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Explanation - Q: 1.1
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The correct answer is B. This woman has many of the classic symptoms of
heart failure, with symptoms of both poor forward cardiac output (fatigue, poor
appetite) and of vascular congestion in both the right and left atria (edema,
abdominal distension that may be ascites, cardiomegaly, pulmonary vascular
congestion and effusions seen on chest x-ray, dyspnea with exertion, and
paroxysmal nocturnal dyspnea.)
Acute leukemia (choice A) is a potential cause of fatigue, poor energy, and
poor nutritional status (which can cause edema and pleural effusion). Usually
some abnormality will be apparent, most commonly pancytopenia, due to
replacement of bone marrow with leukemic cells; the leukocyte count may be
elevated due to the presence of leukemic cells in the peripheral blood. They
often present with bleeding or infectious complications of pancytopenia.
Anemia could potentially cause a murmur due to elevated cardiac output, but
an acute leukemia would not typically cause cardiomegaly or pulmonary
edema.
Fibromyalgia (choice C) is a potential cause of fatigue, poor energy, and poor
sleep, especially in women ages 25-45: its principal sign, however, is diffuse
musculoskeletal pain and stiffness, with characteristic tender trigger points. It
is not consistent with this patient's chest x-ray abnormalities or cardiac and
lung findings.
Based on examination, this patient could certainly have hypothyroidism
(choice D). Symptoms are usually insidious in onset and include fatigue, poor
appetite with weight gain, poor sleep and possibly, obstructive sleep apnea.
Patients often complain of constipation, cold intolerance, stiffness and muscle
cramping, as well as decreased intellectual activity. Severe hypothyroidism
can result in cardiomegaly, pericardial effusion, and symptoms of cardiac
failure. The skin often appears dry, rough, and doughy in texture. The normal
TSH, however, makes hypothyroidism in this patient very unlikely: The TSH is
nearly always elevated, as most hypothyroidism is primary, which means the
pituitary is secreting maximal TSH in an attempt to stimulate a hypofunctional
thyroid gland. Rarely, TSH may be normal or depressed (even undetectable)
in pituitary or hypothalamic failure. To rule this out, one might test first for T4
and T3 levels. Normal levels of these, in conjunction with the normal TSH,
would rule out hypothyroidism as a cause of this clinical presentation.
Major depression (choice E) should always be in the differential for a patient
who presents with disturbances in sleep, appetite, and energy, and can also
result in weight loss or gain. These "vegetative signs" of depression may be
the presenting abnormality in a depressed patient who does not note a mood
disturbance themselves. One should also ask about depressed mood,
anhedonia (loss of interest in or inability to take pleasure in activities the
person normally enjoys), an inability to concentrate and carry on usual
intellectual activities, feelings of worthlessness or guilt, and suicidal ideation.
Depression cannot, however, on its own, produce the physical findings this
patient has, which taken together, are worrisome for some physiologic
abnormality.
Question 2 of 5
Which of the following is the most likely cause of the patient's murmur?
/A. Aortic insufficiency
/B. Aortic stenosis
/C. High-output flow murmur
/D. Mitral regurgitation
/E. Mitral stenosis
/F. Pulmonic insufficiency
/G. Pulmonic stenosis
/H. Tricuspid regurgitation
/I. Tricuspid stenosis
Explanation - Q: 1.2
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BIood in the pulmonary veins is at the same pressure (during all phases of the
cardiac cycle) as blood in which of the following?
/A. Aorta
/B. Left atrium
/C. Left ventricle
/D. Right atrium
/E. Right ventricle
Explanation - Q: 1.3
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The correct answer is B. The pressures in two chambers, which are not
separated by a closed valve, will be equal. The pulmonary vein empties into
the left atrium, and no valve separates the two chambers, therefore the
pressures are equal in all phases of the cardiac cycle. This patient's
pulmonary vascular congestion is likely due to elevated pulmonary venous
pressure, which is, in turn, likely due to elevated left atrial pressures.
