patho pyqs - cardiovascular module

Question 1

A 63-year-old woman has the sudden onset of ‘knife-like’ pain in the chest radiating to the back. She has been previously healthy except for a history of poorly controlled hypertension. She is transported to the hospital and on arrival she has a heart rate of 90/minute, respirations 20/minute, temperature 36.8°C, and blood pressure 150/100 mm Hg. No murmurs, rubs, or gallops are audible. A chest radiograph reveals a widened mediastinum. Laboratory findings include a total serum creatine kinase of 55 U/L, creatinine 0.9 mg/dL, and glucose 123 mg/dL. Which of the following is the most likely diagnosis?

Fibrinous pericarditis
Aortic dissection
Infective endocarditis
Dilated cardiomyopathy
Myocardial infarction

Answer 1

Aortic dissection

Question 2

A 45-year-old man was rushed to the hospital following the sudden onset of an episode of crushing substernal chest pain. He receives advanced life support measures. An EKG shows changes consistent with a large transmural anterolateral area of infarction involving wall of the left ventricle. He develops cardiogenic shock. Which of the following microscopic findings is most likely to be present in this area 4 days following the onset of his chest pain?

Fibroblasts and collagen deposition
Capillary proliferation and macrophages
Myofiber necrosis with neutrophils
Granulomatous inflammation
Perivascular lymphocytic infiltrates

Answer 2

Myofiber necrosis with neutrophils

Question 3

A 45-year-old woman has had worsening shortness of breath for 3 years. She now has to sleep sitting up on two pillows. She has had difficulty swallowing for the past year. She has no history of chest pain. A month ago, she had a ‘stroke’ with resultant inability to move her left arm. She is afebrile. A chest radiograph reveals a near-normal left ventricular size with a prominent left atrial border. Which of the following conditions is most likely to account for her findings?

Essential hypertension
Cardiomyopathy
Mitral valve stenosis
Aortic coarctation
Patent foramen ovale

Answer 3

Mitral valve stenosis

Question 4

A 16-year-old healthy adolescent is involved in a schoolyard gang fight and is stabbed in the chest with a knife in the left midclavicular line. He is taken to the emergency department and on arrival his blood pressure is barely obtainable. His lungs are clear to auscultation. His heart sounds are barely audible. Which of the following is the most useful therapeutic approach for this boy?

Coronary angioplasty
Aortic repair
Pericardiocentesis
Antibiotic therapy
Antiarrhythmic drugs

Answer 4

Pericardiocentesis

Question 5

A 19-year-old woman has had increasing malaise for the past 5 months. On physical examination she has a cardiac murmur characterized by a mid systolic click. An echocardiogram demonstrates mitral insufficiency with upward displacement of one leaflet. There is aortic root dilation to 4 cm. She has a dislocated right ocular crystalline lens. A year later she dies suddenly and unexpectedly. The medical examiner finds a prolapsed mitral valve with elongation, thinning, and rupture of chordae tendineae. A mutation involving which of the following genes is most likely to be present in this patient?

Beta-myosin
CFTR
FGFR
Fibrillin
Spectrin
Dystrophin

Answer 5

Fibrillin

Question 6

A 72-year-old woman has had no major illnesses throughout her life. She has had 3 syncopal episodes during the past 2 weeks. Over the past 2 days she has developed shortness of breath and a cough with production of frothy white sputum. On physical examination she is afebrile. Her blood pressure is 135/90 mm Hg. She has no peripheral edema. A chest radiograph reveals a prominent left heart border in the region of the left ventricle, but the other chambers do not appear to be prominent. There is marked pulmonary edema. Laboratory studies show a total serum cholesterol of 170 mg/dL. Which of the following is the most likely diagnosis?

Acute rheumatic fever
Mitral valve insufficiency
Atherosclerotic aortic aneurysm
Calcific aortic stenosis
Infective endocarditis

Answer 6

Calcific aortic stenosis

Question 7

A 17-year-old girl is short in stature for her age. She has not yet shown any changes of puberty. On physical examination her vital signs include T 37°C, RR 18/minute, P 75/minute, and BP 165/85 mm Hg. She has a continuous murmur heard over both the front of the chest as well as her back. Her lower extremities are cool with diminished pulses and poor capillary filling. She has a webbed neck. A chest radiograph reveals a prominent left heart border, no edema or effusions, and rib notching. Which of the following cardiovascular abnormalities is she most likely to have?

Shortening and thickening of chordae tendineae of the mitral valve
Narrowing of the aorta past the ductus arteriosus
Supravalvular narrowing in the aortic root
Lack of development of the spiral septum and partial absence of conus musculature
Single large atrioventricular valve

Answer 7

Narrowing of the aorta past the ductus arteriosus

Question 8

A 65-year-old man has sudden onset of severe abdominal pain that has persisted for 3 hours. Physical examination reveals his temperature is 37°C, heart rate 110/minute, respirations 25/minute, and blood pressure 145/100 mmHg. He has diminished pulses in the lower extremities. There is a pulsatile abdominal mass. His serum creatine kinase is not elevated. He has had fasting blood glucose measurements in the range of 140 to 180 mg/dL for over 20 years. Which of the following conditions is he most likely to have?

Superior mesenteric artery thrombosis
Atherosclerotic aortic aneurysm
Polyarteritis nodosa
Acute coronary syndrome
Monckeberg’s medial calcific sclerosis

Answer 8

Atherosclerotic aortic aneurysm

Question 9

A 49-year-old woman had atrial fibrillation that was poorly controlled, even with amiodarone therapy. She suffered a ‘stroke’ and died. At autopsy, her 600 gm heart is noted to have a mitral valve with partial fusion of the leaflets along with thickening and shortening of the chordae tendineae. There is an enlarged left atrium filled with mural thrombus. Which of the following underlying causes of death is she most likely to have?

Systemic lupus erythematosus
Coronary atherosclerosis
Marantic endocarditis
Rheumatic heart disease
Cardiac amyloidosis

Answer 9

Rheumatic heart disease

Question 10

A 23-year-old woman has had worsening malaise along with a malar skin rash persisting for 3 weeks. On physical examination, she has an audible friction rub on auscultation of the chest, along with a faint systolic murmur. An echocardiogram reveals small vegetations on the mitral valve and adjacent ventricular endocardium. Laboratory studies show a positive serologic test for anti-Smith antibody, with a titer of 1:2048. Which of the following is the most likely diagnosis?

Polyarteritis nodosa
Scleroderma, diffuse
Systemic lupus erythematosus
ANCA-associated granulomatous vasculitis
Adenocarcinoma of the pancreas

Answer 10

Systemic lupus erythematosus

Question 11

A 27-year-old G2 P1 woman has a screening ultrasound performed at 18 weeks gestation. The fetus is appropriate in size for 18 weeks. The fetal kidneys, liver, head, and extremities appear normal. However, the fetus has a heart with a membranous ventricular septal defect, overriding aorta, and marked pulmonic atresia. If the baby were to be liveborn, which of the following characteristics on physical examination would most likely result from these cardiac defects?

Systemic hypertension
Weak lower extremity pulses
Clubbing of digits
Telangiectasias
Cyanosis

Answer 11

Cyanosis

Question 12

A 50-year-old man has the sudden onset of substernal chest pain. The pain persists for the next three hours. He then becomes short of breath and diaphoretic. He goes to the emergency department and on physical examination his vital signs include T 37°C, P 100/minute, RR 26/minute, and BP 130/90 mm Hg. A chest x-ray shows a slightly enlarged heart and mild pulmonary edema. An EKG shows ST segment elevation in anterior leads V1-6. Which of the following serurn laboratory test findings is most likely to be present in this man?
Urea nitrogen of 110 mg/dL,
Sodium of 115 mmol/L
ALT of 876 U/L
Troponin of 32 ng/mL
HDL cholesterol of 55 mg/dL

Answer 12

Troponin of 32 ng/mL

Question 13

A 44-year-old woman dies as a consequence of a ‘stroke’. At autopsy, she is found to have a large right basal ganglia hemorrhage. She has an enlarged 550 gm heart with predominantly left ventricular hypertrophy. Her kidneys are small, about 80 gm each, with cortical scarring, and microscopically they demonstrate small renal arterioles that have luminal narrowing from concentric intimal thickening. Which of the following is the most likely condition associated with her findings?

A Autosomal dominant polycystic kidney disease
B Diabetes mellitus, type II
C Hypercholesterolemia
D Hypertensive emergency
E Monckeberg’s sclerosis

Answer 13

Hypertensive emergency

Question 14

A 24-year-old woman with rheumatic heart disease becomes febrile. On physical examination she has a systolic murmur. An echocardiogram shows vegetations of the aortic valve cusps. A blood culture is positive for Staphylococcus epidermidis. She receives a porcine bioprosthesis because of her desire to have children and not to take anticoagulant medication. After ten years, she must have this prosthetic valve replaced Which of the following pathologic findings in the bioprosthesis has most likely led to the need for replacement?

A Dehiscence B Endocarditis C Strut failure D Calcification E Thrombosis

Answer 14

Calcification

Question 15

A 25-year-old previously healthy woman collapses suddenly and unexpectedly. Echocardiography shows global hypokinesis with increased left ventricular end diastolic and systolic size, along with systolic left ventricular dysfunction with decreased ejection fraction. An endomyocardial biopsy is obtained and microscopically, the myocardium shows infiltration by small lymphocytes, with focal myocyte necrosis. Which of the following infectious agents is most likely to have caused these findings?

