Cardiology (Y2)
Question 1: A 58-year-old woman with a history of hypertension and obesity presents with exertional dyspnoea. Transthoracic echocardiography (TTE) was attempted but provided suboptimal images due to poor acoustic windows. The clinician is now considering alternative imaging.
Given the need for detailed myocardial tissue characterisation and precise ventricular volume assessment, which imaging modality is the most appropriate?
A) Stress Echocardiography
B) Cardiac MRI
C) Transoesophageal Echocardiography
D) Cardiac CT
E) Nuclear Perfusion Scan
Question 2: A 47-year-old woman with no known cardiac history presents with intermittent chest discomfort. Her clinician is considering a non-invasive test to assess for coronary artery disease (CAD). Given that she is low-risk, the best initial test should have a high negative predictive value to rule out significant atherosclerosis.
Which imaging modality is the most appropriate?
A) Echocardiography
B) Electrocardiography (ECG)
C) Cardiac CT
D) Cardiac MRI
E) Ultrasound
Question 3: A 68-year-old woman presents with sudden-onset right-sided weakness and difficulty speaking. On examination, she has right-sided hemiplegia, right-sided sensory loss, and expressive aphasia. She does not have homonymous hemianopia.
Based on the clinical presentation, which type of stroke is most likely?
a) Total Anterior Circulation Stroke (TACS)
b) Partial Anterior Circulation Stroke (PACS – ACA territory)
c) Partial Anterior Circulation Stroke (PACS – MCA territory)
d) Posterior Circulation Stroke (PCS)
e) Lacunar Stroke (LACS)
Question 4: A 72-year-old man is brought to the emergency department by paramedics after his wife noticed he had sudden-onset facial drooping and slurred speech. On arrival, his blood glucose is 2.8 mmol/L.
Which of the following is the most appropriate initial step in his management?
a) Perform an urgent CT brain scan
b) Administer intravenous glucose
c) Calculate the NIHSS score
d) Proceed with thrombolysis
e) Request a carotid Doppler ultrasound
Question 5: A 25-year-old athlete collapses suddenly during a football match. He is found to have a systolic murmur and an S4 gallop on examination. Echocardiography shows asymmetric septal hypertrophy and reduced left ventricular end-diastolic volume.
What is the most likely diagnosis?
a) Dilated cardiomyopathy
b) Arrhythmogenic cardiomyopathy
c) Restrictive cardiomyopathy
d) Hypertrophic cardiomyopathy
e) Ischaemic cardiomyopathy
Question 6: A 45-year-old man presents with acute, sharp retrosternal chest pain that worsens with deep inspiration and improves when sitting forward. On auscultation, a pericardial friction rub is heard at the left sternal border.
What is the most likely diagnosis?
a) Myocardial infarction
b) Pulmonary embolism
c) Pericarditis
d) Aortic dissection
e) Pneumothorax
Question 7: A 65-year-old male with a history of chronic heart failure (HFrEF) presents with increasing shortness of breath, fatigue, and lower extremity oedema. On examination, he has a raised JVP, an S3 gallop, and bilateral ankle oedema. His most recent echocardiogram showed an ejection fraction of 30%. His current medications include an ACE inhibitor, a β-blocker, and spironolactone.
Given his worsening symptoms despite optimal medical therapy, which of the following would be the most appropriate addition to his treatment regimen to improve his outcomes?
a) Sacubitril/Valsartan (Neprilysin Inhibitor)
b) Hydralazine
c) Digoxin
d) Dobutamine
e) Ivabradine
Question 8: A 50-year-old male presents with recurrent episodes of paroxysmal supraventricular tachycardia (SVT). His physician is considering pharmacologic therapy to help manage the arrhythmia.
Which of the following anti-arrhythmic drugs works by inhibiting sodium channels and is most commonly used for re-entrant supraventricular tachycardias (SVTs)?
a) Flecainide
b) Amiodarone
c) Lidocaine
d) Diltiazem
e) Digoxin
Question 9: A 72-year-old woman with a history of hypertension and a recent myocardial infarction presents to the clinic with complaints of fatigue and occasional dizziness. Her ECG shows a prolonged PR interval of 400 ms, followed by a drop of the QRS complex every second P wave with progressive prolongation of the PR interval. In addition, the patient has no evidence of atrial fibrillation or flutter.
