Medicine III

1. What is the abnormality in this ECG?

4. Diagnosis from this ECG is?

a. Mobitz 1
b. Mobitz 2
c. Complete heart block
d. Multifocal atrial ectopics

2. The abnormality in this ECG?

a. PSVT
b. Ventricular tachycardia
c. Accelerated Idioventricular rhythm
d. Idioventricular arrhythmia

5. What is the axis in this ECG?

a. LBBB
b. RBBB
c. LVH
d. RVH

3. Diagnosis from this ECG is? a. Right Axis deviation

b. Left Axis deviation
c. Normal Axis
d. Extreme Right axis deviation

6. Which of the following is the correct statement

regarding findings in JVP?
a. Cannon a wave: Complete heart block
b. Rapid Y descent: Cardiac Tamponade
c. Giant c wave: Tricuspid stenosis
d. Increased JVP with prominent pulsations: SVC
obstruction

7. Positive hepatojugular reflux is found in all except?

a. Decreased LV after load
b. Increased pulm cap wedge pressure
a. RV hypertryophy with strain pattern c. Tricuspid Regurgitation
b. LV hypertrophy with strain pattern d. LV failure
c. RBBB
d. WPW syndrome 8. Most common cause of death in thrombolytic therapy
in MI is?
a. Reperfusion arrhythmias
b. Intracranial bleeding
c. Myocardial rupture
 d. Restenosis a. Left bundle branch block
b. Right bundle branch block
9. Revascularisation best for done in: c. Pulmonic stenosis
a. Stunned heart d. Mitral regurgitation
b. Hibernating myocardium
c. mixed scarred and viable myocardium
d. non ischaemic viable myocardium

10. A 45 yr has a large VSD and eisenmengers syndrome. All
of the following findings would be expected except:
a. Loud P2
b. Loud systolic murmur
c. Cyanosis
d. Hemoglobin value 19 mg/dl
11. All potentiate digoxin toxicity except:
a. Hypokalemia
b. Hypomagnesemia
c. Hypocalcemia
d. Hypothyroidism
12. A 62-year-old man with hypertension and angina has
severe retrosternal chest pain radiating to the left
shoulder on awakening, accompanied by diaphoresis
and nausea. The pain is not relieved by sublingual
nitroglycerin. An ECG is consistent with an evolving
anterior wall myocardial infarction. Two days later, the
patient develops severe shortness of breath. His
temperature is 36.7 C (98 F), blood pressure is 100/60
mm Hg, pulse is 105/min, and respirations are 29/min.
Bilateral wet crackles are noted, and a holosystolic
murmur is heard at the apex radiating to the left axilla.
No murmur was heard during an examination 4 months
earlier. Which of the following complications has most
likely occurred?
a. Aortic dissection
b. Cardiac rupture
c. Papillary muscle rupture
d. Septal perforation
13. A 55-year-old man with recent syncopal episode is
admitted to the hospital in congestive heart failure. His
blood pressure is 160/100 mm Hg, and pulse is 90/min.
He has a grade 2/6 harsh systolic ejection murmur. An
echocardiogram reveals a thickened ventricular septum
and systolic anterior motion of the mitral valve. Which
of the following will most likely be found in this
patient?
a. Decreased murmur with hand grip
b. Decreased murmur with Valsalva
c. Delayed carotid upstroke
d. Increased murmur with squatting
14. An 18-year-old patient is seen for routine examination
before playing basketball. There is paradoxical splitting
of S2 heard at the base and no murmur. What is the
diagnosis?
15. A 58-year-old man with acute chest pain has ST-
segment elevation in leads II, III, and aVF. BP is 82/52
mm Hg and pulse rate is 54/min. Physical examination
shows jugular venous distention, clear lungs, and no
murmur or S3. Treatment should include:
a. Nitrates
b. IV fluids
c. Diuretics
d. Beta blockers
16. A 48 year old woman with no significant previous
medical history collapses while running a marathon.
Despite attempts at resuscitation, she does not survive.
Postmortem examination reveals asymmetric left
ventricular hypertrophy with disproportionate
thickening of the interventricular septum. A
postmortem diagnosis of hypertrophic cardiomyopathy
is made. What is the most likely cause of this patient's
sudden collapse?
a. Atrial fibrillation
b. Left ventricular failure
c. Right ventricular failure
d. Ventricular arrhythmia
17. The following medical treatments are all associated
with improved symptoms in patients with heart failure
due to left ventricular systolic dysfunction. However,
which of the treatments has NOT been shown to also
improve survival?
a. Enalapril
b. Furosemide
c. Sacubitril-valsartan
d. Spironolactone
18. A patient has a stent placed in his right coronary artery.
On return to the ward, he gets severe chest pain and
becomes very unwell. The nurse undertakes an ECG and
calls the interventional cardiologist to review the
patient because she is concerned that he has a
thrombosed stent. What ECG features would suggest
the stent has become occluded?
a. Atrial fibrillation
b. Atrioventricular block
c. ST elevation in I, aVL and V5, V6
d. ST elevation in V2-V5
19. In a patient, with evidence of infective endocarditis.
What is the commonest feature that the patient is likely
to have?
 a. Haematuria
b. Osler's nodes
c. Roth's spots
d. Splinter haemorrhages

