Summative Exam Questions and Answers High
Level 2023
An 80-year-old man was treated for ventricular arrhythmias. He presents 1 month later with joint
pain. He also has an unusual mask-like rash over his face and body. Discontinuation of drug
therapy causes the symptoms to abate. What drug was most likely administered to this patient?
1 Tocainide
2 Quinidine
3 Procainamide
4 Phenytoin
5 Propranolol - -Procainamide - often prescribed for long-term control of arrhythmias. May
cause lupus like SE.
-A 62-year-old woman with a long-standing history of hypertension presents with severe
headache; it started this morning and is rapidly worsening. During the interview, she suddenly
collapses. Your brief examination shows that she responds with extensor posturing on external
stimuli. Her deep tendon reflexes are 3, and you elicit Babinski bilaterally. You also notice that
her breathing has a peculiar pattern: deep inspiration with a pause at full inspiration, followed by
a brief insufficient release and the end-inspiration pause.
How do you best describe her respiratory pattern?
Answer Choices
1 Cheyne-Stokes
2 Apneusis
3 Ataxic
4 Cluster
5 Central neurogenic hyperventilation - -Her breathing pattern is apneustic. Apneustic breathing
pattern characterizes *deep, gasping inspiration with a pause at full inspiration followed by a
brief, insufficient release and the end-inspiration pause before expiration.*
-What is the mechanism of LMWH? - -Both unfractionated heparin and low molecular weight
Heparin act by *forming a complex with antithrombin III.*
-A 5-day-old male infant has subtle, unusual facial features (i.e., a triangular face, hypertelorism,
and down-slanting eyes). He also has a webbed neck and low-set ears. Suspecting a congenital
disorder, you order a complete work-up, including a CBC, coagulation profile, cardiac
evaluation, karyotyping, and mutation analysis. PTPN11 (protein-tyrosine phosphatase,
nonreceptor-type 11) mutations are detected. Echocardiography detects a cardiac defect.
What's most likely to be found on echo? - -This neonate most likely has Noonan syndrome (NS).
Pulmonary stenosis is the most common cardiac defect in this condition.
,Noonan syndrome is a sporadic, or autosomal dominant, congenital disorder with typical
phenotypical features that may not be visible to the casual onlooker. The most common facial
features include hypertelorism and low-set, backward-rotated ears with a thick helix. The
philtrum is deeply grooved in more than 90% of cases. Congenital cardiac defects, bleeding
disorders, mental retardation, webbed neck, and a short stature are other features.
-A 35-year-old woman presents for follow-up. She has a 6-month past medical history of
hypertension; it has responded poorly to lifestyle approaches. She denies using any medications;
she does not smoke or use illicit drugs. Her review of systems is notable for muscular weakness,
paresthesias, headaches, polyuria, and polydipsia. On physical exam, her blood pressure is
155/95 mm Hg. She has generalized muscular weakness that is measured in all 4 extremities.
The remainder of her exam is unremarkable. Laboratory analysis reveals hypokalemia and a
hemoglobin A1c level of 5.5.
What dx test result is most likely?
1 Metabolic alkalosis
2 Low serum aldosterone to plasma renin activity ratio
3 Hyponatremia
4 Increased erythrocyte sedimentation rate
5 Hypoglycemia - -The correct response is metabolic alkalosis.
This patient is demonstrating signs and symptoms consistent with primary hyperaldosteronism,
which is most commonly caused by a unilateral adrenocortical adenoma (Conn's syndrome), but
in a minority of patients, it is caused by adrenal hyperplasia.
-A 40-year-old man presents with atrial flutter with 2:1 atrioventricular (AV) conduction, giving
him a pulse of 150 per minute, which is perfectly regular. His blood pressure is 70/40 mm Hg.
He takes no medications regularly. You plan to provide him with urgent direct current
cardioversion with conscious sedation. What would be an appropriate level of energy for
cardioversion in order to restore sinus rhythm in this patient?
