CHAPTER
The Heart 12
PBD9 Chapter 12 and PBD8 Chapter 12: The Heart
BP9 Chapter 10 and BP8 Chapter 11: Heart
1 An 82-year-old woman has had increasing fatigue for
the past 2 years. During this time, she has experienced par-
oxysmal dizziness and syncope. On physical examination,
she is afebrile. Her pulse is 44/min, respirations are 16/min,
and blood pressure is 100/65 mm Hg. On auscultation, the
lungs are clear, and no murmurs are heard. An echocardio-
gram shows a normal-sized heart with normal valve motion
and estimated ejection fraction of 50%. After parasympathetic
(vagal) stimulation, the heart rate slows and becomes irregu-
lar. An abnormality involving which of the following is most
likely to be present in this patient?
A Atrioventricular node
B Bundle of His
C Left bundle branch
D Parasympathetic ganglion
E Right bundle branch
F Sinoatrial node
G Sympathetic ganglion
2 A neonate developing normally has a newborn checkup.
On physical examination, there is a systolic murmur. Echocar-
diography reveals a muscular defect of the intraventricular
septum. A checkup 30 years later fails to reveal either a mur-
mur or a flow defect between the ventricles. Which of the fol-
lowing cells most likely proliferated and led to disappearance
of the defect?
A Adipocytes
B Conduction cells
C Endothelial cells
D Fibroblasts
E Mesothelial cells
F Stem cells
3 A 66-year-old man has had cough and worsening short-
ness of breath for 3 years. On examination, there is dullness
to percussion at both lung bases and poorly audible breath
sounds. On physical examination, pulse is 77/min and BP
is 110/80 mm Hg. He does not have anginal pain. His liver
span is increased to 14 cm. He has pitting edema to his knees.
Jugular venous distention is noted to the angle of the jaw at
45-degree elevation of his head while lying down. Which of
the following is most likely causing his heart disease?
A Atrial myxoma
B Essential hypertension
C Hyperlipidemia
D Rheumatic fever
E Smoking
4 A 62-year-old woman has had increasing dyspnea for
the past 2 years. She now awakens at night with air hunger
and cough productive of frothy sputum. On examination, she
has rales in all lung fields. Her point of maximal impulse is
strong and displaced laterally. Echocardiography shows a de-
creased ejection fraction of 30% with concentric increase in left
ventricular wall size. The valves appear normal. Which of the
underlying diseases does she have?
A Amyloidosis
B Cardiomyopathy
C Hypertension
D Myocarditis
E Pericarditis
5 A 41-year-old woman has been awakened at night with
“air hunger” for the past year. She notes sleeping better while
sitting up in bed. Her serum B-type natriuretic peptide is >400
pg/mL (very high). What cardiac disease best explains her
condition?
A Atrial myxoma
B Fibrinous pericarditis
C Giant cell myocarditis
D Libman-Sacks endocarditis
E Rheumatic valvulitis
163
164 UNIT II Diseases of Organ Systems

6 A 50-year-old man has had increasing abdominal dis-

comfort and swelling of his legs for the past 2 years. He has
smoked cigarettes for 35 years. On physical examination, he
has jugular venous distention, even when sitting up. The liver
is enlarged and tender and can be palpated 10 cm below the
right costal margin. Pitting edema is observed on the lower
extremities. A chest radiograph shows bilateral diaphragmat-
ic flattening, pleural effusions, and increased lucency of lung
fields. Thoracentesis on the right side yields 500 mL of clear
fluid with few cells. Which of the following is most likely to be
the underlying disease in this patient?
A Acute myocardial infarction
B Chronic bronchitis
C Primary pulmonary hypertension
D Pulmonary valve stenosis
E Tricuspid valve stenosis
7 An infant born at term is noted to have cyanosis during
the first week of life. On examination a heart murmur is aus-
cultated. Abnormal findings with echocardiography include
an overriding aorta, ventricular septal defect, right ventricular
thickening, and pulmonic stenosis involving the fetal heart.
This infant is most likely to have an inherited mutation involv-
ing which of the following genes?
A β-Myosin heavy chain (β-MHC)
B Fibrillin 1 (FBN1)
C KCNQ1
D NOTCH2
E Transthyretin (TTR)
8 Following an uncomplicated pregnancy, a term infant
appears normal at birth, but at 1 day of life the infant develops
respiratory distress. On physical examination the infant has
tachypnea, tachycardia, and cyanosis. There is an S1 ejection
click and a split S2 with prominent P sound. A radiograph
shows normal heart size but prominent hilar vascular mark-
ings. Echocardiography shows a small left atrium, large right
atrium, normally sized ventricles, widely patent foramen ova-
le, and normally positioned aorta and pulmonary trunk. What
type of congenital heart disease does this infant most likely
have?
A Atrial septal defect
B Coarctation of the aorta, preductal type
C Patent ductus arteriosus
D Tetralogy of Fallot
E Total anomalous pulmonary venous connection
10 A 5-year-old child is not as active as other children his
age. During the past 8 months, the child has had multiple epi-
sodes of respiratory difficulty following exertion. On physical
examination, his temperature is 37° C, pulse is 81/min, respi-
rations are 19/min, and blood pressure is 95/60 mm Hg. On
auscultation, a loud holosystolic murmur is audible. There
are diffuse crackles over the lungs bilaterally, with dullness
to percussion at the bases. A chest radiograph shows a promi-
nent left heart border, pulmonary interstitial infiltrates, and
blunting of the costodiaphragmatic recesses. The representa-
tive gross appearance of the child’s heart is shown in the fig-
ure. Which of the following additional pathologic conditions
would most likely develop in this child?
A Aortic regurgitation
B Coronary atherosclerosis
C Nonbacterial thrombotic endocarditis
D Pulmonary hypertension
E Restrictive cardiomyopathy
11 A 3-year-old child is developing normally. Physical
examination reveals a low-pitched cardiac murmur. An echo-
cardiogram shows the presence of an ostium secundum, with
a 1-cm defect. Which of the following abnormalities is most
likely to be found in this child?
A Cyanosis at rest
B Left-to-right shunt
C Mural thrombosis
D Pericardial effusion
E Pulmonary hypertension

