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    Prof. of Hepatology & Gastroenterology, Cairo University.

    Consultant of Hepatology,Gastroenterology and Endoscopy

    Management Positions: •

    Chief of Hepatology unit El Manial University Hospital (1994-1998).

    • Chief of Gastroentero ICU in Cairo university hospital (1997-2000)

    • President of the board of AlfaScope GI Specialized center (2004-2014).

    • Head of Endoscopy Unit in Cairo University Hospitals (2005-2010).       


     .Read more


    استاذ الكبد و الجهاز الهضمى بكلية الطب جامعة القاهرة

    استشارى الكبد و الجهاز الهضمى و المناظير

    دكتوراه امراض الكبد و الجهاز الهضمى من كلية الطب جامعة القاهرة

    الرئيس السابق لقسم الامراض الباطنية بكلية الطب جامعة ٦ اكتوبر

    الرئيس السابق لوحدة مناظير الجهاز الهضمى و مركز الكبد و الرعاية المركزة بقصر العينى


    إقرأ المزيد


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Friday, Jul 20th

Last update10:09:06 AM


MCQs part I

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MCQs Part I

These MCQs are parts of the MCQs bank of Internal Medicine Department, Kasr El Aini Faculty of medicine and the explanations of the answers are the efforts of many members of this department, and not mine.

Case 1:

While examining a 46-year-old woman, you hear a diastolic murmur that is increased when the patient is in the left lateral decubitus position.You asked her to run in place for 3 minutes, and the murmur is found to be accentuated as well by exercise.


What is the most likely valvular defect?

(A) aortic regurgitation

(B) mitral stenosis

(C) tricuspid stenosis

(D) pulmonic regurgitation



Case 2:

A 42 year-old male admitted with dyspnoea is noted to have a murmur suggestive of mitral stenosis. The presence of which of the following clinical signs suggests that the mitral valve is mobile?


A-    Fourth heart sound

B-   Loud second heart sound

C-   Opening snap      

D-  A soft first heart sound

E-   A third heart sound


Case 3:

On auscultation of a patient's heart you hear a 'pan-systolic murmur'.


With which of the following conditions is this murmur associated?

A-     Aortic regurgitation

B-   Coarctation of the aorta

C-   Mitral stenosis

D-  Pulmonary stenosis

E-Ventricular septal defect


Case 4:

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 leg and difficulty moving 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 these findings?


A -Essential hypertension

B -Cardiomyopathy

C -Mitral valve stenosis

D -Aortic coarctation

E - Left renal artery stenosis


Case 5:

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?

A - Systemic lupus erythematosus

B - Coronary atherosclerosis

C - Marantic endocarditis

D - Rheumatic fever

E - Amyloidosis


Case 6:

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 antinuclear antibody test, with a titer of 1:2048.


Which of the following is the most likely diagnosis?

A - Polyarteritis nodosa

B - Progressive systemic sclerosis

C - Systemic lupus erythematosus

D - ANCA-associated granulomatous vasculitis

E - Adenocarcinoma of the pancreas


Case 7:

A 72-year-old woman has had no major illnesses throughout her life. She has had 3 syncopal episodes over 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?

A - Acute rheumatic fever

B - Mitral valve stenosis

C - Atherosclerotic aortic aneurysm

D - Calcific aortic stenosis

E - Infective endocarditis

Case 8:

A 70-year-old woman with established aortic stenosis attends for annual review.

Which one of the following factors is the most important in deciding the timing of surgery?

A-     Aortic valve gradient of 50 mmHg 

B-   Left ventricular hypertrophy

C-   Valvular calcification

D-  The Patient's symptomatology        

E-   The intensity of the murmur


Case 9:

A 23-year-old woman presents with “skipped heart beats” and on cardiac examination is found to have a midsystolic click followed by a late systolic murmur. Echocardiogram shows prolapse of the mitral valve.


Which of the following is true about this condition?

(A) Mitral valve prolapse is present in up to10% of the population.

(B) Mitral valve prolapse is more commonin men.

(C) Prophylaxis against bacterial endocarditisis never recommended.

(D) Risk of pulmonary embolism is high.

(E) Ventricular arrhythmias do not occur.


Case 10:

26 year old female experiences chest pain. She also complains of paplitations. An ECHO is done and shows that she has mitral valve prolapse.

Which of the following is associated with mitral valve prolapse

a) Large v wave in the jugular pulse

b) Diastolic rumbling murmur

c) Increased pulse pressure

d) Large a wave in the jugular pulse

e) Mid systolic click with a systolic murmur

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Case 11:

A 42-year-old woman has noted increasing dyspnea for the past 6 years. On examination rales are auscultated in both lungs. She is afebrile. A chest radiograph shows an enlarged cardiac silhouette and bilateral pulmonary edema. Past history reveals that, as a child she suffered recurrent bouts of pharyngitis with group A beta hemolytic streptococcal infections.

Which of the following cardiac valves are most likely to be abnormal in this woman?

A Aortic and tricuspid

B Mitral and pulmonic

C Aortic and pulmonic

D Tricuspid and pulmonic

E Mitral and aortic


Case 12:

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 has no chest pain. On physical examination her vital signs show T 36.9 C, P 80/minute, RR 20/minute, and BP 110/75 mm Hg. She has no pedal edema. 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?

A Cardiac amyloidosis

B Left atrial myxoma

C Tuberculous pericarditis

D Mitral valve prolapse

E Ischemic cardiomyopathy


Case 13:

A 17-year-old woman loses consciousness whilst out jogging one afternoon. She has had similar blackouts over the last two to three years which have all occured during exertion.  There is no family history of note. She is taken to Accident and Emergency, where a chest X-ray, CT brain scan, FBC, and biochemistry are all normal. Her ECG 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 conditions is she most likely to have had?

A-                     Diabetes mellitus        

B-   Hypertrophic cardiomyopathy 

C-   Rheumatic heart disease

D-  Systemic lupus erythematosus

E-   Viral myocarditis

Case 14:

25-year-old man presents with headache, dizziness, and claudication. Blood pressure measurements reveal hypertension in the upper limbs and hypotension in the lower limbs. Which of the following additional findings would be most likely in this case?

a) Aortic valvular stenosis

b) Notching of inferior margins of ribs

c) Patent ductus arteriosus

d) Pulmonary valvular stenosis

e) Vasculitis involving the aortic arch



Case 15:

A 60-year-old man has left ventricular failure and clinically he is classified as NYHA Class III. He takes furosemide, aspirin and ramipril. The addition of which one of the following beta-blockers would be expected to further improve his prognosis?