Pressures in the aorta (choice A) will be higher than pressures in the
pulmonary veins during the cardiac cycle.
The left ventricle (choice C) is separated from the left atrium and the
pulmonary veins by the mitral valve. The pulmonary veins and the left atrium
are at the same pressure as the left ventricle during diastole, when the mitral
valve is open. With complete mitral insufficiency, the pulmonary veins are
completely exposed to left ventricular pressures during systole, resulting in
severe pulmonary edema.
The right atrium (choice D) is not in communication with the pulmonary veins,
being separated from them by, in sequence, the tricuspid valve, the right
ventricle, the pulmonic valve, the pulmonary arterial system, and the
pulmonary capillary bed.
The right ventricle (choice E), during systole, is at the same pressure as the
pulmonary artery, not the pulmonary veins. During diastole, the pulmonary
arterial pressure exceeds right ventricular pressure, and the valve is closed.
Question 4 of 5
To improve her shortness of breath, the patient is given furosemide. What is the
molecular mechanism and site of action of this drug?
/A. ADH antagonism of in the collecting ducts
/B. AIdosterone antagonism in the distal tubule
/C. BIockade of sodium reabsorption in the proximal tubule
/D. BIockade of sodium transport in the distal tubule
/E. Inhibition of carbonic anhydrase in the proximal tubule
/F. Inhibition of sodium-potassium-chloride cotransport in the loop of Henle
Explanation - Q: 1.4
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What important physiologic effect will starting this patient on an angiotensinconverting-enzyme inhibitor achieve?
/A. Decrease in arteriolar resistance, resulting in less resistance to forward
cardiac output
/B. Decrease in cardiac filling pressures, resulting in less pulmonary congestion
/C. Increase in arteriolar resistance, resulting in improved blood pressure
/D. Increase in left-ventricular end-diastolic volume, improving stroke volume
via Starling forces
/E. Increase in myocardial contractility, resulting in improved stroke volume
/F. Stabilization of myocardial membranes, resulting in reduced risk of
arrhythmia
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Explanation - Q: 1.5
A 23-year-old man presents to the urgent care clinic complaining of severe throat
pain, fever, chills, and diffuse joint pains. He first developed
symptoms two weeks ago and was evaluated by another physician at the same
clinic. A throat culture was done, and the patient was given a
prescription for antibiotics that he did not filI. He now returns with a worsening of
his symptoms. He has since developed severe joint pain and
swelling, which first affected his right wrist, then spread to both knees, and now
has also affected his left ankle. He also complains of
moderate to severe chest discomfort and shortness of breath. His temperature is
38.7 C (101.6 F), blood pressure is 118/86 mm Hg, pulse
is 104/min, and respirations are 20/min. There is an exudate on his oropharynx
and bilateral anterior cervical lymphadenopathy. On lung
examination, there are bibasilar crackles, and the cardiac examination reveals
tachycardia, but a normal rhythm and no murmurs or rubs.
Examination of his joints reveals synovitis in his right wrist, Ieft ankle, and both
knees. A c
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Question 1 of 5
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Which of the following is the most likely cause of this patient's cardiac findings?
/A. Acute myocardial infarction
/B. Aortic dissection
/C. Mitral regurgitation
/D. Myocarditis
/E. Wolff-Parkinson-White (WPW) syndrome
Explanation - Q: 2.1
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What underlying condition can explain the patient's upper respiratory as well as
cardiac and joint signs and symptoms?
/A. Acute rheumatic fever
/B. Budd-Chiari syndrome
/C. Ebstein's anomaly
/D. Sjgren syndrome
/E. Takayasu arteritis
Explanation - Q: 2.2
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Which of the following test results would help confirm the most likely diagnosis?
