CVS MCQ 2010.pdf

Page 1 of 23 SCMD 3000 – GEMP 1 – CARDIOVASCULAR MCQ Exam – 24 MAY 2010

Venue: LT- _____ Seat No: ___________ Student No: ______________________

UNIVERSITY OF THE WITWATERSRAND,

JOHANNESBURG

Faculty of Health Sciences

MB BCh III / GEMP I

INTEGRATED BASIC MEDICAL

AND HUMAN SCIENCES

(SCMD 3000)

Block 3: Cardiovascular MCQ Exam

Venue: _____________________________________

Seat Number: _____________________________

Student Number: _____________________________

Time allowed: 92 minutes

Date: 24th

May 2010

%

MCQ

TOTAL


GENERAL INSTRUCTIONS Please read the following carefully: 1) There are 46 multiple choice questions (MCQ’s) in this paper. 2) Answer all MCQ questions on the MCQ cards provided 3) Write your group number, seat number and student number on each page of this

question paper and on the MCQ Cards 4) Please hand in all cellphones, calculators and removable drives prior to the start of the

examination. 5) You may not remove any question papers from the examination room.

A-TYPE QUESTIONS Select the single best answer to each question. (Note: several options may be correct but only one is the best answer.) Answers must be entered on the question paper and on the MCQ Cards If you give more than one answer for a question, you will score zero for that question. There will be no penalty for incorrect answers. If you do not know an answer you may leave it blank, in which case you will neither earn a mark nor be penalised. X-TYPE QUESTIONS There is at least one correct statement and at least one incorrect statement. Identify BOTH the correct and incorrect statements. Answers must be entered on the question paper and on the MCQ Cards If you are unsure of a statement, leave it blank on the MCQ card Negative marking will be applied to wrong answers but negative marks will not be carried forward. This means the minimum mark for a question is zero. R-TYPE QUESTIONS Here you are offered a number of answers. This is followed by a set of questions. Select the single best answer to each question. Note that each answer may be used more than once or not at all unless you are specifically instructed otherwise. Fill in your answers in the spaces provided on the question paper and online. If you do not know an answer you may leave it blank, in which case you will neither earn a mark nor be penalised. Note: Each A-type, X-type and R-type question has the same mark value unless

specified differently

IMPORTANT: THERE ARE SOME A-TYPE QUESTIONS BETWEEN THE X-TYPES


Venue: LT- _____ Seat No: ___________ Student No: ______________________ A-types (Answer on red MCQ Card CSX-289)

A1. A 42-year-old woman has noted increasing dyspnoea for the past 6 years. On

examination rales are auscultated in both lungs. She is afebrile. A chest radiograph

shows an enlarged cardiac silhouette and bilateral pulmonary oedema. Past history

reveals that, as a child she suffered recurrent bouts of pharyngitis with group A beta

haemolytic streptococcal infections.

Which valve or pair of valves is the most likely valve abnormality in this woman?

a. Aortic and pulmonary

b. Aortic and tricuspid

c. Mitral alone

d. Mitral and aortic

e. Mitral and pulmonary

Option C & D marked correct

Feedback C - CORRECT.

She has chronic rheumatic valvulitis with scarring associated with rheumatic heart disease. If the tricuspid valve is involved, then the mitral and aortic are probably involved as well. The most common single valve

involved is the mitral.

A2. Mrs Banda is a 26 year old accountant who has a history of 4 first trimester

miscarriages. She is planning another pregnancy. On clinical examination of Mrs Banda

and her partner no abnormalities were detected. From the following, which genetic test

would be most appropriate for Mrs Banda? a. Fluorescent in situ hybridization (FISH) analysis

b. Chromosome analysis

c. DNA mutation analysis

d. PCR aneuploidy analysis

e. MLPA microdeletion screen

Correct answer: B – to look for balanced translocation which may have resulted in the multiple

miscarriages.

FISH, DNA analysis incorrect because need to request specific test (underlying diagnosis)

Aneuploidy analysis unlikely to reveal any abnormality with normal clinical examination

MLPA microdeletion – not appropriate test

A3. When breaking bad news, which statement is the most important to consider: a. to only speak to patients once you have a definitive diagnosis

b. have experts on hand to answer the patients questions immediately

c. to give information in simple terminology

d. to discuss all the relevant information in detail with the patient so that

the patient is fully informed

e. bad news should not be given to patients who are anxious or unwell

Option C & D marked correct

Feedback

C - CORRECT.