A-     Acebutolol         

B-   Bisoprolol           

C-   Esmolol

D-  Propranolol          .

E-   Sotalol


Case 16:

A fifty-five year old with chronic cardiac failure is on treatment with digoxin and a loop diuretic.
This combination is likely to cause digoxin toxicity by the following reason:

a) This combination increases the half-life of digoxin

b) Diuretics decrease potassium levels

c) Frusemide and digoxin interact to form a poisonous compound

d) Digoxin is a competitive inhibitor of frusemide

e) The above statement is wrong, loop diuretics are not a recognized cause of increased digoxin toxicity

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Case 17:

A 68-year-old lady presents to her GP for an annual review of her heart failure treatment. She has a blood pressure of 165/90. She is currently taking furosemide and aspirin and she experiences dyspnoea on walking up hills.

Which of the following is the most appropriate medication to add?

A-     Bendroflumethiazide   

B-   Enalapril                                                                                                      

C-   Isosorbide mononitrate

D-  Spironolactone            

E-      Titrate dose of furosemide


Case 18:

A 60-year-old man has worsening dyspnea and swelling of his legs for the past month. On physical examination he has pitting edema to the hips as well as sacral edema. Diffuse rales are present in all lung fields. He is afebrile and normotensive. A chest radiograph shows a markedly enlarged heart along with pulmonary edema and bilateral pleural effusions. He develops abdominal pain in the last two days of life. At autopsy he is found to have patchy mucosal erythema involving 200 cm of small intestine.

Which of the following conditions is most likely to produce this finding in his bowel?

A Adenocarcinoma

B Venous thrombosis

C Volvulus

D Incarcerated hernia

E Ischemia


Case 19:

A 16-year-old healthy adolescent is involved in a schoolyard gang fight and 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 likely acute condition that may preclude his survival?

A -Myocardial contusion

B -Aortic laceration

C -Pericardial tamponade

D -Endocarditis

E -Acute infarction

Case 20:

A 21-year-old man has had increasing malaise over the past three weeks. On physical examination his vital signs show T 39.2 C, P 105/minute, RR 29/minute, and BP 80/40 mm Hg. The physician auscultates a loud systolic cardiac murmur. His lungs on auscultation 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?

A Creatine kinase-MB of 8% with a total CK 389 U/L

B Positive blood culture for Pseudomonas aeruginosa

C Total serum cholesterol of 374 mg/dL

D Blood urea nitrogen of 118 mg/dL

E Antinuclear antibody titer of 1:512


Case 22:

A dentist asks you to evaluate a 42-year-old woman before tooth extraction.


I. Which of the following would prompt you toprescribe prophylactic antibiotics?

(A) midsystolic click at the left sternal border

(B) insulin-dependent diabetes

(C) a prior history of infective endocarditis

(D) a history of congestive heart failure

(E) S4 gallop


II. Which of the following is the prophylactic antibiotic of choice for dental procedures?

(A) amoxicillin

(B) vancomycin

(C) cephalexin

(D) penicillin

(E) clindamycin


III. In patients who are not intravenous (IV) drug users and who do not have prosthetic valves,which of the following organisms is the most common cause of bacterial endocarditis?

(A) Enterococcus

(B) Streptococcus

(C) gram-negative bacilli

(D) Candida

(E) Pseudomonas

Case 23:

Which of the following investigations is used to monitor the treatment of IE?

A-     Blood culture

B-   C Reactive Protein                                                                    

C-   Echocardiography

D-  Erythrocyte Sedimentation Rate      

E-      Serum bactericidal litres of antibiotics


Case 24:

A 54-year-old man presents to the emergencydepartment complaining of epigastric discomfort, which began while he was walking his dog after dinner about one-half hour earlier. He has not receive medical care for several years. On examination, he is moderately obese and in obvious discomfort and seems restless. His BP is 160/98mmHg, and his examination is otherwise unremarkable. His ECG showed elevated S –Tsegment in leads II,III and AVF.


I. Which of the following is the most likely diagnosis?

(A) Gastro-esophageal reflux

(B) Costochondritis

(C) Pericarditis

(D) Inferior wall myocardial infarction

(E) Anterolateral myocardial infarction


II. Which of the following is the most appropriate next step in management?

(A) Trial of antacid immediately

(B) Reassurance and arrange outpatientfollow-up

(C) Arrange for cardiac intensive care bed

(D) Begin thrombolytic therapy in the emergencydepartment

(E) Arrange for urgent echocardiogram


Case 25:

A 60-year-old male with angina comes to the emergency room with severe chest pain unresponsive to sublingual nitroglycerin since 2 hours. An EKG shows ST segment elevation in the anterolateral leads.

What is the appropriate management?

a) Thrombolytic therapy.

b) Aspirin

c) Aspirin + clopidogrel

d) Follow up with close monitoring in ICU

e) Beta – Blockers

Case 26:

A 50-year-old man has the sudden onset of substernal chest pain one afternoon. The pain persists for the next three hours. He then becomes short of breath and diaphoretic. He goes to the emergency department that evening. On physical examination his vital signs include T 37 C, P 95/minute, RR 25/minute, and BP 130/90 mm Hg. A chest radiograph shows a slightly enlarged heart and mild pulmonary edema. An EKG shows ST segment elevation in anterior leads V1 - 6. Which of the following serum laboratory test findings is most likely to be present in this man?

A Urea nitrogen of 110 mg/dL

B Sodium of 115 mmol/L

C ALT of 876 U/L

D Troponin I of 32 ng/mL

E HDL cholesterol of 55 mg/dL


Case 27:

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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 he is afebrile. Laboratory studies show a serum troponin I of 18 ng/mL and CK-MB of 8%. Angiography reveals a thrombosis of the 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 - Cardiac arrhythmia

C - Hepatic necrosis

D - Thromboembolism

E - Myocardial ruptureBottom of Form

Case 28:

59-year-old male presents with a 1 hour history of central crushing chest pain. He is known to be diabetic, hypertensive and is a non-smoker. On examination his pulse rate is 90 beats/min, blood pressure 130/85 mmHg, S1& S2 are audible with no murmurs. There is no evidence of cardiac failure. An EKG is performed.

Which of the following would be an indication for thrombolysis?

A-     Right bundle branch block

B-   Supraventricular tachycardia

C-   ST elevation of 2mm in V4-V6

D-  ST depression of 2mm in leads IIJII, avF

E-   Atrialfibirillation>150min-l


Case 29:

A 65-year-old male is admitted to the coronary care unit with an acute inferior myocardial infarction. There are no centra indications to thrombolysis and he receives streptokinase with good resolution of ECG changes. 