1. 10 Joules
2. 15 Joules
3. 50 Joules
4. 200 Joules
5. 300 Joules
6. 360 Joules - -Of all of the arrhythmias, both supraventricular and ventricular, atrial flutter is
the easiest to cardiovert back to a regular sinus rhythm. Direct cardioversion is usually successful
with low energy - 25 to 100 Joules. There is no need to apply especially high energies such as
200 Joules, 300 Joules, or 360 Joules as the initial energy for cardioversion in case of atrial
flutter, as higher energies have a greater probability of causing burns or broken bones. On the
other hand, 10 or 15 Joules is unlikely to result in a successful cardioversion.
*50*
,-A 48-year-old man is brought to the ER complaining of difficulty breathing, fatigue, and
intermittent chest pain for the past month. On further questioning, he states that the breathing
seems to worsen when lying down. On physical exam, you note elevated respiratory and heart
rates and pale, sweaty skin. On auscultation, rales are noted as well as a 3rd heart sound. Which
of the following is the most likely diagnosis?
1 Right Ventricular failure
2 Pulmonary Embolism
3 Mitral Valve Stenosis
4 Left Ventricular failure
5 Chronic Obstructive Pulmonary Disease (COPD) - -Left Ventricular failure
The clinical picture is suggestive of left ventricular failure (LVF). Clinical presentation includes
dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. The patient may also have hemoptysis,
chest pain, fatigue, nocturia, and confusion. On physical exam, the patient may present with cold,
pale sweaty skin, tachypnea and tachycardia, rales, and 3rd and 4th heart sounds. This is
diagnostically different from right ventricular failure.
Right ventricular failure (RVF) has a clinical picture of shortness of breath, pedal edema, and
abdominal pain. On PE, RVF will present with a S3, jugular venous distention (JVD) and may
have signs of LVF.
-A 41-year-old woman presents for follow-up regarding elevated blood pressure. This is her third
visit to the office, and her blood pressure has been elevated on multiple readings at each visit.
She has a history of eczema but is otherwise healthy. Labs reveal the following:
WBC: 14.5 k/uL
Hgb: 13.5 g/dL
HCT: 41%
PLT: 152 k/uL
Na: 135 mmol/L
K: 2.8 mmol/L
Cl: 99 mmol/L
CO2: 32 mmol/L
BUN: 10 mmol/L
Cr: 1.02 mmol/L
What lab abnormality is most likely to be causing her secondary htn? - -*Hypokalemia is
correct.* Patients with primary hypertension should not have abnormalities in serum electrolytes.
The patient's hypokalemia suggests a secondary cause of hypertension. *The most common
cause of secondary hypertension is renal artery stenosis caused by fibrosmuscular dysplasia.* If
the adult is middle-aged, then the most common secondary cause of hypertension would be
*aldosteronism and a highly recommended initial diagnostic test would be an aldosterone/renin
ratio.*
Age is incorrect. This patient is 41 years old. Secondary hypertension is more likely in patients
under 30 years old or over 50 years old.
, Female gender is incorrect. Primary hypertension is more common in middle-aged males than
middle-aged females. The gender distribution for secondary hypertension varies with the specific
cause of secondary hypertension. Hypokalemia is the most suggestive risk factor of secondary
hypertension in this patient.
Eczema is incorrect. Eczema is not a risk factor for secondary hypertension
Leukocytosis is incorrect. Leukocytosis is not associated with secondary hypertension.
-A 78-year-old man with known left-sided congestive heart failure presents with a complaint of
cough, worsening dyspnea with exertion, and orthopnea. What is the most direct cause of his
symptoms?
1. Tricuspid insufficiency
2. Left ventricular hypertrophy
3 .Decreased peripheral vascular resistance
4. Increased pulmonary venous pressure
5. Mucus plugging - -Increased pulmonary venous pressure
In left-sided congestive heart failure, the predominant feature is *low cardiac output and elevated
pulmonary venous pressure, resulting in dyspnea.* As dyspnea worsens, the patient will also
begin to experience shortness of breath at rest, which is worsened in the supine position.