/A. EIevated antinuclear antibody
/B. Low anti-deoxyribonuclease B titer
/C. Low anti-hyaluronidase titer
/D. Low anti-streptolysin O titer
/E. Throat culture positive for group A streptococci
Explanation - Q: 2.3
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A biopsy of the affected cardiac tissue would most likely show which of the
following?
/A. Angiosarcoma
/B. Aschoff body
/C. Atheromas
/D. Hyperplastic arteriolosclerosis
/E. Libman-Sacks lesions
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Explanation - Q: 2.4
The correct answer is B. The Aschoff body is the classic lesion of rheumatic
fever. It is an area of focal interstitial myocardial inflammation. It is
characterized by large cells, known as Anitschkow myocytes, and Aschoff
cells, which are multinucleated giant cells.
Angiosarcoma (choice A), a rare malignant tumor affecting the vascular
tissue, can occur in the skin, breast, liver, or musculoskeletal system.
Atheromas (choice C) are fibrous plaques within the intima of arteries. They
are a finding of atherosclerosis.
Hyperplastic arteriolosclerosis (choice D) is characterized by concentric,
laminated thickening of arteriolar walls. It often occurs in the kidneys, and
may lead to malignant nephrosclerosis.
Libman-Sacks lesions (choice E) are small vegetations that occur on valvular
heart tissue. They can occur on either side of the valve, and are associated
with endocarditis in systemic lupus erythematous.
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Explanation - Q: 2.5
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A 78-year-old man had been previously active, but found that his health was
declining. Over a four-month period, his ability to perform even
very minimal exercise, such as walking around his yard, declined precipitously.
The family took him from doctor to doctor, none of whom were
initially able to figure out what was wrong with him. Because of the patient's age,
most of the physicians that the family consulted were
unwilling to do much other than to listen to the family's story and then run a few
screening tests. In some ways, he acted as if he were in
congestive heart failure, but he initially had no evidence of fluid overload and his
lungs were clear. The cardiac profile on chest X-ray was
slightly enlarged. His ECG studies were interpreted as within the normal range
for his age. Angiography studies showed no evidence of
significant coronary artery occlusion. Pulmonary function studies were
unrevealing.
Question 1 of 6
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The correct answer is B. Large, salty, holiday meals are notorious for setting
off (potentially fatal) exacerbations of what might have been previously mild
congestive failure. There are a number of drugs with diuretic activity that can
increase the amount of urine that is produced. Pharmacologists subclassify
these drugs based on the mechanisms by which they act. Furosemide is a
diuretic that is commonly used in the hospital setting in intravenous form to
rapidly reduce the degree of fluid overload present in a patient in severe
congestive heart failure. This diuretic acts by inhibiting the Na/K/2Cl
cotransporter on the luminal membrane of the thick ascending portion of the
loop of Henle. It is consequently classified as a loop diuretic, as is ethacrynic
The patient is seen the following morning by a cardiologist. The cardiologist does
a very careful physical examination. He notes that the heart
sounds appear distant. He then has the patient lie at an angle of 30 to 45
degrees, and does a careful examination of the right jugular pulse,
which he finds very worrisome. The pulse is both very elevated and shows
dramatic x and y descents. Further, he notes that the venous
distention paradoxically increases during inspiration. This last finding is
sometimes called which of the following?
/A. Chvostek's sign
/B. Corrigan's sign
/C. Homans' sign
/D. KussmauI's sign
/E. Murphy's sign
*** If your relatives ever use the Kleptomania... ***
Explanation - Q: 3.2
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The correct answer is D. The sign described is Kussmaul's sign. The act of
inflating the lungs during inspiration lowers the pressure in the chest while
increasing that in the abdomen, drawing blood from the abdomen into the
chest (and increased abdominal pressure helps to directly drive blood toward
the chest). If the right atrium cannot fill, then the jugular venous pressure
rises paradoxically (not so much from blood flow from the head as from the
abdomen, because the inferior vena cava and superior vena cava are
functionally connected through the right atrium). Kussmaul's sign is seen in
patients who have non-compliant right ventricles. It can also be seen in
patients with severe ascites (which increases the intra-abdominal pressure).
