1. 1. A 60 year old male patient on aspirin, nitrates and beta blocker being followed for chronic stable angina, presents to the ER with a history of tw to three episodes of more severe and long lasting anginal chest pain each day over the past 3 days. His ECG and cardiac enzymes are normal. The best course of action of the following is to:a. Admit the patient and begin intravenous digoxinb. Admit the patient and begin intravenous heparinc. Admit the patient and give prophylactic thrombolytic Rx d. Admit the patient for observation with no change in medication e. Discharge the patient from the ER with increases in nitrates and beta blockers

2. 2. A 60 year old white female presents with epigastric pain, nausea and vomiting, hear rate of 50, and pronounced first degree AV block on ER cardiac monitor. Blood pressure is 130\80. The coronary artery most likely to be involved in this process is the: • a. Right coronary artery • b. Left main • c. Left anterior descending • d. Circumflex

3. 3. You are seeing in your office a patient with chief complaint of relatively sudden onset of shortness of breath and weakness but no chest pain. ECG shows non-specific ST-T changes. You would be particularly tuned to the possibility of painless, or silent, Myocardial infarction in the: • a. Advanced coronary artery disease patient with unstable • angina on multiple medications • b. Elderly diabetic • c. Premenopausal female • d. Inferior MI patient • e. MI patient with PVCs

4. 4. A 75 year old African American female is admitted with acute MI and congestive heart failure, then has as episode of ventricular tachycardia. She is prescribed multiple medications and soon develops confusion and slurred speech. The most likely cause of this confusion is: • a. Captopril • b. Digoxin • c. Furosemide • d. Lidocain • e. Nitroglycerin

5. 5. Two weeks after hospital discharge for documented MI, a 65 yr old returns to your office very concerned about low grade fever & pleuritic chest pain.There is no associated SOB.Lungs are clear to auscultation and heart exam is free of significant murmurs,gallops, or rubs. ECG is unchanged from the last one in the hospital. The most effective therapy is likely: • a. Antibiotics • b. Anticoagulation with warfarin • c. An anti-inflammatory agent • d. An increase in anti-anginal medication • e. An anti-anxiety agent

6. 6. A 72yr old male presents to the ER with the chief complaints of SOB that awakens him at night and also night cough. Further questioning confirms recent dyspnea on exertion. As you pursue the diagnosis of CCF using the Framingham criteria, you note physical findings below. Which of the findings is considerd among the less specific minor criteria? • a. Neck vein distention • b. Rales • c. S3 Gallop • d. Positive hepatojugular reflux • e. Extremity edema

7. 7. A 55yr old patient presents to you with a history of having recently had a MI with a 5 day hospital stay while away on a business trip. He reports being told he had mild CCF then, but is asymptomatic now with normal physical exam. You recommend which of the following medications? • a. An ACE inhibitor • b. Digoxin • c. Diltiazem • d. Furosemide • e. Hydralazine plus nitrates

8. 8. A 75 yr old patient presents to the ER after a sudden syncopal episode. He is again alert and in retrospect describes occasional substernal chest pressure and SOB on exertion. His lungs have a few bibasilar rales, & his BP is 110\80. On cardiac auscultation the classic finding you expect to hear is: • a. A harsh systolic crescendo decrescendo murmur heard best at • the upper right sternal border • b. A diastolic decrescendo murmur heard at the mid left sternal • border • c. A holosystolic murmur heard best at the apex • d. A midsystolic click

9. 9. A 72yr old male comes to the office with intermittent symptoms of dyspnea on exertion, palpitations and cough occasionally productive of blood. On cardiac auscultation, a low pitched diastolic rumbling murmur is faintly heard toward the apex. The origin of the patient’s problem probably relates to: • a. Rheumatic fever as a youth • b. Long standing hypertension • c. Silent MI within the past year • d. Congenital origin

10. 10. A 40yr old male presents to the office with a history of palpitations that last for a few seconds and occur 2-3 times a week. There are no other symptoms. ECG shows a rare single unifocal PVC. The most likely cause of this finding is: • a. Underlying coronary artery disease • b. Valvular heart disease • c. Hypertension • d. Apathetic hyperthyroidism • e. Idiopathic or unknown