A4. A proposed research study has the following study question: What is the experience at

Chris Hani Baragwanath Hospital of using thrombolysis with streptokinase during

cardiopulmonary resuscitation?Which of the study designs below would be the most

appropriate? a. Case-control study

b. Cohort study

c. Randomised controlled trial

d. Cross-sectional study

e. Case series

X-types (Answer on orange MCQ Card CSX-292)

On receiving the news of the tragic passing of her daughter Mrs. Kapinski became dizzy and

fell to the floor. The following table lists Mrs Kapinski’s and a healthy person’s data when

asked to perform a Valsalva manoeuver. Mrs Kapinski’s problem was subsequently attributed

to an emotional response exacerbated by a β-adrenergic receptor blocker that she was

receiving at the time.

Patient

Healthy person

No Valsalva

Valsalva

No Valsalva

Valsalva

Blood pressure (mm Hg)

136/82

92/42

134/84

122/86

Heart rate (beats/minute)

76

76

76

92

X1. The effect of the Valsalva manoeuver on systolic blood pressure in the healthy person

is attributed to

a. an increased intrathoracic pressure. True False

b. a decreased myocardial β-adrenoreceptor activation. True False

c. increased parasympathetic nervous system activation. True False

d. a decreased ventricular filling. True False

e. a tachycardia. True False

Reasons

a) Correct. The valsalva maneuver involves expiration against a closed glottis and hence

increases intrathoracic pressure. The consequence is a decreased venous return, which

depends on low intrathoracic pressures and hence a reduced cardiac filling and hence

stroke volume and cardiac output. As cardiac output is reduced so is systolic blood

pressure.

b) Incorrect. Systolic blood has decreased in response to a reduced venous return. The

compensatory increase in sympathetic nervous system activity, as indicated by the

increased heart rate, will produce β-receptor activation and hence an increase and not

decrease in systolic blood pressure.

c) Incorrect. The normal person has a compensatory increase in sympathetic nervous

system rather than parasympathetic activity, as evidenced by the increased heart rate.

d) Correct. As indicated in the answer to a), the valsalva maneuver increases intrathoracic

pressure. The consequence will therefore be a decreased venous return.

e) Incorrect. A tachycardia will increase cardiac output and an increased cardiac output will

increase systolic blood pressure (BP=CO x TPR). The increase in heart rate is not

sufficiently high to reduce ventricular filling.


Venue: LT- _____ Seat No: ___________ Student No: ______________________ X2. In Mrs Kapinski, the markedly greater decrease in blood pressure as compared to the

normal person when performing the Valsalva manoeuver is attributed to

a. excessive α-adrenoceptor activation. True False

b. decreased baroreceptor sensitivity. True False

c. a decreased ability of sympathetic activation to increase

heart rate. True False

d. a decreased ability of sympathetic activation to increase

cardiac contractility. True False

e. a greater decrease in cardiac filling produced by the

manoeuver. True False

Reasons

a) Incorrect. Although α-adrenoreceptor activation will be greater than β-adrenoreceptor

activation in the presence of a β-blocker, α-adrenoreceptor activation will increase and

not decrease blood pressure.

b) Incorrect. There is no reason to believe that the use of β-blockers will decrease

baroreceptor sensitivity.

c) Correct. Her heart rate shows no change in response to the valsalva maneuver and this is

very likely to be because of β-adrenoreceptor blockade at the SA node. Thus an increase

in heart rate will not contribute to maintaining an increased cardiac output and blood

pressure produced by sympathetic activation during the valsalva maneuver.

d) Correct. As previously indicated, her heart rate shows no change in response to the

valsalva maneuver and this is very likely to be because of β-adrenoreceptor blockade at

the SA node. Thus, it is likely that the same degree of β-adrenoreceptor blockade will

have occurred in the myocardium. Thus, an increase in myocardial contractility will not

contribute to maintaining an increased cardiac output and blood pressure produced by

sympathetic activation during the valsalva maneuver.

e) Incorrect. For this to occur she would have had to have had a decreased blood volume or

increased vascular capacitance. There is no evidence to suggest that her blood volume

would be decreased or that her venous tone is markedly reduced.


The following information relates to questions X3 to X6

Two patients, whom had previously been diagnosed as having either systemic (Mr

Naidoo) or pulmonary (Mr Mahlaba) hypertension, had electrocardiograph (ECG)

recordings that showed electrical axis shifts. Mr Naidoo had an electrical axis in the

vertical plane leads of -60o and Mr Mahlaba an electrical axis in the vertical plane leads

of +120o. Special investigations revealed a markedly enlarged left ventricle in Mr

Naidoo and markedly enlarged right ventricle in Mr Mahlaba.