9 A 77-year-old woman fell and fractured her ankle. She

has spent most of her time in bed for the past 16 days. She
develops sudden chest pain, dyspnea, and diaphoresis. On
examination she has left thigh swelling and tenderness. A
chest CT shows areas of decreased attenuation in the right and
left pulmonary arteries. A day later she has difficulty speak-
ing. MR angiography shows focal occlusion of a left middle
cerebral artery branch. Which of the following cardiac abnor-
malities is she most likely to have?
A Atrial myxoma
B Infective endocarditis
C Nonbacterial thrombotic endocarditis
D Patent foramen ovale
E Ventricular aneurysm
  
 CHAPTER 12 The Heart 165

12 A 2-year-old child had an illness 1 year ago character-

ized by a high fever. Staphylococcus epidermidis was cultured
from the blood. The child was given antibiotic therapy and
recovered. Now on physical examination, a harsh, waxing
and waning, machinery-like murmur is heard on auscultation
of the upper chest. A chest radiograph shows prominence of
the pulmonary arteries. Echocardiography shows all cardiac
valves to be normal in configuration. Laboratory studies show
normal arterial oxygen saturation level. Which of the follow-
ing congenital heart diseases is most likely to explain these
findings?
A Aortic atresia
B Aortic coarctation
C Atrial septal defect
D Patent ductus arteriosus
E Tetralogy of Fallot
F Total anomalous pulmonary venous return

13 A 5-year-old girl who is below the 5th percentile for

height and weight for age has exhibited easily fatigability
since infancy. On physical examination, she appears cyanotic.
Her temperature is 37° C, pulse is 82/min, respirations are
16/min, and blood pressure is 105/65 mm Hg. Pulse oxi­metry
shows decreased oxygen saturation. One month later, she has
fever and obtundation. A cerebral CT scan shows a right pari-
etal, ring-enhancing, 3-cm lesion. Which of the following con-
genital heart diseases is the most likely diagnosis?
A Atrial septal defect
B Bicuspid aortic valve
C Coarctation of the aorta
D Patent ductus arteriosus
E Truncus arteriosus
F Ventricular septal defect
14 In a clinical study of tetralogy of Fallot, patients are ex-
amined before surgery to determine predictors observed on
echocardiography that correlate with the severity of the dis-
ease and the need for more careful monitoring. A subset of
patients is found to have more severe congestive heart failure,
poor exercise tolerance, and decreased arterial oxygen satura-
tion levels. Which of the following is most likely to predict a
worse clinical presentation for these patients?
A Degree of pulmonary stenosis
B Diameter of the tricuspid valve
C Presence of an atrial septal defect
D Size of the ventricular septal defect
E Thickness of the left ventricle
  
