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SCMD3000/1 CVS BLOCK (Paper 1) Student No: -----------------------------------------------------------

Venue: __________________________________ Seat No: -------------------------------------

UNIVERSITY OF THE WITWATERSRAND,

JOHANNESBURG
Faculty of Health Sciences

MB BCh III / GEMP I

INTEGRATED BASIC MEDICAL

AND HUMAN SCIENCES A
(SCMD3000/1)

CVS Examination: Multiple Choice Questions

Paper 1

Time allowed: 1.5 hours

2 June 2008
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SCMD3000/1 CVS BLOCK (Paper 1) Student No: ----------------------------------
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Instructions:
Please read the following carefully:

1. There are 46 multiple choice questions (MCQs) in this paper.

2. Two minutes have been allocated per question.
3. Read the instructions to students printed on the MCQ sheet carefully.
4. Write your name, the degree for which you are registered and your student number on the
BACK of the computer sheet.
5. On the FRONT of each sheet, in the block headed “student number” write in your student
registration number and fill in the corresponding circles.
6. Leave Group blank.

A-TYPE QUESTIONS

8. Select the single best answer to each question. (Note: several options may be correct
but only one is the best answer.)
9. Answers must be entered on the special A-type MCQ sheet provided.
10. If you give more than one answer for a question, you will score zero for that question.
11. There will be no penalty for incorrect answers.
12. If you do not know an answer you may leave it blank, in which case you will neither
earn a mark nor be penalised.

X-TYPE QUESTIONS

13. There is at least one correct statement and at least one incorrect statement.
14. Identify BOTH the correct and incorrect statements.
15. Fill in your answers on the special X-type MCQ sheet provided (different from the
ones above).
16. If you are unsure of a statement leave it blank.
17. Negative marking will be applied to wrong answers but negative marks will not be
carried forward. This means the minimum mark for a question is zero.

R-TYPE QUESTIONS

18. Here you are offered a number of answers. This is followed by a set of questions.
Select the single best answer to each question.
19. Fill in your answers on the R-type MCQ card provided.
20. If you give more than one answer for a question, you will score zero for that question.
21. There will be no penalty for incorrect answers.
22. If you do not know an answer you may leave it blank, in which case you will neither
earn a mark nor be penalised.

Note: Each A-type, X-type and R-type question has the same mark value.
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A-TYPE QUESTIONS

A1 A2

A3 A4

A1. A 40 year-old black male was admitted to hospital in cardiac failure and died suddenly a week
later.
At autopsy the cause of death was shown to be due to a massive intra-cerebral haemorrhage.
The kidneys showed features illustrated in macrophotograph A1 and in the histological sections
( A2, A3 & A4)
COLOUR VERSIONS OF THESE IMAGES ARE FOUND ON THE SEPARATE SHEET
Which one of the following pathological changes confirms the patient’s underlying disease
process.

a. Malignant nephrosclerosis
b. Non-specific chronic pyelonephritis
c. Mucoid hyperplasia of the interlobular artery
d. Hyaline arteriolosclerosis of the afferent arteriole
e. Fibrinoid necrosis of the afferent arteriole

Correct answer/s: d
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A2. A 45 yr old man with rheumatic heart disease with chronic mitral regurgitation, is currently in
heart failure.
Which of the following is not an adaptive change of the heart:

a. Eccentric hypertrophy of the left ventricular myocardium

b. An increase in the left ventricular end diastolic volume
c. Right shift of the Frank-Starling curve
d. An increase in the circulating level of angiotensin II
e. An increase in the tissue inhibitors of metalloproteinases

Correct answer/s: e

A3. A 60 yr old man with the metabolic syndrome presented with an acute anterior myocardial infarction
one month prior to presenting with ischaemic cardiomyopathy in left ventricular failure.
Which of the following best represents remodeling of the myocardium?

a. Dilatation and thinning of the anterior wall of the myocardium

b. Fibrosis with an increase in collagen deposition and calcification of the infracted anterior wall
c. Increase level of natriuretic peptides
d. Compensatory dilatation of the left ventricle especially in the non-infarcted territories
e. Compensatory hypertrophy of the infarcted territory

