PANCE and PANRE | Cardiology Review and Practice Exam

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Question 1

A 36 year-old male complains of occasional episodes of "heart fluttering". The patient describes these episodes as frequent, short-lived and episodic. He denies any associated chest pain. Based on this information, which one of the following tests would be the most appropriate to order?

A	Holter monitor
B	Cardiac catheterization Hint: See answer for explanation
C	Stress testing Hint: See answer for explanation
D	Cardiac nuclear scanning Hint: See answer for explanation

Question 1 Explanation:

Holter monitoring is a non-invasive test done to obtain a continuous monitoring of the electrical activity of the heart. This can help to detect cardiac rhythm disturbances that can correlate with the patient symptoms. Cardiac catheterization is an invasive procedure done to assess coronary artery disease. Stress testing and cardiac nuclear scanning are non-invasive testing maneuvers done to assess coronary artery disease.

Question 2

A patient with a mitral valve replacement was placed post-operatively on warfarin (Coumadin) for anticoagulation prophylaxis. To monitor this drug for its effectiveness, what test would be used?

A	PTT Hint: PTT is a reflection of the intrinsic clotting system and is used to monitor heparin administration.
B	PT-INR
C	Platelet aggregation Hint: Platelet aggregation tests are utilized to assess platelet dysfunction.
D	Bleeding time Hint: Bleeding time is used to assess platelet function.

Question 2 Explanation:

PT-INR is a reflection of the extrinsic and common pathway clotting system. Coumadin interferes with Vitamin K synthesis which is needed in the manufacture of factors II, VII, IX, X which are part of the extrinsic clotting pathway.

Question 3

A 64 year-old male, with a long history of COPD, presents with increasing fatigue over the last three months. The patient has stopped playing golf and also complains of decreased appetite, chronic cough and a bloated feeling. Physical examination reveals distant heart sounds, questionable gallop, lungs with decreased breath sounds at lung bases and the abdomen reveals RUQ tenderness with the liver two finger-breadths below the costal margin, the extremities show 2+/4+ pitting edema. Labs reveal the serum creatinine level 1.6 mg/dl, BUN 42 mg/dl, liver function test's mildly elevated and the CBC to be normal. Which of the following is the most likely diagnosis?

A	Right ventricular failure
B	Pericarditis Hint: See answer for explanation
C	Exacerbation of COPD Hint: See answer for explanation
D	Cirrhosis Hint: See answer for explanation

Question 3 Explanation:

Signs of right ventricular failure are fluid retention i.e. edema, hepatic congestion and possibly ascites.

Question 4

A 56 year-old male with a known history of polycythemia suddenly complains of pain and paresthesia in the left leg. Physical examination reveals the left leg is cool to the touch and the toes are cyanotic. The popliteal pulse is absent by palpation and Doppler. The femoral pulse is absent by palpation but weak with Doppler. The right leg and upper extremities has 2+/4+ pulses throughout. Given these findings what is the most likely diagnosis?

A	Venous thrombosis Hint: Venous occlusion does not result in loss of arterial pulse.
B	Arterial thrombosis
C	Thromboangiitis obliterans Hint: See answer for explanation
D	Thrombophlebitis Hint: Thrombophlebitis does not result in loss of arterial pulse.

Question 4 Explanation:

Arterial thrombosis has occurred and is evidenced by the loss of the popliteal and dorsalis pedis pulse. This is a surgical emergency. Venous occlusion and thrombophlebitis do not result in loss of arterial pulse.

Question 5

A 48 year-old male with a known history of hypertension is brought to the ED complaining of headache, general malaise, nausea and vomiting. The patient currently takes nifedipine (Procardia)90mg XL every day and atenolol (Tenormin) 50 mg every day. Vital signs reveal temperature 98.6°F, pulse 72/minute, respiratory rate 20/minute, and the blood pressure is 168/120 mmHg. BP reading taken every 15 minutes from the time of admission reveal the systolic to run from 176 to 186 mmHg and the diastolic to run from 135 to 150 mmHg. Physical examination reveals papilledema bilaterally. There are no renal bruits noted. The EKG is normal. Based upon this presentation, what is the most likely diagnosis?

