32 - CVS pathology mcqs - 21 to 25

Question 21
While playing cards, a 63-year-old woman has the sudden onset of "knife-like" pain in the chest radiating to the back. She has been previously healthy except for a history of poorly controlled hypertension. Paramedics are called, and she is transported to the hospital. On admission, she has a heart rate of 90/minute, respirations 20/minute, temperature 36.8 C, and blood pressure 150/100 mm Hg. No murmurs, rubs, or gallops are audible. A chest radiograph reveals a widened mediastinum. Laboratory findings include a total serum creatine kinase of 55 U/L, creatinine 0.9 mg/dL, and glucose 123 mg/dL. Which of the following is the most likely diagnosis?
A Fibrinous pericarditis
B Aortic intimal tear
C Infective endocarditis
D Dilated cardiomyopathy
E Myocardial infarction
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(B) CORRECT. This is a classic history for an aortic dissection. A tear in the aortic intima is followed by dissection of blood outward, often to the thoracic cavity, with fatal hemothorax. The risk factors in most adults include atherosclerosis and hypertension. In Marfan syndrome, the risk for aortic dilation and dissection results from cystic medial necrosis, but this occurs at a much younger age.
(A) Incorrect. A pericarditis can produce pain, but not typically knife-like and not suddenly.
(C) Incorrect. Infective endocarditis is not typically associated with chest pain, unless a septic embolus occludes a coronary artery.
(D) Incorrect. Cardiomyopathies are not typically associated with chest pain.
(E) Incorrect. The pain of a myocardial infarction more typically is substernal and crushing, with radiation to the arm, but an MI needs to be ruled out.
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Question 22
A 20-year-old primigravida delivers a term baby girl following an uncomplicated pregnancy. No anomalies are noted at the time of birth. Five weeks later, the mother brings the baby to the clinic because she has difficulty breathing and occasionally turns pale. On physical examination a pansystolic murmur is audible. Which of the following congenital cardiac anomalies is most likely to be present in this infant?
A Hypertrophic subaortic stenosis
B Hypoplastic left heart syndrome
C Coarctation of the aorta
D Ventricular septal defect
E Bicuspid aortic valve
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(D) CORRECT. The most common cardiac defect is a VSD. The baby may first become symptomatic when the pulmonary arteries dilate after the first month of life and the shunting from left-to-right increases.
(A) Incorrect. IHSS is a rare cause for a hypertrophic cardiomyopathy, and it occurs in adults.
(B) Incorrect. This condition is manifested at birth. If the hypoplasia is not severe, the baby may survive.
(C) Incorrect. The preductal form seen in neonates is severe and usually accompanied by a patent ductus arteriosus.
(E) Incorrect. Although a bicuspid valve is present at birth, it functions fairly well. It calcifies and malfunctions in later adult life.
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Question 23
A 65-year-old man has had congestive heart failure with increasing pulmonary congestion and edema for the past year. He had been previously healthy all his life with no major illnesses. On physical examination his blood pressure is 125/85 mm Hg and he is afebrile. A chest radiograph shows cardiomegaly with a prominent left heart border and pulmonary edema. Laboratory studies show a serum glucose of 95 mg/dL and total serum cholesterol of 175 mg/dL. His serum creatine kinase is not elevated. Which of the following underlying diseases is he most likely to have?
A Alcoholic cardiomyopathy
B Calcified bicuspid aortic valve
C Tricuspid valve endocarditis
D Aortic dissection
E Amyloidosis
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(B) CORRECT. Although bicuspid aortic valves are present from birth, they do not manifest with significant calcification and stenosis until later adult life. The lack of peripheral edema points to a left-sided cause for congestive failure.
(A) Incorrect. Both the right and the left heart are typically involved with a cardiomyopathy, and right-sided failure would lead to peripheral edema.
(C) Incorrect. Right-sided failure from tricuspid involvement with endocarditis would lead to peripheral edema.
(D) Incorrect. This most often results in abrupt onset of shock and/or chest pain.
(E) Incorrect. Amyloidosis produces a restrictive type of cardiomyopathy that typically involves both right and left heart.
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Question 24
A 35-year-old man was found down and was delirious and talking incoherently. On examination in the emergency department his temperature is 39.3 C, pulse 110/minute, and blood pressure 70/palpable. He has a heart murmur, palpable spleen tip, and splinter hemorrhages of fingernails. Which of the following laboratory findings is most likely to be present in this man?
A Positive urine screen for opiates
B Elevated anti-streptolysin O (ASO)
C Increased urinary free catecholamines
D Elevated Coxsackie B viral titer
E Rising creatine kinase (CK) in serum
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(A) CORRECT. This history points to an infective endocarditis. A common risk factor for infective endocarditis is intravenous drug use.
(B) Incorrect. He does not have rheumatic disease.
(C) Incorrect. He does not have a pheochromocytoma.
(D) Incorrect. He does not have a viral myocarditis.
(E) Incorrect. He does not have an acute myocardial infarction. The valvular disease does not necessarily involve the adjacent myocardium.
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Question 25
A 69-year-old woman with a 7 kg weight loss over the past 6 months now has developed painless jaundice over the past 2 weeks. On physical examination she is afebrile. An abdominal CT scan shows a large mass involving the head of the pancreas, along with widespread nodules in the liver. Nodules are seen in both lungs by chest radiograph. Which of the following cardiac lesions is she most likely to develop?
A Dilated cardiomyopathy
B Non-bacterial thrombotic endocarditis
C Acute fibrinous pericarditis
D Endocardial fibrosis
E Acute myocardial infarction
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(B) CORRECT. Such cancers can be associated with a hypercoagulable state (Trousseau's syndrome) with formation of marantic cardiac valvular vegetations.
(A) Incorrect. This is often idiopathic.
(C) Incorrect. Fibrinous pericarditis is most often seen with renal failure and uremia. It can also occur with myocardial infarction and with acute rheumatic fever.
(D) Incorrect. This is an uncommon idiopathic process in children. The left ventricle is involved more than the right by deposition of a thick collagen layer that interferes with contractility.
(E) Incorrect. Patients with advanced cancer often have a reversal of atherosclerotic lesions.
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