Cardiology Practice Questions

Q: A 45-year-old woman presents to the clinic for a routine examination. She has a chronic history of systemic lupus erythematosus, diagnosed at age 27. Medications include hydroxychloroquine and low-dose prednisone. She has had no recent flare-ups and is compliant with her medication. Anticardiolipin and anti-beta-2 glycoprotein-1 antibodies are negative, and she has had no history of thrombi or emboli. Physical examination is normal except for mild bilateral tenderness and swelling of the knees. Creatinine and GFR are normal. Which of the following is the next best step in management to monitor disease activity?

Anti-dsDNA antibody levels. ***Anti-dsDNA antibody levels*** - **Anti-dsDNA antibodies** correlate well with **disease activity** in SLE, especially with **lupus nephritis**, making them a useful marker for monitoring. - While her GFR is normal now, monitoring these antibodies can help detect early changes or increased risk of renal involvement. *Anti-Smith antibody levels* - **Anti-Smith antibodies** are highly specific for SLE but do not typically fluctuate with disease activity, so they are not useful for monitoring. - They are primarily used for diagnosis rather than follow-up. *Urinalysis and renal biopsy* - A **renal biopsy** is an invasive procedure and is not indicated at this time given her normal creatinine and GFR, and reported absence of recent flare-ups. - While **urinalysis** is important for monitoring, it is not the *next best step* to broadly assess systemic disease activity, and the question asks for monitoring disease activity, not just kidney function. *Reduce dosage and taper off hydroxychloroquine* - **Hydroxychloroquine** is a cornerstone of SLE management, even in quiescent disease, to prevent flares and organ damage. - Reducing its dosage without evidence of sustained remission or adverse effects is generally not recommended and could lead to a flare. *Arthrocentesis and synovial fluid analysis* - **Arthrocentesis** is a diagnostic procedure to identify the cause of joint effusion but is not a routine measure to monitor overall SLE disease activity. - Her mild knee tenderness and swelling could be part of her chronic SLE and does not automatically warrant an invasive joint procedure as the primary next step for overall disease monitoring.

Q: A 65-year-old man is brought to the emergency department by his wife because of progressive lethargy and confusion during the past 2 days. His wife reports that he has been complaining of nausea and increased urination for the past 5 days. He also developed a cough 1 week ago. He has a history of a cerebrovascular accident 3 years ago and was diagnosed with hypertension 10 years ago. Current medications include lisinopril and aspirin. His temperature is 38.5°C (101.3°F), pulse is 114/min, respirations are 15/min, and blood pressure is 108/75 mm Hg. He is somnolent and oriented only to person. Examination shows dry mucous membranes and decreased skin turgor. Crackles are heard at the left lung base. The remainder of the physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

Blood glucose measurement. ***Blood glucose measurement*** - The patient's symptoms of **lethargy, confusion, nausea, increased urination, and dehydration** are highly suggestive of **hyperglycemia**, possibly diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), especially in the setting of a recent infection (cough, fever). - Rapid determination of blood glucose levels is crucial for immediate diagnosis and initiation of appropriate treatment, which can be life-saving. *Chest x-ray* - While crackles at the lung base suggest **pneumonia**, a chest x-ray would confirm the diagnosis but is not the most immediate next step given the patient's severe neurological symptoms and signs of metabolic derangement. - Addressing the metabolic emergency (hyperglycemia) takes precedence for initial stabilization. *Broad-spectrum antibiotics* - The patient has signs of infection (cough, fever, crackles) and potential sepsis, making antibiotics important, but **uncontrolled hyperglycemia can mimic or worsen sepsis** and needs immediate attention. - Antibiotics should be considered after initial assessment and stabilization of immediate life threats, and often after obtaining cultures. *Arterial blood gas analysis* - An ABG would be useful to assess **acid-base status** in suspected DKA or lactic acidosis, but it is a more invasive and time-consuming test than a point-of-care blood glucose measurement. - Determining blood glucose will guide the urgency and interpretation of an ABG. *Serum calcium measurement* - While hypercalcemia can cause lethargy and confusion, the patient's symptoms of **polyuria** and **nausea** are also prominent in diabetic emergencies, and his past medical history does not strongly suggest hypercalcemia. - Blood glucose measurement is a more targeted and urgent test given the full constellation of symptoms.

Q: A 25-year-old female presents with recent muscle weakness, fatigue, and constipation. Physical examination reveals a bradycardic patient with cool, dry skin. Which of the following lab values would be most likely to be present with this patient's presentation?