20. A 43 year old man undergoes a routine health check

with his employers. He is found to have a murmur,
isolated systolic hypertension (180/60 mmHg) and LVH
a. Hypertrophic cardiomyopathy
on his ECG. A significant regurgitant blood flow is
b. Amyloid cardiomyopathy
noticed across the aortic valve on echocardiogram.
c. Dilated Cardiomyopathy
Which of the following clinical signs is likely to be
d. Arrythmogenic RV cardiomyopathy
observed?
a. Palpable thrill over the carotids
b. Sustained forceful apical Impulse
23. A 30 year old woman has recently been diagnosed with
c. Pulsations in the nails
dilated cardiomyopathy. Her diagnosis was made with
d. Slow rising pulse
echocardiography, which showed moderate left
ventricular dilatation and impairment. She has noticed
21. The EGG given below was recorded in a coronary care
herself becoming increasingly fatigued on moderate
unit from a patient admitted 2 h previously with an
exertion. Her younger sister died suddenly the previous
acute anterior myocardial infarction. The patient was
year and she is very worried about the risk of sudden
cold and clammy, and confused, and his blood pressure
death. Which of the following treatments is known to
was unrecordable. All are true about management of
reduce her risk of sudden death?
this patient except:
a. Aspirin
b. Beta blocker (e.g. metoprolol)
c. Calcium channel blocker (e.g. verapamil)
d. Loop diuretic (e.g. furosemide)

24. Which of the following is not feature associated with

Tetrology of Fallot:
a. Clubbing
b. Squatting
a. Next step in management is electrical shock c. Episode of deep cyanosis
b. Inj Lignocaine works more rapidly than amiodarone d. Cardiomegaly
but does not work in all patients
c. Shock administered is 200J AC 25. Which of the following associations are least common
d. IV Beta blockers should be given to control to occur together in a case of rheumatic fever?
ventricular rate a. Carditis and arthritis
b. Carditis and chorea
22. A 63-year-old man develops dyspnea and fatigue. c. Chorea and arthritis
Physical examination shows jugular venous distention, a d. Carditis and subcutaneous nodules
prominent jugular a wave, a prominent S4, and a grade
2/6 holosystolic murmur at the left sternal border. The 26. An 18-year-old patient is seen for routine examination
lungs are clear. Other findings include an enlarged, before playing basketball. There is paradoxical splitting
tender liver; petechiae over the feet; and periorbital of S2 heard at the base and no murmur. What is the
ecchymoses. His ECG is given below Diagnosis: diagnosis?
a. Left bundle branch block
b. Right bundle branch block
c. Pulmonic stenosis
d. Mitral regurgitation

