Cardiovascular MCQs

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Q. A 27 year old underwent the study shown below. What symptom do you
think he may have been complaining about?

a. Dyspnea
b. Dysphagia
c. Hoarseness
d. Chest pain
e. Loss of pulses in right arm
during exercise
f. Paresthesias in right arm
b
1. This disorder is known as dysphagia lusoria. The right subclavian has an aberrant course.
It goes behind the esophagus while traveling to the right arm-thus it often compresses the
esophagus
2. To see if the esophagus is compressed, a barium swallow is often done. There is a
posterior compression- a Very common exam question
3. An aberrant right subclavian artery is a relatively common congenital anomaly. It has a
prevalence of up to 1.8%. About a third of people with this anatomic variant experience
symptoms. Dysphagia is experienced in 90% of such cases, whereas dyspnea, is less
common.
4. Dysphagia secondary to extrinsic esophageal compression by an aberrant right
subclavian artery is known as dysphagia lusoria. This term dates back to the first
description of the condition in 1794 by David Bayford, who called it “lusus naturae,”
meaning “freak or jest of nature.”
• During development of aortic arch, if the proximal portion of the right fourth arch
disappears instead of distal portion, the right subclavian artery will arise as the
last branch of aortic arch. It then courses behind the esophagus (or rarely in front
of esophagus, or even in front of trachea) to supply blood to right arm. This
causes pressure on esophagus and results in dysphagia. It can sometimes result in
upper gastrointestinal tract bleeding. Investigation of choice - CT angiography
Q. You are performing a routine physical exam on a 16 year old. As
soon as you get him to undress, you see the image shown below.
What syndrome is this disorder often associated with?
a. Down
b. Turner
c. Poland
d. William
e. Sweet
f. Pompe
https://youtu.be/XlLsTkn74gQ
c
1. Pectus excavatum, also known as sunken or funnel chest, is a congenital chest wall deformity in which several
ribs and the sternum grow abnormally, producing a concave, or caved-in, appearance in the anterior chest wall.
2. Despite the lack of an identifiable genetic marker, the familial occurrence of pectus deformity is reported in
35% of cases. Moreover, the condition is associated with Marfan syndrome and Poland syndrome.
3. Some patients with pectus excavatum experience chest and back pain that is usually musculoskeletal in origin.
The exact cause of the pain is poorly understood. Pectus excavatum and pectus carinatum are frequently
associated with scoliosis. Although such association is probably coincidental, the poor posture noted in many
patients with pectus deformities may be a key factor in the development of pain.
4. Poland syndrome can present with ipsilateral involvement of the chest muscles, skin and subcutaneous
tissues, bones, and upper extremity. The absence of the sternal head of the pectoralis major muscle is
considered the minimal expression of this syndrome. Involvement of adjacent muscles, including the pectoralis
minor, serratus, latissimus dorsi, and external oblique, also has been described.
5. The skin of the area is hypoplastic with a thinned subcutaneous layer, and the axillary hair may be absent. The
ipsilateral nipple is often smaller and higher in both male and female patients, and the breast is generally
hypoplastic in female patients.
Q. You are seeing a 57-year old male who has been complaining of vague pain in left leg for the
past several weeks. He says the crampy pain is worse when he is on his feet and diminishes at
rest. He denies any night pain or pain during walking. He is a heavy smoker and drinker. He is on
no medications and has no allergies. Other than a remote inguinal hernia repair, he has no other
medical problems. Before you examine the patient, he tells you that he recently had a radiological
study: the image is shown below. Based on this finding, in your physical exam, you will pay
particular attention to what part of the body?