15 A 27-year-old woman gives birth to a term infant after
an uncomplicated pregnancy and delivery. The infant is cya-
notic at birth. Two months later, physical examination shows
the infant to be at the 37th percentile for height and weight.
The representative gross appearance of the infant’s heart is
shown in the figure. What is the most likely diagnosis?
A Aortic stenosis
B Pulmonic stenosis
C Tetralogy of Fallot
D Transposition of the great vessels
E Truncus arteriosus
16 A 15-year-old boy complains of pain in his legs when he
runs more than 300 m. Physical examination shows tempera-
ture, 36.8° C; pulse, 76/min; respirations, 22/min; and blood
pressure, 165/90 mm Hg. The radial pulses are 4+, and the
dorsalis pedis pulses are 1+. Arterial blood gas measurement
shows a normal oxygen saturation level. Which of the follow-
ing congenital cardiovascular anomalies is most likely to be
present in this patient?
A Aortic valve stenosis
B Coarctation of the aorta
C Patent ductus arteriosus
D Transposition of the great arteries
E Tricuspid valve atresia
166 UNIT II Diseases of Organ Systems
17 A 21-year-old primigravida gives birth at term to a 2800-
g infant with no apparent external anomalies. The next day, the
infant develops increasing respiratory distress and cyanosis.
Echocardiography reveals a slitlike left ventricular chamber,
small left atrium, and atretic aortic and mitral valves. Through
which of the following structures could blood from the lungs
most likely have reached the infant’s systemic circulation?
A Anomalous venous return
B Foramen ovale
C Patent ductus arteriosus
D Right fourth aortic arch
E Truncus arteriosus
F Ventricular septal defect
18 A 60-year-old man has had angina on exertion for the
past 6 years. A coronary angiogram performed 2 years ago
showed 75% stenosis of the left circumflex coronary artery
and 50% stenosis of the right coronary artery. For the past
3 weeks, the frequency and severity of his anginal attacks have
increased, and pain sometimes occurs even when he is lying in
bed. On physical examination, his blood pressure is 110/80 mm
Hg, and pulse is 85/min with irregular beats. An ECG shows
ST segment elevation. Laboratory studies show serum glucose,
188 mg/dL; creatinine, 1.2 mg/dL; and troponin I, 1.5 ng/mL.
Which of the following is most likely to explain these findings?
A Atheromatous plaque fissure with thrombosis
B Constrictive pericarditis with calcification
C Endomyocardial fibrosis
D Extensive myocardial fiber hypertrophy
E Left ventricular mural thrombosis
F Mitral valve prolapse with regurgitation
19 A 37-year-old woman has the sudden onset of chest
pain. On examination she is afebrile but tachycardic and hypo-
tensive. An ECG shows ST segment elevation and pathologic
Q waves. The representative microscopic appearance of her
left circumflex artery is shown in the figure. Which of the fol-
lowing underlying conditions is she most likely to have?
A Acute myelogenous leukemia
B Chronic alcoholism
C Diabetes mellitus
D Marfan syndrome
E Polyarteritis nodosa
20 A 56-year-old man experiences episodes of severe sub-
sternal chest pain every time he performs a task that requires
moderate exercise. The episodes have become more frequent
and severe over the past year, but they can be relieved by sub-
lingual nitroglycerin. On physical examination, he is afebrile,
his pulse is 78/min and regular, and there are no murmurs
or gallops. Laboratory studies show creatinine, 1.1 mg/dL;
glucose, 130 mg/dL; and total serum cholesterol, 223 mg/
dL. Which of the following cardiac lesions is most likely to be
present in this man?
A Calcific aortic stenosis
B Coronary atherosclerosis
C Restrictive cardiomyopathy
D Rheumatic mitral stenosis
E Serous pericarditis
F Viral myocarditis
21 A retrospective study of myocardial infarction is per-
formed to analyze patterns of cardiac injury. One pattern of
injury involves the posterior left ventricular wall and septum.
Which of the following pathologic abnormalities is most likely
to produce this pattern?
A Ascending aortic dissection
B Left anterior descending arterial plaque rupture
C Left circumflex arterial vasculitis
D Right coronary sinus embolization
E Right posterior descending arterial thrombosis
  
22 A 48-year-old woman has had increasing dyspnea for
the past 2 days. She experiences sudden cardiac arrest. The
representative light microscopic appearance of her left ven-
tricular free wall is shown in the figure. Which of the following
is the most likely diagnosis?
A Acute rheumatic myocarditis
B Cardiomyopathy
C Myocardial infarction
D Septic embolization
E Viral myocarditis
 CHAPTER 12 The Heart 167

23 A study of ischemic heart disease analyzes cases of in-

dividuals hospitalized with acute chest pain in which myo-
cardial infarction was documented at autopsy. The gross and
microscopic appearances of the hearts are correlated with the
degree of coronary atherosclerosis and its complications, clinical
symptoms, and therapies given before death. Hemorrhage and
contraction bands in necrotic myocardial fibers are most likely
to be seen with infarction in which of the following settings?
A Acute coronary vasculitis
B Anti-arrhythmic drug usage
C Angioplasty with stent placement
D Septic embolization
E Thrombolytic therapy