X3. Mr Naidoo’s ECG recording is likely to show

a. an equiphasic QRS complex in lead aVR. True False

b. a negative QRS complex in lead aVL. True False

c. an increased R wave of the QRS complex in lead V5. True False

d. a positive QRS complex in lead V1. True False

e. a negative QRS complex in lead III. True False

Reasons

a) Correct. With an electrical axis of -60 degrees, the lead that lies at 90 degrees to this

axis, and hence the lead that will show an equiphasic recording, is lead aVR.

b) Incorrect. Lead aVL lies at -30 degrees and this is close to the electrical axis. This lead

will therefore show a positive QRS complex.

c) Correct. With marked left ventricular hypertrophy, the electrical axis in horizontal plane

leads may not shift but there will be a greater degree of conduction through the left

ventricular wall. This the R wave increases in amplitude.

d) Incorrect. As the electrical axis in the horizontal plane does not change in left

ventricular hypertrophy, lead V1 which faces the right ventricle, will continue to produce a

negative QRS complex.

e) Correct. The electrical axis faces away from lead III (120 degrees). Thus, this lead will

show a large negative QRS complex.

X4. Mr Mahlaba’s ECG recording is likely to show

a. an equiphasic QRS complex in lead aVR. True False

b. a negative QRS complex in lead aVL. True False

c. an positive QRS complex in lead V5. True False

d. a positive QRS complex in lead V1. True False

e. a negative QRS complex in lead III. True False

Reasons

a) Correct. With an electrical axis of +120 degrees, the lead that lies at 90 degrees to this

axis, and hence the lead that will show an equiphasic recording, is lead aVR.

b) Correct. Lead aVL lies at more than +90 degrees to the electrical axis and hence will

show a negative QRS complex.

c) Incorrect. With marked right ventricular hypertrophy, the electrical axis in horizontal

plane leads will be toward the right ventricle and away from the left ventricle. In this

instance, lead V5 which faces the left ventricle will be a negative QRS complex.

d) Correct. As indicated above with marked right ventricular hypertrophy, the electrical axis

in horizontal plane leads will be toward the right ventricle and away from the left

ventricle. In this instance, lead V1 which faces the right ventricle will be a negative QRS

complex.

e) Incorrect. The electrical axis faces lead III (120 degrees). Thus, this lead will show the

largest positive QRS complex.


Venue: LT- _____ Seat No: ___________ Student No: ______________________ X5. Mr. Naidoo, who had severe uncontrolled systemic hypertension had a chest X-ray

that showed upper lobe blood diversion, peribronchial cuffing, fluid in the fissures, a

cardiothoracic ratio of 75%, an unfolded aorta, and an enlarged left atrium.

Echocardiography revealed a left ventricle with function and geometry that suggested

the presence of diastolic heart failure.

The chest X-Ray features described above for Mr. Naidoo are consistent with

a. right heart failure. True False

b. a dissecting aortic aneurysm. True False

c. increased pressures in the left atrium. True False

d. pulmonary congestion. True False

e. left heart failure. True False

Reasons

a) Incorrect. Upper lobe blood diversion, peribronchial cuffing, and fluid in the fissures are

signs of left and not right heart failure.

b) Incorrect. An unfolded aorta is a sign of high loads or pressures in the aorta and not of

aortic dissection.

c) Correct. As previously indicated upper lobe blood diversion, peribronchial cuffing, and

fluid in the fissures are signs of left and not right heart failure. This occurs as a

consequence of increased left atrial pressures. Moreover an enlarged left atrium is also

consistent with increased pressures in the left atrium.

d) Correct. Left heart failure produces pulmonary oedema which tends to occur in the lung

bases following gravity effects. The consequence is that blood in the lung bases is

hypoxic and vasoconstriction occurs in this pulmonary region. Blood is therefore shunted

to the upper lobes of the lung. Moreover, peribronchial cuffing and fluid in the fissures are

early signs of pulmonary oedema.

e) Correct. See answers to question c.

X6. Echocardiographic evidence of diastolic heart failure in Mr. Naidoo may include a

a. dilated left ventricle. True False

b. preserved left ventricular ejection fraction despite evidence

of heart failure. True False

c. thin-walled left ventricle. True False

d. concentric cardiac geometry (increased wall thickness-to-

radius ratio). True False

e. high cardiac output. True False

Reasons

a) Incorrect. Diastolic heart failure is associated with a stiff ventricular wall and hence will

have a normal or decreased left ventricular chamber diameter. Only systolic heart failure

will produce a dilated ventricle through adverse remodeling.

b) Correct. In the context of a patient with left heart failure, as is the case in Mr Naidoo, a

normal left ventricular pump function is evidence for the presence of diastolic heart

failure.

c) Incorrect. As indicated in the answer to a, diastolic heart failure is associated with a stiff

ventricular wall. This is unlikely to occur if the wall thins.

d) Correct. Diastolic heart failure is associated with a stiff ventricular wall and hence will

have a normal or decreased left ventricular chamber diameter, whilst wall thickness will

be increased. This is the definition of a concentric geometry.


e) Incorrect. Although pump function may be normal or even increased in diastolic heart

failure, cardiac output is not enhanced. This would only occur in high output heart failure.

The following information relates to questions X7 and X8

Mr Thompson experienced acute chest pain and was immediately admitted to hospital.