Elevated serum TSH. ***Elevated serum TSH*** - This patient presents with classic signs and symptoms of **primary hypothyroidism**: muscle weakness, fatigue, constipation, bradycardia, and cool, dry skin. - **Elevated TSH** is the hallmark laboratory finding in primary hypothyroidism, occurring in virtually all cases as the pituitary attempts to stimulate the underactive thyroid gland. - This is the **most likely** lab abnormality to be present and is the first-line diagnostic test for suspected hypothyroidism. *Elevated serum CK* - While **creatine kinase (CK)** can be elevated in hypothyroid myopathy due to muscle breakdown, this occurs in only 30-50% of hypothyroid patients. - It is a **secondary consequence** rather than a primary diagnostic finding, making it less likely to be present than elevated TSH. - CK elevation would not be the first test ordered in a patient with suspected hypothyroidism. *Activating TSH-receptor immunoglobulins* - These antibodies are characteristic of **Graves' disease**, which causes **hyperthyroidism**, not the hypothyroid symptoms presented. - The patient's **bradycardia**, **cool/dry skin**, and **constipation** are inconsistent with hyperthyroidism, which typically presents with tachycardia, warm/moist skin, and diarrhea. *Hypocalcemia* - While muscle weakness can occur with **hypocalcemia**, the constellation of findings including **fatigue**, **constipation**, **bradycardia**, and **cool, dry skin** do not point to a primary calcium disorder. - Hypocalcemia typically presents with perioral numbness, paresthesias, tetany, and positive Chvostek's/Trousseau's signs. *Elevated serum calcitonin* - An elevated **calcitonin** level is primarily associated with **medullary thyroid carcinoma**. - This condition does not explain the patient's constellation of symptoms, particularly the generalized hypothyroid signs and does not cause TSH-mediated thyroid dysfunction.

Q: A 33-year-old woman presents to the clinic complaining of a 9-month history of weight loss, fatigue, and a general sense of malaise. She additionally complains of an unusual sensation in her chest upon rapidly rising from a supine to a standing position. Current vitals include a temperature of 36.8°C (98.2°F), pulse of 72/min, blood pressure of 118/63 mm Hg, and a respiratory rate of 15/min. Her BMI is 21 kg/m2. Auscultation demonstrates an early-mid diastole low-pitched sound at the apex of the heart. A chest X-ray reveals a poorly demarcated abnormality in the heart and requires CT imaging for further analysis. What would most likely be seen on CT imaging?

Tumor within the left atrium. ***Tumor within the left atrium*** - The patient's symptoms of **weight loss, fatigue, malaise**, and **orthostatic symptoms** (unusual chest sensation upon rising) are classic for a **cardiac myxoma**, particularly one arising in the left atrium. - The auscultation finding of an **early-mid diastole low-pitched sound at the apex** (often called a "tumor plop") is highly suggestive of a left atrial myxoma prolapsing into the mitral valve orifice during diastole. *Tumor within the right atrium* - While cardiac myxomas can occur in the right atrium, left atrial myxomas are significantly more common (approximately 75% of cases). - A right atrial tumor would typically cause symptoms related to **right-sided heart failure** (e.g., peripheral edema, jugular venous distension) and would likely present with a different auscultatory finding, such as a right-sided "tumor plop" or tricuspid flow murmur. *Connection between the pulmonary artery and aorta* - This describes a **patent ductus arteriosus (PDA)**, a congenital heart defect. - A PDA typically presents with a **continuous "machinery-like" murmur** and symptoms like exertional dyspnea or failure to thrive, not the systemic symptoms or "tumor plop" described. *Fistula between the right and left atria* - This describes an **atrial septal defect (ASD)**. - ASDs typically cause a **fixed split S2** and can lead to right heart enlargement and pulmonary hypertension over time, but they do not cause a "tumor plop" or the constellation of systemic symptoms seen here. *Normal cardiac imaging* - Given the patient's clear symptoms, the suggestive auscultation finding, and an abnormal chest X-ray, it is highly unlikely that cardiac imaging would be normal. - The clinical picture strongly points to a structural cardiac abnormality, making normal imaging a very improbable finding.