24 A 50-year-old man with diabetes mellitus and hyperten-

sion has had pain in the left shoulder and arm for the past
12 hours. Over the next 6 hours, he develops shortness of
breath, which persists for 2 days. On day 3, he visits the phy-
sician. On physical examination, his temperature is 37.1° C,
pulse is 82/min, respirations are 18/min, and blood pressure
is 160/100 mm Hg. Laboratory studies show total creatine
kinase (CK) activity within reference range, but the troponin
I level is elevated. He continues to experience dyspnea for the
next 3 days. On day 7 after the onset of shoulder pain, he has a
cardiac arrest and is resuscitated. Cardiac imaging now shows
a large fluid collection around the heart. Which of the follow-
ing complications has he most likely developed?
A Aortic valvular perforation
B Hemopericardium
C Left ventricular aneurysm
D Papillary muscle rupture
E Pericarditis
25 A 45-year-old man experiences crushing substernal
chest pain after arriving at work one morning. Over the next
4 hours, the pain persists and begins to radiate to his left arm.
He becomes diaphoretic and short of breath, but waits until
the end of his 8-hour shift to go to the hospital. An elevated
serum value of which of the following laboratory tests would
be most useful for diagnosis of this patient on admission to the
hospital?
A ALT
B AST
C CK-MB fraction
D C-reactive protein
E LDH-1
F Lipase
26 A 19-year-old man suddenly collapses and is brought to
the emergency department. His vital signs are temperature,
37.1° C; pulse, 84/min; respirations, 18/min; and blood pres-
sure, 80/40 mm Hg. Laboratory findings include hemoglobin,
13.5 g/dL; platelet count, 252,000/mm3; WBC count, 7230/
mm3; serum glucose, 73 mg/dL; and creatinine, 1.2 mg/dL.
The total creatine kinase (CK) level is elevated, with a CK-MB
fraction of 10%. Which of the following underlying conditions
is most likely to be present in this patient?
A DiGeorge syndrome
B Down syndrome
C Familial hypercholesterolemia
D Hereditary hemochromatosis
E Marfan syndrome
27 A 69-year-old man with metabolic syndrome had chest
pain and an elevated serum troponin I level 1 year ago. He
was treated in the hospital with anti-arrhythmic agents for
1 week. An echocardiogram showed an ejection fraction
of 28%. He now has markedly reduced exercise tolerance.
On physical examination, his temperature is 37° C, pulse is
68/min, respirations are 17/min, and blood pressure is
130/80 mm Hg. Diffuse crackles are heard on auscultation of
the lungs. The representative gross appearance of his heart is
shown in the figure. Which of the following complications of
this disease is the patient most likely to develop?
A Atrial myxoma
B Cardiac tamponade
C Constrictive pericarditis
D Hypertrophic cardiomyopathy
E Infective endocarditis
F Systemic thromboembolism
28 A 72-year-old man with poorly controlled diabetes mel-
litus has worsening exercise tolerance for 5 years. For the past
year he has had chest pain with minimal exertion. On physi-
cal examination he has bilateral pulmonary rales and pitting
edema of his legs. He has an irregular heart rate. A chest
radiograph shows prominent right and left heart borders. Echo-
cardiography shows decreased left ventricular ejection fraction
(25%) with diminished wall motion. Laboratory studies show
an elevated serum B-type natriuretic peptide. Which of the fol-
lowing pathologic findings is most likely present in this man?
A Critical coronary stenosis
B Left atrial mural thrombus
C Hypertrophic cardiomyopathy
D Mitral and tricuspid valve thickening
E Pericardial fibrinohemorrhagic exudate
168 UNIT II Diseases of Organ Systems

29 A 68-year-old woman has had increasing dyspnea and

orthopnea for the past year. She does not report any chest
pain. On physical examination, her temperature is 37° C, pulse
is 77/min, respirations are 20/min, and blood pressure is
140/90 mm Hg. On auscultation of the chest, diffuse crack-
les are heard in all lung fields. No murmurs or gallops are
heard, and the heart rate is regular. A chest radiograph shows
prominent right and left heart borders. Coronary angiography
shows 90% occlusion of the left anterior descending artery.
Echocardiography shows no valvular abnormalities, but there
is decreased left ventricular wall motion and an ejection frac-
tion of 32%. Laboratory studies show serum glucose of 81 mg/
dL, creatinine of 1.6 mg/dL, total cholesterol of 280 mg/dL,
triglyceride of 169 mg/dL, and troponin I of 1 ng/mL. Which
of the following pharmacologic agents is most likely to be ben-
eficial in the treatment of this patient?
A Amiodarone 32 A 59-year-old man has experienced chronic fatigue for the
B Alteplase past 18 months. On physical examination, he is afebrile. A chest
C Glyburide radiograph shows bilateral pulmonary edema and a prominent
D Nitroglycerin left heart border. The representative gross appearance of his
E Propranolol heart is shown in the figure. Laboratory studies show serum
F Simvastatin glucose, 74 mg/dL; total cholesterol, 189 mg/dL; total protein,
7.1 g/dL; albumin, 5.2 g/dL; creatinine, 6.1 mg/dL; and urea
30 A 50-year-old man has sudden onset of severe subster- nitrogen, 58 mg/dL. What is the most likely diagnosis?
nal chest pain that radiates to the neck. On physical examina- A Chronic alcoholism
tion, he is afebrile, but has tachycardia, hyperventilation, and B Diabetes mellitus
hypotension. No cardiac murmurs are heard on auscultation. C Hemochromatosis
Emergent coronary angiography shows a thrombotic occlusion D Pneumoconiosis
of the left circumflex artery and areas of 50% to 70% narrowing E Systemic hypertension
in the proximal circumflex and anterior descending arteries.   
Which of the following complications of this disease is most
likely to occur within 1 hour of these events?
A Myocardial rupture
B Pericarditis
C Valvular insufficiency
D Ventricular fibrillation
E Thromboembolism

31 A study of persons receiving emergent medical services

is conducted. It is observed that 5% of persons with sudden
cardiac arrest who receive cardiopulmonary resuscitation sur-
vive. Which of the following is the most likely mechanism for
cardiac arrest in these survivors?
A Arrhythmia
B Infarction
C Inflammation
D Valve failure 33 A 56-year-old man has worsening cough and orthopnea
E Ventricular rupture for the past 2 years. On physical examination, he has dullness
   to percussion at both lung bases and diffuse crackles in the
upper lung fields. He is afebrile. Echocardiography shows
marked left ventricular hypertrophy and severe aortic steno-
sis. The representative gross appearance of the opened heart
is shown in the figure. A coronary angiogram shows no sig-
nificant coronary arterial narrowing. Which of the following
underlying conditions best accounts for his findings?
A Congenital anomaly
B Diabetes mellitus
C Infective endocarditis
D Marfan syndrome
E Systemic hypertension