A	Meningitis Hint: See answer for explanation
B	Secondary hypertension Hint: See answer for explanation
C	Pseudotumor cerebri Hint: Pseudotumor cerebri presents with papilledema, but not hypertension and is more common in young females.
D	Malignant hypertension

Question 5 Explanation:

Malignant HTN is characterized by diastolic reading greater than 140 mm Hg with evidence of target organ damage.

Question 6

A 55 year-old male is seen in follow-up for a complaint of chest pain. Patient states that he has had this chest pain for about one year now. The patient further states that the pain is retrosternal with radiation to the jaw. "It feels as though a tightness, or heaviness is on and around my chest". This pain seems to come on with exertion however, over the past two weeks he has noticed that he has episodes while at rest. If the patient remains non- active the pain usually resolves in 15-20 minutes. Patient has a 60-pack year smoking history and drinks a martini daily at lunch. Patient appears overweight on inspection. Based upon this history what is the most likely diagnosis?

A	Acute myocardial infarction Hint: Pain does not resolve in an acute MI, it gradually gets worse.
B	Prinzmetal variant angina Hint: Pain typically occurs at rest is one of the hallmarks of Prinzmetal variant angina. This patient has just started to develop pain at rest.
C	Stable angina Hint: Pain in stable angina is relieved with rest and usually resolves within 10 minutes. angina does not have pain at rest.
D	Unstable angina

Question 6 Explanation:

Pain in unstable angina is precipitated by less effort than before or occurs at rest.

Question 7

An unresponsive patient is brought to the ED by ambulance. He is in ventricular tachycardia with a heart rate of 210 beats/min and a blood pressure of 70/40 mmHg. The first step in treatment is to...

A	Administer IV adenosine. Hint: Adenosine is used to treat PSVT.
B	DC cardiovert.
C	Administer IV lidocaine. Hint: See answer for explanation
D	Apply overdrive pacer. Hint: Overdrive pacing is indicated in Torsades de Pointes.

Question 7 Explanation:

The first step in treatment of unstable ventricular tachycardia with a pulse is to cardiovert using a 100 J countershock.

Question 8

Which of the following beta-adrenergic blocking agents has cardioselectivity for primarily blocking beta-1 receptors?

A	Propranolol (Inderal) Hint: Propranolol and timolol are nonselective beta-adrenergic antagonists.
B	Timolol (Blocadren) Hint: Propranolol and timolol are nonselective beta-adrenergic antagonists.
C	Metoprolol (Lopressor)
D	Pindolol (Visken) Hint: Pindolol is an antagonist with partial agonist activity.

Question 8 Explanation:

Metoprolol is selective for beta-1 antagonists

Question 9

A 23 year-old female with history of palpitations presents for evaluation. She admits to acute onset of rapid heart beating lasting seconds to minutes with associated shortness of breath and chest pain. The patient states she can relieve her symptoms with valsalva. Which of the following is the most appropriate diagnostic study to establish a definitive diagnosis in this patient?

A	Cardiac catheterization Hint: Cardiac catheterization evaluates coronary arteries but has no role in the diagnosis of supraventricular tachycardia
B	Cardiac MRI Hint: Cardiac MRI cannot diagnose and define pathway of supraventricular tachycardia.
C	Chest CT scan Hint: Chest CT scan will not establish definitive diagnosis of supraventricular tachycardia.
D	Electrophysiology study

Question 9 Explanation:

Electrophysiology study is useful in establishing the diagnosis and pathway of complex arrhythmias such as supraventricular tachycardia

Question 10

Which of the following ECG findings is consistent with hyperkalemia?

A	prolonged QT interval Hint: Prolonged QT interval is seen in hypocalcemia.
B	delta wave Hint: Delta wave is a sign of ventricular preexcitation seen in Wolf-Parkinson-White (WPW) Syndrome.
C	peaked T waves
D	prominent U waves Hint: Prominent U waves are a sign of prolonged ventricular repolarization seen in hypokalemia.

Question 10 Explanation:

Narrowing and peaking of T waves are the beginning EKG changes associated with hyperkalemia.

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