A 21-year-old man presents to your office for a preemployment physical examination. He is 6 ft, 3 in.

tall and weighs

70 kg. Heart examination is remarkable for a midsystolic click and a grade 2 systolic murmur that increases with
Valsalva maneuver. The patient has an arm span that exceeds his height and has long, slender fingers. The thumb sign
(Steinberg sign) is positive. Which of the following is the most likely diagnosis?
A.Lesch-Nyhan syndrome
B.Turner syndrome
C.Ehlers-Danlos syndrome
D.Marfan syndrome
E.Noonan syndrome

A 24-year-old Hispanic woman is found to have rheumatic mitral stenosis and is a candidate for mitral valve
replacement. She is in sinus rhythm. You are meeting with her to discuss the option of a mechanical or bioprosthetic
(tissue) valve implantation. Which of the following statements is true?
Select one:
a. The hemodynamic demands of pregnancy are better tolerated in patients with bioprosthetic valves
b. Antibiotic prophylaxis for dental procedures that manipulate gingival tissue is recommended for patients with
mechanical but not bioprosthetic valves
c. Compared with mechanical prosthetic valves, the rate of structural deterioration of bioprosthetic valves is less and the
expected valve life is greater
d. Patients with bioprosthetic valves do not need regular follow-up
e. In the absence of atrial fibrillation, long-term anticoagulation is not needed in most patients with bioprosthetic
valves

A 59-year-old patient presents with fever and agitation. On physical examination, his temperature is 103.2°F His
respirations are 26/min, pulse 126/min, and blood pressure is 100/70 mm Hg. He appears to be warm and flushed. A
Swan-Ganz catheter is inserted that demonstrates an increased cardiac output, a decreased peripheral vascular
resistance (vasodilation), and a normal pulmonary capillary wedge pressure (PCWP). The patient's urine gram stain
reveals pyuria and gram-negative rods. Which of the following is the most likely diagnosis?
a. Late septic shock
b. Early septic shock
c. Cardiogenic shock
d. Hypovolemic shock
e. Neurogenic shock

A 52-year-old woman returns for yearly follow-up of mitral valve prolapse (MVP). She is asymptomatic; she jogs daily
without undue shortness of breath. She takes metoprolol 25 mg bid because of previous palpitations and occasional
non exertional chest pain. These symptoms are well controlled. Physical examination shows normal vital signs with
BP 126/72. Lungs are clear and neck veins flat. Auscultation shows a mid systolic click followed by a 3/6 blowing
systolic murmur that radiates to the axilla. Her echocardiogram, however, shows deterioration of LV function, with
ejection fraction dropping from 65% to 50%. The LV has dilated, with LV end-systolic diameter rising from 35 to 45
mm (normal 28±7). Transesophageal echocardiogram (TEE) confirms the mitral valve prolapse and LV dilation; the TEE
shows evidence of severe mitral regurgitation. What is the best next recommendation for management of her
valvular abnormality?
a. Begin lisinopril 10 mg daily
b. Begin digoxin 0.125 mg daily
c. Emphasize endocarditis prophylaxis with antibiotics before dental procedures, and continue yearly follow-up
d. Refer for mitral valve repair
e. Refer for ICD implantation
A 24-year-old woman is seen for a complaint of shortness of breath and wheezing. She reports the symptoms to be
worse when she has exercised outdoors and is around cats. She has had allergic rhinitis in the spring and summer for
many years and suffered from eczema as a child. On physical examination, she is noted to have expiratory wheezing.
Her pulmonary function tests demonstrate a forced expiratory volume in 1 second (FEV1) of 2.67 (79% predicted),
forced vital capacity of 3.81 L (97% predicted), and an FEV1/FVC ratio of 70% (predicted value 86%). Following
administration of albuterol, the FEV1 increases to 3.0 L (12.4%). Which of the following statements regarding the
patient’s disease process is TRUE?
A. Confirmation of the diagnosis will require methacholine challenge testing.
B. Mortality due to the disease has been increasing over the past decade.
C. The most common risk factor in individuals with the disorder is genetic predisposition.
D. The prevalence of the disorder has not changed in the last several decades.
E. The severity of the disease does not vary significantly within a given patient with the disease.

