1.

A 72-year-old female with a history of diabetes mellitus and no history of heart disease presents to
the emergency department with chest pains at rest intermittently for the past 4 hours. She has
associated shortness of breath and diaphoresis. Her heart rate is 60/minute, blood pressure 134/72mm
Hg, respiratory rate 20/minute, and oxygen saturation 95% on room air. Physical examination reveals
normal lung sounds and an S4 gallop. Her ECG reveals ST segment depression in leads V1 to V3. No
other ECG changes. She is given aspirin immediately. Her troponin levels remain negative. Which of the
following is the correct diagnosis?

A) Stable angina

2.An 18-year-old male with no significant past medical history presents to his primary care physician for
a routine physical examination. He has no physical complaints. His blood pressure is 115/85, heart rate
80, respirations 12, and he is afebrile. His physical examination reveals normal lung sounds, a 5/6
holosystolic murmur with a thrill at the right lower sternal border and no change in intensity with
inspiration, no gallops or extra heart sounds, and normal jugular venous pressures. His ECG and
laboratory studies are normal. What is his most likely diagnosis?

D) Ventricular septal defect

3. A 35-year-old woman has a 6- week history of effort intolerance, and shortness of breath at night
accompanied by cough with hemoptysis. She has a history of rheumatic heart disease since childhood.
On examination her pulse is 128/min irregularly irregular, blood pressure 102/82mmHg, respirations
20/min and temperature 98.2F. Heart rate on auscultation is irregularly irregular and148/min, faster
than the pulse rate. There is a low pitched mid-diastolic cardiac murmur heard at 5th left interspace
just inside the midclavicular line. Jugular venous pressure is normal. Which of the following additional
findings is most likely to be present in this patient?

C. Tapping apex beat on palpation (Mitral Stenosis)

4.A new born is under first examination in a delivery suite by the pediatric team. On auscultation of
heart a murmur sounding like engine running, is noticed in all areas of precordium. The murmur is
present in both systole and diastole. Which of the following is the most likely cause of this murmur?

A. Patent ductus arteriosus (Prostaglandins keep open, NSAID like Indomethacin close PDA)

5.A 45-year-old man has a 6- week history of exercise intolerance, and shortness of breath at night
accompanied by cough. His childhood history is significant for a fever lasted for more than two weeks.
On examination pulse is 128/min with plus 1 volume, blood pressure 102/82mmHg, respirations 20/min
and temperature 98.2F. On auscultation there is a low pitched mid-diastolic cardiac murmur heard at
5th left interspace just inside the midclavicular line. Jugular venous pressure is normal. Which of the
following is most likely diagnosis?

D. Mitral stenosis
6. A 24 year old man presents to his primary care physician for pre-employment physical examination.
He has no physical complaints and no significant past medical history. His blood pressure is 120/70,
heart rate 80/minute, respirations 16/minute, and he is afebrile. His physical examination reveals
normal lung sounds, a normal first heart sound and split second heart sound on deep inspiration best
heard in pulmonic area. There are no murmur, gallops, clicks or rubs present. His ECG and laboratory
studies are normal. What is his most likely cause of this splitting?

C. Normal physiologic splitting

7. A 60 year old Afro-American man complains of progressive pain in his chest and dyspnea for 5
weeks. The pain is described as heaviness right behind breastbone, radiates to his neck. Pain gets
worse on exertion and is relieved within five minutes of resting. He was diagnosed with
hypertension ten years ago but is noncompliant with his medications. His social history is significant
for cigarette smoking, which he stopped at age of 50.
Physical examination shows a pulse of 98/minute regular, and a respiratory rate of 25/minute.
BP140/90 mmHg. Auscultation reveals normal S1 and S2 without any added heart sounds or crackles.
An EKG showed a deep T wave inversion. The level of specific cardiac proteins is 0.13microgram/Liter
(Normal is <0.35 mcg/L). Based on this information which of the following is most likely diagnosis?

B. Stable angina

8. A 35 year old man brought to the ER with complaint of Chest pain that felt like heavy pressure
behind the sternum. His past history is insignificant. Social history indicates excessive use of fried
food. On examination he was diaphoretic and in painful distress. His vitals are normal except the
respiratory rate of 22 breaths /minute. His EKG is given below. What is the probable diagnosis?