Three days later examination is normal, with a blood pressure of 134/76 mmHg. Results reveal a total cholesterol of 270 mg%

Which one of the following drugs does not have good evidence for reducing future morbidity and mortality?

A-     Aspirin

B-   Atenolol

C-   Simvastatin

D-  Nifedipine                                                                           

E-   Ramipril


Case 30:

A 56-year-old male with left ventricular systolic dysfunction was dyspnoeic on climbing stairs but not at rest. The patient was commenced on ramipril and furosemide.?

Which one of the following drugs would improve the patient's prognosis?

A-     Amiodarone      

B-   Amlodipine

C-   Bisoprolol  

D-  Digoxin

E-   Nitrate therapy   

Case 31:

A 63-year-old male is admitted with a 30 minute history of central chest pain associated with nausea and sweating. His ECG reveals ST elevation in leads II, III and aVF. Which of the following coronary arteries is most likely to be occluded?

A-     Circumflex artery        

B-   Left anterior descending artery

C-  Obtuse marginal artery            

D-  Posterolateral artery

E-Right coronary artery 





Case 32:

Primary prevention trials for the treatment of hypercholesterolaemia reveal a reduction in all-cause mortality following treatment with which of the following?

A-     Fibrates

B-   Fish Oils    

C-   Nicotinic acid      

D-  Resins



Case 33:

A 76-year-old woman presented with an acute myocardial infarction. The ECG showed ST segment elevation in leads II, III and a VF.

Which coronary artery is most likely to be occluded?

A-     Circumflex artery

B-   Diagonal branch of the left anterior descending artery

C-   Left anterior descending artery

D-  Left Coronary artery

E-   Right coronary artery   

Case 34:

A 58-year-old man presents with sudden onset chest pain. He has a known history of ischaemic heart disease. ECG shows ST segment elevation in V1-V5 without reciprocal depression. In which territory is the infarction most likely to have take place?

A-     Anterior   

B-   Inferior

C-   Lateral       

D-  Inferio-lateral



Case 35:

Which ONE of the following is a contraindication to thrombolysis?       

A-     Age over 75 years                     

B-   The presence of atrial fibrillation     

C-   Asthma                           

D-     Pregnancy  

     E- Background diabetic retinopathy

Case 36:

A 65-year-old man presents with severe central crushing chest pain. ECG shows evidence of an inferior myocardial infarction. He receives TPA, Heparin and Aspirin. Four hours after initial presentation, he starts feeling dizzy and breathless. His pulse is 40 bpm regular, BP 80/50. Heart sounds are soft and chest clear to auscultation. ECG shows 2:1 AV block with T wave inversion inferiorly. IV atropine was administered but had no effect. What is the next most important treatment?

A-  IV Dopamine.

B-   IV Isoprenaline.

C-   Insert a permanent pacemaker.

D-  Insert a temporary pacemaker.                                     

E-   Monitor his progress.




Case 37:

A 72-year-old woman presented with acute severe chest pain with an ECG revealing ST segment elevation in leads II, III and aVF. She was treated with thrombolysis but two days later became acutely unwell. Examination revealed a loud systolic murmur at the apex which radiated into the axilla with associated pulmonary oedema. What is the most likely diagnosis?

A-     Acute left ventricular failure

B-   Cardiogenic shock

C-   Pericarditis

D-  Ruptured papillary muscle

E-   Ventricular septal defect


Case 38:

A 60-year-old male diabetic presents to clinic for advice on prevention of a further heart attack after having sustained a myocardial infarction five years previously. He takes metformin 500 mg tds, bendroflumethiazide 2.5 mg daily and asprin 150 mg daily. His body mass index was 33.5 kg/m , with a pulse of 82 beats per minute regular and a blood pressure of 152/92 mmHg. His cholesterol concentration is 160 mg/1 (< 200). What is the most appropriate strategy for this patient?


A-     24 hour ambulatory ECG

B-   Atorvastatin

C-   Increase aspirin from 150 mg to 300 mg daily

D-  Orlistat


Case 39:

A 65-year-old woman undergoes temporary pacing due to complete heart block following acute myocardial infarction. Which coronary artery is most likely to have been occluded?

A-     Anterior descending

B-   Circumflex

C-  Left main coronary

D-  Obtuse marginal

E-     Right coronary  


Case 40:

A 54-year-old man presents with central crushing chest pain. Examination is normal. 12-lead ECG shows ST segment elevation in leads II, III, aVF and ST depression in VI, V2 and V3. Which coronary artery is occluded?

A-     Circumflex         

B-   Left Anterior Descending       

C-  Left Main Stem             

D-  Obtuse Marginal 

E-     Right Coronary Artery



Case 41:

A 59-year-old man is admitted with chest pain of 8 hours duration and has ST elevation inn the inferior leads on his admission ECG. An electrocardiogram from a previous clinic visit shows sinus rhythm two months ago. He has insulin dependent diabetes mellitus and chronic renal failure. Investigations reveal:


7.4 mmol/L

Fasting plasma glucose


137 mmol/L



4.4 mmol/L



10 mmol/L



200 µmol/L



Which of the following  represent an absolute contraindication to the use of thrombolysis?

A-              Allergy to penicillin.

B-   Gastro intestinal bleeding in last 3 months.

C-   History of haemorrhagic stroke.                                

D-  Ischaemic stroke 12 months ago

E-   On warfarin therapy

Case 42:

On the 11th postoperative day following a radical prostatectomy for adenocarcinoma of the prostate, a 70-year-old man is recovering uneventfully. He then ambulates to the bathroom, but upon returning to his bed he suddenly becomes extremely dyspneic and diaphoretic, with chest pain, palpitations, and a feeling of panic. Which of the following post-operative complications has he most likely developed?

A Pulmonary edema

B Pleural effusion

C Atelectasis

D Thromboembolus

E Diffuse alveolar damage

Case 43:

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A 70-year-old woman has been bedridden for 5 weeks following a cerebrovascular accident (CVA). She has the sudden onset of dyspnea, but has no further symptoms until two days later when she experiences left sided pleuritic chest pain. Which of the following pathologic findings in her pulmonary arterial branches is she most likely to have?

A Atherosclerosis

B Aspergillosis

C Fat embolism

D Vasculitis

E Thromboembolism

Case 44:

Which of the following forms of pulmonary embolism is the commonest cause of secondary pulmonary hypertension?