Which of the following is the most likely diagnosis based on this presentation?
a) 1st Degree AV Block
b) 2nd Degree AV Block, Mobitz I (Wenckebach)
c) 2nd Degree AV Block, Mobitz II
d) 3rd Degree AV Block
e) Left Bundle Branch Block
Question 10: A 22-year-old woman with no significant past medical history presents to the emergency department with palpitations, dizziness, and mild shortness of breath. Her symptoms started suddenly while she was at rest. On examination, she is haemodynamically stable with a heart rate of 180 bpm and a regular, narrow QRS complex tachycardia on ECG. The ECG also shows absence of visible P waves. Vagal manoeuvres are attempted but do not resolve the arrhythmia.
Which of the following best explains the mechanism underlying her arrhythmia?
a) Enhanced automaticity of an ectopic atrial focus
b) Atrial fibrillation originating from pulmonary veins
c) Re-entry circuit within the atrioventricular node
d) Ventricular pre-excitation due to an accessory pathway
e) Delayed afterdepolarisations triggering focal atrial tachycardia
Question 11: A 67-year-old man with a history of hypertension and heart failure presents to the emergency department with palpitations, dizziness, and mild shortness of breath. His blood pressure is 120/80 mmHg, and his pulse is irregularly irregular at 140 bpm. An ECG shows an absence of P waves, an irregularly irregular rhythm, and a narrow QRS complex tachycardia.
Which of the following best describes the pathophysiology of this patient’s arrhythmia?
a) A single re-entrant circuit around the tricuspid isthmus
b) Disorganised electrical activity from multiple foci in the atria
c) A rapidly firing ectopic atrial focus
d) Pre-excitation of the atria through an accessory pathway
e) Enhanced automaticity of the sinoatrial node
Question 12: A 54-year-old man with a history of coronary artery disease and prior myocardial infarction is brought to the emergency department after experiencing a sudden loss of consciousness while at home. Upon arrival, he is unresponsive, pulseless, and cyanotic. ECG shows a chaotic rhythm with no discernible P waves, QRS complexes, or T waves.
Which of the following is the most appropriate immediate management?
a) Intravenous β-blockers
b) Intravenous magnesium sulphate
c) Synchronised cardioversion
d) Immediate defibrillation
e) Atropine and transcutaneous pacing
Question 13: A 67-year-old man with a history of hypertension and diabetes presents to the clinic for evaluation of fatigue and occasional dizziness. ECG reveals a broad QRS complex (>120 ms) with a characteristic M-shaped R wave in leads V1 and V2.
Which of the following is the most likely diagnosis?
a) Left Bundle Branch Block (LBBB)
b) Right Bundle Branch Block (RBBB)
c) Ventricular Tachycardia
d) Atrial Flutter
e) Wolff-Parkinson-White Syndrome
Question 14:A 45-year-old woman presents to her primary care physician with complaints of fatigue and pallor. Blood tests reveal:
• Low MCV (microcytosis)
• Low MCH
• Increased Red Cell Distribution Width (RCDW)
• Low haematocrit
Which of the following is the most likely cause of her condition?
a) Vitamin B12 deficiency
b) Iron deficiency anaemia
c) Chronic kidney disease
d) Aplastic anaemia
e) Hereditary spherocytosis
Question 15: A healthy adult undergoes a study measuring erythropoiesis and haemoglobin metabolism. Researchers observe that newly formed erythrocytes enter circulation as reticulocytes and mature within a day.
In this process, which of the following best explains how iron is transported and stored for erythrocyte production and breakdown?
a) Haptoglobin binds free iron and delivers it to the liver for storage
b) Transferrin transports iron in the blood, while ferritin stores it in the liver
c) Haemoglobin is broken down into biliverdin and directly stored in the spleen
d) Reticulocytes retain their nuclei to store iron before releasing it into circulation
e) Hemopexin binds to free globin chains, which are then excreted by the kidneys
Question 16: A 65-year-old male presents with increasing fatigue, recurrent infections, and easy bruising over the past several months. Examination reveals pallor, hepatosplenomegaly, and multiple bruises on his extremities. His full blood count shows anaemia, leukopenia, and thrombocytopaenia, with a peripheral blood smear revealing a high percentage of immature blast cells. A bone marrow biopsy is performed, confirming a blast count of 35%.
