carcinoma of the thyroid

Question 5

A 25-year old man comes to the physician because of fatigue over the past 6 months. He has been to the emergency room several times over the past 3 years for recurrent shoulder and patella dislocations. Physical examination shows abnormal joint hypermobility and skin hyperextensibility. A high-frequency mid-systolic click is heard on auscultation. Which of the following is most likely to result in an earlier onset of this patient’s auscultation finding?

Accepted Answer

Abrupt standing

Answer

Hand grip

Answer

Rapid squatting

Answer

Leaning forward

Answer

Valsalva release phase

Question 6

A 41-year-old woman presents to urgent care with complaints of a new rash. On review of systems, she endorses ankle pain bilaterally. Otherwise, she has no additional localized complaints. Physical examination reveals numerous red subcutaneous nodules overlying her shins, bilaterally. Complete blood count shows leukocytes 7,300, Hct 42.0%, Hgb 14.0 g/dL, mean corpuscular volume (MCV) 88 fL, and platelets 209. Chest radiography demonstrates bilateral hilar adenopathy with clear lungs. Which of the following is the most likely diagnosis?

Accepted Answer

Sarcoidosis

Answer

Yersiniosis

Answer

Coccidioidomycosis

Answer

Histoplasmosis

Answer

Chlamydophila pneumoniae

Question 7

A 37-year-old man presents to the clinic for evaluation of a chronic cough that has increased in frequency and severity for the past 2 days. His cough began 2 weeks ago but was not as bothersome as now. He states that he can hardly get to sleep because he is coughing all the time. Upon further questioning, he says that he had a low-grade fever, runny nose, and fatigue. However, everything resolved except for his cough. He has a history of hyperlipidemia and takes simvastatin. His vital signs are within normal limits. On physical examination, the patient is in no apparent distress and is alert and oriented. His head is normocephalic with non-tender sinuses. Sclerae are not jaundiced and there are no signs of conjunctivitis. Nares are clear without erythema. Examination of the pharynx shows erythematous mucosa without exudate. Lungs are clear to auscultation bilaterally. Posteroanterior chest X-ray shows no regions of consolidation, hypervascularity or effusion. Which of the following is the next best step in the management of this patient?

Accepted Answer

Supportive treatment

Answer

Azithromycin

Answer

Amoxicillin

Answer

Levofloxacin

Answer

Azithromycin with amoxicillin-clavulanate

Question 8

A 75-year-old man comes to the physician because of fatigue and decreased urine output for 1 week. He takes ibuprofen as needed for lower back pain and docusate for constipation. Physical examination shows tenderness to palpation over the lumbar spine. There is pedal edema. Laboratory studies show a hemoglobin concentration of 8.7 g/dL, a serum creatinine concentration of 2.3 mg/dL, and a serum calcium concentration of 12.6 mg/dL. Urine dipstick is negative for blood and protein. Which of the following is the most likely underlying cause of this patient's symptoms?

Accepted Answer

Immunoglobulin light chains

Answer

Hypersensitivity reaction

Answer

Antiglomerular basement membrane antibodies

Answer

Anti double-stranded DNA antibodies

Answer

Renal deposition of AL amyloid

Question 9

A 63-year-old man presents to his primary care provider complaining of changes in his vision. He says that he has been having transient episodes of "shimmering lights" and generalized blurring of his vision for the past 3 months. He is disturbed by this development as he worries it may interfere with his job as a bus driver. He additionally reports a 12-pound weight loss over this time unaccompanied by a change in appetite, and his gout flares have grown more frequent despite conforming to his recommended diet and allopurinol. His temperature is 98.0°F (36.7°C), blood pressure is 137/76 mmHg, pulse is 80/min, and respirations are 18/min. Hemoglobin and hematocrit obtained the previous day were 18.1 g/dL and 61%, respectively. Peripheral blood screening for JAK2 V617F mutation is positive. Which of the following findings is most likely expected in this patient?

Accepted Answer

Decreased erythrocyte sedimentation rate

Answer

Schistocytes on peripheral smear

Answer

Decreased oxygen saturation

Answer

Thrombocytopenia

Answer

Increased erythropoietin levels

Question 10

A 42-year-old woman presents with complaints of a sharp, stabbing pain in her chest upon coughing and inhalation. She says that the pain started acutely 2 days ago and has progressively worsened. Her past medical history is significant for a rash on her face, joint pains, and fatigue for the past few weeks. The patient is afebrile and her vital signs are within normal limits. On physical examination, there is a malar macular rash that spares the nasolabial folds. There is a friction rub at the cardiac apex that does not vary with respiration. Which of the following additional physical examination signs would most likely be present in this patient?

Accepted Answer

Chest pain that improves with leaning forward

Answer

Mid-systolic click

Answer

Displaced apical impulse

Answer

High-pitched diastolic murmur

Answer

Pain improvement with inspiration

Cardiology — MCQs

Cardiology — MCQs

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