A-     Air embolism (Caisson's disease)

B-   Fat embolism

C-   Massive pulmonary embolism (e.g., saddle embolism)

D-  Multiple small recurrent pulmonary embolism                

E-   Paradoxical embolism

Case 45:

While playing cards, 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. Paramedics are called, and she is transported to the hospital. On admission, 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?

A Fibrinous pericarditis

B Aortic Dissection

C Infective endocarditis

D Dilated cardiomyopathy

E Myocardial infarction

Case 46:

A 59-year-old man who was active all his life develops sudden severe anterior chest pain that radiates to his back. Within minutes, he is unconscious. He has a history of hypertension, but a recent treadmill test had revealed no evidence for cardiac disease.

Which of the following is the most likely diagnosis?                        

A-     Acute myocardial infarction

B-   Group A streptococcal infection

C-   Pulmonary embolus

D-  Right middle cerebral artery embolus

E-   Tear in the aortic intima

Case 47:

 A54-year-old woman with diabetes is noted tohave BP in the range of 140/90 mmHg on severaloccasions. Which of the following is thebest next step in management?


(A) initiate antihypertensive therapy

(B) advise weight loss and recheck BP in3 months

(C) advise regular exercise and recheck BPin 3 months

(D) no further intervention is necessary

(E) follow-up in 6 months for recheck of BP


Case 48:

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 diagnosis?

A Dominant polycystic kidney disease

B Arterial changes with diabetes mellitus

C Vascular disease with hyperlipidemia

D Malignant hypertension

E Monckeberg's sclerosis

Case 49:

A 39-year-old woman is found to have a blood pressure of 160/105 mm Hg while at a free health screening clinic. She feels fine and has had no major medical problems in her life. An abdominal ultrasound reveals that the left kidney is smaller than the right, but that neither is cystic and no masses appear to be present. MR angiography reveals focal narrowing with thickening and beading of the left main renal artery. A urinalysis reveals no abnormal findings. She has an elevated plasma renin. Which of the following is the most likely diagnosis?

A Diabetes mellitus

B Antiphospholipid syndrome

C Renal Artery Fibromuscular dysplasia

D Thrombotic thrombocytopenic purpura

E Cholesterol emboli syndrome

Case 50:

A 65-year-old man has sudden onset of severe abdominal pain. 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?

A - Superior mesenteric artery thrombosis

B - Atherosclerotic aortic aneurysm

C - Polyarteritis nodosa

D - Septic embolization

E - Monckeberg's medial calcific sclerosis

Case 51:

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A 50-year-old man has experienced episodic headaches for the past 3 months. On physical examination his blood pressure is 185/110 mm Hg, with no other remarkable findings. Laboratory studies show sodium 145 mmol/L, potassium 4.3 mmol/L, chloride 103 mmol/L, C02 26 mmol/L, glucose 91 mg/dL, and creatinine 1.3 mg/dL. An abdominal CT scan shows a 7 cm left adrenal mass. During surgery, as the surgeon is removing the left adrenal gland, the anesthesiologist notes a marked rise in blood pressure. Which of the following laboratory test findings would have been most likely have been present in this patient prior to surgery?

A Decreased serum cortisol

B Decreased urinary homovanillic acid

C Increased serum ACTH

D Increased urinary free catecholamines

E Elevated serum ANCA

Case 52:

A 45-year-old man has had headaches for 4 months. On physical examination he is found to have a blood pressure of 170/110 mm Hg. Laboratory studies show a serum sodium of 146 mmol/L, potassium 2.3 mmol/L glucose 82 mg/dL, and creatinine 1.2 mg/dL. His plasma renin activity is 0.1 ng/mL/hr. Which of the following abnormalities is the most likely cause for these findings?

A 21-hydroxylase enzyme deficiency

B Adrenal adenoma

C Pituitary adenoma

D Exogenous corticosteroid administration

E Renal cell carcinoma

Case 53:

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A 43-year-old man goes to his physician for a routine check of his health status. He is found to have a blood pressure of 150/95 mm Hg. His urinalysis shows pH 6.5, specific gravity 1.015, no glucose, blood, or protein, and no casts. His serum creatinine is 1.4 mg/dL. If he is not treated, which of the following conditions will most likely cause his death?

A Intracerebral hemorrhage (stroke)

B Aortic aneurysm rupture

C Congestive heart failure

D Chronic renal failure

E Intracranial aneurysm rupture

Case 54:

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A clinical study is performed with subjects diagnosed with hypertension who underwent an extensive workup to determine possible treatable causes for the hypertension. It is observed that some causes for hypertension are surgically correctable, while other causes are amenable to pharmacologic therapy. Laboratory findings in the subjects are analyzed. Which of the following laboratory test findings is most likely to be present in subjects with hypertension treated by drugs, rather than by surgery?

A Hyperaldosteronemia

B Hyperreninemia

C Increased catecholamines

D Hypercalcemia

E Autoantibodies

Case 55:

A 30-year-old man has had increasing malaise with fever, abdominal pain, and weight loss of 3 kg over the past 3 weeks. On physical examination his blood pressure is 160/110 mm Hg. He has a stool positive for occult blood. A urinalysis reveals hematuria but no proteinuria or glucosuria. He has no serum anti-neutrophil cytoplasmic autoantibodies and his antinuclear antibody test is negative. Aneurysmal arterial dilations and occlusions are seen in the medium sized renal and mesenteric arteries with angiography. He improves with corticosteroid therapy. Which of the following is the most likely diagnosis

A Benign nephrosclerosis

B Fibromuscular dysplasia

C Nodular glomerulosclerosis

D Polyarteritis nodosa

E Systemic lupus erythematosus

Case 56:

A 35-year-old lady at 14 weeks gestation is found to have a blood pressure of 160/100 mmHg. Her father is known to have hypertension. Electrocardiogram demonstrates features of left ventricular hypertrophy. What is the most likely diagnosis?

A-     Eclampsia

B-   Essential hypertension                                                                   

C-   Pre-eclampsia

D-  Pregnancy-induced hypertension

E-   Renal hypertension

Case 57:

A 65-year-old woman, a heavy smoker for many years, has had worsening dyspnoea for the past 5 years, without a significant cough. A chest X-ray shows increased lung size along with flattening of the diaphragms, consistent with emphysema. Over the next several years she develops worsening peripheral oedema. BP 115/70 mmHg. Which of the following cardiac findings is most likely to be present?


A-     Constrictive pericarditis       

B-   Left ventricular aneurysm      

C-   Mitral valve stenosis

D-  Non-bacterial thrombotic endocarditis      

E-   Right ventricular hypertrophy

Case 58:

A 70-year-old woman has a history of dyspnoea and palpitations for six months. An ECG at that time showed atrial fibrillation. She was given digoxin, diuretics and aspirin. She now presents with two short-lived episodes of altered sensation in the left face, left arm and leg. There is poor coordination of the left hand. ECHO was normal as was a CT head scan.