A. Anterior wall infarction

B. Non STEMI
C. Posterior wall infarction
D. Inferior wall infarction
E. Anteroseptal infarction

9.A 60 year old woman presents to the ED with complaints of a sudden, oppressive mid chest pain
that comes and go with the activity and rest. It lasts for 5-10 minutes. She has a long standing
 history of hypertension. On exam, she is restless, pale and diaphoretic. Vitals: BP 150/100 mmHg, PR
90/min, RR 26/min and temperature 98.6oF. Chest auscultation reveals a murmur shown in the figure
below in second right intercostal space. The prognosis of her heart disease is most probably related
to which of the following?

A. The presence of a midsystolic click on auscultation. (Advanced AS causes MVP)

10.A 27 year old primigravida at her 20th week of pregnancy is in doctor’s office for the prenatal
check-up. She has no complaints and she is taking her folic acid, iron tablet and multivitamin tablet
regularly. On examination her vitals are: BP110/65 mmHg. Pulse 82 beats per minute, regular, 3+ in
volume, symmetrical. Respiratory rate 18/minute adequate in depth, temperature 98.8°F.There is
slight edema on the ankle and pigmentation on the cheekbones is noted. On auscultation the lungs
were clear. First and second heart sounds are normal however a soft systolic murmur is heard at left
sternal border (tricuspid + VSD) that does not increase on performing any maneuver. The murmur
was not present on the last prenatal visit. Which of the following is the most likely cause related to
murmur?

A. Innocent murmur of iron deficiency anemia

11. A woman with a history of left mastectomy and subsequent radiation therapy for breast cancer
two years ago presents with a 3-cm mass along the edge of the surgical suture line. She denies fever,
chills, night sweats, and weight loss. Physical examination reveals some generalized induration and a
tanned appearance of the skin overlying the mastectomy secondary to radiation therapy. There is a
nonmobile nontender mass along the suture line that is not warm or fluctuant. She has no axillary
lymphadenopathy. A biopsy specimen of the breast mass is likely to show which of the following?

b. Malignancy
 12. 63. An 18-year-old woman presents with arthritis that is asymmetrical and involves more than three
joints. The arthritis is migratory, affecting one joint for several days and improving, then affecting
another r joint. On physical examination, the patient has several subcutaneous nodules and her cardiac
exam reveals and Sɜ gallop. Which of the following is the most likely diagnosis?

B. Endocarditis (Osler’s Nodes)

13.A 16-year-old boy is found to have an unexpected sound audible in the right side of the neck. The
sound is the loudest in diastole and with the patient in the sitting position. The sound disappears
when the patient is lying down or with the Valsalva maneuver. He has no complaints and is very
athletic in school. He has no clubbing or cyanosis. Blood pressure and heart rate is normal. The rest of
the physical examination is normal. Which of the following is the most likely diagnosis?

C. Carotid bruit

14. 18-year-old college student presents to your office for evaluation of episodes of chest pain and
shortness of breath. She has no medical problems. She does not smoke, drink alcohol, or use
illicit drugs. She is on the dean’s list and is studying electrical engineering. On auscultation of her
heart, you hear a mid-systolic murmur at aortic area along with Austin – flint murmur at the
apex. What is the Austin-Flint cardiac murmur?

A. Mitral diastolic murmur associated with the diastolic murmur of Aortic Regurgitation.

15.A38-year-old file clerk presents to your office for evaluation of fatigue. She has a 20-pack-ayear
history of smoking and had rheumatic fever in childhood. On auscultation of her heart, the S2
sound is widely split; that is, it persists throughout the respiratory cycle. What is the MOST
LIKELY cause of the widely split S2?

B. Pulmonic stenosis

16. A 5-year-old child presents with his parents for a regular checkup. He has normal growth and
development and is appropriately physically active. On auscultation of his heart, you hear a
grade 2 murmur at the 2nd through 4th left interspaces between the left sternal border and
 the apex. It has a medium pitch, and the quality of the sound is variable. It does not radiate. It
disappears when the patient is sitting. What is the MOST LIKELY cause of this murmur?

A. Innocent

17. A 62-year-old construction worker presents to your office for evaluation of fatigue. He has an
elevated blood pressure with a widened pulse pressure. Upon auscultation of his heart, you
hear a mid-systolic murmur at the right second interspace that radiates to the neck. It has a
medium pitch and a harsh quality. It is best heard when you sit the patient up and lean him
forward. What is your MOST LIKELY diagnosis?