Q: A 45-year-old chronic smoker presents to the physician with a complaint of worsening left shoulder pain for several months which has become acutely worse the past 2 weeks and now radiates down his left arm. Physical examination reveals a palpable 2 x 1.5 cm supraclavicular lymph node along with decreased grip strength in his left hand. Examination of the face reveals partial ptosis of the left eyelid and miosis of the left eye. Laboratory testing shows the following values: Sodium (Na+) 135 mEq/L Potassium (K+) 3.6 mEq/L Chloride (Cl-) 100 mEq/L BUN 12 mg/dL Creatinine (Cr) 0.6 mg/dL Magnesium (Mg2+) 1.5 mg/dL Phosphate 3 mg/dL Calcium (Ca2+) 8.5 mg/dL An X-ray of the chest reveals a soft tissue mass at the apex of the left lung with possible involvement of the first rib. What is the most likely diagnosis?

Pancoast tumor. **Pancoast tumor** - The patient presents with **shoulder pain**, **Horner's syndrome** (ptosis, miosis), **lymph node involvement**, **decreased grip strength** (due to brachial plexus involvement), and a **mass at the lung apex on X-ray**. These are classic signs of a Pancoast tumor, a type of **non-small cell lung cancer** often seen in **chronic smokers**. - The location of the tumor at the **lung apex** allows it to invade surrounding structures such as the **brachial plexus** (causing arm pain and weakness), adjacent ribs, vertebrae, and the **sympathetic chain** (leading to Horner's syndrome). *Mesothelioma* - **Mesothelioma** is a rare and aggressive cancer primarily associated with **asbestos exposure**, not typically presenting as an apical lung mass. - It usually affects the **pleura** and can cause shortness of breath and chest pain, but not specifically the constellation of symptoms observed here. *Pulmonary hamartoma* - A **pulmonary hamartoma** is a benign lung tumor that is typically **asymptomatic** and discovered incidentally. - It does not typically cause symptoms such as **Horner's syndrome**, **shoulder pain**, or **lymphadenopathy** as described in the patient's presentation. *Subclavian aneurysm* - A **subclavian aneurysm** could cause arm pain due to nerve compression or embolization, but it would not explain the **lung mass**, **Horner's syndrome**, or **supraclavicular lymph node** found in this patient. - It is a vascular abnormality, not a primary lung lesion. *Osteophyte* - An **osteophyte**, or bone spur, is a bony outgrowth typically associated with **osteoarthritis** and can cause pain due to nerve compression or joint impingement. - While it can cause arm pain, it does not explain the **lung mass**, **Horner's syndrome**, or **lymph node involvement** seen in this case.

Q: A 33-year-old Honduran woman presents to your clinic with shortness of breath. She reports that her symptoms have progressed over the past several months and are now impacting her quality of life because she cannot complete her usual exercise routine. She recalls "normal" childhood illnesses, including sore throats and fevers, but never required hospitalization. Vital signs are temperature 37 degrees Celsius, blood pressure 110/70 mm Hg, heart rate 109/min, respiratory rate 22/min, and oxygen saturation 98% on room air. Physical exam reveals a holosystolic, high-pitched, blowing murmur at the cardiac apex. One would expect that this murmur would also:

Increase with squatting or handgrip. ***Increase with squatting or handgrip*** - The patient's symptoms (shortness of breath, history of repeated sore throats, and a **holosystolic, high-pitched, blowing murmur at the cardiac apex**) are highly suggestive of **mitral regurgitation**, likely due to **rheumatic heart disease**. - **Dynamic maneuvers** like **squatting** (increases preload and afterload) and **handgrip** (increases afterload) will **increase the intensity** of the murmur in mitral regurgitation as they increase left ventricular volume and pressure. *Also have a mid-systolic click loudest at S2* - A **mid-systolic click** followed by a late systolic murmur is characteristic of **mitral valve prolapse**, not typically severe mitral regurgitation. - The description of a **holosystolic murmur** at the apex does not fit the timing and quality of a mitral valve prolapse murmur. *Increase with inspiration* - Murmurs that typically **increase with inspiration** are those originating from the **right side of the heart**, such as tricuspid regurgitation. - A mitral regurgitation murmur, originating from the left side, is generally **unaffected or slightly decreased** by inspiration. *Radiate to the neck* - Murmurs that classically **radiate to the neck** are those of **aortic stenosis**, due to the turbulent flow ejecting into the carotid arteries. - Mitral regurgitation typically **radiates to the axilla** or left sternal border, not the neck. *Have a characteristic machine-like sound* - A **continuous, machinery-like murmur** is the classic description of a **patent ductus arteriosus (PDA)**. - This murmur is typically heard in congenital heart disease and is distinct from the holosystolic murmur of mitral regurgitation.