Based on the physiological characteristics of haematological malignancies, which of the following is the most likely diagnosis?
a) Aplastic anaemia
b) Myelodysplastic syndrome
c) Acute myeloid leukaemia
d) Hodgkin’s lymphoma
e) Multiple myeloma
Question 17: A 32-year-old female presents with progressive fatigue, jaundice, and dark-coloured urine. Blood tests show low haemoglobin, high reticulocyte count, elevated bilirubin, and lactate dehydrogenase (LDH). Urinalysis reveals haemoglobinuria and haemosiderinuria. Further testing shows low serum haptoglobin and low hemopexin.
Based on the physiology of haemolytic anaemia, which of the following best describes the underlying process?
a) Increased extravascular haemolysis in the reticuloendothelial system
b) Increased intravascular haemolysis leading to haemoglobinemia
c) Decreased erythropoiesis due to bone marrow failure
d) Defective haemoglobin synthesis leading to microcytosis
e) Autoimmune destruction of erythroid precursors in the bone marrow
Question 18: A 30-year-old male presents with a family history of sudden cardiac death and a history of fainting spells during exercise. Genetic testing reveals a mutation in the gene responsible that causes prolonged repolarisation, and ECG analysis shows a prolonged QT interval. The patient’s condition is associated with a higher risk of life-threatening arrhythmias, including Torsades de Pointes.
Which of the following potassium channels is most likely affected in this patient’s condition?
a) Rapidly activating potassium channel (IKr)
b) Slowly activating potassium channel (IKs)
c) Inward rectifier potassium channel (IK1)
d) ATP-sensitive potassium channel (KATP)
e) Calcium-activated potassium channel (KCa)
Question 19: A 45-year-old male with a history of hypertension presents with symptoms of fatigue and shortness of breath during exercise. His SvO2 is measured at 70%, which is considered on the lower end of normal. The patient’s global oxygen delivery (DO2) is found to be greater than his oxygen consumption (VO2) during rest, but during exercise, both DO2 and VO2 increase significantly.
Which of the following best explains the relationship between SvO2, DO2, and VO2 in this patient?
a) A low SvO2 indicates that oxygen consumption exceeds oxygen delivery to tissues, resulting in fatigue.
b) SvO2 is directly proportional to cardiac output, but does not reflect tissue oxygen extraction.
c) Oxygen consumption (VO2) should be less than oxygen delivery (DO2), and during exercise, both increase in response to higher metabolic demand.
d) A SvO2 of 70% indicates a significant oxygen deficit, suggesting impaired tissue oxygen delivery.
e) Venous oxygen content (CV(O2)) decreases during exercise, leading to decreased oxygen availability to tissues.
Question 20: A 28-year-old man presents to the emergency department after hiking at a high altitude of 4,000 meters for the past three days. He complains of increasing shortness of breath, dizziness, and fatigue. Upon physical examination, he has mild tachycardia, and his oxygen saturation is 92% on room air. Arterial blood gas analysis shows the following:
• pH: 7.36 (normal: 7.35-7.45)
• pCO2: 35 mmHg (normal: 35-45 mmHg)
• pO2: 65 mmHg (normal: 75-100 mmHg)
• HCO3-: 22 mEq/L (normal: 22-26 mEq/L)
Given his symptoms and the lab results, which of the following physiological changes is most likely responsible for the observed change in the oxygen-haemoglobin dissociation curve?
a) Increased levels of 2,3-DPG in response to low ambient oxygen levels
b) Decreased pCO2 due to hyperventilation
c) Reduced pH due to hypoventilation
d) Increased oxygen saturation due to improved lung oxygen exchange
e) Increased haemoglobin affinity for oxygen due to low temperature
Question 21: A 65-year-old female patient with a history of diabetes and hypertension presents with complaints of increasing pain in her lower legs, particularly while walking. She also notes that her legs swell, especially by the end of the day, and has developed an ulcer on her medial malleolus. The ulcer has a pink base and is moderately painful. Upon examination, the patient’s lower extremities show thickened, mottled skin and visible varicose veins. Pulses are normal, and there is no significant pallor on leg elevation. The patient denies any coldness or hair loss on her legs.
Which of the following is most likely to be responsible for her condition?
a) Decreased blood flow to tissues due to atherosclerosis
b) Venous valve incompetence and chronic venous hypertension
c) Intermittent claudication due to ischemia from arteriosclerosis
d) Peripheral neuropathy and diminished sensation leading to ulcer formation
e) Systemic vasculitis affecting small vessels in the legs
Question 22: A 58-year-old male with a history of hypertension and hyperlipidaemiapresents to the emergency department with acute chest pain radiating to his left arm. The pain started 30 minutes ago while he was at rest, and he describes it as a heavy, crushing sensation. His blood pressure is 150/90 mmHg, heart rate is 95 bpm, and oxygen saturation is 98%. On examination, he appears anxious and diaphoretic. ECG reveals ST-segment elevation in the anterior leads, and the diagnosis of acute coronary syndrome (ACS) is confirmed.