On examination his blood pressure was 92/56 mm Hg, his heart rate was 136 beats per

minute and he was pale, his skin was cold to the touch, he was sweating and nauseous

and he had a raised jugular venous pressure, but no evidence of pulmonary congestion.

His electrocardiograph recording showed ST segment elevation in leads V2 to V6 in the

horizontal plane and leads aVL and I in the vertical plane of the heart, as well as ST

segment depression in leads II, aVF, and III.

X7. Mr Thompson’s ECG recording indicates the presence of

a. left ventricular hypertrophy. True False

b. transmural myocardial ischaemia in the anterior wall of the

left ventricle. True False

c. subendocardial ischaemia in the lateral wall of the heart. True False

d. transmural myocardial ischaemia in the inferior wall of the

heart. True False

e. an increased permeability of cardiomyocyte cell membranes

to K+ ions. True False

Reasons

a) Incorrect. Although left ventricular hypertrophy may produce ST segment depression,

this occurs in lateral wall leads (lead I, V4-V6).

b) Correct. Transmural ischaemia produces ST segment elevation in leads facing the

ischaemic zone. As V2 and V3 show ST segment elevation and these leads face the

anterior wall of the left ventricle, this indicates that transmural ischaemia exists in the

anterior wall of the left ventricle.

c) Incorrect. The lateral wall leads, V4, V5, V6, and I all show ST segment elevation. This

indicates transmural rather than subendocardial ischaemia.

d) Incorrect. The inferior wall leads, II, III and aVF all show ST segment depression. This

indicates subendocardial rather than transmural ischaemia.

e) Correct. The charge difference between ischaemic and normal tissue that cause ST

segment changes is generated by leakiness of the cardiomyocyte to K+ ions.

X8. Mr Thompson has clinical signs consistent with

a. marked vasodilation. True False

b. cardiogenic shock. True False

c. hypovolaemic shock. True False

d. high output heart failure. True False

e. an increased sympathetic nervous system activity. True False

Reasons

a) Incorrect. Marked vasodilation leading to shock will result in a plethoric rather than a

pale appearance and filling pressures in the heart and hence jugular venous pressure will

be reduced and not increased.

b) Correct. Mr Thompson has a raised jugular venous pressure and occlusion of the left

anterior descending coronary artery. The myocardial ischaemia would cause marked

increases in left atrial pressures, increased pulmonary artery pressures, an increased



afterload to the right ventricle and hence a raised jugular venous pressure. The reduced

blood pressures indicate the presence of shock.

c) Incorrect. Mr Thompson has a raised jugular venous pressure and hence evidence of

increased cardiac filling pressures. Hypovolaemic shock will decrease cardiac filling

pressures.

d) Incorrect. High output heart failure would result in a high systolic blood pressure, a

widened pulse pressure and would not show the sympathetic response noted in the

patient.

e) Correct. Mr Thompson has a number of symptoms and signs that indicate sympathetic

over-activation including signs of vasoconstriction (pallor and cold skin), sweating, a

tachycardia, and nausea.

The following information relates to questions A5 and X9 to X11

Mrs Sibeko, a 65 year old lady with a 20 year history of hypertension consulted her

doctor. Mrs Sibeko complained that she frequently felt dizzy especially when standing

up quickly and that she felt short of breath when walking up an incline. Her blood

pressure (mean of three measurements in the seated position off medication) was

160/92 mm Hg and an additional heart sound (S3 or S4) was heard. She was noted to

have pulmonary oedema, a raised jugular venous pressure and left ventricular

hypertrophy, but no cardiac murmurs were detected. Her ejection fraction was normal

but her left ventricular end diastolic diameter was decreased.

A-type question (answer on red MCQ Card CSX-289)

A5. Mrs Sibekos dizziness and shortness of breath are likely to be due to decreased a. blood volume

b. left ventricular filling

c. cardiac contractility

d. peripheral vasoconstriction

e. afterload

Answers:

a) incorrect, no evidence of blood loss

b) correct, left ventricular hypertrophy could cause diastolic dysfunction and hence

decreased filling, a reduced stroke volume and hence symptoms of dizziness and

shortness of breath

c) incorrect, decreased contractility would result in decreased ejection fraction

d) incorrect, decreased peripheral vasoconstriction unlikely as her DBP is increased

(vasodilation increases venous return)

e) incorrect, a decreased afterload would increase stroke volume (she is unlikely to have

a decreased afterload as she has hypertension)


X-type questions (answer on orange MCQ Card CSX-292)