Question 1

A 45-year-old woman presents to the clinic for a routine examination. She has a chronic history of systemic lupus erythematosus, diagnosed at age 27. Medications include hydroxychloroquine and low-dose prednisone. She has had no recent flare-ups and is compliant with her medication. Anticardiolipin and anti-beta-2 glycoprotein-1 antibodies are negative, and she has had no history of thrombi or emboli. Physical examination is normal except for mild bilateral tenderness and swelling of the knees. Creatinine and GFR are normal. Which of the following is the next best step in management to monitor disease activity?

Accepted Answer

Anti-dsDNA antibody levels

Answer

Anti-Smith antibody levels

Answer

Urinalysis and renal biopsy

Answer

Reduce dosage and taper off hydroxychloroquine

Answer

Arthrocentesis and synovial fluid analysis

Question 2

A 65-year-old man is brought to the emergency department by his wife because of progressive lethargy and confusion during the past 2 days. His wife reports that he has been complaining of nausea and increased urination for the past 5 days. He also developed a cough 1 week ago. He has a history of a cerebrovascular accident 3 years ago and was diagnosed with hypertension 10 years ago. Current medications include lisinopril and aspirin. His temperature is 38.5°C (101.3°F), pulse is 114/min, respirations are 15/min, and blood pressure is 108/75 mm Hg. He is somnolent and oriented only to person. Examination shows dry mucous membranes and decreased skin turgor. Crackles are heard at the left lung base. The remainder of the physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

Accepted Answer

Blood glucose measurement

Answer

Chest x-ray

Answer

Broad-spectrum antibiotics

Answer

Arterial blood gas analysis

Answer

Serum calcium measurement

Question 3

A 25-year-old female presents with recent muscle weakness, fatigue, and constipation. Physical examination reveals a bradycardic patient with cool, dry skin. Which of the following lab values would be most likely to be present with this patient's presentation?

Accepted Answer

Elevated serum TSH

Answer

Hypocalcemia

Answer

Elevated serum CK

Answer

Activating TSH-receptor immunoglobulins

Answer

Elevated serum calcitonin

Question 4

A 65-year-old man comes to the physician because of fatigue and nausea for 1 week. Over the past six months, he has had to get up twice every night to urinate. Occasionally, he has had discomfort during urination. He has arterial hypertension. His father died of renal cell carcinoma. Current medications include ramipril. His temperature is 37.3°C (99.1°F), pulse is 88/min, and blood pressure is 124/78 mm Hg. The abdomen is soft and nontender. Cardiac and pulmonary examinations show no abnormalities. Rectal examination shows a symmetrically enlarged and smooth prostate. Serum studies show:
Hemoglobin 14.9 g/dL
Leukocyte count 7500/mm3
Platelet count 215,000/mm3
Serum
Na+ 136 mEq/L
Cl- 101 mEq/L
K+ 4.9 mEq/L
HCO3- 23 mEq/L
Glucose 95 mg/dL
Urea nitrogen 25 mg/dL
Creatinine 1.9 mg/dL
PSA 2.1 ng/mL (normal <4 ng/mL)
Urine
Blood negative
Protein 1+
Glucose negative
RBC casts negative
Which of the following is the most appropriate next step in management?

Accepted Answer

Renal ultrasonography

Answer

Ureteral stenting

Answer

CT scan of the abdomen and pelvis

Answer

Four-glass test

Answer

Transrectal ultrasonography

Question 5

A 33-year-old woman presents to the clinic complaining of a 9-month history of weight loss, fatigue, and a general sense of malaise. She additionally complains of an unusual sensation in her chest upon rapidly rising from a supine to a standing position. Current vitals include a temperature of 36.8°C (98.2°F), pulse of 72/min, blood pressure of 118/63 mm Hg, and a respiratory rate of 15/min. Her BMI is 21 kg/m2. Auscultation demonstrates an early-mid diastole low-pitched sound at the apex of the heart. A chest X-ray reveals a poorly demarcated abnormality in the heart and requires CT imaging for further analysis. What would most likely be seen on CT imaging?

