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1 Alexandria University Faculty of Medicine Cardiology Department Clinical Round Examination (Time allowed 45 minutes) (Date: 17/11/2011) Group:

Student's Name: 1. Pulsus paradoxus occurs in: a. Pericardial tamponade b. Acute myocarditis c. Atrial fibrillation d. Acute myocardial infarction

Seat No.:

2. A positive Kussmauls sign i.e. paradoxical increase in CVP during inspiration occurs in: a. Left-sided heart failure b. Severe tricuspid regurgitation c. Constrictive pericarditis d. Superior vena caval obstruction 3. Holosystolic murmurs are usually caused by all except: a. Mitral incompetence b. Tricuspid incompetence c. VSD d. Pulmonary stenosis 4.The most common factor precipitating digitalis intoxication is a. Advaced age b. Potassium depletion c. Hypothyroidism d. Magnesium depletion` e. 5. All of the following medications have been shown to worsen heart failure in patients with left ventricular systolic dysfunction except a. angiotensin converting enzyme inhibitors b. calcium channel antagonists c. nonsteroidal anti-inflammatory drugs (NSAIDs) d. Atenolol e. Adriamycin 6. Which of the following medications has been shown to improve mortality in congestive heart failure (choose one or more) ? a. ACE-inhibitors b. Beta blockers c. Prazosin d. Nitrates e. Digoxin 7.Furosemides main site of action is a. Proximal convoluted tubule b. Distal convoluted tubule c. Thick ascending limb of loop of Henle d. Bowmans capsule

2 8. Unless contra-indicated, Angiotensin Converting Enzyme inhibitors (ACEIs) should be given to: a. all patients with heart failure b . patients with fluid retention only c. patients who are breathless only d. patients who are fatigued only Collecting ducts 9 .Marked limitation of physical activities: Comfortable at rest but less than the ordinary daily activities causes symptoms means NYHA class a) Class I b) Class II c) Class III d) Class IV 10. Troponin T is a sensitive and specific marker for: a. typical angina b. crescendo angina c. myocardial infarction d. arrhythmia e. Prinzmetal's angina 11.The most common congenital heart lesions predisposing to infective endocarditis include the following except a. Bicuspid aortic valve b. Patent ductus artriosus c. Ventricular septal defect d. Fallots tetralogy e. Secundum atrial septal defect 12.The most commonly affected valve in intravenous drug abusers is a. The pulmonary valve b. The tricuspid valve c. The mitral valve d. The aortic valve 13. Oslers nodes are small, tender, erythematous subcutaneous nodules which can be seen on the a. Scalp b. Abdomen c. Face d. Pulp of the digits e. Interscapular area 14.Cannon a waves occur in the jugular venous pulse in a. Atrila fibrillation b. Atrial flutter c. Supraventricular tachycardia d. Complete atrioventricular block

3 15.Water hammer pulse is characteristic of a. Aortic stenosis b. Severe aortic regurgitation c. Ventricular septal defect d. Atrial septal defect 16. In a patient with rheumatic heart disease, valvular mitral stenosis (choose the correct answer) 16-1 The first heart sound is usually a. Normal b. Weak c. Accentuated 16-2.The longer the duration of the diastolic murmur, the more severe is the stenosis a. False b. True 16-3 The presence of an opening snap implies a. Heavily calcific immobile mitral valve b. Pliable mobile mitral valve c. Associated severe mitral regurgitation d. Big left atrial thrombus 16-4. Pinkish frothy sputum indicates a. Pulmonary infarction b. Pulmonary congestion c. Pulmonary edema d. Broncopneumonia 16-5. The presence of atrial fibrillation is an indication for a. Acteylsalicylic acid b. Clopidogrel c. Warfarin d. Streptokinase 16-6. In the presence of severe mitral stenosis with pliable and mobile leaflets, the intervention of choice is a. Mitral valve replacement b. Mitral annuloplasty c. Percutaneous balloon mitral valvotomy d. Open mitral commissurotomy 16-7. The presence of a diastolic shock indicates a. Left atrial enlargement b. Pulmonary venous congestion c. Pulmonary arterial hypertension 17. A patient with chronic heart failure has been complaining of recent persistent irritating cough. Cardiac auscultation revealed an S3 and an apical systolic murmur. He has no fever. Auscultation of the lungs was unremarkable. Which of the following medications may be the cause of his cough? a. Furosemide b. Digoxin c. Atenolol d. Captopril e. Spironolactone

4 18. 74-year-old woman, presented to her physician with complaints of increasing shortness of breath upon exertion. She could only sleep on 3 pillows. She also noted that the typical swelling she's had in her ankles for years has started to get worse over the past two months. In the past week, she's had a decreased appetite, some nausea and vomiting, and tenderness in the right upper quadrant of the abdomen. On physical examination, her jugular veins were noticeably distended. Blood pressure in both arms was 188/100 mm Hg. Auscultation of the heart revealed a low-pitched, systolic murmur, heard best over the apex of the heart together with a S3 gallop. She is on the following medications: digoxin 0.25 mg qd, furosemide 40 mg qd, spironolactone 25 mg qd and -methyl dopa 250 mg bid. 18.1.What is the diagnosis which best describes this condition? a. Chronic obstructive pulmonary disease b. Pulmonary thrombo-embolism c. Bronchial asthma d. Congestive heart failure 18.2. Is the elevated blood pressure relevant to her current symptoms? a. Yes b. No 18.3. Which is the probable cause of nausea? a. Furosemide b. Digoxin c. Spironolactone d. -methyl dopa 18.4.What is the best diagnostic imaging tool in this case? a. Abdominal ultrasonography b. Computed tomography of the chest c. Coronary angiography d. Echocardiography 18.5.What is the likely cause of pain and tenderness in the right hypochondrium? 1. Gastritis 2. Appendicitis 3. Nephritis 4. Congestive hepatomegaly 18.6.What other useful medication should be added to her therapy? 1. Ampicillin 500 mg tds 2. Aspirin150 mg qd 3. Enalapril 10 mg bid 4. Vitamin E 400 U qd 19. A 23 yearold female presented to OP clinic because of nausea and severe occipital headache, her BP was 210/130 mmHg, optic fundus showed hemorrhages and exudates. There was an audible bruit during abdominal examination; the most likely provisional diagnosis is: a) Brain tumor b) Renal artery stenosis c) Pheochromocytoma d) Severe essential HTN

20- A 64-year-old man was admitted to the ED because of chest pain that started 1 hr ago. The pain persisted despite he was given sublingual nitroglycerin twice. ECG was performed.

20-1. What does the ECG indicate? a. b. c. d. e. Pericarditis Pulmonary embolism ST-elevation myocardial infarction Non-ST-elevation myocardial infarction Aortic dissection

20-2. The next best step for management should be: a. Thrombolytic therapy b. Sedation with diazepam c. Non-steroidal anti-inflammatory drug to relieve pain d. Pericardiocentesis