X9. Mrs Sibeko’s raised jugular venous pressure is likely to result

a. from an increased right atrial pressure True False

b. from an increased right ventricular afterload True False

c. from a decreased pulmonary vascular resistance True False

d. in hepatomegaly True False

e. in a decreased systemic capillary hydrostatic pressure True False

Answers:

a) correct, if right atrial pressure is increased then jugular venous pressure would be

increased as there is no valve between the right atrium and the jugular vein

b) correct, an increased right ventricular afterload (which is likely as she has pulmonary

oedema) would result in decreased stroke volume and hence increased right atrial

pressure

c) incorrect, with pulmonary oedema hypoxic hypoxia would result which would cause

pulmonary vasoconstriction and hence an increased pulmonary vascular resistance

d) correct, increased right atrial pressure results in decreased venous return and hence

venous congestion in the liver, resulting in an enlarged liver

e) incorrect, a raised jugular venous pressure is likely to cause an increased systemic

capillary hydrostatic pressure

X10. Mrs. Sibeko’s heart failure is likely to be due to a

a. thiamine deficiency. True False

b. prior myocardial infarction. True False

c. stiff (non-compliant) left ventricle. True False

d. high afterload to the left ventricle. True False

e. reduced myocardial contractility. True False

Answers:

a) incorrect, a thiamine deficiency would result in an increased venous return and hence

an increased left ventricular end diastolic diameter.

b) incorrect, she has a normal ejection fraction

c) correct, she has a decreased left ventricular end diastolic diameter

d) correct, she has a history of hypertension and left ventricular hypertrophy therefore

she is likely to have an increased left ventricular afterload

e) incorrect, she has a normal ejection fraction

X11. The additional heart sound (S3 or S4) in Mrs. Sibeko is likely to be due to

a. pericardial effusion. True False

b. increased left ventricular filling pressures. True False

c. high velocity of blood flow in the left ventricle during diastole. True False

d. reduced capacity of the left ventricle to fill during early

diastole. True False

e. mitral stenosis. True False

Answers:

a) incorrect, a pericardial effusion produces a friction rub which is generally heard

throughout the cardiac cycle.



b) correct, she has heart failure and hence increased filling pressures, which would

impede early left ventricular filling (passive filling) and hence increase the reliance on

atrial contraction for filling which would increase the velocity and hence turbulence of

blood flow across the mitral valve.

c) correct, as the heart has increased reliance on atrial contraction for filling (see b

above), the velocity and hence turbulence of blood flow across the mitral valve is

increased giving rise to the additional heart sound

d) correct, she has left ventricular hypertrophy and a decreased left ventricular end

diastolic diameter. Also she has heart failure and hence increased filling pressures,

which would impede early left ventricular filling (passive filling) and hence increase

the reliance on atrial contraction for filling which would increase the velocity and

hence turbulence of blood flow across the mitral valve.

e) incorrect, a mitral stenosis would result in an diastolic murmur (she has no cardiac

murmurs)

X12. Mr. Mbelwa is a 43 year old male patient with a 10 year history of high blood pressure.

He later diagnosed with diabetes mellitus and he had also developed vascular

remodeling.

You are concerned about the development of atherosclerosis in Mr. Mbelwa because

hypertension is associated with:

a. decreased oxidative stress True False

b. platelet aggregation True False

c. decreased collagen production True False

d. smooth muscle cell proliferation True False

e. increased plasma HDL cholesterol concentration True False

Answers:

a) incorrect, diabetes mellitus is a contraindication for the use of beta blockers

b) correct,

c) incorrect, as the patient does not have blood pressures >180/110 mm Hg

d) correct, he has diabetes mellitus and hence increased cardiovascular risk, hence he

has a compelling indication for the use of an ACE inhibitor.

e) incorrect, as Mr Mbelwa has increased cardiovascular risk and hence complicated

hypertension which warrants the use of pharmacological agents

X13. In myocardial ischaemia, myocyte

a. metabolite washout is increased. True False

b. oxygen delivery is reduced. True False

c. Na+/K+-ATPase pump activity is increased. True False

d. adenosine production is increased. True False

e. lactate production is increased. True False

Reasons:

a) Incorrect. Decreased myocardial blood flow reduces washout of metabolic waste.

b) Correct. Reduced myocardial blood flow reduces oxygen delivery to myocytes.

c) Incorrect. A lack of ATP decreases activity of the Na+/K+-ATPase pump and this results in

ion imbalances in the myocyte.

d) Correct. In ischaemia adenosine is produced by the sequential breakdown of ATP to ADP

to AMP and eventually to adenosine.

e) Correct. A lack of oxygen delivery increases lactate production by anaerobic glycolysis.


A-type question (answer on red MCQ Card CSX-289)

A6. In the cardiac cycle

a. the second heart sound occurs at the beginning of ventricular systole.

b. peak ventricular pressure equals systolic blood pressure.

c. the P-wave of an ECG coincides with the beginning of isovolumetric ventricular

contraction.

d. atrial contraction increases ventricular end-diastolic volume by more than 50%.

e. the mitral valve is open during isovolumetric ventricular relaxation.