34 A 73-year-old woman had an episode a week ago in
which she became disoriented, had difficulty speaking, and
had persisting weakness on the right side of her body. On phys-
ical examination, she is now afebrile with pulse of 68/min, res-
pirations of 15/min, and blood pressure of 130/85 mm Hg. On
auscultation, the lungs are clear, the heart rate is irregular, and
there is a midsystolic click. A chest CT scan shows a focus of
bright attenuation within the heart. An echocardiogram shows
that one valvular leaflet appears to balloon upward. The ejec-
tion fraction is estimated to be 55%. Laboratory findings show
serum creatine kinase (CK), 100 U/L; glucose, 77 mg/dL;
creatinine, 0.8 mg/dL; calcium, 8.1 mg/dL; and phosphorus,
3.5 mg/dL. Which of the following is the most likely diagnosis?
A Carcinoid heart disease
B Hyperparathyroidism
C Infective endocarditis
D Mitral annular calcification
E Rheumatic heart disease
F Senile calcific stenosis
  
35 A 77-year-old woman has had episodes of syncope
with exertion for the past month. On physical examination,
she is afebrile. Her pulse is 66/min, respirations are 14/min,
and blood pressure is 125/85 mm Hg. On auscultation, a sys-
tolic ejection murmur is heard. There are a few crackles over
the lung bases posteriorly. From the representative gross
appearance of the opened aorta shown in the figure, which of
the following most likely contributed to the development of
this lesion?
A Aging
B Atherosclerosis
C Chromosomal aneuploidy
D Hypercalcemia of malignancy
E Systemic lupus erythematosus
F Tertiary syphilis
CHAPTER 12 The Heart 169
36 A 65-year-old healthy woman has a check of her health
status and the only finding is a midsystolic click on ausculta-
tion of the heart. Within 5 years she has increasing dyspnea.
Echocardiography now shows mitral regurgitation from pro-
lapse of a leaflet. Which of the following pathologic changes is
most likely present in this valve?
A Destructive vegetations
B Dystrophic calcification
C Fibrinoid necrosis
D Myxomatous degeneration
E Rheumatic fibrosis
37 A 35-year-old woman has had palpitations, fatigue,
and worsening chest pain during the past year. On physical
examination, she is afebrile. Her pulse is 75/min, respirations
are 15/min, and blood pressure is 110/70 mm Hg. Ausculta-
tion of the chest indicates a midsystolic click with late systolic
murmur. A review of systems indicates that the patient has
one or two anxiety attacks per month. An echocardiogram is
most likely to show which of the following?
A Aortic valvular vegetations
B Mitral valve prolapse
C Patent ductus arteriosus
D Pulmonic stenosis
E Tricuspid valve regurgitation
38 An 11-year-old boy had a sore throat, no cough, tonsil-
lar exudates, and 38.3° C fever 3 weeks ago, and a throat cul-
ture was positive for group A β-hemolytic Streptococcus. On
the follow-up examination, the child is afebrile. His pulse
is 85/min, respirations are 18/min, and blood pressure is
90/50 mm Hg. On auscultation, a diastolic mitral murmur
is audible, and there are diffuse rales over both lungs. Over
the next 2 days he has several episodes of atrial fibrillation
accompanied by signs of acute left ventricular failure. Which
of the following pathologic changes occurring in this child’s
heart is most likely to be the cause of the left ventricular
failure?
A Amyloidosis
B Fibrinous pericarditis
C Mitral valve fibrosis
D Myocarditis
E Tamponade
F Verrucous endocarditis
  
170 UNIT II Diseases of Organ Systems
39 A 14-year-old girl has fever and chest pain 2 weeks after
having a mild upper respiratory tract infection. On physical
examination, her temperature is 37° C, pulse is 90/min, res-
pirations are 20/min, and blood pressure is 85/45 mm Hg.
A friction rub is audible on auscultation of the chest. A chest
radiograph shows pulmonary edema. An echocardiogram
shows small vegetations at the closure line of the mitral and
aortic valves. An endomyocardial biopsy shows focal intersti-
tial aggregates of mononuclear cells enclosing areas of fibri-
noid necrosis. Her condition improves over the next month.
The representative gross appearance of the affected heart is
shown in the figure. Which of the following cardiac abnormal-
ities is most likely to occur in this patient?
A Constrictive pericarditis
B Dilated cardiomyopathy
C Left ventricular aneurysm
D Myxoma
E Valvular stenosis
40 A 10-year-old girl develops subcutaneous nodules over
the skin of her arms and torso 3 weeks after a bout of acute
pharyngitis. She manifests choreiform movements and begins
to complain of pain in her knees and hips, particularly with
movement. A friction rub is heard on auscultation of her chest.
An abnormality detected by which of the following serum lab-
oratory findings is most characteristic of the disease affecting
this girl?
A Antistreptolysin O antibody titer
B Antinuclear antibody titer
C Creatinine level
D Rapid plasma reagin test
E Troponin I level
  