This case illustrates the importance of considering the jugular venous pulse
as well as the arterial pulse, since the cardiologist was able to find a number
of significant findings pertaining to the jugular venous pulse, which other
physicians had missed. The jugular venous pressure can be used at the
bedside to estimate the right atrial filling pressure. The jugular venous
pressure is estimated by measuring the height of the visible venous pulse
above the sternal angle, and then adding 5 cm (corresponding to how far
below the sternum the right atrium is located). The jugular venous waveform
has an A wave, which is followed by an X descent, then a V wave, and finally
a Y descent. The A wave (first rise in pressure) reflects the right atrial
contraction, while the X-descent reflects right atrial diastole, and then early
right ventricular systole. The V wave is the second major positive wave, and
reflects continued venous inflow into the right atrium in opposition to a closed
mitral valve. The following Y-descent is the negative deflection that occurs
when the tricuspid valve opens in early diastole.
Chvostek's sign (choice A) is seen in tetany, and is a facial muscle spasm
occurring when the facial nerve is tapped anterior to the external auditory
meatus.
Corrigan's sign (choice B), which suggests aortic regurgitation, is a full, hard
arterial pulse, which is followed by a sudden collapse.
Homans' sign (choice C) is pain at the back of the knee or calf when the
ankle is dorsiflexed, and suggests venous thrombosis of the leg.
Murphy's sign (choice E) is pain on palpation of the right subcostal area
during inspiration, and is frequently seen in acute cholecystitis.
Question 3 of 6
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The correct answer is E. The "distant" heart sounds and jugular venous
pulse findings both suggest that this patient has restrictive cardiomyopathy
that is limiting the heart's ability to fill during diastole and is also impairing
ventricular contraction. Other findings that may be encountered on physical
examination in patients with restrictive cardiomyopathy include S3 and/or S4
heart sounds, occasional mitral or tricuspid regurgitation murmurs, and, if the
patient is in secondary congestive failure, peripheral edema and pulmonary
rales. Restrictive cardiomyopathy is relatively rare and the findings on
physical examination are subtle, and consequently this patient's history of
missed diagnosis is unfortunately not all that uncommon. Underlying causes
of restrictive cardiomyopathy include endomyocardial fibrosis, Loeffler
eosinophilic endomyocardial disease, hemochromatosis, amyloidosis,
Explanation - Q: 3.4
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crystalline deposits.
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Question 5 of 6
Which of the following features of proteins is most likely responsible for the bright
green appearance of the Congo red-stained materiaI?
/A. Beta pleated sheet configuration
/B. Calcium binding
/C. Iron containing heme moiety
/D. Multiple alpha helices
/E. Presence of multiple subunits
Explanation - Q: 3.5
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Which of the following would most likely be found in the Congo red-stained
extracellular deposits with the bright green appearance under
polarized light?
/A. Amyloid AA
/B. Beta-2-microglobulin
/C. Beta protein precursor
/D. Immunoglobulin light chains
/E. Transthyretin
Explanation - Q: 3.6
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The correct answer is A. This patient has cor pulmonale, which is defined as
/D.
Left subclavian vein, Ieft jugular vein, superior vena cava, right atrium, right
ventricle, pulmonary artery
/E. Left subclavian vein, superior vena cava, right atrium, right ventricle,
pulmonary artery
Explanation - Q: 4.2
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The correct answer is A. The correct sequence for a catheter inserted into
the left subclavian vein is as follows: left subclavian vein, left brachiocephalic
vein, superior vena cava, right atrium, right ventricle, pulmonary artery. With
this catheter in place, a variety of cardiac parameters can be measured,
including pressures in the pulmonary artery. Thus, this catheter can aid in
establishing the diagnosis of pulmonary hypertension.
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/E.
Piecemeal necrosis
Explanation - Q: 4.5
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