A 43-year-old man who is an alcoholic is admitted to the hospital with acute pancreatitis. He is given intravenous
hydration and is placed NPO. Which of the following findings is a poor prognostic sign?
A. His age
B. Initial serum glucose level of 60 mg/dL
C. Blood urea nitrogen (BUN) level rises 7 mg/dL over 48 hours
D. Hematocrit drops 3%
E. Amylase level of 1000 IU/L

A 36-year-old man presents with the sensation of a racing heart. His blood pressure is 110/70, respiratory rate
14/min, and O2 saturation 98%. ECG is shown. Carotid massage and Valsalva maneuver do not improve the heart
rate. Which of the following is the initial therapy of choice?

a. Adenosine 6-mg rapid IV bolus

b. Verapamil 2.5 to 5 mg IV over 1 to 2 minutes
c. Diltiazem 0.25-mg/kg IV over 2 minutes
d. Digoxin 0.5 mg IV slowly
e. Electrical cardioversion at 50 J
The patient woke up with central oppressive chest pain which are increase with deep inspiration and when lying on
the back.

AVNRT
Sinus tachycardia
Typical atrial flutter
Atrial fibrillation

CABG 15 years ago. Transcatheter aortic valve implantation 1 month ago. Severe chest pain and shortness of breath
for one hour, palor and cold sweats. BP 160/90 mmHg. ECG diagnosis

Inferoposterior STEMI
Pacemaker rhythm
Anterior STEMI
LBBB

A 37-year-old postal worker from Atlantic City, New Jersey, presents to the emergency room with the chief complaint
of dry cough for several days. He has fever, malaise, dyspnea on exertion and pleuritic chest pain. He has experienced
mild nausea and diffuse abdominal pain. He has been in good health otherwise he has no recent travel history. No
contacts have been ill. Physical examination is remarkable for a temperature of 38.5*C and decreased breath sounds
at the lung bases bilaterally. Chest radiograph reveals pleural effusions and a widened mediastinum. Which of the
following is the most likely diagnosis?
Pneumonic plague
Hantavirus pulmonary syndrome
Tularemia
Inhalation anthrax
One month after hospital discharge for documented myocardial infarction, a 65-year-old man returns to your office
concerned about low-grade fever and chest pain. He describes the chest pain as sharp, worse on deep inspiration, and
better when sitting up. He denies shortness of breath; his lungs are clear to auscultation. On cardiac examination you
hear a soft, scratchy sound both in mid-systole and in mid-diastole. ECG is shown in the following figure. Which
therapy is most likely to be effective in relieving his chest pain?

a. An antibiotic
b. Warfarin
c. An anti-inflammatory agent
d. Nitrates
e. An anxiolytic

A 35-year-old woman was recently diagnosed with systemic lupus erythematosus. She presents with progressive
dyspnea and chest pain for 2 weeks. Jugular venous distension is present and heart sounds are muffled. ECG shows
electrical alternans. Chest x-ray is shown in the following figure. Which of the following is the most likely additional
physical finding?

a. Basilar rales halfway up both posterior lung fields

b. S3 gallop
c. Pulsus paradoxus
d. Strong apical beat
e. Epigastric tenderness
A 70-year-old woman has been healthy except for hypertension treated with a thiazide diuretic. She presents with
sudden onset of a severe, tearing chest pain, which radiates to the back and is associated with dyspnea and
diaphoresis. Blood pressure is 210/94. Lung auscultation reveals bilateral basilar rales. A faint murmur of aortic
insufficiency is heard. The brain-natriuretic peptide (BNP) level is elevated at 550 pg/mL (normal < 100). ECG shows
nonspecific ST-T changes. Chest x-ray (CXR) suggests a widened mediastinum. Which of the following choices
represents the best initial management?
a. IV furosemide plus IV loading dose of digoxin
b. Percutaneous coronary intervention with consideration of angioplasty and/or stenting
c. Blood cultures and rapid initiation of vancomycin plus gentamicin, followed by echocardiography
d. IV beta-blocker to control heart rate, IV nitroprusside to control blood pressure, transesophageal echocardiogram,
and emergency thoracic surgery consultation
e. IV heparin followed by CT pulmonary angiography

A 37-year-old woman is noted to have gallstones on ultrasonography. She is placed on a low-fat diet. After 3 months
she is noted to have severe right upper quadrant pain, fever to 102°F, and nausea. Which of the following is the most
likely diagnosis?
A. Acute cholangitis
B. Acute cholecystitis
C. Acute pancreatitis
D. Acute perforation of the gallbladder

