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History and Physical Examination

1. 1.1. A 25‐year‐old woman presents for routine follow up. She has a 2/6 ejection systolic murmur best heard in the second left intercostal space with normal S1. The S2 is split during inspiration only, and P2 intensity is normal. No apical or parasternal heave. The murmur diminishes during expiration and standing up. What is the likely cause of the murmur?
   1. Physiological or normal
   2. Atrial septal defect (ASD)
   3. Bicuspid aortic valve
   4. Hypertrophic obstructive cardiomyopathy (HOCM)
2. 1.2. A 29‐year‐old pregnant woman was found to have a systolic murmur best heard in the second left intercostal space. It is rough and there was a palpable thrill in the same area and in the suprasternal notch. Patient is asymptomatic and has normal exercise tolerance. What is the likely explanation for the murmur?
   1. Pulmonary stenosis (PS)
   2. Normal flow murmur due to increased cardiac output
   3. Posterior mitral leaflet prolapse causing an anteriorly directed jet
   4. Mammary soufflé
3. 1.3. A 22‐year‐old patient has a hypoplastic radial side of the forearm and fingerized thumb. What might this be associated with?
   1. ASD
   2. Tetralogy of Fallot
   3. Coarctation of aorta
   4. Ebstein's anomaly
4. 1.4. A 28‐year‐old man presented with a history of shortness of breath on exertion. On examination, the pulse rate was 76 bpm and blood pressure (BP) 126/80 mmHg. The left ventricular apex was prominent and forceful. The S1 and S2 were normal, but there was a 2/6 ejection systolic murmur best heard in the third right intercostal space. There was no appreciable variation with respiration, but there was an increase in intensity with the Valsalva maneuver and on standing up. It seemed to be less prominent on squatting. There was no audible click. This patient is likely to have?
   1. Valvular aortic stenosis
   2. Hypertrophic obstructive cardiomyopathy (HOCM)
   3. Mitral valve prolapse (MVP)
   4. Innocent murmur
5. 1.5. A 36‐year‐old asymptomatic woman was found to have a systolic murmur best heard in the apex, but also in the aortic area. It was mid to late systolic and was associated with a sharp systolic sound. What is the likely cause of the murmur?
   1. Posterior mitral leaflet prolapse
   2. Anterior mitral leaflet prolapse
   3. Valvular aortic stenosis
   4. Aortic subvalvular membrane
6. 1.6. A 78‐year‐old man with hypertension and diabetes mellitus presented with exertional shortness of breath of 6months' duration. Examination revealed a 4/6 crescendo‐decrescendo or ejection systolic murmur best heard in the second right intercostal space. The first component of the second sound was soft. The murmur was also heard along the right carotid artery. What is this patient likely to have?
   1. Mild aortic stenosis
   2. Moderate or severe aortic stenosis
   3. Pulmonary stenosis
   4. MR
7. 1.7. A thrill and a continuous machinery murmur in the left infraclavicular area is indicative of what?
   1. Patent ductus arteriosus (PDA)
   2. Increased flow due to left arm arteriovenous (AV) fistula for dialysis
   3. Venous hum
   4. Pulmonary AV fistula
8. 1.8. Which of the following is not a feature of aortic coarctation?
   1. A continuous murmur on the back
   2. Lower blood pressure in the legs compared with an arm
   3. Radiofemoral delay
   4. Pistol shot sounds on femoral arteries
9. 1.9. A 22‐year‐old newly immigrant woman was referred to the high‐risk pregnancy clinic because of clubbing and cyanosis. Examination in addition revealed a parasternal heave, 4/6 ejection systolic murmur in the third left intercostal space, normal jugular venous pressure (JVP), and oxygen saturation of 75%. What will you recommend after confirmation of the diagnosis?
   1. Continue pregnancy with sodium restriction
   2. Continue pregnancy, but deliver at 28 weeks
   3. Advise termination of pregnancy
   4. Perform percutaneous ASD closure and continue pregnancy
10. 1.10. What is the cause of murmur in ASD?
    1. Continuous due to flow across the defect
    2. Ejection systolic due to increased flow across the pulmonary valve
    3. Mid‐diastolic due to increased flow across the tricuspid valve
    4. Continuous murmur over lung fields due to increased flow in lungs
11. 1.11. What is a systolic click that disappears on inspiration likely to be due to?