A Coxsackie B virus B Candida albicans C Aspergillus fumigatus D Streptococcus, viridans group E Staphylococcus aureus F Cytomegalovirus
Streptococcus, group A

Answer 15

Coxsackie B virus B

Question 16

A 22-year-old man has had increasing malaise over the past 3 weeks. On physical examination his vital signs show T 39.2°C, P 105/minute, RR 30/minute, and BP 80/40 mm Hg. On auscultation of his chest a loud systolic cardiac murmur is heard, and his lungs have bibasilar crackles. Needle tracks are seen in his left antecubital fossa. He has splinter hemorrhages noted on fingernails, as well as painful erythematous nodules on palmar surfaces. A tender spleen tip is palpable. A chest radiograph shows pronounced pulmonary edema. Which of the following laboratory test findings is most likely to be present in this patient’s peripheral blood?

Creatine kinase-MB of 8% with a total CK 389 U/L
Positive blood culture for Pseudomonas aeruginosa
Total serum cholesterol of 374 mg/dL
Blood urea nitrogen of 118 mg/dL
Antinuclear antibody titer of 1:512

Answer 16

Positive blood culture for Pseudomonas aeruginosa

Question 17

A 2-year-old child has had failure to thrive for a year, becoming increasingly listless. On examination she is found to have a soft, rumbling systolic ejection murmur. An echocardiogram reveals a large membranous ventricular septal defect. Which of the following complications is she most likely to experience as an adult 2 decades later if this lesion remains untreated?

A Rib notching B Mitral valve prolapse C Pulmonary hypertension D Myocardial infarction E Cardiac tamponade

Answer 17

Pulmonary hypertension

Question 18

A 53-year-old woman has noted increasing dyspnea for the past 2 years. On examination she is afebrile. She has an irregular pulse. A chest radiograph shows an enlarged right cardiac silhouette and bilateral pleural effusions. Echocardiography shows thinning of the right ventricular wall with reduced ejection fraction. Which of the following is the most likely etiology for her cardiac disease?

A Atherosclerosis B Chronic alcohol use C Gene mutation DHypertension

Answer 18

Gene mutation

Question 19

A 26-year-old previously healthy woman has had worsening fatigue with dyspnea, palpitations, and fever over the past week. On physical examination her vital signs show T 38.9°C, P 104/minute, RR 30/minute, and BP 95/65 mm Hg. Her heart rate is slightly Irregular. An ECG shows diffuse ST-T segment changes. A chest x-ray shows mild cardiomegaly. An echocardiogram shows slight mitral and tricuspid regurgitation but no valvular vegetations. Laboratory studies show a high sensitivity cardiac troponin of 12 ng/mL. She recovers over the next two weeks with no apparent sequelae. Which of the following laboratory test findings best explains the underlying etiology for these events?

Anti-streptolysin O titer of 1:512
Total serum cholesterol of 537 mg/dL
Echovirus serologic titer of 1:160
Blood culture positive for Streptococcus, viridans group
ANCA titer of 1:80

Answer 19

Echovirus serologic titer of 1:160

Question 20

A 45-year-old man has had no major medical problems throughout his life, except for arthritis pain involving all extremities for the past 5 years. He has had worsening orthopnea and pedal edema in the past 6 months. There is no chest pain. On examination he is afebrile. A chest radiograph shows cardiomegaly with prominent left and right heart borders, along with pulmonary edema. Laboratory studies show serum sodium 139 mmol/L, potassium 4.3 mmol/L, chloride 99 mmol/L, CO₂ 25 mmol/L, urea nitrogen 18 mg/dL, creatinine 1.3 mg/dL, and glucose 167 mg/dL. Which of the following additional laboratory test findings is he most likely to have?

A Spherocytes on his peripheral blood smear B Hemoglobin of 10.7 g/dL with MCV of 72 fL C Erythrocyte sedimentation rate of 79 mm/Hr Anti-centromere antibody titer of 1:320 D E Serum ferritin of 800 ng/mL

Answer 20

Serum ferritin of 800 ng/mL

Question 21

37-year-old previously healthy man has had worsening dyspnea along with peripheral edema for the past two years. On physical examination he has diffuse crackles auscultated over both lungs. A chest radiograph shows that the heart nearly fills the chest. A chest CT scan demonstrates a 10 cm mass involving the right ventricle that appears to have areas of hemorrhage and necrosis within it. Which of the following neoplasms is this man most likely to have?

A Rhabdomyosarcoma B Mesothelioma C Myxoma D Angiosarcoma E Papillary fibroelastoma F Kaposi sarcoma G Rhabdomyoma

Answer 21

Angiosarcoma

Question 22

A 20-year-old primigravida delivers a term baby girl following an uncomplicated pregnancy. No anomalies are noted at the time of birth. Five weeks later, the mother brings the baby to the clinic because she has difficulty breathing and occasionally turns pale. On physical examination a pansystolic murmur is audible. Which of the following congenital cardiac anomalies is most likely to be present in this infant?

A Hypertrophic subaortic stenosis
B Hypoplastic left heart syndrome
C Coarctation of the aorta
D Ventricular septal defect
E Bicuspid aortic valve

Answer 22

Ventricular septal defect

Question 23

A 66-year-old man has had congestive heart failure with increasing pulmonary congestion and edema for the past year. He had been previously healthy all his life with no major illnesses. On physical examination his blood pressure is 125/85 mm Hg and he is afebrile. A systolic ejection click is auscultated. A chest x-ray shows cardiomegaly with a prominent left heart border and pulmonary edema. Laboratory studies show a serum glucose of 95 mg/dL and total serum cholesterol of 175 mg/dL. His serum creatine kinase is not elevated. Which of the following underlying diseases is he most likely to have?

Alcoholic cardiomyopathy
Calcified bicuspid aortic valve
Tricuspid valve endocarditis
Aortic dissection
Cardiac amyloidosis

Answer 23

systolic ejection click - highly suggests –> Calcified bicuspid aortic valve

Question 24

A 35-year-old man was found down, was delirious, and talking incoherently. On examination in the emergency department his temperature is 39.3°C, pulse 110/minute, and blood pressure 70/palpable. He has a heart murmur, palpable spleen tip, and splinter hemorrhages of fingernails. Which of the following laboratory findings is most likely to be present in this man?

Positive urine screen for opiates
Elevated anti-streptolysin O (ASO)
Increased urinary free catecholamines
Elevated Coxsackie B viral titer
Rising creatine kinase (CK) in serum

Answer 24

Positive urine screen for opiates

Question 25

A 69-year-old woman with a 7 kg weight loss over the past 6 months now has developed painless jaundice over the past 2 weeks. On physical examination she is afebrile. An abdominal CT scan shows a large mass involving the head of the pancreas, along with widespread nodules in the liver. Nodules are seen in both lungs by chest radiograph. Which of the following cardiac abnormalities is she most likely to develop? A Dilated cardiomyopathy B Non-bacterial thrombotic endocarditis C Acute fibrinous pericarditis D Endocardial fibrosis E Acute myocardial infarction

Answer 25

Non-bacterial thrombotic endocarditis

Question 26

A 51-year-old woman has had several syncopal episodes over the past year. Each episode is characterized by sudden but brief loss of consciousness. She reports no chest pain. On physical examination her vital signs show T 36.9°C, P 80/minute, RR 16/minute, and BP 110/75 mm Hg. She has no pedal edema. On brain MR imaging there is a 1.5 cm cystic area in the left parietal cortex. A chest radiograph shows no cardiac enlargement, and her lung fields are normal. Her serum total cholesterol is 165 mg/dL. Which of the following cardiac lesions is she most likely to have? Cardiac armyloidosis Left atrial myxoma Tuberculous pericarditis Mitral valve prolapse Ischemic cardiomyopathy

Answer 26

Left atrial myxoma Recurrent sudden syncope + embolic brain lesion (1.5 cm cystic infarct) + normal heart size → classic for atrial myxoma, which intermittently obstructs the mitral valve and causes emboli.

Question 27

A 58-year-old man develops deep venous thrombosis during a hospitalization for prostatectomy. He exhibits decreased mental status 10 days postoperatively, with right hemiplegia. A CT scan of the head shows an acute cerebral infarction in the distribution of the left middle cerebral artery. A chest radiograph reveals cardiac enlargement and prominence of the main pulmonary arteries consistent with pulmonary hypertension. Laboratory studies show a serum cardiac troponin of <0.4 ng/mL. Which of the following lesions is most likely to be present on echocardiography? A Coarctation of the aorta B Tetralogy of Fallot C Atrial septal defect D Pulmonic stenosis E Dextrocardia

Answer 27

Atrial septal defect Explanation: Postop DVT with paradoxical cerebral embolus implies an intracardiac right-to-left shunt (eg, ASD/PFO). Chronic pulmonary hypertension and enlarged pulmonary arteries point to a long-standing ASD.

Question 28

A 25-year-old man dies suddenly and unexpectedly while at a nightclub late one evening. The medical examiner performs an autopsy. There is no evidence for trauma on external examination of the body. There are no gross pathologic findings of internal organs. Postmortem toxicologic findings are significant for high blood levels of cocaine and its metabolite benzoylecgonine. Which of the following is the most likely histopathologic finding involving his heart? A Contraction band necrosis B Lymphocytic myocarditis C Myofiber disarray D Coronary thrombosis E Pericardial tamponade

Answer 28

Contraction band necrosis Explanation: Acute cocaine toxicity causes catecholamine surge → hypercontraction and contraction-band necrosis of myocytes (classic histologic finding).