An active 78-year-old woman with hypertension presents with a new left hemiparesis. Cardiac monitoring reveals
atrial fibrillation. She had been in sinus rhythm 3 months ago. She takes a betablocker for her blood pressure. Aside
from blood pressure and heart rate control, which of the following is appropriate?
a. ICD and permanent pacemaker
b. Immediate direct-current cardioversion
c. Aspirin 81 mg daily
d. Antiplatelet therapy plus warfarin with a target INR of 1.5
e. Warfarin with a target INR of 2.0 to 3.0

A 72-year-old man comes to the office with intermittent symptoms of dyspnea on exertion, palpitations, and cough
occasionally productive of blood. On cardiac auscultation, a low-pitched diastolic rumbling murmur is faintly heard at
the apex. What is the most likely cause of the murmur?
a. Rheumatic fever as a youth
b. Long-standing hypertension
c. A silent MI within the past year
d. A congenital anomaly
e. Anemia from chronic blood loss

A 62-year-old man with underlying COPD develops a viral upper respiratory infection and begins taking an over-the-
counter decongestant. Shortly thereafter he experiences palpitations and presents to the emergency room, where the
following rhythm strip is obtained. What is the most likely diagnosis?

a. Normal sinus rhythm

b. Junctional rhythm
c. Atrial flutter with 4:1 atrioventricular block
d. Paroxysmal supraventricular tachycardia (SVT) with 2:1 atrioventricular block
e. Complete heart block
A 29-year-old woman was an unbelted passenger in a motor vehicle accident. On arrival at the hospital, the
paramedics inform you that her calculated Glasgow Coma Scale score is 5. Vital signs reveal a blood pressure 100/60
mmHg, a pulse of 50, and a respiratory rate of 6 breaths per minute. Pupils are 5 mm bilaterally and poorly reactive to
light. Heart and lung examinations are normal. Electrocardiogram reveals a sinus bradycardia, and oximetry shows an
oxygen saturation of 88%. Which of the following is the most appropriate next step in the management of this
patient?
a. airway intubation
b. intravenous naloxone
c. CT scan of the head
d. Intravenous fluids

A 35-year-old woman notices fatigue and exertional dyspnea gradually worsening for the past several months. She
denies cough and is a nonsmoker. On physical examination, her pulse rate is 100 and RR is 20. Room air O2 saturation
is 94%. On examination her neck veins are distended 12 cm above the sternal angle with prominent v-waves. Her
lungs are clear. On cardiac examination the pulmonic component of the second heart sound (P2) is prominent, and
she has a right parasternal heave. An S4 gallop increases in intensity with inspiration. Chest x-ray shows cardiomegaly
but clear lung fields; there is no pulmonary edema or cephalization of flow. Central pulmonary arteries are prominent
but the peripheral vessels appear truncated or “pruned.” ECG is shown in the following figure.

What is the likely pathogenesis of her cardiac problem?

a. Plexiform changes in the small pulmonary arteries, leading to pressure overload on the right ventricle.
b. Constriction of diastolic filling of both ventricles from pericardial fibrosis, leading to equalization of diastolic pressure
in all four chambers.
c. Left-to-right shunt across an atrial septal defect, leading to chronic volume overload of the right ventricle.
d. Impaired diastolic relaxation of the left ventricle leading to elevated pulmonary capillary wedge pressure.
e. Impaired oxygen transport across damaged and distended alveoli, leading to reversible pulmonary vasoconstriction.

You are volunteering with a dental colleague in a community indigent clinic. A nurse has prepared a list of patients
who are scheduled for a dental procedure and may need antibiotic prophylaxis beforehand. Of the patients listed
below, who would be most likely to benefit from antibiotic prophylaxis to prevent infective endocarditis?
a. 17-year-old male with coarctation of the aorta
b. 26-year-old female with a ventricular septal defect repaired in childhood
c. 42-year-old female with mitral valve prolapse
d. 65-year-old male with prosthetic aortic valve
e. 72-year-old female with aortic stenosis
Mrs. Wittstine, a 72-year-old woman, has been complaining of low-grade fever and dyspnea for 2 weeks. She has a
10-year history of scleroderma with involvement of the digits and esophagus. She has a 30-pack-year history of
cigarette smoking but quit 8 years ago. On chest radiograph, she has a nodular infiltrate in the right lower lobe.
Positron emission tomography (PET)/CT shows the right lower lobe lesion to be 3 cm in diameter with nodular
infiltrate characteristics and enhanced fluorodeoxyglucose (FDG) uptake. Which of the following statements about
Mrs. Wittstine is most accurate?
A. Additional diagnostic studies are indicated.
B. The findings on PET/CT make infection very likely.
C. The findings on PET/CT make infection very unlikely.
D. The findings on PET/CT make malignancy very likely.
E. The findings on PET/CT make malignancy very unlikely.