Correct answer/s: d

A4. Blockage of which of the following arteries would most likely lead to ischaemia of the apex of
the heart?

a. Anterior interventricular (descending)

b. Left circumflex .
c. Posterior interventricular (descending)
d. Right marginal
e. Right coronary

Correct answer/s: a

A5. If the ductus arteriosus does not spontaneously close off soon after birth (to become the
ligamentum arteriosum), it may have to be surgically ligated. When clamping or ligating it,
what important structure immediately behind it must be identified and saved?

a. arch of the azygos vein

b. internal thoracic artery
c. left phrenic nerve
d. left recurrent laryngeal nerve
e. left superior intercostal vein

Correct answer/s: d

A6.Which chamber forms most of the sternocostal surface of the heart?

a. right atrium
b. right ventricle
c. left atrium
d. left ventricle
e. both right and left ventricles, equally

Correct answer/s: b

A7. The relationship between hypertension and low birth weight (<2500g) was studied based on
10,000 births in 1975. These participants were studied at several ages up till the age of 30
years. Of the 946 low birth weight infants, 110 (11.7%) developed hypertension, compared to
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299 (3.3%) of the 9054 infants of normal birth weight.
What study design was used?

a. Case series
b. Case-control study
c. Cohort study
d. Cross-sectional study
e. Randomised controlled trial

Correct answer/s: c

A8. Which one of the following is the most important risk factor for cardiovascular disease?

a. High Blood Pressure

b. Abnormal Blood Lipids
c. Tobacco use
d. Obesity
e. Physical inactivity

Correct answer/s: b

A9. Which of the following can the area of cardiovascular epidemiology NOT fulfill?

a. Detection and the occurrence and distribution of cardiovascular disease in population,

surveillance, monitoring, trends of changes
b. The study of the natural history of cardiovascular disease
c. Formulation and testing of aetiological hypotheses (causes)
d. Contribution to the development of cardiovascular prevention programmes
e. Contribution to the measurement of the effectiveness of cardiovascular prevention programmes

Correct answer/s: c

X-TYPE QUESTIONS
X1.

A 25 year old male athlete collapses and dies suddenly while playing a game of rugby at his school
At the autopsy the heart was slightly enlarged and flabby, with dilatation of both ventricular
chambers

The photomicrographs above represents a histological section taken from the heart.
The left hand image shows the features under medium-power magnification. The area within the
dotted circle is shown on the right under high-power magnification.
COLOUR VERSIONS OF THESE IMAGES ARE FOUND ON THE SEPARATE SHEET.
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The following features are illustrated in these photomicrographs:

a. Fragmentation of myocytes
b. Infiltration by neutrophil leucocytes
c. Diffuse infiltration by lymphocytes and macrophages
d. Endothelial cell proliferation
e. Myocyte disarray

Correct answer/s: a,c

Questions X2 to X5 relate to the following case scenario

Mrs Zondo, a 32 year old, became increasingly short of breath with even mild effort. She repeatedly
awoke at night short of breath and had to get out of bed to relieve the breathlessness. On examination
she was noted to have marked sacral oedema and a raised height of the jugular venous pulse. She also
had a third heart sound (S3) and a diastolic murmur heard best over the mitral area. On a chest
roentogram (X-Ray) she was noted to have an enlarged left atrium and right heart (ventricle and
atrium), upper lobe blood diversion, and peribronchial cuffing. Her left ventricle appeared normal sized.
On echocardiography she had a left ventricular ejection fraction of 76% and a valvular abnormality was
diagnosed as the cause of her problems.

X2. Mrs Zondo is likely to have a valve abnormality that:

a. generates a pressure gradient across the aortic valve.

b. reduces left ventricular filling.
c. increases aortic systolic blood pressure.
d. generates a pressure gradient across the mitral valve.
e. produces a collapsing pulse.

Correct answer/s: b,d

X3. The three waves that characterise the jugular venous pulse in Mrs Zondo are generated by:

a. right atrial contraction.

b. closure of the pulmonary valve.
c. closure of the tricuspid valve.
d. filling of the right ventricle.
e. right ventricular contraction.