Question 29

A 49-year-old man has the sudden onset of substernal chest pain with radiation to his left arm. This persists for the next 6 hours. He goes to the emergency department and on examination is afebrile. Laboratory studies show a serum cardiac troponin of 18 ng/mL.. Angiography reveals a thrombosis of the anterior interventricular (left anterior descending) coronary artery. During the next 24 hours, which of the following is the most likely complication he will experience? A Constrictive pericarditis B Arrhythmia C Hepatic necrosis D Thromboembolism E Cardiac tamponade

Answer 29

Acute large LAD MI within the first 24 hours — the most common and most likely complication is B — Arrhythmia

Question 30

A 60-year-old man had chest pain and was hospitalized. On the first day of admission, his cardiac troponin is elevated. A coronary angiogram revealed 75% stenosis of the anterior interventricular (left anterior descending) artery. Four days later he suddenly becomes worse, with marked hypotension. A pericardiocentesis is performed and returns 150 cc of bloody fluid. Which of the following microscopic findings is most likely to be present in his left ventricular myocardium at the time of this hypotensive episode? A Extensive transmural collagen deposition B Lymphocytic infiltrates C Coronary arterial dissection D Necrosis with neutrophils and macrophages E Interstitial edema and loss of myofiber cross striations

Answer 30

Necrosis with neutrophils and macrophages Four days after MI a sudden hemopericardium causing tamponade suggests free-wall rupture — the infarct zone at this time shows D — Necrosis with neutrophils and macrophages (macrophage infiltration and tissue weakening around days 3–7 precedes rupture).

Question 31

A 27-year-old man has become severely ill with fever and malaise over the past 3 days following tooth extraction. On examination he has a temperature of 38.8°C, heart rate of 105/minute, respiratory rate of 24/min, and blood pressure of 80/40 mm Hg. He has a widely split S2 heart sound and a rumbling mid-diastolic murmur. He has small hemorrhages visible on nail beds. His spleen tip is palpable. Which of the following cardiac conditions is most likely to predispose him to this acute illness? A Hypoplastic left heart syndrome B Atrial septal defect C Chagas disease D Coronary atherosclerosis E Hypertrophic cardiomyopathy

Answer 31

Atrial septal defect the widely split S2 and a mid-diastolic rumble (increased flow across the right-sided valves) point to ASD as the predisposing congenital lesion in this case of endocarditis.

Question 32

An epidemiologic study of eating habits is performed. Dietary patterns of adult patients are recorded and compared to risk for cardiovascular diseases. It is observed that persons who eat bacon for breakfast are more likely to have cardiovascular disease than persons who eat oat bran cereal. Which of the following conditions is the 'bacon' group most likely to have? A Mitral annulus calcification B Ventricular aneurysm C Left atrial dilation D Thoracic aortic aneurysm E Aortic valve stenosis

Answer 32

Aortic valve stenosis — diets high in saturated fats/cholesterol increase atherosclerotic risk and are associated with degenerative (calcific) aortic stenosis in adults.

Question 33

A 74-year-old man has had increasingly severe headaches for 2 months, centered on the right. His vital signs include T 36.9°C, P 82/minute, RR 14/minute, and BP 130/85 mm Hg. There is a palpable tender cord-like area over his right temple. His heart rate is regular with no murmurs, gallops, or rubs. Pulses are equal and full in all extremities. A biopsy of this lesion is obtained, and microscopic examination reveals a muscular artery with luminal narrowing and medial inflammation with lymphocytes, macrophages, and occasional giant cells. He improves with a course of high-dose corticosteroid therapy. Which of the following laboratory test findings is most likely to be present with this man's disease? Erythrocyte sedimentation rate of 110 mm/hr Rheumatoid factor titer of 80 IU/mL HDL cholesterol of 15 mg/dL Anti-double stranded DNA titer of 1:1024 PANCA titer of 1:160

Answer 33

Erythrocyte sedimentation rate of 110 mm/hr Giant cell (temporal) arteritis produces very high ESR/CRP and responds to corticosteroids.

Question 34

A 17-year-old girl experiences syncope while out running for exercise one afternoon, as she has done for many years. Physical examination, chest radiograph, head CT scan, CBC, and chemistry panel are all normal. Over the next year, she develops mild dyspnea and fatigue. She experiences several episodes of near-syncope. After another syncopal episode, she is referred to a cardiologist who orders an EKG that shows changes of left ventricular hypertrophy and broad Q waves. An echocardiogram reveals left ventricular and septal hypertrophy, small left ventricle, and reduced septal excursion. The septum has a 'ground glass' appearance. Which of the following is the most likely microscopic feature of her disease process? A Aschoff bodies B Lymphocytic infiltrates C Pericarditis D Myofiber disarray E Atheroma formation

Answer 34

Myofiber disarray Hypertrophic (obstructive) cardiomyopathy shows myocyte disarray with hypertrophy and interstitial fibrosis — classic microscopic feature.

Question 35

A 78-year-old woman has had increasing dyspnea for the past 5 years. On examination her blood pressure is 130/85 mm Hg. Her BMI is 35 kg/m². Rales are auscultated in both lungs. Her B-type natriuretic peptide, C-reative protein and LDL cholesterol are elevated. A chest x-ray shows infiltrates in all lung fields and an enlarged heart. Echocardiography shows decreased ejection fraction with segmental wall motion abnormalities. Which of the following forms of cardiomyopathy is she most likely to have? A Alcoholic B Arrhythmogenic C Hypertrophic D Infiltrative E Ischemic

Answer 35

Ischemic Clinical summary: Elderly obese woman (BMI 35) Progressive dyspnea → chronic heart failure Elevated BNP, CRP, and LDL CXR: enlarged heart, diffuse pulmonary infiltrates Echo: ↓ ejection fraction, segmental wall motion abnormalities These findings point to ischemic cardiomyopathy due to coronary atherosclerosis causing chronic ischemic injury to the myocardium, resulting in patchy fibrosis and global systolic dysfunction. ✅ Answer: E — Ischemic cardiomyopathy Key differentiators: Segmental wall motion abnormalities = areas of previous infarction or ischemia. Alcoholic and infiltrative cardiomyopathies cause global dysfunction, not segmental. Arrhythmogenic and hypertrophic types typically involve younger patients.

Question 36

A 51-year-old man has the sudden onset of substernal chest pain which radiates to his left arm and neck. He becomes light-headed and diaphoretic over the next 3 hours. He goes to the emergency room. On examination he is afebrile but has a heart rate of 96/minute with an irregular rhythm. Laboratory studies show an increased serum cardiac troponin. Which of the following features would be most prominent by histopathologic examination of his myocardium at this point in time? A Macrophage infiltration B Contraction band necrosis C Neutrophilic infiltration D Capillary proliferation E Collagen deposition

Answer 36

Contraction band necrosis Clinical summary: Acute chest pain radiating to arm and neck Irregular pulse (likely arrhythmia due to ischemia) ↑ Cardiac troponin → acute myocardial infarction Duration: 3 hours At 3 hours after onset, the earliest histologic change seen in the myocardium is contraction band necrosis due to calcium influx and hypercontraction of sarcomeres in irreversibly injured myocytes. ✅ Answer: B — Contraction band necrosis Timeline summary of MI histopathology: Time after infarct Key histologic feature 0–30 min No visible change (reversible injury) 30 min–4 hrs Contraction band necrosis, wavy fibers 4–24 hrs Early coagulative necrosis, neutrophils start 1–3 days Heavy neutrophilic infiltration 3–7 days Macrophages, granulation tissue begins 1–2 wks Fibroblast proliferation, collagen deposition begins >2 wks Dense collagen scar

Question 37

A 58-year-old man has had an enlarging abdomen for 5 months. He has experienced no abdominal or chest pain. On physical examination he has a non-tender abdomen with no masses palpable, but there is a fluid wave. An abdominal CT scan shows a large abdominal fluid collection with a small cirrhotic liver. A chest radiograph shows a globally enlarged heart. He has vital signs showing T 37.1°C, P 78/minute, RR 16/minute, and BP 115/75 mm Hg. Which of the following cardiovascular conditions is he most likely to have? A Severe occlusive coronary atherosclerosis B Lymphocytic myocarditis C Myocardial amyloid deposition D Nonbacterial thrombotic endocarditis E Dilated cardiomyopathy

Answer 37

Clinical summary 58-year-old man Ascites Cirrhotic small liver Globally enlarged heart (cardiomegaly) No chest pain, normal vitals Chronic fluid overload This combination → right-sided heart failure leading to passive liver congestion → “cardiac cirrhosis.” The most common cardiac cause = dilated cardiomyopathy (DCM) → leads to biventricular failure and chronic passive hepatic congestion → ascites. Correct Answer: E — Dilated cardiomyopathy