A 22-year-old woman presents to the emergency department in her 23rd week of pregnancy complaining of acute
dyspnea. She has had an uncomplicated pregnancy and has no other medical problems. She is taking no medications
other than prenatal vitamins. On examination, she appears dyspneic. Her vital signs are as follows: blood pressure
128/78 mmHg, heart rate 126 bpm, respiratory rate 28 breaths/min, and oxygen saturation 96% on room air. She is
afebrile. Her lung and cardiac examinations are normal. There is trace bilateral pitting pedal edema. A chest x-ray
performed with abdominal shielding is normal, and the electrocardiogram (ECG) demonstrates sinus tachycardia. An
arterial blood gas is performed. The pH is 7.52, partial pressure of arterial carbon dioxide (PaCO2) is 26 mmHg, and
partial pressure of arterial oxygen (PaO2) is 85 mmHg. What is the next best step in the diagnosis and management of
this patient?
A. Initiate therapy with amoxicillin for acute bronchitis.
B. Perform a computed tomography (CT) pulmonary angiogram .
C. Perform an echocardiogram.
D. Reassure the patient that dyspnea is normal during this stage of pregnancy and no abnormalities are seen on
testing.
E. Treat with clonazepam for a panic attack.

A 38-year-old woman is admitted to the medical ICU with acute hypoxemic respiratory failure. She was well and
healthy until 4 days prior when she abruptly began to feel ill with fevers, chills, bilateral pleuritic chest pain, and
worsening shortness of breath. She has no significant past medical history but has suffered the recent death of her
father following a car accident. In coping with his loss, she began smoking cigarettes again after a 15-year period of
abstinence. She has been smoking up to two packs of tobacco daily. After she began to feel ill, she started taking
acetaminophen and pseudoephedrine, but otherwise takes no medications. Upon arrival in the emergency
department, her oxygen saturation was 78% on room air. On a non-rebreather mask, the oxygen saturation increased
to 92%. The vital signs are as follows: temperature 38.7°C (101.7°), heart rate 122 bpm, respiratory rate 28
breaths/min, and blood pressure 132/82 mmHg. She appears in moderate respiratory distress. There are bilateral
diffuse crackles. The cardiovascular examination shows a regular tachycardia without murmur. The jugular venous
pressure is not elevated, and no edema is present. The abdomen is soft and not tender. No hepatosplenomegaly is
present. Extremity and neurology examinations are normal. Chest radiograph shows diffuse bilateral infiltrates. Her
echocardiogram shows normal left heart systolic and diastolic function. She is treated with ceftriaxone 1 g
intravenously (IV) daily and azithromycin 500 mg IV daily. Over the course of the first 24 hours, the patient’s clinical
condition continues to deteriorate. She remains febrile, and she requires intubation and mechanical ventilation. The
patient’s ventilator is set on assist control with a rate of 28/min, tidal volume of 330 mL, fraction of inspired oxygen
(FiO2) of 0.8, and positive endexpiratory pressure (PEEP) of 12 cmH2O. On these settings, her arterial blood gas values
are pH 7.28, PaCO2 68 mmHg, and PaO2 62 mmHg. A bronchoalveolar lavage is performed. The cell count shows 58%
neutrophils, 12% lymphocytes, and 30% eosinophils. What is the best approach to the treatment of the patient at this
time?
A. Consult thoracic surgery for surgical lung biopsy.
B. Continue current IV antibiotic regimen while awaiting culture data.
C. Initiate methylprednisolone 60 mg IV every 6 hours.
D. Initiate oseltamivir 75 mg twice a day.
E. Initiate therapy with trimethoprim/sulfamethoxazole IV with prednisone 40 mg twice a day.