What is the most appropriate next step in management?

A-  anticoagulation    

B-   carotid endarterectomy

C-   clopidogrel

D-  corticosteroid treatment

E-   no action

Case 59:

A 60-year-old man with a past history of controlled hypertension presents with acute onset weakness of his left arm, that resolved over 12 hours. He had suffered two similar episodes over the last three months. Examination reveals a blood pressure of 132/82 mmHg and he is in atrial fibrillation with a ventricular rate of 85 per minute. CT brain scan is normal.

What is the most appropriate management?

A-     amiodarone


C-   dipyridamole

D-  warfarin

E-   Digoxin

Case 60:

A patient presents with atrial fibrillation and later they revert to sinus rhythm. Under which of the following circumstances is the patient more likely to remain in sinus rhythm?


A-     age > 75 years old

B-been commenced on warfarin

C-   left atrium size > 6 cm on ECHO     

D-  short history of AF                                                                 

E-   ventricular rate on presentation of 130 bpm

Case 61:

A 60-year-old man presented with an episode of right sided weakness that lasted 10 minutes and fully resolved. Examination reveals that he is in atrial fibrillation. Assuming he remains in atrial fibrillation which of the following is the most appropriate management regime?


A-     Aspirin

B-   No additional drug treatment

C-   Warfarin, INR range 2 - 3 for 6 months then aspirin

D-  Warfarin, INR range 2 - 3      

E-   Warfarin, INR range 3-4 

Case 62:

A 62-year-old male undergoes cardio version for idiopathic atria fibrillation. Post-procedure he was shown to be in sinus rhythm. Medication at admission included Warfarin, digoxin and atenolol, which he had been taking for the last six weeks.

Which of the following agents should he continue to take until he is seen in clinic in six weeks time?

A-     Aspirin    

B-   Atenolol

C-   Digoxin

D-  Sotalol       

     E. Warfarin

Case 63:

A middle aged woman presents with new onset palpitations. She also commented that she had lost weight recently despite an increased appetite. Examination reveals a goitre and a degree of exophthalmos. During physical examination, she fell unconscious. Blood pressure was 70/40 mmHg. Electrocardiogram revealed atrial fibrillation with rapid ventricular response. What is the appropriate immediate management?

A-     Anticoagulation

B-   Carbimazole

C-   DC cardioversion

D-  Intravenous amiodarone

E-   Lugol Iodine

Case 64:

A 26-year-old professional footballer collapses while playing football. He is rushed to the Accident and Emergency Department, and is found to be in ventricular tachycardia. He is defibrillated successfully and his 12 lead ECG demonstrates normal sinus rhythm, without ST segment changes. Ventricular tachycardia recurs and despite prolonged resuscitation, he dies.

What is the most likely diagnosis?

A-     Aortic stenosis  

B-   Cocaine intoxication

C-   Hypertrophic cardiomyopathy                                                     

D-  Myocardial infarction

E-   Pulmonary embolism


Case 65:

A 70-year-old male was receiving amiodarone 200 mg daily for intermittent atrial fibrillation. However; he. was aware of tiredness and lethargy. He appeared clinically euthyroid with no palpable goitre. Investigations revealed:

Serum tree T4                            23pmol/L (9-26)

Serum total T3                          0.8 nmol/L (0.9-2.8)

Serum TSH                               8.2 mU/L (<5)

Which of the following statements would explain these results?

A-     Abnormal thyroxine binding globulin      

B-   Amiodarone-induced hypothyroidism                                                                                       

C-   sick euthyroid syndrome

D-  Spontaneous hypothyroidism

E-      TSH secreting pituitary adenoma




Case 1:

Answer:  (B)

 Heart sounds and murmurs can often be accentuated by various physiologic and pharmacologic maneuvers. These maneuvers aid in the differentiation of multiple valvular and other organic lesions from ordinary sounds.

Mitral stenosis is a diastolic murmur that grows louder with increased flow across the stenotic valve, as in exercise.

Tricuspid stenosis is heard best at the lower left sternal border.

Aortic regurgitation is generally reduced by dynamic exercise due to shortened diastole.

VSD maybe small, and causes a systolic murmur; its murmur will fade with maneuvers favoring forward flow, such as vasodilatation with amylnitrate. The murmur of aortic stenosis is systolic and will grow louder with increased flow across the valve, as with amyl nitrate; it will diminishwith maneuvers that decrease flow across the valve, as in stage two of the Valsalva maneuver.


Case 2:

Answer: (C)

Features of Mitral stenosis include the loud first heart sound, opening snap and if in sinus rhythm, a pre-systolic accentuation. Calcification of the valve results in immobility and loss of the opening snap.


Case 3:

Answer: (E)

A pansystolic or holosystolic murmur extends from the 1st heart sound through to the 2nd heart sound which is often hard to hear because of the murmur. It is seen in septal defects and, more commonly, mitral regurgitation


Case 4:

Answer : (C)

Mitral valve stenosis leads to left atrial enlargement, but the left ventricle is usually small. There is typically a 'fishmouth' shaped mitral valve that has stenosis as well as insufficiency, since it does not close completely. Most mitral valvular disease in adults results from rheumatic valvulitis. The episode(s) of rheumatic fever occurred years before.


Case 5:

Answer: (D)

This can lead to rheumatic mitral stenosis with left atrial enlargement.


Case 6:

Answer: (C)

Patients with systemic lupus erythematosus can develop Libman-Sacks endocarditis, but the vegetations are never large and they rarely embolize, so the endocarditis is not clinically significant in most cases. She probably has a fibrinous pericarditis as a result of uremia from renal failure.


Case 7:

Answer: (D)

Senile calcific aortic stenosis is a condition in which there is gradual calcification of an aortic valve with three cusps. The condition is seen in the elderly and is idiopathic. Aortic valvular stenosis may not manifest itself clinically until there is narrowing of the outflow orifice to less than 1 square centimeter. Aortic valve disease can remain silent and then suddenly result in symptoms.


Case 8:

Answer: (D)  

The patient's symptomatology is probably the most important determinant in terms of the decision to operate. Dyspnea, chest pain and syncope are all features of aortic stenosis and when present suggest a poor prognosis if left. A gradient of 50mrnHg would be regarded as moderate - severe aortic stenosis but if asymptomatic nothing would be done.

LVH is a common feature of AS and does not influence the decision for surgery.