What is the most appropriate initial management for this patient in the pre-hospital setting?
a) Administer 300mg Aspirin and GTN spray
b) Administer morphine and oxygen, followed by 75mg of Aspirin
c) Administer 600mg Aspirin and initiate dual antiplatelet therapy with clopidogrel
d) Administer morphine + metoclopramide and oxygen
e) Initiate statin therapy and ACE inhibitors
Question 23: A 62-year-old male with a history of hypertension and hyperlipidaemiapresents to the emergency department with a sudden onset of chest pain that started 45 minutes ago while he was resting. He describes the pain as tight and crushing, radiating to his left arm. He also feels nauseous and diaphoretic. His vital signs show a blood pressure of 145/90 mmHg, heart rate of 90 bpm, and oxygen saturation of 98%. The ECG shows no ST-segment elevations, but cardiac troponin levels are elevated.
Which of the following diagnoses is most consistent with this patient’s presentation?
a) Unstable Angina
b) Non-ST-Segment Elevation Myocardial Infarction (non-STEMI)
c) ST-Segment Elevation Myocardial Infarction (STEMI)
d) Silent Myocardial Infarction
e) Cocaine-induced Myocardial Ischaemia
Question 24: A 58-year-old male presents to the emergency department with unstable ischaemic chest pain that started 30 minutes ago while he was at rest. He has a history of hypertension and smoking. On examination, he appears diaphoretic and anxious. An ECG shows ischaemic changes consistent with non-ST-segment elevation (non-STEMI), and his cardiac troponin T level is elevated. A routine chest X-ray and full blood count are ordered. The attending physician plans to risk-stratify this patient for potential interventions.
Which of the following scoring systems is most commonly used to assess risk in this patient?
a) CURB-65
b) CRUSADE
c) APACHE II
d) Wells Score
e) GRACE
Question 25: A 62-year-old male with a history of smoking and hypertension presents with sudden-onset chest pain and shortness of breath. His ECG shows signs of ischemia affecting the anterior wall of the heart. Angiography reveals an occlusion of the right coronary artery (RCA).
Given the anatomical features of coronary blood supply, which of the following structures is most likely to be at risk of ischemia due to this occlusion?
a) Left anterior surface of the heart
b) Left posterior surface of the heart
c) Interventricular septum and moderator band
d) SA node
e) AV node
Question 26: A 62-year-old male with a history of smoking and hypertension presents with sudden-onset chest pain and shortness of breath. His ECG shows ischemic changes localized to the lateral wall of the heart. Angiography reveals an occlusion of the left circumflex artery (LCx).
Considering the anatomical features of coronary blood supply, which of the following leads on the ECG would most likely show evidence of ischemia related to this occlusion?
a) Leads V1-V4
b) Leads I, aVL, V5-V6
c) Leads II, III, aVF
d) Leads V3-V6, I, aVL
e) Leads V1, V2, aVF
Question 27: A 58-year-old male with a history of hypertension, hyperlipidaemia, and smoking presents to the emergency department with persistent chest pain and shortness of breath. His ECG shows no ST-segment elevation, but his troponin levels are elevated. The physician is concerned about a possible Non-ST-Elevation Myocardial Infarction (Non-STEMI).
To assess the cause of his chest pain and guide management, which of the following scoring systems should be used?
a) Killip Classification
b) TIMI Score
c) GRACE Score
d) HEART Score
e) APACHE II Score
Question 28: A 60-year-old male with a history of hypertension presents with sudden onset of severe chest pain described as “tearing” and radiating to the back. His blood pressure is elevated, and a CT scan reveals a large aortic abnormality.
Based on the imaging findings, which of the following best describes the type of aneurysm the patient is experiencing?
a) True Aneurysm
b) False Aneurysm
c) Dissecting Aneurysm
d) Fusiform Aneurysm
e) Saccular Aneurysm
Question 29: A 72-year-old male with a long history of smoking and hypertension presents with a history of intermittent leg pain that occurs during exertion, especially after walking short distances. He describes the pain as sharp and stabbing, and it improves with rest. On physical examination, there is noticeable coldness and pallor in the lower leg. The patient has decreased pulses in the affected leg.