Answers:

a) incorrect - the second heart sound occurs at the end of ventricular systole.

b) correct - systolic blood pressure is determined by peak ventricular pressure.

c) incorrect - the P-wave of an ECG coincides with atrial contraction.

d) incorrect - atrial contraction increases ventricular end-diastolic volume by 20-30%.

e) incorrect – no valves are open during isovolumetric ventricular relaxation.

X-type questions (answer on orange MCQ Card CSX-292)

X14. In aortic incompetence

a. a systolic murmur occurs. True False

b. pulse pressure increases. True False

c. blood flows from the aorta to the left ventricle. True False

d. left ventricular filling volume decreases. True False

e. exercise intolerance occurs. True False

Answers:

a) incorrect - a diastolic murmur occurs.

b) correct - pulse pressure increases because systolic pressure is increased and diastolic

pressure is much lower than normal

c) correct - blood flows from the aorta to the left ventricle because the aortic valve stays

open in diastole

d) incorrect - left ventricular filling volume increases because of blood flowing back from the

aorta to the left ventricle

e) correct – exercise intolerance may occur due to insufficient blood supply to (or perfusion

of) the tissues because blood moves back to the left ventricle.


Venue: LT- _____ Seat No: ___________ Student No: ______________________ X15. Cardiac output is increased by an increase in

a. end diastolic volume. True False

b. parasympathetic activity. True False

c. right ventricular end-diastolic pressure. True False

d. ventricular contractility. True False

e. circulating adrenaline. True False

Answers:

a) correct - increased EDV increases SV which is a determinant of CO (CO=HR x SV)

b) incorrect – CO is increased by an increase in SNS activity (not PNS).

c) incorrect – increase RVEDP increases after-load and decreases CO.

d) correct - increased contractility increases SV which is a determinant of CO

e) correct – increased adrenaline increases SNS activity and therefore increases HR, which is

a determinant of CO.

X16. Renin

a. is secreted by cells of the juxtaglomerular complex. True False

b. converts angiotensin I to angiotensin II. True False

c. secretion is increased by sympathetic nervous system

activity. True False

d. secretion is increased in response to a decrease in blood

pressure. True False

e. secretion decreases plasma angiostensinogen levels. True False

Answers:

a) correct - renin is secreted by juxtaglomerular cells following a decreased amount of NaCl

in tubular fluid that reaches the distal tubule.

b) incorrect – renin converts angiotensinogen to angiotensin I.

c) correct – there are both direct and indirect stimulatory SNS effects on renin production.

The direct action is probably via α- adrenoreceptors, whereas the indirect effect is due to the

SNS-mediated increased reabsorption of sodium at the proximal tubule resulting in a reduced

delivery of sodium to the juxtaglomerular complex, which increases renin secretion.

d) correct – in response to decreased BP, the renal barorecptors cause increased SNS

activity which directly increases secretion of renin. (see c) above)

e) correct


X17. Features suggestive of Somatisation include:

a. An acute course of symptoms True False

b. Symptoms in multiple organ systems True False

c. Absence of other psychiatric disorders True False

d. Multiple vague symptoms True False

e. Doctor hopping True False

X18. In a patient with raised cardiac biomarkers:

a. Coronary reperfusion can be considered successful when

the peak of the serum biochemical marker occurs early True False

b. Measured cardiac Troponin I is a subunit of the regulatory

troponin complex True False

c. Myoglobin is an excellent “Rule in” marker for acute

myocardial infarction True False

d. Raised myoglobin is specific for myocardial injury True False

e. Cardiac Troponin T is an excellent “Rule out” marker for

acute myocardial infarction True False

FEEDBACK

A True – due to the “wash out” phenomenon

B True

C False – it is not specific for AMI and is an excellent “Rule out” marker

D False – not specific but sensitive

E True

X19. Regarding the histology of muscular arteries and veins,

a. Muscular arteries have a prominent internal elastic lamina. True False

b. The tunica media of a muscular artery contains many elastic

lamellae. True False

c. Muscular veins have a thinner tunica adventitia than tunica

media. True False

Option D Removed

e. The tunica media of a muscular vein is thicker than that of a

muscular artery. True False


Venue: LT- _____ Seat No: ___________ Student No: ______________________ X20. Regarding beta blockers used in cardiovascular conditions:

a. atenolol is used in the treatment of peripheral vascular

disease True False

b. carvedilol is an alpha-1-adrenoceptor antagonist True False

c. propranolol is a cardioselective beta-adrenoceptor antagonist True False

d. propranolol causes bronchoconstriction in asthmatics True False

e. atenolol inhibits the release of renin from Juxtaglomerular

cells True False

Feedback

a. atenolol is contraindicated in peripheral vascular disease

c. propranolol blocks beta-1- and beta-2-adrenoreceptors

X21. Regarding cardiovascular drugs:

a. isosorbide mononitrate decreases venous capacitance True False

b. adrenaline is an agonist at beta-1-adrenoceptors True False

c. digoxin inhibits the activity of Na+/K+-ATPase True False

d. nitric oxide stimulates the activity of guanylate cyclase True False

e. sildenafil decreases cGMP levels in vascular smooth muscle True False

Feedback

a. isosorbide mononitrate increases venous capacitance

e. sildenafil increases cGMP levels

X22. In the treatment of cardiac conditions:

a. glyceryl trinitrate decreases blood pressure True False

b. amlodipine is an angiotensin receptor antagonist True False

c. hydralazine increases venous capacitance True False

d. nifedipine increases calcium entry into the myocardium True False

e. valsartan is an alpha-1-adrenoceptor antagonist True False

Feedback

b. amlodipine is a calcium channel blocker

d. nifedipine blocks calcium entry


X23. Regarding cardiac drugs:

a. furosemide competitively inhibits the binding of aldosterone to

its receptor True False

b. amiodarone is used to prevent ventricular arrhythmias True False

c. digoxin causes ventricular arrhythmia as an adverse effect True False

d. lignocaine is a sodium channel blocker True False

e. digoxin slows AV-nodal conduction True False

Feedback

a. it’s a potassium sparing diuretic

X24. Which of the following molecular techniques can be used to detect and characterize

subtle (submicroscopic) structural chromosome abnormalities

a. Comparative genomic hybridization (CGH) True False

b. Fluorescence in situ hybridization (FISH) True False

c. PCR aneuploidy screen True False

d. Northern blot True False

e. DNA sequencing True False

X25. Which of the following are famous “firsts” in Cardiology?

a. William Harvey, an English physician, first describes blood

circulation. True False

b. Rene Laennec, a French physician, invents the stethoscope. True False

c. Willem Beethoven, a Dutch physiologist, develops the

electrocardiograph True False

d. Christiaan Barnard, a South African surgeon, performs the

first whole heart transplant from one person to another True False

e. Michael DeBakey, a South African surgeon, implants a

permanent artificial heart into a patient. True False


Venue: LT- _____ Seat No: ___________ Student No: ______________________ X26. Which of the following statements is/are true regarding the South African health care

system?

a. The South African government wants to centralize health

care services True False

b. Primary health care is offered in district hospitals True False

c. Tertiary hospitals refer patients up to regional hospitals for

more specialized care. True False

d. The health care system includes specialized hospitals e.g. TB

hospitals True False

e. Primary health care is delivered through the district health

care system. True False

R-type questions (answer on orange MCQ Card CSX-292)

Mrs Tshabalala has been feeling unusually tired for the past few weeks.

OPTIONS

A. Reason for encounter

B. Limit of tolerance

C. Biopsychosocial approach

D. Illness

E. Limit of anxiety

F. Folk sector

G. Popular sector

H. Professional sector

I. Temporalising

J. Sanctioning

K. Sick role

L. Patient centeredness


For each of the following statements regarding the scenario, choose the single best

answer from the list above. Each option may only be used once.

R1. She tells her husband about her tiredness. He says she’s probably been

working too hard and suggests she spend the weekend just relaxing at home.

A B C D E F G H I J K L

R2. She spends the weekend relaxing but the tiredness continues. She goes

to a pharmacy in the nearest shopping mall and asks the pharmacy nurse

what she should do about her fatigue and loss of energy.

Option D & H marked correct


A. Right coronary artery

B. Left coronary artery

C. Right marginal branch

D. Posterior interventricular artery

E. Atrioventricular nodal branch

F. Sinoatrial nodal branch

G. Anterior interventricular artery

H. Diagonal branch

I. Left marginal branch

J. Left circumflex artery

Regarding the coronary arteries:

R3. Occlusion of this vessel results in infarction of part of the posterior and the inferior

wall of the left ventricle, as well as the right ventricular free wall of the heart.

A B C D E F G H I J

A. Truncus arteriosus

B. Primitive ventricle

C. Primitive atrium

D. Sinus venosus

E. Aorticopulmonary septum

F. Anterior truncal ridge

Regarding the embryological development of the heart

R4. This structure contributes to the

membranous part of the interventricular

septum.

A B C D E F



A. Contraction band necrosis

B. Coronary thrombosis

C. Extensive transmural collagen deposition

D. Lymphocytic interstitial infiltrates

E. Myocarditis

F. Myofibre disarray

G. Necrosis with neutrophils

H. Oedema and loss of cross striations

I. Pericardial tamponade

J. Perivascular and interstitial amyloid deposition

For each of the scenarios below identify the most likely histopathological finding from the

list A to J above.