Question 38

A 77-year-old man with decreasing mental function has developed increasing dyspnea for the past 3 years. On physical examination he has a diastolic murmur. A chest CT scan shows an enlarged heart and prominent aorta. He dies from complications of pneumonia. At autopsy, the thoracic aorta is aneurysmally dilated. A microscopic section of the aorta shows chronic inflammation and luminal narrowing of vasa vasora. There is disruption of the aortic medial elastic fibers. Which of the following conditions is most likely to cause these findings? Hypercholesterolemia Marfan syndrome Polyarteritis nodosa Takayasu arteritis Tertiary syphilis FANCA-associated vasculitis

Answer 38

Clinical summary 77-year-old man Diastolic murmur Thoracic aortic aneurysm Histology: Chronic inflammation of vasa vasorum Endarteritis obliterans Disrupted elastic fibers in media This is classic for tertiary syphilis (syphilitic aortitis). Damage to vasa vasorum causes ischemia of the aortic media → dilation → aneurysm → aortic regurgitation (diastolic murmur). Correct Answer: E — Tertiary syphilis

Question 39

A 23-year-old primigravida gives birth following an uncomplicated pregnancy to a 2870 gm girl infant. The baby initially does well, but 12 hours following delivery she develops respiratory difficulty. On examination the infant has a poor color, weak pulses, and oxygen saturation of only 80%. Which of the following cardiac findings is this infant most likely to have? A Muscular ventricular septal defect B Hypoplastic left heart C Complete transposition with no shunt D Secundum type atrial septal defect E Congenital Group B Streptococcus infection

Answer 39

Newborn with acute respiratory distress at 12 hours Poor color, weak pulses, low O₂ saturation (80%). A critical congenital heart disease that becomes symptomatic when ductus arteriosus closes is likely. Which condition is ductus-dependent for life? → Transposition of the great arteries (TGA) without a shunt becomes fatal as soon as ductus begins to close (within first day). ✅ Answer: C — Complete transposition with no shunt

Question 40

A 66-year-old man has had increasing malaise for the past year. On physical examination auscultation of the chest reveals a friction rub. Laboratory studies show a serum urea nitrogen of 100 mg/dL and creatinine of 9.8 mg/dL. Which of the following forms of pericarditis is he most likely to have? A Fibrinous B Hemorrhagic C Purulent D Serous E Constrictive

Answer 40

Clinical summary: Chronic renal failure: BUN 100, creatinine 9.8 Friction rub → Uremia causes serous or fibrinous pericarditis, most characteristically fibrinous "bread and butter" pericarditis. ✅ Answer: A — Fibrinous pericarditis

Question 41

40-year-old man is undergoing treatment for a proliferative glomerulonephritis. Laboratory studies show an elevated antinuclear antibody and anti-ds-DNA titer. Which of the following cardiac abnormalities is most likely to be present in this man? A Pancarditis B Libman-Sacks endocarditis C Hemorrhagic pericarditis D Lipofuscin deposition E Coronary artery vasculitis

Answer 41

Correct Answer: B — Libman-Sacks Endocarditis Why: Systemic lupus erythematosus causes sterile vegetations on both sides of valve leaflets (most often mitral).

Question 42

A 53-year-old man has had malaise for the past 3 months. On physical examination he is afebrile. On auscultation of the chest, heart sounds are distant and there is a friction rub. An echocardiogram shows a pericardial fluid collection. A pericardiocentesis yields 10 mL of bloody fluid. Which of the following conditions is most likely to give rise to these findings? A Autoimmune disease B Chronic renal failure C Rheumatic fever D Metastatic carcinoma E Acute myocardial infarction

Answer 42

Correct Answer: D — Metastatic carcinoma Why: A hemorrhagic pericardial effusion is most commonly caused by: metastatic lung carcinoma breast carcinoma lymphoma

Question 43

A 56-year-old man has a routine checkup. He is found to have a blood pressure of 175/110 mm Hg. A month later his blood pressure is 170/105 mm Hg. He elects to do nothing about this, because he feels fine. If he remains untreated, this man is at greatest risk for developing which of the following cardiac abnormalities? A Calcific aortic valve stenosis B Dilated cardiomyopathy C Left ventricular hypertrophy D Mitral valvular insufficiency E Non-bacterial thrombotic endocarditis

Answer 43

orrect answer: C — Left ventricular hypertrophy Explanation: Chronic systemic hypertension → increased afterload → concentric LV hypertrophy. This is the earliest and most common cardiac consequence of untreated hypertension.

Question 44

A 48-year-old man has had worsening severe headaches over the past 3 months. There are no abnormal findings on physical examination. Brain MR imaging shows a large 8 cm mass in the right posterior parietal region that extends across the splenium of the corpus callosum. A stereotaxic biopsy reveals an anaplastic astrocytoma. He is treated with radiation and chemotherapy. Two months later he experiences left upper quadrant abdominal pain, accompanied by hematuria. He then has an episode of sudden dyspnea and a chest CT scan shows large thromboemboli filling both main pulmonary arterial branches. Which of the following cardiovascular lesions is most likely to be found in this man? A Tear in the ascending aortic intima B Occlusive coronary atheromatous plaques C Hypertrophic cardiomyopathy DEpicardial metastases E Mitral marantic vegetations

Answer 44

Correct answer: E — Mitral marantic vegetations (Non-bacterial thrombotic endocarditis) Explanation: Patients with advanced malignancy (especially mucin-producing adenocarcinomas, but also high-grade CNS tumors) are hypercoagulable and develop sterile fibrin vegetations on valves → NBTE → systemic emboli (renal infarct causing LUQ pain + hematuria) and DVT/PE.

Question 45

A 50-year-old man has noted increasing swelling of his lower legs along with shortness of breath for 5 months. On physical examination he is afebrile, but diffuse crackles are heard over the lung bases. His heart rate is 80/minute and regular, with no murmurs, rubs, or gallops, but there is a prominent widened split S2. A chest radiograph reveals ar increased size to the right heart border, along with bilateral pleural effusions. Laboratory studies show a serum cardiac troponin of <0.4 ng/mL. Which of the following condition: is he most likely to have? A Alcoholic cardiomyopathy B Viral myocarditis C Bicuspid aortic valve DConstrictive pericarditis E Pulmonary interstitial fibrosis

Answer 45

Answer: D — Constrictive pericarditis Explanation: Right-sided heart failure signs Wide split S2 Enlarged right heart border Pleural effusions These all point to restricted ventricular filling due to a rigid pericardium, not myocardial disease.

Question 46

Which congenital heart disease do we have during left-to-right shunts? Select one: 1. ASD, VSD and PDA 2. ASD, VSD and tetralogy of fallot 3. ASD, VSD and tricuspid atresia 4. Transposition of the great arteries and tetralogy of fallot

Answer 46

ASD, VSD and PDA

Question 47

Which four features can we see during tetralogy of fallot? Select one: 1. VSD, obstruction of the right ventricular outflow tract, aorta that overrides the VSD and right ventricular hypertrophy 2. VSD, obstruction of the right ventricular outflow tract, aorta that overrides the VSD and left ventricular hypertrophy 3. ASD, obstruction of the right ventricular outflow tract, aorta that overrides the VSD and left ventricular hypertrophy

Answer 47

1. VSD, obstruction of the right ventricular outflow tract, aorta that overrides the VSD and right ventricular hypertrophy

Question 48

A 77-year-old man with a history of hypertension, hypercholesterolemia, an abdominal aortic aneurysm, chronic obstructive pulmonary disease, and a 90-pack-year smoking history presents to the ED with lethargy and abdominal pain. At presentation, his temperature was 36.9°C (98.5°F), blood pressure was 82/54 mm Hg. pulse was 125/min, and respiratory rate was 16/min. On physical examination, there is a pulsatile abdominal mass that is palpable just superior to the umbilicus. There is also diffuse abdominal tenderness, though rebound tenderness and guarding are absent. There is also slight skin discoloration noted in the left lower back. Which of the following is the most likely diagnosis? Select one: a. Mesenteric ischemia b. Perforated gastric ulcer c. Aortic dissection d. Ruptured abdominal aortic aneurysm

Answer 48

d. Ruptured abdominal aortic aneurysm Why? He has a known AAA and major risk factors (HTN, smoking). Presents with hypotension + tachycardia + abdominal/back pain, the classic triad of AAA rupture. Pulsatile abdominal mass is palpable. Flank/back ecchymosis (Grey Turner sign) indicates retroperitoneal hemorrhage. No peritonitis → supports retroperitoneal rupture.