a. Neck
b. Abdomen
c. Feet
d. Chest
e. Eyes
f. Joints
https://youtu.be/XlLsTkn74gQ
b
1. A popliteal artery aneurysm is the most common peripheral arterial aneurysm
and the 2nd most common aneurysm after abdominal aortic aneurysms
2. These aneurysms can either be true of false aneurysms. The true aneurysms of
the popliteal artery are usually the result of atherosclerosis or arteriomegaly.
3. False aneurysms are usually the result of knee trauma, surgery/intervention or
infection. Overall they are uncommon and most are detected on a physical exam or
after acute occlusion.
4. There is a strong association with abdominal aortic aneurysms: 30 to 50% of
patients with a popliteal artery aneurysm have a AAA, though only 10 to 14% of
patients with AAA have popliteal artery aneurysms. They are bilateral in 50 to 70%
of cases. There is an increased incidence with age and a strong male preponderance
Q. A 44 year old a male present with complaints of a wet cough, weight loss, malaise, sweating,
shortness of breast and vague joint pains of 3 weeks duration. Other than a nasal endoscopy done 6
weeks ago, his health has other wise been fine. He does have chronic sinusitis and takes
antihistamines. Physical exam reveals a T 100.9, BP 105/84, and P 68. You cannot tell if he has a
murmur but his breath sounds are diminished at the bases. The rest of the physical exam is
unremarkable except the image shown below. His initial blood cultures are negative. The test that will
help you make the diagnosis in this case is?

a. ESR
b. Incision and drainage of the nail bed,
followed by culture of specimen
c. Chest x-ray
d. Gram stain of sputum
e. Echo
f. X-ray of the finger
g. Urine
culturehttps://youtu.be/XlLsTkn74gQ
e
YOU MUST KNOW WHAT A SPLINTER HEMORRHAGE LOOKS LIKE-common exam question.
1. Infective endocarditis (IE) is defined as an infection of the endocardial surface of the heart, which may include
one or more heart valves, the mural endocardium, or a septal defect. Its intracardiac effects include severe
valvular insufficiency, which may lead to intractable congestive heart failure and myocardial abscesses. If left
untreated, IE is generally fatal.
2. Classic signs of IE are found in as many as 50% of patients. They include a) Petechiae - Common but
nonspecific finding b) Subungual (splinter) hemorrhages - Dark red linear lesions in the nailbed c) Osler nodes -
Tender subcutaneous nodules usually found on the distal pads of the digits d) Janeway lesions - Nontender
maculae on the palms and soles e) Roth spots - Retinal hemorrhages with small, clear centers; rare and
observed in only 5% of patients.
3. The criterion standard test for diagnosing infective endocarditis (IE) is the documentation of a continuous
bacteremia (>30 min in duration) based on blood culture results.
4. Echocardiography has become the indirect diagnostic method of choice, especially in patients who present
with a clinical picture of IE but who have non-diagnostic blood culture results (eg, some patients with fungal
endocarditis). The diagnosis of IE can never be excluded based on negative echocardiogram findings, either from
TTE or from TEE.
 During surgery in a patient with severe hypertension, the surgeon wants to
know where is the organ of Zuckerkandl located in the image below. You
point to which site below?

A
B
C
D
Ehttps://youtu.be/XlLsTkn74gQ
a
1. The Organ of Zuckerkandl comprises of a small mass of chromaffin cells derived
from neural crest located along the aorta, beginning cranial to the superior
mesenteric artery or renal arteries and extending to the level of the aortic
bifurcation or just beyond.
2. The highest concentration is typically seen at the origin of the inferior mesenteric
artery.
What is the significance of knowing about the organ of
Zuckerkandl?

a. It secretes catecholamines
b. It enhances blood flow to the
bowel
c. It causes progression of aortic
aneurysms
d. It plays a role in enhancing libido
e. It modules levels of CO2 and pH in
the body
a
1. Its physiological role is thought to be of greatest importance during the early
gestational period as a homeostatic regulator of blood pressure, secreting
catecholamines into the fetal circulation. The organ regresses in the end of
gestation and following birth to form the aorticosympathetic group of the adult
paraganglia.
2. When a patient had a pheochromocytoma, the organ of Zuckerkandl is often the
2nd most common site.
Q1. You are assisting the cardiac surgeon with surgery to replace the most common
valve affected in patients who have had rheumatic fever. In what location, is the
left circumflex coronary artery located based on the image shown below?