Correct answer/s: a,c,d

X4. The peribronchial cuffing in Mrs Zondo’s lungs is likely to be caused by:

a. an increased capillary oncotic (colloid osmotic) pressure.

b. lymphatic obstruction.
c. pulmonary oedema.
d. an increased left ventricular filling (diastolic) pressure.
e. an increased left atrial pressure.

Correct answer/s: c,e

X5. Mrs Zondo has clinical features consistent with:

a. left heart failure.
b. right heart failure.
c. a reduced ability to appropriately increase stroke volume with exercise.
d. decreased right ventricular diastolic (filling) pressures.
e. decreased pulmonary capillary hydrostatic pressures at night.
Correct answer/s: a,b,c

X6. Mrs Zondo has evidence that is consistent with:

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a. New York Heart Association grade III heart failure.
b. a reduced myocardial contractility of the left ventricle.
c. pulmonary congestion.
d. idiopathic dilated cardiomyopathy.
e. high output heart failure.

Correct answer/s: a,c

Questions X7 – X9 relate to the following case scenario

An electrocardiogram performed on Mrs Zondo showed positive QRS complexes in leads V1 and V2,
equiphasic QRS complexes in lead V3 and negative QRS complexes in leads V4-V6. The QRS electrical
axis in vertical plane leads was toward lead III (+1200). Furthermore, the following illustrates the
recording obtained from lead V5.

X7. Mrs Zondo’s electrocardiogram:

a. is likely to show negative QRS complexes in lead aVL.

b. is likely to show equiphasic or isoelectric QRS complexes in lead aVR.
c. is likely to show negative QRS complexes in lead III.
d. suggests the presence of right ventricular hypertrophy.
e. suggests the presence of an electrical axis shift in horizontal plane leads toward V1.

Correct answer/s: a,b,d,e

X8. Mrs Zondo’s electrocardiogram indicates the presence of:

a. atrial flutter.
b. a supraventricular arrhythmia.
c. ventricular complexes that closely follow each atrial complex.
d. atrial irregularities that are causing the irregularly timed QRS complexes.
e. atrial irregularities that are causing QRS complexes of varying amplitude.

Correct answer/s: b,d,e

X9. Mrs Zondo’s electrocardiogram shows an electrical disturbance that

a. is likely to be causing an irregular pulse.

b. contributes to her heart failure.
c. may benefit from the use of digitalis.
d. may be the consequence of her enlarged left atrium.
e. is likely to be causing a bradycardia.

Correct answer/s: a,b,c,d

Questions X10 to X11 relate to the following case scenario

Mr Benjamin, a 52 year old man complained of central, crushing chest pain. On admission to hospital
Mr Benjamin was noted to have S-T segment elevation in leads V2-V5 and leads I and aVL. Horizontal
plane electrocardiograph recordings showed positive QRS complexes in leads V1 and V2, equiphasic
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QRS complexes in lead V3 and negative QRS complexes in leads V4-V6.

X10. Mr Benjamin’s electrocardiogram:

a. shows transmural myocardial ischaemia in the posterior wall of the heart.

b. shows transmural myocardial ischaemia in the inferior wall of the heart.
c. shows transmural myocardial ischaemia in the lateral wall of the heart.
d. is likely to show S-T segment depression in leads III and aVF.
e. recordings in the horizontal plane indicate the presence of myocardial necrosis.

Correct answer/s: c,d

X11. Mr Benjamin is likely to:

a. have unstable angina pectoris.

b. have increased plasma concentrations of biomarkers of myocardial tissue damage.
c. have a stable myocardial ischaemic (coronary) syndrome.
d. require thrombolytic therapy.
e. require an angiotensin-converting enzyme inhibitor in the first 24-hours.

Correct answer/s: b,e

Questions X12 to X14 relate to the following case scenario

After receiving care for his acute problem, over the subsequent 2 weeks in hospital, Mr. Benjamin
became increasingly more short of breath when he exerted himself. On echocardiography he had a left
ventricular ejection fraction of 26% and dilated cardiac chambers.

X12. Mr Benjamin is likely to have:

a. systolic heart failure.

b. an increased left ventricular wall stress.
c. a restrictive cardiomyopathy.
d. high output cardiac failure.
e. diastolic cardiac dysfunction.