Question 49

Common symptoms of Anaphylaxis are all, except: select one: Select one: a. Angioedema b. Bradycardia - low heart rate c. Urticaria d. Bronchospasm

Answer 49

Bradycardia - low heart rate

Question 50

A 55-year-old man suffers from an acute myocardial infarction after occlusion of the left anterior descending coronary artery. The patient undergoes coronary bypass surgery 3 days later. Which of the following is the most frequent cause of saphenous vein graft failure several years following coronary bypass surgery? Select one: 1. Atherosclerosis 2. Acute inflammation 3. Metastatic calcification 4. Microaneurysm

Answer 50

1. Atherosclerosis Why: Timeline matters: Early (<1 month): thrombosis Intermediate (1 month–1 year): intimal hyperplasia Late (>1–5+ years): atherosclerosis → most common cause of late graft failure

Question 51

A 47-year-old woman presents to your office with a complaint of severe fatigue, weakness, and dyspnea on exertion. She has had these symptoms for 2 days. The patient denies having fever, chills, weight changes, or dysuria. Her medical history is significant for pernicious anemia and hypothyroidism. Results of thyroid studies were within normal limits 1 week ago. Her physical examination is positive for mild icterus and hepatosplenomegaly. CBC is normal, with the exception of a hematocrit of 21%. Her hermatocrit was 36% 3 months ago. A direct Coombs test is positive. Which of the following statements regarding autoimmune hemolytic anemia is true? Select one: 1. Autoimmune hemolytic anemia may be idiopathic or secondary to disorders such as systemic lupus erythematosus, chronic lymphocytic leukemia (CLL), HIV infection, or hepatitis C infection 2. Autoimmune hemolytic anemia typically results in intravascular hemolysis 3. Most patients with autoimmune hemolytic anemia are cured with steroid therapy 4. Splenectomy is curative for those patients who do not respond to simple

Answer 51

1. Autoimmune hemolytic anemia may be idiopathic or secondary to disorders such as systemic lupus erythematosus, chronic lymphocytic leukemia (CLL), HIV infection, or hepatitis C infection

Question 52

An 84-year-old man comes to your office complaining of a severe left temporal headache, which he has had for the past 2 days. In addition, the patient states that over the past 2 days, he has had a low-grade fever, fatigue, and loss of appetite. Upon questioning, the patient admits to muscle weakness and jaw pain with mastication but has no visual complaint. The physical examination is within normal limits, with the exception of a tender, palpable left temporal artery. Laboratory evaluation reveals a slight elevation in the white blood cell count and a marked elevation in the erythrocyte sedimentation rate. Which of the following statements regarding giant cell arteritis is true? Select one: a. Giant cell arteritis commonly occurs in patients 50 years of age or younger b. Giant cell arteritis often affects the branches of the proximal aorta c. Standard therapy for this arteritis is prednisone, 5 to 15 mg/day d. Giant cell arteritis never results in complete blindness despite the high frequency of visual complaints

Answer 52

b. Giant cell arteritis often affects the branches of the proximal aorta It frequently involves branches of the carotid artery, especially the temporal artery, and can also involve branches of the proximal aorta, including causing aortic aneurysms — making option b true.

Question 54

A 60-year-old man presents with a 6-month history of increasing fatigue. Physical examination reveals marked pallor, and a CBC shows a macrocytic anemia. Which of the following is the most likely cause of anemia in this patient? Select one: 1. Alcoholis 2. Chronic disease 3. Iron deficiency 4. Renal disease

Answer 54

Alcoholis (Alcoholism is one of the most common causes of macrocytosis. Chronic disease, iron deficiency, and renal disease all cause normocytic or microcytic anemia, not macrocytic.)

Question 55

16-year-old boy is found to have hypertension on routine evaluation. He has no symptoms of shortness of breath or chest discomfort, but occasionally on exertion notes that his legs get tired easily. He has no other past medical history. On physical examination, the blood pressure in his arms is 140/90 mm Hg (bilaterally). Measurement of the blood pressure in his legs is 20mmHg lower than in the arms. The remaining physical examination is normal. Which of the following is the most likely diagnosis? Select one: 1. coarctation of the aorta 2. aortic insufficiency 3. normal variant 4. ventricular aneurysm

Answer 55

coarctation of the aorta Upper extremity BP > lower extremity BP.)

Question 56

A 55-year-old man presents to establish primary care. His medical history is significant only for 40 pack years of smoking. He drinks four beers a night. He is minimally physically active. On physical examination, the patient's blood pressure is 158/98 mm Hg, and he is moderately obese (body mass index, 27) the rest of his examination is normal. His laboratory examination is normal, as is his electrocardiogram. Repeated blood pressure measurements over the next month are similar to the values first obtained. With respect to this patient's blood pressure, what therapeutic option should be offered to this patient now? Select one: 1. Lifestyle modifications, including decreased alcohol consumption, weight loss, smoking cessation, and moderate exercise for 6 months 2. Continued monitoring for 6 months 3. No treatment 4. Pharmacologic therapy

Answer 56

4. Pharmacologic therapy This patient has persistent Stage 2 hypertension: BP repeatedly around 158/98 mm Hg Stage 2 is defined as ≥140 systolic OR ≥90 diastolic He also has multiple cardiovascular risk factors: 40 pack-year smoking history Obesity Alcohol intake Sedentary lifestyle Guidelines (ACC/AHA): For Stage 2 hypertension, drug therapy should be started immediately, along with lifestyle modification. Lifestyle modification alone is recommended only for elevated BP or Stage 1 hypertension without risk factors.

Question 57

What is a major cause of noninfectious vasculitis? Select one: 1. Immune complex deposition; Antineutrophil cytoplasmic antibodies; Antiendothelial cell antibodies; Autoreactive T cells 2. Only immune complex deposition and autoreactive T cells 3. Only autoreactive T cells and antiendothelial cell antibodies 4. Only immune complex deposition

Answer 57

1. Immune complex deposition; Antineutrophil cytoplasmic antibodies; Antiendothelial cell antibodies; Autoreactive T cells Noninfectious vasculitis is most commonly caused by immune-mediated mechanisms, and the major recognized pathways include: Immune complex deposition (e.g., SLE, Henoch–Schönlein purpura) ANCA-associated vasculitis (e.g., microscopic polyangiitis, granulomatosis with polyangiitis) Antiendothelial cell antibodies (e.g., Kawasaki disease) Autoreactive T cells (e.g., giant cell arteritis, Takayasu arteritis)

Question 58

A 38-year-old white woman presents to the physician with a 2-week history of aching pain in her left calf that is made worse by dorsifl exion of her foot. On physical examination, her left calf is found to be erythematous, warm, and swollen. Which of the following measures should she take to decrease similar problems in the future? Select one: a. Begin taking a bile acid resin b. Begin taking low-dose oral contraceptives c. Exercise 30 minutes three times per week d. Quit smoking

Answer 58

d. Quit smoking → Smoking is a strong modifiable risk factor for venous thrombosis. Exercise helps but does not reduce DVT risk as effectively as eliminating smoking.

Question 59

A 23-year-old, previously healthy man of Italian origin develops moderate to severe hemolytic anemia. The previous evening he had celebrated a Saintâ's day with a feast of beans and pasta. Urinalysis shows free hemoglobin, and the direct Coombs test is negative. Supravital staining of the blood smear demonstrates numerous membrane-bound inclusions (Heinz bodies) within erythrocytes. Which of the following is the most likely diagnosis? Select one: 1. G6PD deficiency 2. Paroxysmal nocturnal hemoglobinuria 3. Sickle cell anemia 4. Î-Thalassemia minor

Answer 59

1. G6PD deficiency

Question 60

After undergoing surgical resection for carcinoma of the stomach, a 60-year-old male develops numbness in his feet. On exam, he has lost proprioception in the lower extremities and has a wide-based gait and positive Romberg sign. A peripheral blood smear shows macrocytosis and hypersegmented polymorphonuclear leukocytes. The neurologic dysfunction is secondary to a deficiency of which vitamin? Select one: 1. Vitamin B12 2. Thiamine 3. Vitamin K 4. Folic acid

Answer 60

Vitamin B12 \bcs neurological dysfunction B12 deficiency → subacute combined degeneration, macrocytosis, hypersegmented neutrophils

Question 61

A 19-year-old African American man presents to your office with generalized fatigue and frequent sinus infections. The patient has never seen a physician before and denies any previous history. He is adopted and does not know anything regarding his family history. When he gets recurrent sinus infections, he has been taken to urgent care settings, where he gets antibiotics and starts feeling better. He is generally not active and has frequent joint pains. You get a CBC, which shows some mild anemia with a Hgb of 9 gm/dL, and is otherwise unremarkable. Among other testing, you get a peripheral smear which shows Howell-Jolly bodies. The most likely diagnosis is: Select one: 1. Sickle cell anemia 2. Sickle cell trait 3. Hemoglobin S-hereditary persistence of fetal hemoglobin 4. Hemoglobin C trait

Answer 61

Sickle cell anemia Reasoning: Howell–Jolly bodies indicate asplenia or hyposplenism. In a 19-year-old African American man with chronic anemia, recurrent infections, joint pains, and Howell–Jolly bodies, the most likely cause is functional asplenia from sickle cell disease (HbSS). Sickle cell anemia (HbSS) → autosplenectomy → Howell–Jolly bodies. Sickle cell trait (HbAS) → does not cause functional asplenia; Howell–Jolly bodies would NOT be seen. Hereditary persistence of fetal hemoglobin (HPFH) → mild or no symptoms. Hemoglobin C trait → mild disease, no autosplenectomy.