27. A tall thin 38 year male developed chest pain 3 hours

back that was tearing in nature radiating to the back.
Subsequently patient developed severe epigastric at
 time of admission to emergency. ECG at admission
showed following. Tropinin levels were increased. Xray
showed widened mediastinum:
is tachycardic and tachypnoeic, and has a harsh
holosystolic murmur radiating to the right side of the
chest. There are fine inspiratory crepitations audible at
the lung bases. What is the most likely explanation for
these findings?
a. Acute aortic incompetence
b. Papillary muscle rupture and mitral incompetence
c. Post-infarction pericarditis with pericardial rub
d. Rupture of the interventricular septum

31. In management of acute pericarditis all are first line

treatment options except:
a. Steroids
b. Aspirin
c. Colchicine
All of the following can be done in management except:
d. Ibuprofen
a. Oxygen
32. All of the following are associated with coarctation of
b. IV Morphine
aorta except:
c. Control of blood pressure
a. PDA
d. Thrombolytic therapy
b. Berry aneurysm
c. Bicuspid aortic valve
28. A 52-year-old woman presents to the emergency
d. Renal artery stenosis
department with dyspnea and retrosternal chest pain of
3-hour duration that developed soon after she was in an
33. 1 month child with cyanosis. O/E there is a systolic
intense argument with her daughter. Her past medical
murmur present at 3rd and 4th IC space and Xray shows
history is remarkable for hypertension and diabetes
oligemic lung fields and ECG shows LAD. Probable
mellitus. The chest discomfort is not relieved by
diagnosis
sublingual nitroglycerin. Her heart rate is 100 beats per
a. TOF
minute, and blood pressure is 156/92 mm Hg. Jugular
b. Tricuspid Atresia
venous pressure, carotid pulse, and peripheral pulses
c. Truncus arteriosus
are normal. Cardiac auscultation is normal; lungs are
d. Transposition of great vessels
clear to auscultation. Cardiac troponin T level is 0.12
(reference range, <0.01). The 12-lead
34. A 56 year old man presents with sudden onset of chest
electrocardiography shows 0.5- to 1-mm ST-segment
pain radiating down his left arm, and ECG given below
elevation in precordial leads V2 through V4. She is taken
and a plasma troponin concentration of 1365 ng/L
for an emergency coronary angiography, which
(reference range <34 ng/L). Which of the following
demonstrates mild coronary atherosclerosis. A left
treatments is likely to worsen his prognosis?
ventriculography is performed, which shows severe
hypokinesis of the apical and midsegments of the heart,
with normal function at the base. Which of the
following is the diagnosis?
a. Takotsubo cardiomyopathy
b. Acute coronary syndrome
c. Dilated cardiomyopathy
d. Pericarditis