    1. Pulmonary valvular stenosis
    2. Bicuspid aortic valve
    3. MVP
    4. Pulmonary hypertension
12. 1.12. A 36‐year‐old woman presented with an 8‐month history of progressive exertional dyspnea. Physical examination revealed a heart rate of 74 bpm, regular, BP 126/78 mmHg, with no pedal edema. JVP and carotid upstroke were normal. Cardiac auscultation revealed normal S1, an accentuated P2 with narrow splitting of S2, an ejection click, and a 2/6 ejection systolic murmur. What is the likely diagnosis?
    1. Pulmonary hypertension
    2. PS
    3. Aortic stenosis
    4. ASD
13. 1.13. Causes of prominent “a” wave in jugular venous pulsations include all of the following except which option?
    1. PS
    2. Pulmonary hypertension
    3. Tricuspid stenosis
    4. Aortic stenosis
    5. ASD
14. 1.14. What is a 6‐year‐old Amish boy in Pennsylvania with short stature, polydactyly, short limbs, absent upper incisor teeth with dysplasia of other teeth, and a systolic murmur most likely to have?
    1. ASD
    2. Ventricular septal defect
    3. Aortic coarctation
    4. PS
15. 1.15 Which of the following describes a ventricular septal defect murmur?
    1. Holosystolic
    2. Ejection systolic
    3. Systolic‐diastolic
    4. None of the above
16. 1.16. Clubbing and cyanosis in lower limbs, but not upper limbs, is indicative of which of the following?
    1. PDA with coarctation of the aorta
    2. PDA with pulmonary hypertension
    3. Ventricular septal defect Eisenmenger's
    4. ASD Eisenmenger's with coarctation of aorta
17. 1.17. A 46‐year‐old man presented with progressive fatigue and leg swelling. He had no significant past medical history except a front‐on collision in a car he was driving. Examination revealed 2+ edema, raised JVP, and an enlarged liver, which seemed to expand during systole. What is the likely diagnosis?
    1. Severe tricuspid stenosis
    2. Severe tricuspid regurgitation (TR)
    3. Constrictive pericarditis
    4. Restrictive cardiomyopathy
18. 1.18. A 23‐year‐old has a mid‐diastolic rumble and sharp early diastolic sound. What is the likely explanation?
    1. Mitral stenosis
    2. Constrictive pericarditis
    3. Restrictive cardiomyopathy
    4. Bicuspid aortic valve
19. 1.19. A 28‐year‐old man has history of progressive fatigue and exertional shortness of breath over the previous 6 months. Examination revealed a raised JVP that seemed to increase with inspiration and a sharp precordial sound in early diastole. What is the most likely diagnosis?
    1. Right ventricular infarct
    2. Tricuspid stenosis
    3. Constrictive pericarditis
    4. Restrictive cardiomyopathy
20. 1.20. A 66‐year‐old woman with left breast cancer post mastectomy, radiation, and chemotherapy was admitted with shortness of breath, heart rate of 120 bpm, and BP of 90/60 mmHg. On slow cuff deflation during BP measurement, Korotkoff's sounds started at 90 mmHg during expiration only and throughout the respiratory cycle at a cuff pressure of 70 mmHg. An echocardiogram was obtained. What is this likely to show?
    1. Akinesis of the left anterior descending area
    2. Thick pericardium
    3. Large pericardial effusion
    4. Large, globally hypokinetic left ventricle.
21. 1.21. Features of restrictive cardiomyopathy may include all of the following except?
    1. Raised JVP
    2. Loud S3
    3. Kussmaul's sign
    4. A diastolic knock in the pulmonary area
22. 1.22. Pulsus paradoxus despite tamponade may not be present in which of the following?
    1. ASD
    2. Aortic stenosis
    3. Mitral stenosis
    4. Old age
23. 1.23. Pulsus paradoxus may occur in all of the following except?
    1. Tamponade
    2. Status asthmaticus
    3. Pulmonary embolism
    4. Aortic stenosis
24. 1.24. A Square sign during Valsalva maneuver occurs in which of the...