Question 62

During lymphoid neoplasms, which type of classification can you find? Select one: 1. Precursor B-cell neoplasms (neoplasms of immature B cells); Peripheral B-cell neoplasms (neoplasms of mature B cells); Precursor T-cell neoplasms (neoplasms of immature T cells); Peripheral T-cell and NK-cell neoplasms (neoplasms of mature T cells and NK cells); Hodgkin lymphoma (neoplasms of Reed-Sternberg cells and variants) 2. Precursor B-cell neoplasms (neoplasms of immature B cells); Peripheral B-cell neoplasms (neoplasms of mature B cells); Precursor T-cell neoplasms (neoplasms of immature T cells); Hodgkin lymphoma (neoplasms of Reed-Sternberg cells and variants) 3. Precursor B-cell neoplasms (neoplasms of immature B cells); Peripheral B-cell neoplasms (neoplasms of mature B cells); Hodgkin lymphoma (neoplasms of Reed-Sternberg cells and variants) 4. Peripheral B-cell neoplasms (neoplasms of mature B cells);

Answer 62

1. Precursor B-cell neoplasms (neoplasms of immature B cells); Peripheral B-cell neoplasms (neoplasms of mature B cells); Precursor T-cell neoplasms (neoplasms of immature T cells); Peripheral T-cell and NK-cell neoplasms (neoplasms of mature T cells and NK cells); Hodgkin lymphoma (neoplasms of Reed-Sternberg cells and variants) Classification of lymphoid neoplasms The full WHO classification includes all 5 categories: Precursor B-cell Peripheral B-cell Precursor T-cell Peripheral T/NK-cell Hodgkin lymphoma

Question 63

What is a causes of left-sided heart failure ? Select one: 1. Ischemic heart disease, hypertension, aortic and mitral valvular diseases 2. Only aortic and mitral valvular diseases 3. Only hypertension, aortic and mitral valvular diseases 4. Only Primary myocardial diseases

Answer 63

1. Ischemic heart disease, hypertension, aortic and mitral valvular diseases

Question 64

Which symptoms do we have during superior vena cava syndrome? Select one: 1. Dilation of the veins of the head, neck and cyanosis 2. Constriction of the veins of the head, neck and cyanosis 3. Only cyanosis 4. Dilation of the veins of the head, legs, hands and cyanosis

Answer 64

1. Dilation of the veins of the head, neck and cyanosis Explanation: Superior vena cava (SVC) syndrome occurs when the SVC is obstructed—most commonly by a malignancy such as lung cancer or lymphoma. Because venous return from the head, neck, and upper extremities is impaired, patients develop: Facial swelling Neck and upper chest vein distention Cyanosis (due to impaired venous drainage) Dyspnea, cough, headache

Question 65

A 62-year-old man is discovered to have hyperlipidemia on screening tests after a routine physical examination. Laboratory studies show total serum cholesterol of 285 mg/dL, LDL of 215 mg/dL, HDL of 38 mg/dL, and triglycerides of 300 mg/dL. This patient is most at risk of developing an aneurysm in which of the following anatomic locations? Select one: 1. Abdominal aorta 2. Circle of Willis 3. Coronary artery 4. Renal artery

Answer 65

Abdominal aorta Most common site of atherosclerotic aneurysms.

Question 66

A 3-year-old boy comes to the pediatrician with fever, conjunctivitis, erythema in the oral , and cervical lymphadenopathy. The boy suddenly becomes hypotensive and goes into cardiac arrest and dies shortly thereafter. Autopsy shows aneurysmal dilations of the left circumflex and right coronary arteries. The boy's disease is characterized as a self-limiting disease that most commonly affects the coronary arteries. Which of the following diseases is the correct diagnosis? Select one: a. Polyarteritis nodosa b. Kawasaki's disease c. Takayasu's arteritis d. Buerger's disease

Answer 66

Kawasaki's disease

Question 67

What is most common etiology of ascending aortic aneurysm? Select one: 1. Hypertension 2. Atherosclerosis 3. Cigarette smoking 4. Diabetes

Answer 67

Hypertension --> ascending aortic aneurysm atherosclerosis --> abdominal Ascending aortic aneurysms most commonly result from cystic medial degeneration, a process strongly associated with chronic hypertension. Hypertension increases shear stress on the ascending aorta, weakening the media over time. Other causes include Marfan syndrome and bicuspid aortic valve, but hypertension remains the most common overall cause. In contrast: Atherosclerosis is the most common cause of abdominal aortic aneurysms (AAA), not ascending aneurysms. Smoking is a major risk factor for AAA, not specifically for ascending aneurysms. Diabetes is actually protective against aneurysm formation. ✔️ Thus, hypertension is the most common etiology of ascending aortic aneurysm.

Question 68

A 48-year-old man with diabetes presents with a history of progressive pain in both legs for several years. The pain is severe after walking two blocks or climbing one flight of stairs. Blood pressure is 145/90 mm Hg. Laboratory studies show a serum cholesterol of 320 mg/dL. He neither smokes nor drinks. Bruits are evident upon auscultation of both femoral arteries. The pathogenesis of intermittent claudication in this patient is most closely associated with which of the following risk factors? Select one: 1. Hyperlipidemia 2. Hyperglycemia O3. Obesity 4. Sedentary lifestyle

Answer 68

1. Hyperlipidemia Explanation: Intermittent claudication is caused by peripheral arterial disease (PAD), which results from atherosclerotic narrowing of large and medium-sized arteries (e.g., femoral, popliteal). Among the risk factors listed: Why hyperlipidemia is the strongest association: Atherosclerosis is driven primarily by elevated LDL cholesterol. This patient has very high cholesterol (320 mg/dL). Hyperlipidemia is the most important modifiable risk factor for PAD.

Question 69

Which ofthe following symptoms is most commonly associated with left-sided heart failure? Select one: a. Hepatic engorgement b. Arrhythmias c. Crackles d. Hypotension

Answer 69

Crackles Explanation: Left-sided heart failure leads to: ↑ pulmonary venous pressure Pulmonary congestion Pulmonary edema This produces crackles (rales) on lung auscultation. Other options: Hepatic engorgement → right-sided HF Arrhythmias → nonspecific Hypotension → possible but not the MOST common early symptom

Question 70

Takayasu arteritis classically involves? Select one: 1. Aortic arch 2. Temporal artery 3. Ulnar artery 4. Popliteal artery

Answer 70

1. Aortic arch Explanation: Takayasu arteritis is a large-vessel granulomatous vasculitis affecting: Aortic arch and its major branches Classic presentation: "pulseless disease" in young women.

Question 71

Which drugs can induce thrombocytopenia? Select one: 1. Quinine, quinidine and vancomycin 2. Only heparin and vancomycin 3. Only heparin and quinidine 4. Only heparin and quinine

Answer 71

1. Quinine, quinidine and vancomycin Explanation: Drug-induced immune thrombocytopenia is classically caused by: * Quinine * Quinidine * Vancomycin * Also heparin (HIT), but not in this combination.

Question 72

An 18-year-old man is rushed to the emergency room in shock following a motor vehicle accident. He is transfused with 5 U of blood. Following the transfusion the patient complains of fever, nausea, vomiting, and chest pain. Laboratory data show elevated indirect serum bilirubin, decreased serum haptoglobin, and a positive Coombs test. Which of the following is the most likely diagnosis? Select one: 1. Hemolytic transfusion reaction 2. Disseminated intravascular coagulation 3. Autoimmune hemolytic anemia 4. Hemolytic uremic syndrome

Answer 72

1. Hemolytic transfusion reaction Explanation: This is the classic presentation of an acute hemolytic transfusion reaction, the most dangerous transfusion complication. Why? It occurs when ABO-incompatible blood is transfused. Preformed IgM antibodies activate complement, causing intravascular hemolysis. Key findings in the question that match this: Rapid onset after transfusion Fever, chills, chest/back pain → classic Positive direct Coombs test → antibodies attached to donor RBCs Elevated indirect bilirubin & low haptoglobin → hemolysis Shock is common in severe reactions. Why NOT the other options? 2. DIC – Would show bleeding, prolonged PT/PTT, schistocytes. Not the picture here. 3. Autoimmune hemolytic anemia – Not related to transfusion; develops more gradually. 4. HUS – Seen after infections (E. coli O157:H7), with kidney injury and thrombocytopenia.

Question 73

What is a major cause of abdominal aortic aneurysm? Select one: 1. Atherosclerosis 2. Male gender 3. Cigarette smoking 4. Diabetes

Answer 73

1. Atherosclerosis

Question 74

A 2-week-old girl is found to have a harsh murmur along the left sternal border. The parents report that the baby gets a blueish when she cries or drinks from her bottle. Echocardiogram reveals a congenital heart defect associated with pulmonary stenosis, ventricular septal defect, dextroposition of the aorta, and right ventricular hypertrophy. What is the appropriate diagnosis? Select one: 1. Tetralogy of Fallot 2. Coarctation of aorta, postductal 3. Coarctation of aorta, preductal 4. Atrial septal defect

Answer 74

1. Tetralogy of Fallot

Question 75

A heart murmur is noted during the preschool physical examination of a 4-year-old girl. An echocardiogram reveals a defect between the right and left atrium involving the limbus of the foramen ovale. What is the most likely diagnosis? Select one: 1. ASD, ostium secundum 2. VSD, ventricular septal defect 3. Tetralogy of Fallot 4. Truncus arteriosus

Answer 75

1. ASD, ostium secundum

Question 76

A27year old woman has a screening ultrasound performed at 18 weeks gestation. The fetus is appropriate in size for 18 weeks. The fetal kidneys, liver, head, and extremities appear normal. However, the fetus has a heart with membranous ventricular septal defects, overriding aorta, and marked pulmonic atresia. If the baby were to be liveborn, what characteristic on physical examination would most likely result from these cardiac defects? Select one: ● a.Systemic hypertension ● b.Clubbing of digits ● c.Cyanosis ● d.Weaklower extremity pulses

Answer 76

C — Cyanosis. Membranous VSD + overriding aorta + pulmonic atresia produce a right-to-left shunt (reduced pulmonary flow) → cyanosis (classic for severe tetralogy/related lesions).