Correct answer/s: a,b,e

X13. Mr Benjamin may benefit from:

a. a reduction of left ventricular afterload.

b. an infusion of dopamine
c. an increase in left ventricular preload.
d. a decrease in the activity of enzymes that disrupt myocardial collagen.
e. an increased cardiomyocyte apoptosis.

Correct answer/s: a,d

X14. Factors which enhance arteriolar smooth muscle contraction include:

a. nitric oxide.
b. activation of alpha-adrenergic receptors.
c. phosphorylation of myosin light chain kinase
d. adenosine.
e. angiotensin II.

Correct answer/s: b,c,e

X15. In the medium to long-term control of blood pressure, blood volume is increased when

a. glomerular afferent arterioles constrict.

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b. plasma aldosterone concentration is increased.
c. glomerular efferent arterioles dilate.
d. peritubular capillary hydrostatic pressure is increased.
e. mesangial cells contract.

Correct answer/s: a,b,e

X16. A patient with a blood pressure of 138/88 mm Hg (average over 3 visits), glycosuria and is
receiving three classes of antihypertensive agents

a. is likely to have white coat hypertension.

b. is likely to have refractory hypertension.
c. is likely to be receiving an angiotensin converting enzyme inhibitor.
d. has a normal cardiovascular risk.
e. would require further reductions in blood pressure.

Correct answer/s: b,c,e

X17. A 67 year old male with a history of hypertension is diagnosed with heart failure. His heart rate
is 107 beats per minute. His pressure curve is shown below:

The following points are achieved by the following drugs:

a. point A = IV dobutamine
b. point C = IV glyceryl trinitrate and furosemide
c. point B = enalapril
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d. Point D = IV furosemide
e. point B = hydralazine + isosorbide dinitrate

Correct answer/s: c,d,e

X18. Regarding cardiovascular drugs:

a. enalapril is an alpha-1 adrenoreceptor blocker

b. digoxin increases the entry of calcium into the myocardium
c. isosorbide mononitrate decreases venous capacitance
d. bisoprolol is used in the treatment of NYHA stage II heart failure
e. bezafibrate is a HMG CoA-reductase inhibitor

Correct answer/s: b,d

X19. Regarding drugs used in cardiovascular conditions:

a. enoxaparin inhibits the activity of thrombin

b. at equipotent doses, simvastatin lowers LDL more than rosuvastatin
c. atorvastatin increases serum triglyceride levels
d. morphine decreases total peripheral resistance
e. digoxin stimulates membrane bound Na/K ATPase activity

Correct answer/s: a,b,d

X20. Regarding anti-arrhythmics:

a. digoxin is used to treat ventricular fibrillation

b. verapamil blocks the calcium channels in the SA node
c. amiodarone decreases sodium entry into the myocardium
d. lignocaine blocks voltage gated L- type calcium channel
e. at therapeutic doses amlodipine blocks conduction through the AV node

Correct answer/s: b,c

X21. A 63 year old male is diagnosed with a myocardial infarction. The following week he is
discharged from hospital. Possible combination(s) of drugs for this patient to limit the damage of the
infarct and reduce mortality and improve morbidity would include:

a. low dose aspirin + captopril

b. bisoprolol + enalapril
c. codeine + paracetamol
d. isosorbide mononitrate + enalapril
e. streptokinase + heparin

Correct answer/s: a,b,d

X22. Regarding preventive and promotive health care:

a. Educating people about good nutrition and the importance of exercise are a form of primary
prevention.
b. Rehabilitation of stroke patients falls into the category of secondary prevention.
c. Health promotion involves attempts to move people closer to their optimum well-being.
d. Health promotion does not have relevance at the individual patient level, but only at a
community level.
e. Preventive care includes discovering problems early enough to minimise the amount of
disability.

Correct answer/s: a,c,e

X23. An Adler Museum exhibition during your CVS block chronicled the history of cardiovascular
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medicine. Indicate the historical correctness of each of the following statements:

a. An electrocardiogram was first obtained from a patient at the Johannesburg General Hospital
in 1947.
b. William Harvey invented the first stethoscope
c. Christiaan Barnard pioneered the world’s first heart transplantation in 1979.
d. Louis Washkansky, the recipient of the world’s first heart transplant, survived for less than
three weeks after receiving his new heart
e. Radiography (Xrays) was first used clinically in the late 1800s.