41 A 25-year-old man was found dead at home by the
apartment manager, who had been called by the decedent’s
employer because of failure to report to work for the past
3 days. An external examination by the medical examiner
showed splinter hemorrhages under the fingernails and no
signs of trauma. The gross appearance of the heart at autop-
sy is shown in the figure. Which of the following laboratory
findings is most likely to provide evidence for the cause of his
disease?
A Elevated anti–streptolysin O titer
B Positive ANCA serology
C Increased creatine kinase–MB (CK-MB) fraction
D High double-stranded DNA autoantibody titer
E Positive blood culture for Staphylococcus aureus
42 A 22-year-old previously healthy man undergoes a tooth
extraction, and 4 days later he develops a fever. On physical
examination his temperature is 37.6° C. A high-pitched systolic
murmur is auscultated. A tentative diagnosis of congenital
heart disease is made. In which of the following locations is the
congenital anomaly in this man most likely found?
A Ascending aorta
B Atrial appendage
C Chordae tendineae
D Cusps of valves
E Muscular septum
43 A 26-year-old woman has had a fever for 5 days. On
physical examination, her temperature is 38.2° C, pulse is
100/min, respirations are 19/min, and blood pressure is
90/60 mm Hg. A cardiac murmur is heard on auscultation.
Her sensorium is clouded, but there are no focal neurologic
deficits. Laboratory findings include hemoglobin, 13.1 g/dL;
platelet count, 233,300/mm3; and WBC count, 19,200/mm3.
Blood cultures are positive for gram-positive bacteria. Urinaly-
sis shows hematuria. An echocardiogram shows a 1.5-cm veg-
etation on the mitral valve. Which of the following conditions
is this patient most likely to develop?
A Cerebral arterial mycotic aneurysm
B Dilated cardiomyopathy
C Myxomatous mitral valve degeneration
D Pericardial effusion with tamponade
E Pulmonary abscess