A
B
C
D
E
Q2. From the patient in the previous slide, during surgery you want to make sure he has no
blood clots. In which location are you most likely find the thrombosis?

A
B
C
D
E
F
1c, 2f
1. First you need to know that the only cause of mitral stenosis is rheumatic
fever- the mitral valve is affected in 70% of cases, followed by the aortic valve.
2. It is shocking that some cardiac surgeons have no clue to the location of the
circumflex coronary artery when operating on the mitral valve
3. Placing sutures blindly around the mitral annulus can easily damage the
circumflex coronary artery. The patient will present with features of an MI in the
post op period
4. To avoid this injury, some surgeons use transesophageal echo.
5. TEE is only useful when the heart is beating and by the time the abnormal
wall motion is seen, it is too late. In some cases, it may be difficult to wean the
patient off the heart lung machine because of the injury.
1. Aortic valve has 3 leaflets and so does the tricuspid.
2. The patient gives a history of rheumatic fever and the examination reveals a loud
S1 and a pansystolic murmur- you better know this for the rest of your life-it comes
up in most exams
3. Rheumatic fever is the most common cause of mitral stenosis. The valve appears
with a Fish Mouth like opening because of fibrosis.
4. Mitral valve has anterior and posterior leaflets which can be seen above.
5. The blood clot in mitral stenosis is usually found in the left atrial appendage (Site
F).
Q1. A 55 year old is seen in the cardiology clinic with complaints of dyspnea and lack of
exercise endurance. He claims that the symptoms started a few months ago and have now
progressed to a point where he is not able to perform daily living activities. He had a pneumonia
in the remote past and last year had a fractured femur. The physical is unremarkable and the labs
are pending. His lateral Chest x-ray is shown below. The radiologist has been kind enough to
color (light blue) the area of concern.. What do you see on the Lateral CXR?

a. Aortic aneurysm
b. Right ventricular hypertrophy
c. Mitral valve calcification
d. Pericardial calcification
e. Pericardial effusion
Q2. If you suspect that this patient has constrictive pericarditis, which of the following
jugular venous pressure curves will you observe?

A
B
C
D
1d,2d
1. Lateral x rays are not difficult to interpret if you practice
2. What you see on this CXR is a thick band of pericardial calcification along the inferior
border. The band of calcium also extends up along the RV near the sternum
3. Calcification of pericardium can cause constrictive pericarditis
4. CT is ideal to look for calcification around the pericardium
5. If patient is symptomatic, he will require removal of the calcific pericardium. It is a real
messy operation, bloody and often the results are not impressive.
6. For exam purposes, you need to know several causes of pericardial calcification. Can be
seen with a variety of infections, trauma, and neoplasms
7. Thin, egg-shell like calcification is more often associated with viral infection or uremia
8. Calcification from old TB is often thick, confluent, and irregular in appearance, especially
when compared with myocardial calcification
• Pericardial calcification is more common over the right side, anterior and
diaphragmatic aspects of the heart in the atrioventricular grooves. Calcifications
over the left ventricle or cardiac apex are rare, unless pericardial calcification is
extensive. It is important to assess for signs of associated constrictive pericarditis.
• Since the myocardium is unaffected, early ventricular filling during the first third
of diastole is unimpeded. After early diastole, the stiff pericardium affects flow
and hemodynamics. Accordingly, the ventricular pressure initially decreases
rapidly (producing a steep y descent on right atrial pressure waveform tracings)
and then increases abruptly to a level that is sustained until systole (the “dip-and-
plateau waveform” or “square root sign” seen on right or left ventricular pressure
waveform tracings).
 Thanks For Watching

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