Which of the following diagnostic tests is most appropriate to confirm the diagnosis and assess the severity of his condition?
a) Doppler Ultrasound of the brachial and dorsalis pedis arteries (Ankle-Brachial Index)
b) CT Angiography (CTA)
c) Embolectomy
d) Percutaneous Transluminal Angioplasty (PTA)
e) Magnetic Resonance Angiography (MRA)
Question 30: A 58-year-old male with a history of smoking, hypertension, and poorly controlled diabetes presents with chest discomfort and is found to have decreased peripheral pulses. A coronary angiogram reveals significant atherosclerotic plaque formation in his coronary arteries.
Based on the pathogenesis of atherosclerosis, which of the following mechanisms primarily contributes to the formation of fatty streaks in the early stages of atherosclerosis?
a) LDL invasion into the tunica intima followed by oxidation and monocyte attraction, leading to foam cell formation
b) Platelet aggregation at the site of endothelial damage, followed by smooth muscle cell proliferation
c) Chronic post-prandial hyperglycaemia causing direct endothelial cell injury, leading to glycocalyx dysfunction
d) Calcium deposition within the fibrous plaque resulting in plaque stabilisation
e) Dysfunction of endothelial nitric oxide synthesis resulting in impaired vasomotor control
Question 31: A 62-year-old male with a history of poorly controlled hypertension presents for an eye examination. The optometrist notes tortuosity of the retinal arteries, increased reflectiveness, and arteriovenous nipping. The patient reports no significant visual symptoms.
Based on the Keith-Wagener-Barker (KWB) grading system, which of the following is the most likely diagnosis and subsequent step in the patient’s management?
a) Grade 1 Hypertensive Retinopathy, monitor blood pressure and lifestyle, recheck in 6 months
b) Grade 2 Hypertensive Retinopathy, initiate treatment for hypertension and assess cardiovascular risk using QRISK3
c) Grade 3 Hypertensive Retinopathy, initiate antihypertensive therapy immediately and perform investigations for secondary causes of hypertension
d) Grade 4 Hypertensive Retinopathy, refer urgently for ophthalmology review due to risk of vision loss
e) No retinopathy, continue monitoring blood pressure without changes to management
Question 32: A 30-year-old female presents with long-standing hypertension that is poorly controlled despite treatment. On examination, you note delayed femoral pulses and a systolic murmur heard over the back. Her blood pressure is significantly higher in the upper limbs compared to the lower limbs. She also reports episodes of leg cramps during exercise and has noticed that her ribs appear slightly prominent on her chest.
Which of the following is the most likely diagnosis, and what is the appropriate diagnostic test?
a) Vascular – Coarctation of the aorta, Chest X-ray showing rib notching
b) Renovascular Disease – Renal artery stenosis, Doppler ultrasound of renal arteries
c) Endocrine Hypertension – Primary hyperaldosteronism, Plasma aldosterone/renin ratio
d) Drug-Related Hypertension – Alcohol abuse, Urine drug screen
e) Connective-Tissue Disease – Scleroderma, Anti-nuclear antibody (ANA) test
Question 33: A 2-week-old infant presents to the emergency department with cyanosis, failure to thrive, and severe respiratory distress. Physical examination reveals a loud systolic murmur at the left sternal border, and there is noticeable clubbing of the fingers. On auscultation, you hear a wide split second heart sound (S2) and a ejection systolic murmur. Chest X-ray reveals boot-shaped heart.
Which of the following conditions is most likely to explain these clinical findings, and what is the recommended treatment?
a) Tetralogy of Fallot, Surgery required in the first year of life
b) Coarctation of the Aorta, Surgical repair in neonates
c) Pulmonary Valve Stenosis, Balloon valvuloplasty
d) Transposition of Great Arteries, Immediate prostaglandins at birth
e) Atrial Septal Defect, Surgical closure of the hole
Question 34: A 58-year-old male with a history of rheumatic heart disease presents to the emergency department with fever, fatigue, and a new heart murmur. He also mentions weight loss and occasional night sweats over the past few weeks. His blood cultures are sent, and a transthoracic echocardiogram (TTE) is performed. The results show vegetations on the mitral valve.