44 A 19-year-old man has had a low-grade fever for
3 weeks. On physical examination, his temperature is 38.3° C,
pulse is 104/min, respirations are 28/min, and blood pressure
is 95/60 mm Hg. A tender spleen tip is palpable. There are
splinter hemorrhages under the fingernails and tender hem-
orrhagic nodules on the palms and soles. A heart murmur
is heard on auscultation. Which of the following infectious
agents is most likely to be cultured from this patient’s blood?
A Coxsackievirus B
B Mycobacterium tuberculosis
C Pseudomonas aeruginosa
D Viridans streptococci
E Trypanosoma cruzi
45 A 71-year-old woman has had a 10-kg weight loss
accompanied by severe nausea and vomiting of blood for the
past 8 months. On physical examination, she is afebrile. Labo-
ratory studies show hemoglobin, 8.4 g/dL; platelet count,
227,100/mm3; and WBC count, 6180/mm3. Biopsy specimens
obtained by upper gastrointestinal endoscopy show adeno-
carcinoma of the stomach. CT scan of the abdomen shows
multiple hepatic masses. CT scan of the head shows a cystic
area in the right frontal lobe. Her condition is stable until
2 weeks later, when she develops severe dyspnea. A chest CT
scan shows areas of decreased pulmonary arterial attenua-
tion. Which of the following cardiac lesions is most likely to be
present in this woman?
A Calcific aortic valvular stenosis
B Constrictive pericarditis
C Epicardial metastatic carcinoma
D Left ventricular mural thrombosis
E Nonbacterial thrombotic endocarditis
46 A 41-year-old woman has had increasing dyspnea for the
past week. On physical examination, temperature is 37.3° C,
pulse is 85/min, respirations are 20/min, and blood pressure
is 150/95 mm Hg. There is dullness to percussion over the
lung bases. A chest radiograph shows large bilateral pleural
effusions and a normal heart size. Laboratory findings in-
clude serum creatinine, 3.1 mg/dL; urea nitrogen, 29 mg/dL;
troponin I, 0.1 ng/mL; WBC count, 3760/mm3; hemoglobin,
11.7 g/dL; and positive ANA and anti–double-stranded DNA
antibody test results. Which of the following cardiac lesions is
most likely to be present in this patient?
A Calcific aortic stenosis
B Hemorrhagic pericarditis
C Nonbacterial thrombotic endocarditis
D Libman-Sacks endocarditis
E Mural thrombosis
F Rheumatic verrucous endocarditis
47 A 44-year-old woman with rheumatic heart disease
with aortic stenosis undergoes valve replacement with a bio-
prosthesis. She remains stable for the next 8 years and then
develops diminished exercise tolerance. Which of the follow-
ing complications involving the bioprosthesis has most likely
occurred?
A Embolization
B Hemolysis
C Myocardial infarction
D Paravalvular leak
E Stenosis
CHAPTER 12 The Heart 171
48 A 50-year-old man with a history of infective endocar-
ditis has increasing fatigue. He receives a bileaflet tilting disk
mechanical mitral valve prosthesis. After surgery, he is stable,
and an echocardiogram shows no abnormal valvular or ven-
tricular function. Which of the following pharmacologic agents
should he receive regularly after this surgical procedure?
A Aspirin
B Ciprofloxacin
C Cyclosporine
D Digoxin
E Propranolol
F Warfarin
49 A 44-year-old, previously healthy man has experienced
worsening exercise tolerance accompanied by marked short-
ness of breath for the past 6 months. On physical examina-
tion, his vital signs are normal. He has diffuse rales in all
lung fields and pitting edema to the knees. Laboratory stud-
ies show serum sodium, 130 mmol/L; potassium, 4 mmol/L;
chloride, 102 mmol/L; CO2, 25 mmol/L; creatinine, 2 mg/dL;
and glucose, 120 mg/dL. A 100-mL urine sample is collected.
There is 1.3 mmol sodium and 40 mg creatinine in the urine
sample. A chest radiograph shows cardiomegaly and pul-
monary edema with pleural effusions. An echocardiogram
shows four-chamber cardiac enlargement and mitral and
tricuspid valvular regurgitation, with an ejection fraction of
30%. A coronary angiogram shows less than 10% narrowing
of the major coronary arteries. Which of the following is the
most likely diagnosis?
A Amyloidosis
B Hypercholesterolemia
C Familial cardiomyopathy
D Rheumatic heart disease
E Trypanosoma cruzi infection
50 A 56-year-old man has experienced increased fatigue
and decreased exercise tolerance for the past 2 years. On phys-
ical examination, his temperature is 37° C, pulse is 75/min,
respirations are 17/min, and blood pressure is 115/75 mm Hg.
On auscultation, diffuse crackles are audible. The abdomen is
distended with a fluid wave, and there is bilateral pitting ede-
ma to the knees. A chest radiograph shows pulmonary edema,
pleural effusions, and marked cardiomegaly. An echocar-
diogram shows mild tricuspid and mitral regurgitation and
reduced right and left ventricular wall motion, with an ejec-
tion fraction of 30%. He experiences cerebral, renal, and splen-
ic infarctions over the next year. Chronic use of which of the
following substances has most likely produced these findings?
A Acetaminophen
B Cocaine
C Ethanol
D Lisinopril
E Nicotine
F Propranolol
172 UNIT II Diseases of Organ Systems
51 A 25-year-old man suffers a sudden cardiac arrest. He is
resuscitated. On examination his vital signs are normal. Echo-
cardiography shows that the left ventricle is normal but there
is marked thinning with dilation of the right ventricle. MR im-
aging of his chest shows extensive fibrofatty replacement of
the myocardium, but no inflammation. Which of the following
is the most likely cause for his findings?
A Cardiomyopathy
B Chagas disease
C Hypertension
D Long QT syndrome
E Radiation therapy
52 A 10-year-old girl who is normally developed has
chronic progressive exercise intolerance. On physical exami-
nation, temperature is 37.1° C, pulse is 70/min, respirations
are 14/min, and blood pressure is 100/60 mm Hg. A chest
radiograph shows cardiomegaly and mild pulmonary edema.
An echocardiogram shows severe left ventricular hypertrophy
and a prominent interventricular septum. The right ventricle
is slightly thickened. During systole, the anterior leaflet of the
mitral valve moves into the outflow tract of the left ventricle.
The ejection fraction is abnormally high, and the ventricular
volume and cardiac output are both low. Which of the follow-
ing is the most likely cause of the cardiac abnormalities in this
patient?
A Autoimmunity against myocardial fibers
B β-Myosin heavy chain gene mutation
C Deposition of amyloid fibrils
D Excessive iron accumulation
E Latent enterovirus infection
53 A 17-year-old girl jumps up for a block in the third
match of a volleyball tournament and suddenly collapses.
She requires cardiopulmonary resuscitation. A similar epi-
sode occurs a month later. She had been healthy all her life
and complained only of limited episodes of chest pain in
games during the current school year. Which of the following
pathologic findings of the heart is most likely to be present in
this girl?
A Extensive myocardial hemosiderin deposition
B Haphazardly arranged hypertrophied septal
myocytes
C Large, friable vegetations with destruction of aortic
valve cusps
D Mitral valvular stenosis with left atrial enlargement
E Tachyzoites within foci of myocardial necrosis and
inflammation
54 An 86-year-old man has had increasing dyspnea and
reduced exercise tolerance for the past 7 years. On physical
examination, he is afebrile and has a blood pressure of 135/85
mm Hg. An irregularly irregular heart rate averaging 76/min
is audible on auscultation of the chest. Crackles are heard at
the bases of the lungs. A chest radiograph shows mild car-
diomegaly and mild pulmonary edema. Echocardiography
shows slight right and left ventricular wall thickening with
reduced left and right ventricular wall motion, reduced left
ventricular filling, and an ejection fraction estimated to be
25%. An endomyocardial biopsy specimen shows amor-
phous pink-staining deposits between myocardial fibers, but
no inflammation and no necrosis. Echocardiography would
most likely show which of the following functional cardiac
disturbances?
A Dynamic obstruction to ventricular outflow
B Impaired ventricular diastolic filling
C Increased end-systolic volume
D Mitral and tricuspid valvular insufficiency
E Reduced ejection fraction
55 A 33-year-old woman from Victoria, British Columbia,
goes to the physician because of increasingly severe dyspnea,
orthopnea, and swelling of the legs for the past 2 weeks. She
has no previous history of serious illness or surgery. On physi-
cal examination, her temperature is 37.8° C, pulse is 83/min,
respirations are 20/min, and blood pressure is 100/60 mm Hg.
An ECG shows episodes of ventricular tachycardia. An echo-
cardiogram shows right and left ventricular dilation, but no
valvular deformities. An endomyocardial biopsy shows focal
myocyte necrosis and lymphocytic infiltrate. Which of the fol-
lowing organisms most likely caused the infection?
A Coxsackievirus A
B Mycobacterium kansasii
C Viridans streptococci
D Staphylococcus aureus
E Toxoplasma gondii
F Trypanosoma cruzi
  