Correct answer/s: d,e

X24. Regarding cardiovascular markers:

a. proBNP is a marker of early cardiac failure

b. AST is raised in a haemolysed specimen
c. LDH is decreased in intravascular haemolysis
d. A raised cardiac troponin is diagnostic of myocardial infarction
e. A raised plasma myoglobin is specific early marker of myocardial infarction

Correct answer/s: a,b,d

X25. In South Africa most infants with Down syndrome are born to mothers of advanced maternal
age. Which of the following statements regarding Down syndrome are true?

a. The birth prevalence of Down syndrome in most developing countries is 2-3/10000

b. In industrialized countries most infants with Down syndrome are born to mothers under the
age of 35
c. The birth prevalence of Down syndrome in China is the lowest in the world at less than
1/1000
d. A maternal serum screen (triple test) is an accurate way to confirm the diagnosis of Down
syndrome in the fetus of a 34 year old pregnant woman
e. Translocations account for 20% of cases of Down syndrome

Correct answer/s: b,c

X26. Regarding the following karyotype of a 20 year old individual, which of the statements are
true/false.
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a. This individual is affected with Down syndrome, of the translocation type
b. This individual has an unbalanced translocation
c. As a result of the above karyotype, this individual should be advised that he will be unable to
have normal children
d. This individual has a 2.5% risk of having a child with Down syndrome
e. The karyotype of this individual is 45,XY,t(14;21)

Correct answer/s: d,e

X27. The external carotid artery gives rise to the following arteries:

a. Ascending pharyngeal
b. Inferior thyroid
c. Ophthalmic
d. Inferior thyroid
e. Posterior auricular

Correct answer/s: a,e

X28. When considering a patient who consults a family practitioner:

a. An episode of illness can consists of multiple encounters

b. Therapeutic processes include referral to specialist care
c. The patient’s complaint is the same as the symptom experienced
d. The referral for examination is known as the RFE
e. The complaint is the subjective evidence of a health problem

Correct answer/s: a,b

R-TYPE QUESTIONS
QUESTIONS R1 to R4

A B
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C D

E F

Macrophotographs A to F above show various disease processes affecting the cardiac valves of the
left ventricle.
COLOUR VERSIONS OF THESE PICTURES ARE FOUND ON THE SEPARATE SHEET

Match each one of the following statements below with the one most appropriate Macrophotograph
above

R1. Complicated by subacute infectious vegetative endocarditis

R2. Occurs in a patient with an acute lung abscess

R3. Results from fusion of the commissures

R4. Occurs as a congenital abnormality in 2% of the population

Correct answer/s: c,a,d,b

Questions R5 and R6
Mrs Brown goes to see her doctor after feeling dizzy for 2 days. He checks her blood pressure,
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which measures 180/90. She has no previous history of hypertension.

OPTIONS:
A. Reason for encounter
B. Limit of tolerance
C. Illness
D. Limit of anxiety
E. Folk sector
F. Temporalising
G. Sick role
H. Lay perceptions
I. Illness behaviour
J. Disease

For each of the following statements regarding Mrs Brown, choose the single best answer from
the list above.

R5. Mrs Brown tells her doctor that she feels dizzy, has a headache and generally feels not well.

R6. She says that she decided on day 2, that if she was not better by the next morning, she’d
come to see the doctor.

Correct answer/s: c, f

Questions R7 to R9

OPTIONS:
A. Karyotype analysis of the mother
B. Karyotype analysis of the father
C. Karyotype analysis of both parents
D. Karyotype analysis of the fetus
E. Karyotype analysis of the affected individual/s
F. No karyotype analysis is indicated
G. FISH analysis

For each of the following scenarios, indicate which of the above options would be the most
appropriate initial management choice.
EACH OPTION MAY BE USED MORE THAN ONCE

R7. A pregnant 29 year old woman and her 41 year old husband, with no history of genetic defects

R8. A couple who have two severely retarded sons

R9. A pregnant woman whose first child had cystic fibrosis

Correct answer/s: f,e,f