Accepted Answer

Tumor within the left atrium

Answer

Connection between the pulmonary artery and aorta

Answer

Fistula between the right and left atria

Answer

Normal cardiac imaging

Answer

Tumor within the right atrium

Question 6

A 32-year-old HIV positive female known to be non-adherent to her treatment regimen, presents to the hospital with the complaint of new-onset headaches. Her vital signs are only significant for a low-grade fever. Neurological examination reveals right-sided upper motor neuron signs, as well as inattention and difficulty with concentration. The patient currently does not have a primary medical provider. A CT of the patients head is shown in the image below. What is the next best step in management for this patient?

Accepted Answer

Begin treatment with pyrimethamine-sulfadiazine

Answer

Begin treatment with acyclovir

Answer

Perform an analysis for 14-3-3 protein levels

Answer

Begin treatment with albendazole and corticosteroids

Answer

Perform a biopsy of the lesion

Question 7

A 23-year-old woman presents to the emergency department with pain and frequent urination. She states she has felt uncomfortable with frequent small-volume urinary voids for the past 3 days, which have progressively worsened. The patient has no past medical history. She currently smokes 1 pack of cigarettes per day and engages in unprotected sex with 2 male partners. Her temperature is 103°F (39.4°C), blood pressure is 127/68 mmHg, pulse is 97/min, respirations are 17/min, and oxygen saturation is 98% on room air. Cardiac, pulmonary, and abdominal exams are within normal limits. There is tenderness upon palpation of the left costovertebral angle and the left flank. Urine is collected and a pregnancy test is negative. Which of the following is the best next step in management?

Accepted Answer

Levofloxacin and outpatient follow-up

Answer

Ceftriaxone and hospital admission

Answer

Analgesics, encourage oral fluid intake, and discharge

Answer

Abscess drainage and IV antibiotics

Answer

Nitrofurantoin

Question 8

A 47-year-old man with a history of diabetes mellitus presents for a primary care visit. His diabetes is well controlled on metformin, with fasting glucose concentrations between 110–150 mg/dl. His blood pressure on multiple office visits are between 115-130/75-85 mmHg. Today his temperature is 98°F (36.7 °C), blood pressure is 125/80 mmHg, pulse is 86/min, and respirations are 15/min. Labs are obtained with the following results:

Hemoglobin A1c: 6.7%
Glucose: 120 mg/dl
Cholesterol (plasma): 190 mg/dL
Urine albumin: 60mg/24hr

Which of the following treatments is effective in slowing the progression of the most likely cause of this patient's abnormal albumin result?

Accepted Answer

Enalapril

Answer

No effective treatments

Answer

Aspirin

Answer

Metformin

Answer

Simvastatin

Question 9

A 45-year-old chronic smoker presents to the physician with a complaint of worsening left shoulder pain for several months which has become acutely worse the past 2 weeks and now radiates down his left arm. Physical examination reveals a palpable 2 x 1.5 cm supraclavicular lymph node along with decreased grip strength in his left hand. Examination of the face reveals partial ptosis of the left eyelid and miosis of the left eye. Laboratory testing shows the following values:
Sodium (Na+) 135 mEq/L
Potassium (K+) 3.6 mEq/L
Chloride (Cl-) 100 mEq/L
BUN 12 mg/dL
Creatinine (Cr) 0.6 mg/dL
Magnesium (Mg2+) 1.5 mg/dL
Phosphate 3 mg/dL
Calcium (Ca2+) 8.5 mg/dL
An X-ray of the chest reveals a soft tissue mass at the apex of the left lung with possible involvement of the first rib. What is the most likely diagnosis?

Accepted Answer

Pancoast tumor

Answer

Mesothelioma

Answer

Pulmonary hamartoma

Answer

Subclavian aneurysm

Answer

Osteophyte

Question 10

A 33-year-old Honduran woman presents to your clinic with shortness of breath. She reports that her symptoms have progressed over the past several months and are now impacting her quality of life because she cannot complete her usual exercise routine. She recalls "normal" childhood illnesses, including sore throats and fevers, but never required hospitalization. Vital signs are temperature 37 degrees Celsius, blood pressure 110/70 mm Hg, heart rate 109/min, respiratory rate 22/min, and oxygen saturation 98% on room air. Physical exam reveals a holosystolic, high-pitched, blowing murmur at the cardiac apex. One would expect that this murmur would also:

Accepted Answer

Increase with squatting or handgrip

Answer

Also have a mid-systolic click loudest at S2

Answer

Increase with inspiration

Answer

Radiate to the neck

Answer

Have a characteristic machine-like sound

Cardiology — MCQs

Cardiology — MCQs

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