C. Aortic stenosis

18. A 52-year-old computer analyst presents to the office for a checkup. He is doing well except that he
has noticed increasing shortness of breath with physical exertion, so he has cut down on his
recreational activities. On auscultation of the heart, you hear a blowing, medium-pitched
pansystolic murmur at the apex. It radiates to the left axilla and does not change with
inspiration. What may be the cause for this murmur ?

A. Mitral regurgitation

19. A 41-year-old intravenous drug abuser presents with shortness of breath and pleuritic chest pain.
He is febrile with the temperature of 39.7°C. He has no skin lesions, and funduscopic exam is negative.
He has jugular venous distension that increases with compression of the liver. The liver is pulsatile. The
jugular venous pulse shows a prominent v wave. The patient has splenomegaly. Heart auscultation
reveals a holosystolic murmur heard best at the left lower sterna border. The murmur increases with
inspiration (Muller maneuver). Which of the following is the most likely diagnosis?

A. Bacterial endocarditis (tricuspid regurgitation)

20. A 45*year*old runner develops chest pain and collapses while

jogging. He arrives in the ER within an hour. He is awake and
is given a sublingual nitroglycerin tablet which reduces his
discomfort. His rhythm is sinus at 90 bpm; BP 120/85. An ECG
shows 3 mm of ST segment depression in leads II, III, AVF, V 5 and
V 6 . The best next step is:

a. admission with initiation of Asprin, ß blocker, and heparin therapy

21. A 72-year-old female with no significant past medical history passes out while exercising. She has
intermittent exertional chest pains and dyspnea on exertion as well. Her physical examination reveals a
III/VI late-peaking crescendo-decrescendo murmur at the right upper sternal border and a III/VI
holosystolic murmur at the apex. Her S2 heart sound is very soft and her carotid upstroke is weak and
delayed. Which of the following is most likely causing her symptoms?

B. Aortic valve stenosis

Classic triad: syncope (passing out), exertional angina, or exertional dyspnea from heart
failure). The more severe the aortic stenosis the later the peak of the murmur in systole and the
softer the A2 component of the S2 heart sound

22. A 29-year-old male with a history of ectopia lentis presents for a routine physical examination. He is
noted to have pectus excavatum, pes planus, a high arched palate, and a positive wrist and thumb
sign. Which of the following cardiac disorders is associated with his condition?

A. Aortic valve stenosis

B. Coarctation of the aorta

C. Mitral valve prolapse

D. Ventricular septal defect

E. Ebstein’s anomaly
25 A 68 year old male suffers a myocardial infarction. Six weeks later he begins to have sharp substernal
chest pains radiating to his left neck worse with laying flat and better while sitting up and leaning
forward. His electrocardiogram is below. Which of the following is his likely diagnosis?

C. Pericarditis (Dresslers Syndrome)

Dressler's syndrome is an autoimmune pericarditis what occurs weeks to months after

myocardial infarction. The typical ECG changes of pericarditis occur (diffuse ST segment
elevation in a concave upward shape with PR depression). Symptoms of pericarditis include
sharp chest pain worse with laying flay and better with leaning forward and pain that radiates to
the left trapizius muscle

26. An 18 year old male dies suddenly during a track and field event. During a recent sports physical he
was noted to have a II/VI systolic crescendo-decreshendo murmur at the right upper sternal border
that became louder with Valsalva. A paradoxical split S2 heart sound was heard. Which of the following
is his likely diagnosis?

C. Idiopathic hypertrophic subaortic stenosis

Hypertrophic cardiomyopathy (HCM) is very common and can affect people of any age. It affects men
and women equally. It is a common cause of sudden cardiac arrest in young people, including young
athletes.
Hypertrophic cardiomyopathy occurs if heart muscle cells enlarge and cause the walls of the ventricles
(usually the left ventricle) to thicken. The ventricle size often remains normal, but the thickening may
block blood flow out of the ventricle. If this happens, the condition is called obstructive hypertrophic
cardiomyopathy.

27 A young male presented with dyspnea, bleeding and petechial hemorrhage in the chest after 2 days
following fracture shaft of the femur right side. A diagnosis of Pulmonary embolism was made which of
the following is characteristic finding on a ECG ?

a) S1Q3T3 pattern

DVT: causes stasis  up IVC  Heart  PE (quick onset stabbing pain radiates to back)