Question 77

Apatient with a history of chronic alcoholism presents with a macrocytic anemia and thrombocytopenia. Blood smear examination demonstrates numerous oval macrocytes and hypersegmented neutrophils. A Schilling test is normal. Which of the following is the most likely diagnosis? Select one: ● a.Anemia of chronic disease ● b.Folic acid deficiency ● c.G6PDdeficiency ● d. Iron Deficiency Anemia

Answer 77

B — Folic acid deficiency. Chronic alcoholism → folate deficiency causing macrocytic anemia with oval macrocytes and hypersegmented neutrophils; a normal Schilling test rules out B12 malabsorption.

Question 78

A70-year-old woman has a long history of metastatic colon cancer, and she donates her body for use in medical school anatomy courses. At death, the body is emaciated and cachectic, and gross dissection reveals small fibrin deposits arranged around the line of closure of the leaflets of the mitral valve. The valvular lesions most likely represent Select one: ● a.endocarditis of the carcinoid syndrome ● b. libman-Sacks endocarditis ● c.bacterial endocarditis ● d.nonbacterial thrombotic (marantic) endocarditis

Answer 78

D — Nonbacterial thrombotic (marantic) endocarditis. Small sterile fibrin thrombi along valve closure lines in a cachectic patient with advanced malignancy are typical of marantic endocarditis.

Question 79

A72-year-old man presents with difficulty breathing. He says that he becomes short of breath at night unless he uses three pillows to prop himself up. Measurements of vital signs reveal normal temperature. mild tachypnea, and a blood pressure of 180/100 mm Hg. Physical examination discloses obesity, bilateral 2+ pitting leg edema, hepatosplenomegaly, and rales at the bases of both lungs. An X-ray film of the chest shows mild enlargement of the heart and a mild pleural effusion. Echocardiography reveals left ventricular hypertrophy without valvular heart defects. Which of the following is the most likely diagnosis? Select one: ● a.Constrictive pericarditis ● b.Dilated cardiomyopathy ● c.Hypertensive heart disease ● d.Acute cor pulmonale

Answer 79

C — Hypertensive heart disease. Longstanding hypertension with LV hypertrophy, orthopnea, rales, peripheral edema and cardiomegaly reflects hypertensive (pressure-overload) heart disease causing heart failure.

Question 80

A62-year-old man is discovered to have hyperlipidemia on screening tests after a routine physical examination. Laboratory studies show total serum cholesterol of 265 mg/SL, LDL of 215 ma/&, HOL or38 mg/dL, and triglycerides of 300 mg/dL. This patient is most at risk of developing an aneurysm in which el the following anatomic locations? Select one: ● a.Abdominal aorta ● b.Renal artery ● c.Circle of Willis ● d.Coronary artery

Answer 80

A — Abdominal aorta. High LDL / atherosclerosis predisposes to atherosclerotic aneurysms, most commonly infrarenal abdominal aorta (AAA)

Question 81

A56-year-old woman presents with dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea and pulmonary edema She also presents with severe dizziness and syncope, fatigue, weight loss, and arthralgias. After undergoing several tests, she is diagnosed with a primary heart tumor that is causing ball-valve obstruction" of her mitral valve. Which of the following is the most likely tumor? Select one: ● a. lipoma ● b.Myxoma ● c.Leiomyoma ● d.Fibroma

Answer 81

B — Myxoma. Cardiac myxomas (classically left atrial, attached to the atrial septum) can produce constitutional symptoms and act as a "ball-valve obstruction" of the mitral orifice, causing syncope, dyspnea, orthopnea.

Question 82

A56-year-old man presents with a 2-week history of fatigue. The patient's past medical history is significant for aortic and mitral valve replacement 5 months ago. A CBCshows moderate anemia with an increased reticulocyte count. Which of the following best explains the pathogenesis of anemia in this patient? Select one: ● a.Decreased blood flow ● b.Direct red cell trauma ● c.Complement-mediated hemolysis ● d.Sludging of erythrocytes

Answer 82

B — Direct red cell trauma. Mechanical hemolysis from prosthetic (mechanical) heart valves causes "shear-stress destruction of RBCs", producing anemia with reticulocytosis.

Question 83

A78-year-old man presents with increasing fatigue. A CBC shows pancytopenia, with moderate anemia (hemoglobin = 10.5 g/dL) and normochromic, hypochromic RBCs. Mild neutropenia and thrombocytopenia are noted. A bone marrow evaluation reveals erythroid hyperplasia with increased iron. Which of the following is the appropriate diagnosis? Select one: ● a.Hairy cell leukemia ● b.Multiple myeloma ● c.Myelodysplastic syndrome ● d.Polycythemia vera

Answer 83

C — Myelodysplastic syndrome. An elderly patient with pancytopenia and a marrow showing dysplastic/ineffective hematopoiesis and iron-loaded erythroid precursors is most consistent with myelodysplastic syndrome (MDS).

Question 84

A30-year-old man has had a progressively worsening productive cough for one month. On physical examination, a few small non-tender lymph nodes are palpable in the axillae, and the tip of the spleen is palpable. Laboratory studies show Hgb 10.2 g/dL, Hct 31.1%, MCV 90 fL, WBC count 67,000/microliter, and platelet count 36,000/microliter. Microscopic examination of his peripheral blood smear shows many blasts with Auer rods. Which of the following is the most likely diagnosis? Select one: ● a.Leukemoid reaction ● b.Acute myelogenous leukemia ● c.Chronic lymphocytic leukemia ● d.Lymphoblastic leukemia

Answer 84

B — Acute myelogenous leukemia (AML) Very high WBC count, anemia, thrombocytopenia "Blasts with Auer rods" → pathognomonic for AML Leukemoid reactions never have Auer rods.

Question 85

A heart murmur is noted during the preschool physical examination of a 4-year-old girl. An echocardiogram reveals a defect between the right and left atrium involving the limbus of the foramen ovale. What is the most likely diagnosis? Select one: ● a.VSD,ventricular septal defect ● b.ASD,ostium secundum ● c.Tetralogy of Fallot ● d.Truncus arteriosus

Answer 85

B — ASD, ostium secundum The most common ASD, arising from defective formation/resorption of septum primum or secundum, typically involving the fossa ovalis/limbus region.

Question 86

A 47-year-old woman presents to your office with a complaint of severe fatigue, weakness, and dyspnea on exertion. She has had these symptoms for 2 days. The patient denies having fever, chills, weight changes, or dysuria. Her medical history is significant for pernicious anemia and hypothyroidism. Results of thyroid studies were within normal limits 1 week ago. Her physical examination is positive for mild icterus and hepatosplenomegaly. CBC is normal, with the exception of a hematocrit of 21%. Her hematocrit was 36% 3 months ago. A direct Coombs test is positive. Which of the following statements regarding autoimmune hemolytic anemia is true? Select one: ● a.Mostpatients with autoimmune hemolytic anemia are cured with steroid therapy ● b.Autoimmune hemolytic anemia typically results in intravascular hemolysis ● c.Splenectomy is curative for those patients who do not respond to simple steroid therapy ● d.Autoimmune hemolytic anemia may be idiopathic or secondary to disorders such as systemic lupus erythematosus, chronic lymphocytic leukemia (CLL), HIV infection, or hepatitis C infection

Answer 86

D — AIHA may be idiopathic or secondary to SLE, CLL, HIV, HCV Direct Coombs-positive = warm autoimmune hemolytic anemia Key fact: warm AIHA is often secondary to autoimmune disease, lymphoproliferative disorders, or infections. Why the others are incorrect: A: Steroids help many, but “most are cured” is inaccurate. Many require long-term therapy or second-line agents. B: Warm AIHA = extravascular hemolysis (splenic destruction), not intravascular. C: Splenectomy helps but is not reliably curative.

Question 87

A 6-year-old boy presents with fatigue, fever, and night sweats. Physical examination reveals marked pallor. Palpation of his sternum demonstrates diffuse tenderness. Laboratory studies disciose anemia, thrombocytopenia, and leukocytosis. The WBC differential count shows that 90% blasts. A bone marrow a biopsy stained immunohistochemically for terminal deoxynucleotidyl transferase (tdt), Which of the following is the appropriate diagnosis? Select one: ● a.Chronic lymphocytic leukemia ● b.Acute promyelocytic leukemia ● c.Acute lymphoblastic leukemia ● d.Acute myelogenous leukemia

Answer 87

Acute lymphoblastic leukemia (ALL). Young child with fever, bone pain (sternal tenderness), pancytopenia with 90% blasts, and TdT-positive blasts — classic for ALL (TdT marks lymphoblasts).

Question 88

A 19-year-old African American man presents to your office with generalized fatigue and frequent sinus infections. The patient has never seen a physician before and denies any previous history. He is adopted and does not know anything regarding his family history. When he gets recurrent sinus infections, he has been taken to urgent care settings, where he gets antibiotics and starts feeling better. He is generally not active and has frequent joint pains. You get a CBC, which shows some mild anemia with a Hgb of 9 gm/dL and is otherwise unremarkable. Among other testing, you get a peripheral smear which shows Howell-Jolly bodies. The most likely diagnosis is: Select one: ● a.Sickle cell anemia ● b.Hemoglobin C trait ● c.Sickle cell trait ● d.Hemoglobin S-hereditary persistence of fetal hemoglobin

Answer 88

A — Sickle cell anemia. Young Black man with anemia (Hgb ~9), recurrent infections, Howell–Jolly bodies (functional asplenia from autosplenectomy) and joint pain — consistent with homozygous sickle cell disease (HbSS).