29. In a patient with Hypertensive emergency with

myocardial ischemia the preferred drug/s to reduce BP
are: a. Aspirin
a. Hydralazine b. Fondaparinux
b. Minoxidil c. Intravenous tissue plasminogen activator
c. Nitroprusside d. Ticagrelor
d. Nicardipine and esmolol
35. A 45-year-old man presents to his general practitioner
30. You assess a 62 year old woman 2 days after treatment with a persistent headache and recurrent epistaxis. A
for anterior myocardial infarction. On examination she murmur is noted and he is referred for a cardiology
 opinion.
The findings on cardiac catheterisation are summarised
below:
What is the most likely diagnosis?
a. Coarctation of the aorta
b. Hypertrophic obstructive cardiomyopathy
c. Mitral regurgitation
d. Ventricular septal defect
36. A 65-year-old man with ischaemic heart disease
presents with a two month history of stiffness of the
fingers and a mild photosensitive rash. He had been
started on procainamide a year ago.
Examination reveals puffy swelling of the hands and
wrists, associated with tenderness of the
metacarpophalangeal joints. The chest x ray ordered by
the GP shows small bilateral pleural effusions.
Which of the following tests is characteristic of this
patient's condition?
a. Anti-centromere antibody
b. Anti-double stranded DNA antibodies
c. Anti-histone antibodies
d. Anti-ribonucleoprotein antibody
37. A 46 year old man presents to the emergency
department for his 2nd episode of hepatic
encephalopathy as a complication of cirrhotic end-stage
liver disease. He also has volume overload and episode
of congestive heart failure, with an ejection fraction of
30%. His family is adamant that he has never consumed
alcohol excessively. Comorbidities include poorly
controlled diabetes mellitus on insulin therapy and
osteoporosis. Aspiration of ascites does not suggest
spontaneous bacterial peritonitis. He is treated with
lactulose and loop diuretics, and his clinical status
improves greatly. On hospital day 4, the patient
stumbles and reports some pain in the right hand and
wrist. It is not red, warm, or swollen, but on x ray
chronic bony deformities are present in the distal
interphalanged (DIP), proximal interphalangeal (PIP),
and metacarpophalanged (MCP) joints. His MCP joints
show hooked osteophytes and osteosclerosis:
a. Rheumatoid arthritis
b. Hemochromatosis
c. Primary osteoarthritis of the hands
d. Chronic alcoholism
38. All of the following vasculitis are seen in adult except:
a. HSP
b. Kawasaki
c. PAN
d. Giant cell arteritis
39. Which is not a complication of Rheumatoid arthritis?
a. Endocarditis
b. Pericarditis
c. Splenic infarcts
d. Polycythemia
40. A 43-yr man presents with a 4-year history of joint pain.
The distribution is asymmetric, involving the proximal
and distal small joints of the right hand, the left knee,
the ankle, and right elbow. Pain and morning stiffness
are moderate. Examination reveals nail pitting, and the
distal third interphalangeal joint is partially subluxated.
X-rays of the hands show resorption of the distal end of
the phalanx. The erythrocyte sedimentation rate (ESR)
is elevated to 46 mm/hr, and rheumatoid factor is
negative. Which of the following is the most likely
diagnosis?
a. Primary generalized osteoarthritis
b. Pseudogout
c. Psoriatic arthritis
d. Rheumatoid arthritis
41. A 30-yr woman presents with low back pain, and a
swollen and painful right ankle and left knee for 1 week.
Temp 39.0 C . She recalls that a few weeks ago, she had
diarrhea, abdominal cramps, and fever, which lasted for
a few days. She does not have previous history of joint
diseases or sexually transmitted diseases. Examination
reveals skin pustules and crusted vesicles on her palms
and soles, red conjunctivae, and arthritis of the left
 knee and right ankle. There is no hepato- splenomegaly,
or lymphadenopathy. Lab data show an elevated ESR,
but no anemia. Which of the following is the most likely
diagnosis?
a. Psoriatic arthritis
b. Reiter syndrome
c. Rheumatic fever
d. Rheumatoid arthritis
42. ANCA positive disease are all of the following except:
a. Microscopic polyangiitis
b. Henoch Schonlein Purpura
c. Churg Strauss Syndrome
d. Wegener’s Granulomatosis
43. An 18-years-old boy presents with digital gangrene in
third and fourth fingers for last 2 weeks. He has
occasional pain abdomen. On examination the blood
pressure is 170/110 mm of Hg and all peripheral pulses
were palpable. Blood and urine examinations were
unremarkable. Antinuclear antibodies, antibody to