Calcific aortic disease is not of itself important and the gradient should be considered.           


Case 9:

Answer:  (A)

Mitral valve prolapse can be diagnosed by auscultation and echocardiogram in as much as10% of the population.

They may be asymptomatic or complain of atypical chest pain, palpitation, shortness of breath, or weakness.

An increasing number of complications are being recognized. Although they occur infrequently, they may be life threatening and demand careful evaluation of individuals at risk.

Both supraventricular and ventricular arrhythmias occur, as may sudden death.

Mitral insufficiency, if present, is usually insignificant but may progress and require valve replacement.

There is an increased risk of infective endocarditis.

Intra atrial thrombus formation may occur, predisposing to cerebral and peripheral embolism.

Because the clot originates in the left atrium, however, pulmonary embolism does not occur more frequently in these patients.


Case 10:

Answer: (E)

Bottom of Form

A mid systolic click with a systolic murmur is heard with mitral valve prolapse. Mitral valve prolapse is also called \'click murmur syndrome\'. A large v wave in the jugular pulse (choice a) is seen with tricuspid insufficiency. A diastolic rumbling murmur (choice b) is heard with mitral stenosis, not with mitral valve prolapse. The pulse pressure is the difference between systolic and diastolic pressure. An increased pulse pressure (choice c) is seen with aortic regurgitation A large a wave in the jugular pulse (choice d) is seen with tricuspid stenosis.


Case 11:

Answer: (E)

She has chronic rheumatic valvulitis with scarring associated with rheumatic heart disease. If the tricuspid valve is involved, then the mitral and aortic are probably involved as well. The most common single valve involved is the mitral.


Case 12:

Answer : (B)

Atrial myxomas are more often on the left. Though benign, they can occlude the mitral valve and produce sudden loss of cardiac output. They may embolize small portions of themselves or thrombus formed over their surface.


Case 13:

Answer: (B)

The history of collapses in this young woman with echocardiographic features of  hypertrophy are highly suggestive of hypertrophic obstructive cardiomyopathy.

Hypertrophic cardiomyopathy is defined as the unexplained, asymmetrical or concentric hypertrophy of the undilated left ventricle. There is also hypertrophy of the right ventricle. Incidence is approximately 1 in 500. It is inherited as an autosomal dominant trait but often an inheritance pattern is not found on questioning.

Case 14:

Answer: (B) 

In the adult form of aortic coarctation, collateral arteries between the precoarctation and postcoarctation aorta (eg, the intercostal and internal mammary arteries) enlarge and establish communication between aortic segments proximal and distal to stenosis. Enlarged intercostal arteries produce notching of the inferior margins of the ribs, which can be detected on x-ray and is diagnostic of this condition.

Vasculitis involving the aortic arch (choice E) is found in Takayasu arteritis, in which chronic inflammatory changes develop in the aortic arch and its branches (brachiocephalic trunk, left common carotid, and left subclavian arteries). This condition causes stenosis of these arteries; therefore, there will be signs and symptoms of ischemia to the upper part of the body. Since the radial pulses are very weak or absent, this disorder is also known as pulseless disease.

Case 15:

Answer: (B)

Bisoprolol is a highly selective beta(l)-adrenoceptor antagonist. Administration of bisoprolol to patients with chronic heart failure is associated with increase in left ventricular function and reduction in heart rate; increases in heart rate variability are also seen. Two major randomised, double-blind, placebo-controlled, multicentre trials have examined the clinical efficacy of bisoprolol in combination with ACE inhibitors and diuretics in patients with stable chronic heart failure (New York Heart Association class III or IV).


Case 16:

Answer: (B)

Bottom of Form

Loop and thiazide diuretics decrease potassium and magnesium levels, predisposing patients taking both a diuretic and digoxin to an increased risk of digoxin toxicity. Also, amphotericin B (Fungizone), an antifungal, has an additive potassium-lowering effect when given with a thiazide or loop diuretic. Thiazides may increase the blood levels of lithium. Bile acid sequestrants cholestyramine (Questran) and colestipol (Colestid) decrease the absorption of thiazide diuretics when given concomitantly, while nonsteroidal anti-inflammatory drugs such as indomethacin (Indocin) may decrease the therapeutic effects of both the loop and thiazide diuretics

Case 17:

Answer: (B)

ACE inhibitors remain one of the corner stones of the treatment of heart failure [SOLVD and CONSENSUS trials]. There is clear evidence that higher doses exert greater benefit. They are usually very well tolerated, especially in milder cases.

Case 18:

Answer: (E)

Hypotension with ischemia is probably the most common cause for ischemic enteritis and/or colitis. This man's heart disease (probably a dilated form of cardiomyopathy with both right and left-sided congestive heart failure) led to reduced cardiac output with reduced tissue perfusion. Though the bowel has a rich anastomosing blood supply, when flow is reduced in all branches, then ischemic can occur.

Case 19:

Answer: (C)

A stab wound into heart can lead to hemopericardium with tamponade.


Case 20:

Answer: (B)

The history points to infectious endocarditis and acute congestive heart failure. Staphylococcus aureus and Pseudomonas aeruginosa are the most likely organisms to be found with a history of injection drug use.


Case 22:

Answer I: (C)

Guidelines for antibiotic prophylaxis of infective endocarditis (IE) underwent a major revision in 2007. Prophylaxis is now only recommended for those patients at highest risk of IE including:

- Patients with a prosthetic valve.

- History of IE.

- Cardiac transplant patients that develop valvulopathy.

- Cyanotic congenital heart disease that remains unrepaired.

- Cyanotic congenital heart disease that has been repaired with a prosthesis during the first 6 months after the procedure or if a defect remains at the site of the prosthesis after 6 months.

Congestive heart failure, an S4 gallop, and diabetes do not increase risk.

Answer II: (A)

Recommended antibiotic coverage for high-risk patients before dental procedures is amoxicillin 2 g PO 1 hour before the procedures.

Penicillin-allergic patients can receive clarithromycin, cephalexin, cefadroxil, or clindamycin as prophylaxis.

Answer III: (B)

Streptococci and S. aureus are responsible for the majority of community-acquired native valve endocarditis cases.

In IV drug abusers, S. aureus is responsible for more than 50% of cases, and Candida and Pseudomonas for about 6% each. Patients with prior endocarditis are at high risk.

Bacterial endocarditis carries a mortality rate of about 25%, and prevention is of paramount importance. In S. aureus endocarditis in injection drug users, mortality is only 10–15%.  As many as 40% of cases occur without underlying heart disease.