R5. Question Removed

R6. A 60-year-old man had chest pain and was hospitalized. On the first day of

admission, a coronary angiogram revealed 75% stenosis of the left anterior descending

artery. Four days later he suddenly becomes worse, with marked hypotension. A

pericardiocentesis is performed and returns 150ml of bloody fluid. He dies, despite

appropriate resuscitative measures. Which of the microscopic findings above is most

likely to be present in his left ventricular myocardium at the time of his death?

A B C D E F G H I J

Feedback:

Necrosis with neutrophils CORRECT. He has had an acute myocardial infarction complicated by rupture. This is a typical complication about 3 to 5 days following the onset. 75% arterial narrowing is the point at

which coronary occlusion becomes very serious.


A. Aortic coarctation

B. Atherosclerotic aortic aneurysm

C. Cardiomyopathy

D. Coronary atherosclerosis

E. Marantic endocarditis

F. Mitral valve stenosis

G. Mönckeberg's medial calcinosis

H. Polyarteritis nodosa

I. Rheumatic fever

J. Superior mesenteric artery thrombosis

K. Systemic lupus erythematosus

L. Takayasu arteritis

For each of the scenarios below identify the most likely diagnosis from the list A to L

above.

R7. A 45-year-old woman has had worsening shortness of breath for 3 years.

She now has to sleep sitting up on two pillows. She has had difficulty

swallowing for the past year. She has no history of chest pain. A month ago,

she had a "stroke" with resultant inability to move her left leg and difficulty

moving her left arm. She is afebrile. A chest radiograph reveals a near-normal

left ventricular size with a prominent left atrial border.


Feedback

Mitral valve stenosis CORRECT. Mitral valve stenosis leads to left atrial enlargement, but the left ventricle is usually small. THere is typically a 'fishmouth' shaped mitral valve

that has stenosis as well as insufficiency, since it does not close completely. Most mitral

valvular disease in adults results from rheumatic valvulitis. The episode(s) of rheumatic fever occurred years before

R8. A 65-year-old man has sudden onset of severe abdominal pain. Physical

examination reveals his temperature is 37ºC, heart rate 110/minute,

respirations 25/minute, and blood pressure 145/100 mmHg. He has

diminished pulses in the lower extremities. There is a pulsatile abdominal

mass.


Feedback Atherosclerotic aortic aneurysm CORRECT. The aorta involved with an atherosclerotic

aneurysm is markedly enlarged and filled with thrombus. Risk factors for atherosclerosis include

both diabetes mellitus and hypertension. Atherosclerotic aortic aneurysms are typically located in the abdominal portion below the renal arteries.



A. Acute fibrinous pericarditis

B. Acute myocardial infarction

C. Dilated cardiomyopathy

D. Myocardial rupture

E. Non-bacterial thrombotic endocarditis

F. Pulmonary hypertension

G. Thrombo-embolism

For each of the following scenarios which of the complications in the list A to G above is

most likely to occur?

R9. A 2-year-old child has had failure to thrive for a year, becoming increasingly

listless. On examination she is found to have a soft, rumbling systolic ejection

murmur. An echocardiogram reveals a large membranous ventricular septal defect.

Which of the complications is she most likely to experience as an adult 2 decades later

if this lesion remains untreated?

A B C D E F G

Feedaback Pulmonary hypertension

CORRECT. The left-to-right shunt eventually leads to pulmonary hypertension and reversal of the shunt (Eisenmenger complex).

R10. Question Removed

A. Bicuspid aortic valve

B. Coarctation of the aorta

C. Dextrocardia

D. Hypertrophic sub-aortic stenosis

E. Hypoplastic left heart syndrome

F. Pulmonary valve stenosis

G. Tetralogy of Fallot

H. Ventricular septal defect

For the following scenario identify the most likely congenital abnormality in the list A to G

above

R11. 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 B C D E F G H

Feedback Ventricular septal defect 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. Maternal serum alpha-fetoprotein

B. Amniocentesis

C. Cordocentesis

D. Ultrasound

E. Nuchal translucency scan

F. Chorionic Villus Sampling

For the following scenario, select the most appropriate prenatal test to offer the patient:

R12. A woman is referred to the Genetics Clinic to discuss fetal

abnormalities seen on ultrasound examination at 27 weeks of pregnancy.

The fetal medicine specialist advises testing to determine whether the

fetus has a chromosome abnormality.

A B C D E F

A. Malformation

B. Deformation

C. Disruption

D. Dysplasia

E. Sequence

For each patient with a birth defect select the mechanism most likely to be the

underlying cause

R13. In a twin pregnancy the first twin is noted to be normal but the

second twin has bilateral club feet, contractures at the wrists and fingers

and an asymmetrical head

A B C D E



A. Balanced translocation

B. Duplication

C. Deletion

D. Numerical abnormality

E. Unbalanced translocation

R14. Which of the above types of chromosome abnormality best describes the following

karyotype?

A B C D E

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