Based on the findings and diagnostic criteria, which of the following statements about the diagnosis of infective endocarditis (IE) is most accurate?
a) The patient likely meets the major criteria for infective endocarditis, as he has positive blood cultures and evidence of endocardial involvement.
b) The patient’s blood cultures are not required to meet the major criteria, as long as imaging shows vegetations on the valve.
c) The patient only meets the minor criteria for infective endocarditis, as there is no mention of a predisposition or heart disease history.
d) The patient meets the major criteria based solely on the presence of Osler’s nodes and Roth’s spots.
e) The patient’s new heart block is sufficient for diagnosis under the minor criteria of infective endocarditis.
Question 35: A 70-year-old male with a history of hypertension and bicuspid aortic valve presents with symptoms of dyspnoea, fatigue, and chest pain on exertion. On physical examination, you note a harsh systolic murmur radiating to the neck. An echocardiogram confirms the presence of aortic stenosis.
Based on the pathophysiology of aortic stenosis, which of the following statements best explains the mechanism by which this patient’s condition has led to heart failure?
a) The aortic stenosis has caused a decrease in left ventricular afterload, leading to reduced myocardial oxygen demand and improved coronary artery perfusion.
b) The narrowed aortic valve increases left ventricular pressure, causing concentric hypertrophy of the left ventricle and eventually leading to heart failure due to impaired left ventricular filling.
c) The Frank-Starling mechanism compensates for the decreased stroke volume, improving cardiac output and preventing right heart failure.
d) The patient’s right heart failure is primarily due to reduced left ventricular ejection fraction, causing systemic venous congestion and eventually affecting the right side of the heart.
e) The reduced coronary artery perfusion due to aortic stenosis results in complete myocardial ischemia and sudden death.
Question 36: A 55-year-old woman presents to the clinic with complaints of progressive shortness of breath, fatigue, and occasional palpitations. She reports feeling increasingly tired with minimal exertion, and she has noticed some swelling in her ankles. On examination, she has a pansystolic murmur best heard at the apex of the heart, along with a hyperdynamic apex beat. She also has a displaced apical impulse and signs of pulmonary congestion.
Which valve disorder is most likely to be responsible for her symptoms?
a) Mitral Stenosis
b) Mitral Regurgitation
c) Aortic Regurgitation
d) Tricuspid Regurgitation
e) Pulmonary Regurgitation
Question 37: A 35-year-old man presents with progressive shortness of breath, fatigue, and dizziness. On auscultation, a crescendo-decrescendo systolic murmur is heard best at the upper left sternal border, which increases in intensity with inspiration. Echocardiography reveals right ventricular hypertrophy (RVH) and a pressure gradient of 55 mmHg across the pulmonary valve.
What is the most likely diagnosis?
A) Aortic stenosis
B) Mitral stenosis
C) Pulmonary stenosis
D) Tricuspid stenosis
E) Atrial septal defect (ASD)
Question 38: A 50-year-old woman with a history of rheumatic heart disease presents with exertional dyspnoea, palpitations, and haemoptysis. On auscultation, a low-pitched diastolic murmur with an opening snap is best heard at the apex in the left lateral position. ECG shows left atrial enlargement and atrial fibrillation.
Which of the following best describes the pathophysiology of her condition?
A) Increased afterload leading to left ventricular hypertrophy
B) Increased pulmonary venous pressure leading to pulmonary congestion
C) Right ventricular pressure overload leading to right heart failure
D) Decreased preload leading to hypotension
E) Increased left ventricular end-diastolic pressure (LVEDP) causing systolic dysfunction
Question 39: A 72-year-old man with a history of hypertension and hyperlipidaemia presents with exertional dyspnoea, syncope, and chest pain. His blood pressure is 110/70 mmHg, and heart rate is 75 bpm. On auscultation, a harsh, crescendo-decrescendo systolic murmur is heard best at the right upper sternal border, radiating to the carotids.
Echocardiography shows:
• Left ventricular hypertrophy (LVH)
• Increased left ventricular end-systolic pressure (LVESP)
• Aortic valve area of 0.8 cm² (normal >2.5 cm²)
• Mean transvalvular gradient of 45 mmHg
What is the most likely pathophysiological mechanism responsible for this patient’s symptoms?