56 A 68-year-old man has become increasingly lethargic
and weak for the past 7 months. On physical examination,
his temperature is 36.9° C, pulse is 70/min, respirations are
15/min, and blood pressure is 160/105 mm Hg. On ausculta-
tion of his chest, a friction rub is audible. There are no other
remarkable findings. The representative gross appearance of
the heart is shown in the figure. Which of the following labo-
ratory findings is most likely to be reported for this patient?
A Elevated serum anti–streptolysin O titer
B Elevated plasma renin level
C Increased blood urea nitrogen level
D Increased serum CK-MB level
E Positive ANA with “rim” pattern
F Positive viral serology

57 A 52-year-old woman has had a chronic cough for the
past 2 years, accompanied by a small amount of occasionally
blood-streaked, whitish sputum. On physical examination, her
temperature is 37.9° C, pulse is 72/min, respirations are 22/min,
and blood pressure is 125/80 mm Hg. Crackles are heard on
auscultation over the upper lung fields. Heart sounds are faint,
and there is a 15 mm Hg inspiratory decline in systolic arterial
pressure. The chest radiograph shows prominent heart borders
with a “water bottle” configuration. Pericardiocentesis yields
200 mL of bloody fluid. Infection with which of the following
organisms is most likely to produce these findings?
A Candida albicans
B Coxsackievirus B
C Group A streptococcus
D Mycobacterium tuberculosis
E Staphylococcus aureus
  
58 A 31-year-old man experienced chest pain, became in-
creasingly dyspneic and nauseated, and lost consciousness
multiple times. Seven days after the appearance of these
symptoms, he was found dead in his sleep. External examina-
tion of the body by the medical examiner shows no evidence
of trauma. The body is 166 cm (5 ft 5 in) in height and weighs
75 kg (BMI 27). The gross appearance of the chest cavity at
autopsy with the pericardial sac opened is shown in the figure.
What is the most likely underlying cause of his death?
A Coronary atherosclerosis
B Dilated cardiomyopathy
C Disseminated tuberculosis
D Systemic sclerosis
E Malignant melanoma
F Marfan syndrome
G Takayasu arteritis
CHAPTER 12 The Heart 173
59 A 73-year-old woman has had episodes of chest pain
during the past week. She is afebrile. Her pulse is 80/min, res-
pirations are 16/min, and blood pressure is 110/70 mm Hg.
On auscultation of the chest, heart sounds seem distant, but
the lung fields are clear. Neck veins are distended to the angle
of the jaw, even while sitting. There is a darkly pigmented,
irregular, 1.2-cm skin lesion on the right shoulder. A chest ra-
diograph shows prominent borders on the left and right sides
of the heart. Pericardiocentesis yields bloody fluid. Labora-
tory findings include a serum troponin I level of 0.3 ng/mL.
Which of the following lesions is the most likely cause of these
findings?
A Calcific aortic stenosis
B Coronary atherosclerosis
C Epicardial metastases
D Mitral valvulitis
E Tuberculous pericarditis
60 A 48-year-old, previously healthy woman reports having
suddenly lost consciousness four times in the past 6 months.
In three instances, she was unconsciousness for only a few
minutes. After the fourth episode 1 month ago, she was uncon-
scious for 6 hours and had weakness in her right arm and dif-
ficulty speaking. On physical examination, she is afebrile, and
her blood pressure is normal. No murmurs are auscultated. She
has good carotid pulses with no bruits. Which of the following
cardiac lesions is most likely to be present in this woman?
A Bicuspid aortic valve
B Coronary artery thrombosis
C Left atrial myxoma
D Mitral valve stenosis
E Pericardial effusion
61 A 55-year-old man undergoes orthotopic cardiac trans-
plantation. Two months later, an endomyocardial biopsy
specimen shows focal myocardial cell death with scattered
perivascular lymphocytes and plasma cells. He is treated with
sirolimus. Which of the following pathologic processes best
accounts for these biopsy findings?
A Autoimmunity
B Autophagy
C Ischemia
D Infection
E Rejection
62 A 45-year-old man receives a cardiac allograft for dilated
cardiomyopathy. He has no problems with rejection, but 5 years
later he has worsening exercise tolerance with increasing dys-
pnea and peripheral edema. Echocardiography shows a reduced
ejection fraction of 35%. Which of the following pathologic
abnormalities has he most likely developed in the allograft?
A Amyloidosis
B Constrictive pericarditis
C Coronary arteriopathy
D Non-Hodgkin lymphoma
E Toxoplasmosis