double stranded DNA and anti-neutrophil cytoplasmic
antibody were negative. The most likely diagnosis is:
a. Wegner's granulomatosis
b. Polyarteritis nodosa
c. Takayasu's arteritis
d. Systemic lupus erythematosus (SLE)
44. In a patient with Kawasaki’s vasculitis all are used in
management except:
a. Steroids
b. IV immunoglobulins
c. Aspirin
d. Warfarin
45. A previously healthy 45 year old man is woken up at
0400 hrs with acute pain, swelling and redness of the
right ankle with no obvious trigger factor. Height is 168
cm, weight 104 kg He has a history hypertension treated
with thazide 2.5 mg daily. He drinks 2-3 pints of beer
each night and consumes 26 units of alcohol per week.
What is the most likely diagnosis?
a. Gout
b. Osteoarthritis
c. Psoriatic arthritis
d. Rheumatoid arthritis
46. A 66 year old woman presents with pain and stiffness
affecting the wrists, proximal interphalangeal (PIP) and
metacarpophalangeal MCP) joints of the hands,
gradually worsening over a period of 6-8 weeks. On
examination, there is symmetrical swelling and
tenderness of both wrists and the MCP and PIP joints of
the hands. Investigations show that anti- citrullinated
peptide antibodies (ACPAs) and rheumatoid factor are
negative, but that she has an elevated ESR (45 mm/hr)
and a raised CRP (65 mg/L). X-rays of the hands are
normal. Which of the following statements is correct?
a. Rheumatoid arthritis is excluded by the negative
ACPA test and normal radiographs
b. The joint pain and swelling is most likely due to
generalised osteoarthritis
c. The presentation is consistent with polymyalgia
rheumatica (PMR)
d. The presentation is typical of seronegative
rheumatoid arthritis
47. Blood is taken from a pre-menopausal woman with
joint pains, xerostomia and fatigue. Antinuclear
antibody (ANA) is positive; anti-ds DNA antibody
negative, anti-Ro(SSA) positive, anti-La(SSB) positive,
complement C3 and C4 normal, rheumatoid factor
positive, ACPA negative. Based on the following
immunology results, which is the most likely diagnosis?
a. Sjogren's syndrome (PSS)
b. RA and systemic lupus erythematosus (SLE) together
c. SLE
d. Systemic sclerosis
48. A 40 year old woman presents with recurrent bouts of
fatigue, arthralgia (oligoarticular: elbow, wrists and a
knee), headaches and crops of painful mouth and
genital ulcers, occasional raised erythematous nodular
lesions in lower limbs and a single sore red eye. ESR is
35 mm/hr but CRP is normal; full blood count shows
slight lymphopenia, normal neutrophil- and platelet
counts. Serum adjusted calcium and PTH are in the
reference range. Which is the most likely diagnosis?
a. Polyarteritis Nodosa
b. Behcets disease
c. Sarcoidosis
d. Systemic Lupus
49. 21-year-old woman presents for evaluation of arthritis.
She reports a 2-month history of pain and swelling of
the MCP and PIP joints, wrists, and feet. She has 1-2
hours of morning stiffness. The patient also reports
anorexia, and slight thinning of scalp hair. No history of
malar rash, oral ulcers or pleurisy. Daily medications are
Amlodipine and Hydralazine for control of
hypertension. Exam: a slightly erythematous rash on
the upper chest. There is trace swelling of the MCP and
PIP joints bilaterally. Lab shows ANA positive. ESR 45.
Which of the following is the most appropriate next
step in the management of this patient?
a. Start prednisone, 5mg BID
b. Discontinue Hydralazine
c. Start methotrexate, 10 mg weekly
d. Start hydroxychloroquine 200 mg daily
50. A 29-year-old woman presents for evaluation of
Raynaud's phenomenon and arthralgias. She also has a
non-healing, painful ulceration of the distal middle
finger. Physical examination reveals thickening of the
skin over her hands, forearms, upper arms and chest.
She brings a copy of lab results that include a positive
fluorescent antinuclear antibody (ANA) test (1:1280)
and positive antibody to RNA polymerase III. Her Scl- 70
antibody is negative. The rest of her labs are normal.
Which of the following is the most likely diagnosis?
a. Limited scleroderma (CREST)
b. Mixed connective tissue disease
c. Diffuse scleroderma
d. Primary Raynaud's phenomenon
 Medicine III

ANSWER KEY
1. C 45. A
2. A 46. D
3. B 47. A
4. C 48. B
5. B 49. B
6. A 50. C
7. A
8. B
9. B
10. B
11. C
12. C
13. A
14. A
15. B
16. D
17. B
18. B
19. A
20. C
21. D
22. B
23. B
24. D
25. C
26. A
27. D
28. A
29. D
30. D
31. A
32. D
33. B
34. C
35. A
36. C
37. B
38. B
39. D
40. C
41. B
42. B
43. B
44. A