VSD, PDA, and tetralogy of Fallot are most commonly associated; whereas, ASD is rarely a predisposing factor

Case 23:

Answer: (B)

Serum bactericidal titers against the infecting organism are no longer recommended. There was always great variation in the monitoring methods used for these tests and in the interpretation of their results. At best they could only predict bacteriological not clinical cure and bacteriological failure is very rare.

The most useful laboratory test for monitoring the response to treatment (which is usually obvious clinically) is serial C-reactive protein estimation. This is of much more use than the erythrocyte sedimentation rate, which is much slower to fall.


Case 24:

Answer: I: (D)

This ECG reveals ST-segment elevation in II, III and AVF, indicating acute injury of the inferior wall of the myocardium. Inferior wall ischemia can be perceived as pain in the epigastric area.

Antero-lateral myocardial infarction would show loss of  R-wave progression in V4 through V6.

Pericarditis would show diffuse ST segment elevation in limb and precordial leads.

Although his symptoms could suggest gastro esophageal reflux, this ECG shows this cardiac event.

Costochondritis is not present by examination.

Answer II: (D)

When ST segment elevation is present, a patient should be considered a candidate for reperfusion therapy or percutaneous coronary intervention (PCI) such as angioplasty and stenting. If no contraindications are present and PCI is unavailable, thrombolytic therapy should ideally be initiated within 30 minutes, right in the emergency department. The goal of both thrombolysis and PCI is prompt restoration of coronary arterial patency. Thrombolytic therapy can reduce the risk of in-hospital death by up to 50% when administered within the first hour of symptoms, so time is of the essence.

Arranging for a bed may waste time for limiting infarct size.

The ECG would obviously preclude the other two options: immediate trial of antacid or reassurance and arranging outpatient follow-up.


Case 25:

Answer: (A)


Case 26:

Answer: (D)

The findings suggest an early ischemic event as part of a developing myocardial infarction. The troponin I can be elevated within a few hours, similar to the CK-MB.


Case 27:

Top of Form

Answer: (B)

A primary reason for putting a patient with an acute myocardial infarction in hospital is to prevent arrhythmiasTop of Form


Case 28:

Answer: (C)

This patient is having an acute myocardial infarction, the EKG changes of ST elevation of 2mm in V4-V6 suggest a anterolateral MI. Given this history and EKG changes he should be given thrombolytic treatment, Along with aspirin, heparin, beta blockade, statin therapy and subsequent ACE inhibition.

EKG criteria for thrombolysis include:

- ST elevation of >lmm in standard limb leads.

- ST elevation > 2mm in anterior chest leads.

- New left bundle branch block.

Within 24 hours of typical pain. Evidence beyond 12 hours of pain is equivocal, thrombolysis at this time tends to be used if there is clinical deterioration or persistent pain.


Case 29:

Answer: (D)

Aspirin leads to a 12% reduced risk of death and 31% reduced risk of reinfarction in evidence reviewed by the Antiplatelet therapy trialists and also GISSI studies.

Several trials have demonstrated benefit from long term treatment with beta blockers, by reducing the incidence of recurrent MI, and death from all causes.

Numerous trials have shown benefit from ACE inhibitor therapy post MI in those with and without evidence of left ventricular impairment. 

The 4S (Scandinavian Simvastatin Survival Study) demonstrated a benefit from lowering cholesterol with Simvastatin in patients with coronary disease.

There is no evidence to support a beneficial effect of nifedipine post MI.


Case 30:

C is correct.

This patient has stage II heart failure. Studies such as REVEAL had showed that beta-blockers significantly reduce morbidity and mortality in heart failure.

Case 31:

E is correct.

This patient has had an inferior MI and this is most likely due to occlusion of the right coronary artery.

LAD occlusion results in anterior infarction.

Circumflex or lateral branch of the LAD results in lateral infarction. RCA occlusion may also cause posterior infarction .


Case 32:

E is correct.

Primary prevention refers to the prevention of cardiovascular disease in subjects without pre-existent IHD. Although many lipid lowering agents have demonstrated reductions in cardiovascular mortality, the question refers to all cause mortality.

Pravastatin and lovastatin demonstrated reductions in overall mortality not just cardiovascular mortality following treatment with statins.

None of the other agents are proven to reduce all cause mortality in primary prevention.

Fibrates are however well proven in secondary prevention trials


Case 33:

E is correct.

This patient has an inferior myocardial infarction which is usually due to occlusion of the Right Coronary artery and less commonly Circumflex occlusion may be responsible.

Case 34:

A is correct.

This MI is likely to be in the LAD and represents an anterior infarction.


Case 35:

D is correct.

Those over 75 years benefit as much or more than younger MI patients from thrombolysis,

Proliferative diabetic retinopathy is a relative contraindication. Important contraindications to thrombolysis include pregnancy, GI bleeding, heavy vaginal bleeding, recent stroke or surgery, uncontrolled severe hypertension, GI malignancy and prolonged CPR (more than half an hour).

Case 36:

D is correct.

This patient has had an inferior MI which is commonly associated with conduction abnormalities. He now develops heart block which leaves him bradycardic, symptomatic and with a low BP.

Isoprenaline is contraindicated in acute MI due to its positive inotropic effects and arrhythmogenic potential.

A temporary wire would deal with the situation until the inferior MI has fully resolved.

He is unlikely to need a Permanent Pacemaker.


Case 37:

D is correct.

The most likely explanation in this patient with a prior inferior myocardial infarct is mitral valve prolapse due to papillary muscle rupture


Case 38:

E is correct.

The most appropriate strategy for secondary prevention would involve further blood pressure reduction with an ACEI which would not only reduce CV risk as suggested by the HOPE study but also reduce microvascular risk. Cholesterol is less than 200 and this patient already has a low and would not benefit as much from the addition of a statin.

The increase of aspirin from 150 to 300 mg would offer no added advantage. There's no reason here for a 24 hr tape.


Case 39:

E is correct.

Myocardial infarction complicated by bradycardia is most commonly seen in inferior wall myocardial infarction. This area of the heart is supplied by the Right coronary artery. The right coronary artery gives branches to SAN and AVN therefore disease within this vessel can cause damage to the cardiac conducting system and can therefore lead to brady-arrhythmias.


Case 40:

E is correct.

The ECG describes an infero-posterior MI. This territory is supplied by a dominant Right Coronary Artery,


Case 41:

C is correct.

Absolute contraindications to thrombolysis include:

ýPrevious hemorrhagic stroke.

ýIschemic stroke in last 6 months.

ýCentral nervous system damage or neoplasm.

ýWithin 3 weeks of head injury, major trauma or major surgery.