11. 11. Subsequent 24hr Holter monitoring in the preceding patient confirms occasional single PVCs plus occasional premature atrial contractions (PACs). The BEST anti arrhythmic management in this case is: • a. Anxiolytics • b. Beta blocker therapy • c. Digoxin • d. Quinidine • e. Observation, no medications

12. 12. An active 78 yr old female has been followed for hypertension but presents with new onset of mild left hemiparesis and the finding of atrial fibrillation on the ECG, which persists throughout the hospital stay. She had been in sinus rhythm 6 months earlier. Optimal treatment by the time of hospital discharge includes anti hypertensive plus • a. Close observation • b. Permanent pacemaker • c. Aspirin • d. Warfarin • e. Subcutaneous heparin

13. 13. In the ICU, a patient suddenly becomes unresponsive, pulseless & hypotensive, with cardiac monitor indicating ventricular tachycardia. The crash cart is immediately available. The first therapeutic step among the following should be: • a. Amiodarone 3oomg IV push • b. Lidocaine 1.5 mg\kg IV push • c. Epinephrine 1mg IV push • d. Defibrillation at 200 joules • e. Defibrillation at 360 joules

14. 14. A 55yr old African American female presents to the ER with lethargy & BP of 250\150. Her family members indicate that she was complaining of sever headache & visual disturbance earlier in the day. They report a past history of asthma but no known kidney disease. On physical exam, papilledema & retinal hemorrhages are present. The best approach is: • a. Intravenous labetalol therapy • b. Continous infusion of nitroprusside • c. Clonidine by mouth to lower BP slowly but surely • d. Nifedipine sublingually to lower BP rapidly & remove the • patient from danger • e. Further history about recent home anti hypertensives before • deciding current therapy

15. 15. A 50 yr old construction worker continues to have an elevated BP of 160\95 even after third agent is added to his antihypertensive regiment. Physical examination is normal, electrolytes are normal and the patient is taking no over-the-counter medications. The next helpful step for this patient is to: • a. Check pill count • b. Evaluate for Cushing syndrome • c. Check chest x-ray for coarctation of aorta • d. Obtain renal angiogram • e. Obtain an adrenal CT scan

16. 16. A 35 year old male complains of substernal chest pain aggravated by inspiration and relieved by sitting up. He has a history of tuberculosis. Lung fields are clear to auscultation and heart sounds are somewhat distant. Chest x-ray shows an enlarged cardiac silhouette. The next step in evaluation is: • a. Right lateral decubitus film • b. Cardiac catheterization • c. Echocardiogram • d. Serial ECGs • e. Thallium stress test

17. 17. The above mentioned patient then develops jugular venous distention and hypotension. The ECG shows electrical alternance. The most likely additional physical finding is • a. Basilar rales halfway up both posterior lung fields • b. S3 gallop • c. Pulsus paradoxus • d. Strong apical beat

18. 18. You are reviewing a number of patients with congenital heart disease with specific attention to whether they need an antiobiotic prophylaxis for dental work. Which of the following cardiac conditions creates the lowest risk for development of infective endocarditis? • a. Coarctation of the aorta • b. VSD • c. ASD • d. PDA • e. Prosthetic heart valves

19. 19. An 80 year old with a past history of MI is found to have LBBB on ECG. He is asymptomatic with BP of 130/80, lungs clear to auscultation and no leg edema. On cardiac auscultation the most likely finding is : • a. Fixed (wide) split S2 • b. Paradoxical (reversed) S2 • c. S3 • d. S4 • e. Opening snap • f. Midsystolic click

20. 20. You are assisting for one month in a cardiology vavular heart disease clinic detecting a variety of murmurs and associated features. Match they physical findings with the most likely vavular or related heart disease. • a. Mitral stenosis • b. Tricuspid regurgitation • c. Mitral regurgitation • d. Aortic regurgitation • e. Aortic stenosis • f. Hypertrophic cardiomyopathy