A) Decreased cardiac output due to left ventricular outflow obstruction
B) Right ventricular hypertrophy due to increased pulmonary resistance
C) Increased left atrial pressure leading to atrial fibrillation
D) Diastolic dysfunction due to mitral stenosis
E) Pulmonary artery stenosis leading to right-sided heart failure
Question 40: A 65-year-old man with a history of mitral valve prolapse (MVP) presents with fever, night sweats, and weight loss for two weeks. On examination, he has:
• Splinter haemorrhages in the fingernails
• New systolic murmur at the apex
• Tender nodules on the fingertips (Osler nodes)
Blood cultures grow Gram-positive cocci in chains.
What is the most likely cause of this patient’s condition?
A) Coxiella burnetiid causing culture-negative endocarditis
B) Staphylococcus aureus causing acute infective endocarditis
C) Pseudomonas aeruginosa causing right-sided infective endocarditis
D) Streptococcus viridians causing subacute infective endocarditis
E) Rheumatic fever leading to chronic valvular damage
Question 41: A 55-year-old man with a history of chronic alcohol use and liver cirrhosis presents with bilateral leg swelling, ascites, and jugular venous distension (JVD). On examination, he has:
• Pulsatile liver
• Holosystolic murmur at the left lower sternal border
• Murmur increases with inspiration
What is the most likely cause of his murmur?
A) Rheumatic fever
B) Right ventricular infarction
C) Endocarditis
D) Carcinoid syndrome
E) Pulmonary hypertension
Question 42: A 9-year-old boy presents for a routine check-up. His parents have noted that he gets tired easily when playing sports. On examination, his blood pressure is 150/90 mmHg in the upper extremities and 100/70 mmHg in the lower extremities. Femoral pulses are weak and delayed compared to the radial pulses. A systolic murmur is heard over the left infraclavicular area and the back.
What is the most likely underlying pathology?
A) Post-ductal narrowing of the aorta, leading to increased upper body perfusion and reduced lower body perfusion
B) Malformation of the pulmonary valve leading to right ventricular hypertrophy
C) Patent ductus arteriosus-dependent circulation causing cyanosis
D) Abnormal mitral valve chordae leading to left atrial dilation and pulmonary congestion
E) Defective endocardial cushion formation leading to an atrioventricular septal defect
Question 43: A 3-month-old infant is brought to the clinic for episodes of cyanosis, especially during feeding and crying. On examination, the infant has central cyanosis and a harsh systolic murmur at the left upper sternal border.
Echocardiography shows: Right ventricular hypertrophy, Ventricular septal defect (VSD), Pulmonary stenosis and an Overriding aorta.
What is the most likely pathophysiological mechanism causing this infant’s cyanosis?
A) Increased left-to-right shunting leading to pulmonary over circulation
B) Obstruction of the right ventricular outflow tract leading to right-to-left shunting
C) Patent ductus arteriosus-dependent circulation requiring prostaglandins
D) Atrial septal defect (ASD) leading to paradoxical embolism
E) Left ventricular outflow obstruction leading to decreased systemic blood flow
Question 44: A 72-year-old man presents with progressive exertional dyspnea, chest pain, and occasional dizziness over the past year. He reports nearly fainting while climbing stairs. On examination, he has delayed and diminished carotid pulses (pulsus parvus et tardus), a harsh systolic ejection murmur best heard at the right second intercostal space, radiating to the carotids and soft second heart sound (S2).
What is the most likely diagnosis?
A) Pulmonary stenosis
B) Aortic regurgitation
C) Aortic stenosis
D) Mitral regurgitation
E) Mitral stenosis
Question 45: A 68-year-old man presents with palpitations and dizziness. His ECG shows an irregularly irregular rhythm with absent P waves and narrow QRS complexes. What is the most likely diagnosis?
A) Atrial fibrillation
B) Atrial flutter
C) Ventricular tachycardia
D) Junctional tachycardia
E) Sinus tachycardia
Question 46: A 38-year-old woman presents with progressive dyspnoea and exercise intolerance. She denies significant past medical history but reports a recent viral illness. On examination, she has bilateral basal crackles and peripheral oedema. ECG shows low-voltage QRS complexes. BNP is 1800 pg/mL, and troponin is 0.12 ng/mL. Echocardiography reveals a severely dilated left ventricle with an ejection fraction of 25% and mid wall fibrosis on MRI. What is the most likely underlying cause?
A) Hypertrophic cardiomyopathy
B) Restrictive cardiomyopathy
C) Dilated cardiomyopathy due to viral myocarditis
D) Arrhythmogenic right ventricular cardiomyopathy
E) Constrictive pericarditis
Question 47: A 5-year-old boy presents with cyanosis and clubbing of fingers. His parents say he often squats after playing. On auscultation, you hear a harsh systolic ejection murmur at the left upper sternal border.