ýActive internal bleeding or GI bleeding within the past month.

ýKnown or suspected aortic dissection.

ýKnown bleeding disorder.

ýProliferative diabetic retinopathy.

ýPregnancy, severe hypertension & prolonged CPR

Allergy and oral anticoagulants are relative contraindications.

Case 42:


The activity of ambulation resulted in sudden movement of a thrombus that formed during his period of immobilization in the leg or pelvic veins. The thrombus became an embolus and traveled to the lungs.


Case 43:

Top of Form


An embolus to a medium-sized arterial branch is not large enough to kill the patient, but large enough to cause an infarction. Her bedridden state predisposes her to deep venous thrombosis & thromboembolism.

Case 44:

D is correct.

Case 45:


This is a classic history for an aortic dissection. A tear in the aortic intima is followed by dissection of blood outward, often to the thoracic cavity, with fatal hemothorax.

The risk factors in most adults include atherosclerosis and hypertension.

In Marfan syndrome, the risk for aortic dilation and dissection results from cystic medial necrosis, but this occurs at a much younger age.


Case 46:

(E) is correct .

The history is typical of aortic dissection. All the others could cause sudden collapse but not with acute chest pain radiating to the back in the presence of a recent normal exercise test. Acute MI is possible but not the most likely.


Case 47:

Answer:  (A).

The Hypertension Optimal Treatment Study and the UK Prospective Diabetes Study, both showed benefit in targeting BP to the normal range in patients with diabetes (i.e.130/85 mmHg). This patient has multiple readings of 140/90 mmHg and should be treated with antihypertensive medication.

Case 48:


The small arteries of the kidney are affected by hyperplastic arteriolosclerosis. Malignant hypertension is often preceded by chronic hypertension that leads to left ventricular hypertrophy. Hypertension is a risk for CNS hemorrhage.

Case 49:


Fibromuscular dysplasia is an uncommon but surgically treatable cause for hypertension. The abnormal segment of artery can be treated with angioplasty or removed and replaced with a graft.

Case 50:


The aorta involved with an atherosclerotic aneurysm is markedly enlarged and filled with thrombus. Risk factors for atherosclerosis include both diabetes mellitus and hypertension. Atherosclerotic aortic aneurysms are typically located in the abdominal portion below the renal arteries.



Case 51:

Top of Form

Top of Form

Top of Form

Top of Form


The history is most consistent with a pheochromocytoma of the adrenal medulla (about 10% of pheochromocytomas can be extra-adrenal), which can episodically secrete large amounts of catecholamines. When the surgeon manipulated the mass, catecholamines were released

Case 52:


The history points to an aldosterone secreting neoplasm, which is usually a small adenoma within adrenal cortex. This is known as Conn syndrome, one of the surgically treatable causes for hypertension


Case 53:

Top of Form

Top of Form

Top of Form


Top of Form

Top of Form


Hypertension leads to cardiac enlargement, then dilation, and eventual failure. This is the most common outcome with untreated hypertension.


Case 54:

Top of Form


Immunologic diseases of the kidney often produce glomerulonephritis, and renal damage often leads to hypertension.

Case 55:


Classic polyarteritis nodosa often affects multiple organs, not just the kidney. The classic form of polyarteritis affects medium to small sized arteries.

Case 56:

B is correct.

ECG feature of LVH is the key, telling that her hypertension is not of recent onset, ruling out pregnancy-related causes. Of all types of hypertension, essential hypertension is the most prevalent. Her family history also supports the diagnosis.



Case 57:

E is correct.

This lady has Chronic Obstructive Airways disease and subsequent Cor Pulmonale leading to right heart failure.

Non-bacterial thrombotic endocarditis is a condition seen in flail ill individuals.


Case 58:

A is correct.

This patient is having symptoms of transient ischaemic attacks most likely due to a cardiac source of emboli. A normal ECHO or CT head does not rule out thrombo-embolic events. There is an increased risk of strokes in patients with atrial fibrillation and hence with the given symptoms formal anticoagulation with warfarin should be considered.


Case 59:

D is correct.

This patient has had three transient ischaemic attacks due to atrial fibrillation. The most appropriate therapeutic strategy for this patient would be warfarin. Studies reveal that warfarin would be therapeutically superior than aspirin in such a patient's case.


  Case 60:

D is correct.

The patient with very recent onset of atrial fibrillation is more likely to stay in sinus rhythm.

Atrial fibrillation, in older patients is more likely to be associated with structural heart disease.

Anticoagulation should have no effect on the risk of paroxysmal atrial fibrillation.

An enlarged left atrium is unlikely to remain in sinus rhythm.

Those presenting with a relatively slow ventricular rate and, especially if they are not on betablockers, Calcium antagonists or digoxin, are likely to have chronic atrial fibrillation.


Case 61:

D is correct.

This is a high risk patient for future stroke and should be anticoagulated with warfarin. An initial target range of INR 2 - 3 is the most appropriate.


Case 62:

E is correct.

This patient has undergone successful cardio version for idiopathic AF and needs to remain on warfarin as his risk of further thromboembolism, due to the fact that his Atria are now contracting, normally remains high up until six weeks after achieving sinus rhythm.

Digoxin is not required post procedure as neither it, nor atenolol, maintains sinus rhythm. Aspirin is not as good as warfarin in preventing thromboembolic disease. Sotalol, like amiodarone, is good at chemical cardioversion and maintaining SR but its role post cardio version is uncertain.

Case 63:

C is correct.

The patient is hemodynamically compromised due to AF. The emergency management is DC cardioversion Adverse signs necessitating DC cardioversion are BP ≤ 90mmHg, chest pain, heart failure, impaired consciousness and heart rate > 200bpm.


Case 64:

C is correct.

The history of sudden arrhythmia in a young previously well individual is suggestive of Hypertrophic cardiomyopathy, relatives should be screened for the condition.

There is no history to suggest drug abuse, aortic stenosis is rare in the absence of congenital or Rheumatic heart disease. A myocardial infarction and massive pulmonary embolism would have given ECG changes.

Case 65:

B is correct.

The results show normal T4, low T3 with elevated TSH. These results are typical of amiodarone induced hypothyroidism which inhibits the peripheral conversion of T4 to T3.

Many conditions result in euthyroid hyperthyroxinemia or hypothyroxinemia, which are characterized by increases or decreases in serum total thyroxine (T4) and triiodothyronine (T3) concentrations, but little change in serum free T4 and T3 concentrations, no change in serum TSH concentrations, and no symptoms or signs of thyroid dysfunction



MCQs part I


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