Question 89

A 2-week-old girl is found to have a harsh murmur along the left sternal border. The parents report that the baby gets "bluish" when she cries or drinks from her bottle. Echocardiogram reveals a congenital heart defect associated with pulmonary stenosis, ventricular septal defect, dextroposition of the aorta, and right ventricular hypertrophy. What is the appropriate diagnosis? Select one: ● a.Tetralogy of Fallot ● b.Atrial septal defect ● c.Coarctation of aorta, preductal ● d.Coarctation of aorta, postductal

Answer 89

Tetralogy of Fallot. Pulmonary stenosis + VSD + overriding (dextroposition) aorta + RV hypertrophy = the four findings of Tetralogy of Fallot; cyanotic spells when crying are typical.

Question 90

A 66-year-old woman collapses while shopping and expires suddenly of cardiac arrest. Her past medical history is significant for long-standing type 2 diabetes mellitus. Her relatives note that she had complained of chest heaviness and shortness of breath for the past 2 weeks. Sterile fibrinous pericarditis and pericardial effusion are observed at autopsy. What additional finding would be expected during autopsy of this patient? Select one: ● a.Endocardial fibroelastosis. ● b.Marantic endocarditis ● c.Mitral valve prolapse. ● d.Myocardial infarct.

Answer 90

D — Myocardial infarct. Sterile fibrinous pericarditis with recent chest heaviness for 2 weeks points to a transmural (epicardial) myocardial infarct producing fibrinous pericarditis (postinfarct inflammation).

Question 91

Two days after receiving the antimalarial drug primaquine, a 27-year-old black man develops sudden intravascular hemolysis resulting in a decreased hematocrit, hemoglobinemia, and hemoglobinuria. Examination of the peripheral blood reveals erythrocytes with a membrane defect forming “bite” cells; when crystal violet stain is applied, many Heinz bodies are seen. Which of the following is the most likely Diagnosis? Select one: ● a.Hereditary spherocytosis ● b.Glucose-6-phosphate dehydrogenase deficiency ● c.Paroxysmal nocturnal hemoglobinuria ● d.Autoimmune hemolytic anemia

Answer 91

B — Glucose-6-phosphate dehydrogenase (G6PD) deficiency Oxidative stress from primaquine → denatured Hb → Heinz bodies → macrophages remove them → “bite cells.” Classic in African-American men.

Question 92

A 4-month-old infant is anemic with a hemoglobin level of 9.5 g/dl and MCV 77 fL. The baby looks well, the height and weight growth parameters are normal, and she is breastfeeding well. Which of the following is the most likely cause for her anemia? Select one: ● a.folate deficiency ● b. iron malabsorption ● c. inadequate dietary iron ● d.Hemolysis

Answer 92

C — Inadequate dietary iron Breast milk is low in iron. Babies around 4–6 months are commonly mildly iron deficient unless supplemented. Infant looks well → dietary iron deficiency most likely

Question 93

A 65-year-old man presents with a 2-week history of abdominal discomfort. Pagical caminatos revals » pulsatile, abdominal mass in the periumbilical region. A CT scan shone a segment of abscenical acta proximal to the bifurcation that is dilated (5 cm) and calcified. The patient is scheduled for corrective surgery but suffers a massive stroke and expires. Which of the following is the most likely underlying cause of this patient's abdominal mass ? Select one: ● a.Cystic medial necrosis ● b.Hypercalcemia ● c.Atherosclerosis ● d.Angiosarcoma

Answer 93

C — Atherosclerosis Atherosclerosis is the most common cause of abdominal aortic aneurysm, especially in older men, typically infrarenal aneurysms.

Question 94

A 42-year-old man presents for his first visit to your clinic. He has always been cyanotic,clubbed and physically restricted. His hematocrit is 68%, with a hemoglobin level of 24 g. He has never undergone surgery , and his oxygen saturation on room air is 62%. Cardiac catheterization demonstrates a large VSD, overriding aorta, and severe calcification of the entire right ventricular outflow tract small pulmonary arteries bilaterally. The diagnosis in this patient is? Select one: ● a.Atrioventricular (AV) canal ● b.Double-outlet right ventricle ● c.Truncus arteriosus : ● d.Tetralogy of Fallot (TOF)

Answer 94

D — Tetralogy of Fallot (TOF) Severe RV outflow tract obstruction and hypoplastic pulmonary arteries → classic for untreated severe TOF (“tetralogy physiology”). Cyanosis and clubbing since childhood fit perfectly.

Question 95

A 19-year-old pregnant female feels tired and out of pep. Her conjunctive are pale; laboratory tests show she has a mild normocytic, normochromic anemia with a low serum iron and an increased TIBC (transferrin iron-binding capacity). Hemoccult tests are negative. Which is the likely cause of her anemia? Select one: ● a.Vitamin 812 deficiency ● b.Autoantibodies ● c. Iron or folate deficiences ● d.Gastrointestinal bleeding

Answer 95

C — Iron or folate deficiency (specifically iron deficiency) Pregnancy increases iron demand → most common cause is iron deficiency. Low serum iron + increased TIBC = classic for iron deficiency anemia. Normocytic early; becomes microcytic later.

Question 96

A 64-year-old male presents with recurrent chest pain that develops whenever he attempts to mow his yard. He relates that the pain goes away after a couple of minutes if he stops and rests. He also states that the pain has not increased in frequency or duration in the last several months. What is the correct diagnosis for this patient? Select one: ● a.Myocardial infarction ● b.Unstable angina ● c.Prinzmetal's angina ● d.Stable angina

Answer 96

D — Stable angina Predictable, exertional chest pain relieved by rest = stable angina. No increase in frequency, duration, or severity → rules out unstable angina

Question 97

An 18-year-old man is rushed to the emergency room in shock following a motor vehicle accident. He is transfused with 5 U of blood. Following the transfusion the patient complains of fever, nausea, vomiting, and chest pain. Laboratory data show elevated indirect serum bilirubin, decreased serum haptoglobin, and a positive Coombs test. Which of the following is the most likely diagnosis? Select one: ● a.Hemolytic uremic syndrome ● b.Hemolytic transfusion reaction ● c.Disseminated intravascular coagulation ● d.Autoimmune hemolytic anemia

Answer 97

B — Hemolytic transfusion reaction Acute hemolytic transfusion reaction = Type II hypersensitivity due to ABO incompatibility. Causes complement-mediated intravascular hemolysis → ↓ haptoglobin, ↑ bilirubin, fever, hemoglobinuria.

Question 98

Three weeks following a myocardial infarction, a 54-year-old male presents with fever productive cough and chest pain. The pain is worse with inspiration, better when he is sitting up, and not relieved by nitroglycerin. Physical examination finds a friction rub along with increased jugular venous pressure and pulsus paradoxus (excess blood pressure drop with inspiration). What is the most likely explanation for these findings? Select one: ● a.Dressler's syndrome ● b.Caplan's syndrome ● c.Ruptured papillary muscle ● d.Ruptured ventricular wall

Answer 98

A — Dressler's syndrome Occurs 2–6 weeks after MI. Autoimmune pericarditis → friction rub, pleuritic pain relieved by sitting up, often with pericardial effusion causing pulsus paradoxus.

Question 99

A 9-year-old girl is diagnosed with acute rheumatic fever. Instead of recovering as expected, her condition worsens, and she dies. Which of the following is the most likely cause of death? Select one: ● a.Endocarditis ● b.Central nervous system involvement ● c.Myocarditis ● d.Pericarditis

Answer 99

C — Myocarditis Rheumatic myocarditis (Aschoff bodies) is the most common cause of death in acute rheumatic fever. Leads to arrhythmias and heart failure.

Question 100

A 19-year-old primigravida of Southeast Asian ancestry gives birth at 35 weeks gestation a male infant On physical examination the infant is markedly hydropic. Laboratory studies show his hematocrit is 17% and the peripheral blood smear reveals numerous nucleated red blood cells and even a few erythroblasts. The red blood cells display marked anisocytosis and poikilocytosis. Which of the following diseases is most likely to be present in this infant? Select one: ● a.Sickle cell anemia ● b.Hemoglobin E disease ● c.Alpha-thalassemia ● d.G6PDdeficiency

Answer 100

C — Alpha-thalassemia. Severe fetal hydrops with profound anemia, many nucleated RBCs and marked poikilocytosis in a baby of Southeast Asian ancestry is classic for hydrops fetalis from alpha-thalassemia (--/--, Hb Bart).

Question 101

A 10-year-old boy with a 2-week history of an upper respiratory infection was admitted to the hospital with malaise, fever, joint swelling, and diffuse rash. The patient is treated and discharged. However, the patient suffers from recurrent pharyngitis and, a few years later, develops a heart murmur. This patient's heart murmur is most likely caused by exposure to which of the following pathogens? ● a.Candida albicans ● b.Beta-hemolytic streptococcus ● c.Epstein-Barr virus ● d.Staphylococcus aureus

Answer 101

B — Beta-hemolytic streptococcus. Recurrent/pharyngitis in childhood followed years later by a murmur fits rheumatic heart disease, which is a postinfectious complication of group A beta-hemolytic Streptococcus pyogenes