Which of the following is the most likely diagnosis?
A) Atrial septal defect
B) Ventricular septal defect
C) Tetralogy of Fallot
D) Coarctation of the aorta
E) Transposition of the great arteries
Question 48: A 35-year-old woman presents with sharp, pleuritic chest pain that worsens when lying down and improves when leaning forward. ECG shows diffuse ST-segment elevations. Which of the following physical exam findings is most characteristic of this condition?
A) S3 heart sound
B) Kussmaul’s sign
C) Epsilon waves
D) Pulsus paradoxus
E) Pericardial friction rub
Question 49: A 76-year-old man presents with syncope. ECG shows complete dissociation between P waves and QRS complexes, with a ventricular rate of 35 bpm. His blood pressure is 88/60 mmHg. What is the most likely diagnosis?
A) First-degree AV block
B) Second-degree AV block Type I (Wenckebach)
C) Second-degree AV block Type II
D) Third-degree AV block
E) Sinus bradycardia
Question 50: A 22-year-old male collapses suddenly while playing football. EMS finds him pulseless, and resuscitation is unsuccessful. His family has no known history of cardiac disease. What is the most likely underlying pathology?
A) Dilated cardiomyopathy
B) Hypertrophic cardiomyopathy
C) Arrhythmogenic right ventricular cardiomyopathy
D) Brugada syndrome
E) Myocarditis
Question 51: A 58-year-old man with a 15-year history of untreated hypertension presents with progressive shortness of breath and leg swelling. He has no history of coronary artery disease. Blood pressure is 180/110 mmHg. ECG shows left ventricular hypertrophy (LVH) with deep S waves in V1 and tall R waves in V5-V6. What is the most likely cause of his symptoms?
A) Pulmonary embolism
B) Aortic dissection
C) Hypertensive heart disease with diastolic heart failure
D) Acute coronary syndrome
E) Constrictive pericarditis
Question 52: A 45-year-old man with untreated hypertension presents to the emergency department with severe headache, blurry vision, and confusion. His BP is 240/130 mmHg. Fundoscopy shows papilledema and flame-shaped retinal haemorrhages. What is the most likely diagnosis?
A) Pheochromocytoma crisis
B) Hypertensive emergency with malignant hypertension
C) Subarachnoid haemorrhage
D) Primary aldosteronism
E) Stroke
Question 53: A 58-year-old male presents to the emergency department with crushing substernal chest pain that began 30 minutes ago. His ECG shows ST-segment elevations in leads II, III, and aVF. Troponin is elevated at 0.5 ng/mL (normal <0.01 ng/mL). Which of the following is the most likely diagnosis?
A) ST-elevation myocardial infarction (STEMI)
B) Non-ST elevation myocardial infarction (NSTEMI)
C) Unstable angina
D) Stable angina
E) Pericarditis
Question 54: A 65-year-old man with a history of hypertension, hyperlipidaemia, and smoking presents with intermittent claudication. Which of the following is the primary pathological mechanism underlying his condition?
A) Deposition of immune complexes in arteries
B) Deposition of cholesterol-laden plaques in arterial walls
C) Vasospasm of the arteries due to autonomic dysfunction
D) Autoimmune-mediated endothelial destruction
E) Thrombocytopenia causing microvascular occlusion
Question 55: A 72-year-old woman with a history of diabetes, hypertension, and smoking presents with right-sided weakness and slurred speech that started 3 hours ago. On examination, she has right-sided hemiparesis, facial droop, and dysarthria. Her BP is 180/95 mmHg. CT head shows no haemorrhage. What is the most likely underlying cause of her symptoms?
A) Ischemic Stroke due to Atherosclerosis
B) Haemorrhagic Stroke
C) Transient Ischemic Attack (TIA)
D) Venous Thromboembolism (VTE)
E) Peripheral Arterial Disease
Question 56: A 65-year-old man with a history of smoking and diabetes presents with pain in his right calf when walking. He says the pain improves with rest. On examination, his right foot is pale and cool, and his dorsalis pedis pulse is weak. What is the most likely diagnosis?
A) Cellulitis
B) Deep Vein Thrombosis (DVT)
C) Chronic Venous Insufficiency
D) Peripheral Arterial Disease (PAD)
E) Compartment Syndrome
Med Wiz 