Tricuspid function is not related to CHF.
Peripheral vascular resistance typically increases in CHF, which is designed to help maintain
perfusion to vital organs.
Mucus plugging is not associated with CHF.
-A 58-year-old woman presents with a 3-month history of postprandial abdominal pain. This
crampy pain occurs 30 minutes after eating, every time. Due to these symptoms, the patient has
lost 30 pounds and is afraid to eat. Her past medical history includes hypertension treated with
enalapril, coronary artery disease for which she has undergone a right coronary artery stent, and
she underwent a carotid endarterectomy for symptomatic carotid stenosis. She has smoked 2
packs of cigarettes a day for 30 years.
What is the best initial test for this patient?
1 Mesenteric angiogram
2 Mesenteric duplex ultrasound
3 Computerized tomography (CT)
4 Magnetic resonance angiography (MRA)
5 Computerized tomography angiography (CTA) - -The symptoms of chronic mesenteric
ischemia have a typical presentation, including a cachectic, middle-aged patient with crampy
Level 2023
An 80-year-old man was treated for ventricular arrhythmias. He presents 1 month later with joint
pain. He also has an unusual mask-like rash over his face and body. Discontinuation of drug
therapy causes the symptoms to abate. What drug was most likely administered to this patient?
1 Tocainide
2 Quinidine
3 Procainamide
4 Phenytoin
5 Propranolol - -Procainamide - often prescribed for long-term control of arrhythmias. May
cause lupus like SE.
-A 62-year-old woman with a long-standing history of hypertension presents with severe
headache; it started this morning and is rapidly worsening. During the interview, she suddenly
collapses. Your brief examination shows that she responds with extensor posturing on external
stimuli. Her deep tendon reflexes are 3, and you elicit Babinski bilaterally. You also notice that
her breathing has a peculiar pattern: deep inspiration with a pause at full inspiration, followed by
a brief insufficient release and the end-inspiration pause.
How do you best describe her respiratory pattern?
Answer Choices
1 Cheyne-Stokes
2 Apneusis
3 Ataxic
4 Cluster
5 Central neurogenic hyperventilation - -Her breathing pattern is apneustic. Apneustic breathing
pattern characterizes *deep, gasping inspiration with a pause at full inspiration followed by a
brief, insufficient release and the end-inspiration pause before expiration.*
-What is the mechanism of LMWH? - -Both unfractionated heparin and low molecular weight
Heparin act by *forming a complex with antithrombin III.*
-A 5-day-old male infant has subtle, unusual facial features (i.e., a triangular face, hypertelorism,
and down-slanting eyes). He also has a webbed neck and low-set ears. Suspecting a congenital
disorder, you order a complete work-up, including a CBC, coagulation profile, cardiac
evaluation, karyotyping, and mutation analysis. PTPN11 (protein-tyrosine phosphatase,
nonreceptor-type 11) mutations are detected. Echocardiography detects a cardiac defect.
What's most likely to be found on echo? - -This neonate most likely has Noonan syndrome (NS).
Pulmonary stenosis is the most common cardiac defect in this condition.
,Noonan syndrome is a sporadic, or autosomal dominant, congenital disorder with typical
phenotypical features that may not be visible to the casual onlooker. The most common facial
features include hypertelorism and low-set, backward-rotated ears with a thick helix. The
philtrum is deeply grooved in more than 90% of cases. Congenital cardiac defects, bleeding
disorders, mental retardation, webbed neck, and a short stature are other features.
-A 35-year-old woman presents for follow-up. She has a 6-month past medical history of
hypertension; it has responded poorly to lifestyle approaches. She denies using any medications;
she does not smoke or use illicit drugs. Her review of systems is notable for muscular weakness,
paresthesias, headaches, polyuria, and polydipsia. On physical exam, her blood pressure is
155/95 mm Hg. She has generalized muscular weakness that is measured in all 4 extremities.
The remainder of her exam is unremarkable. Laboratory analysis reveals hypokalemia and a
hemoglobin A1c level of 5.5.
What dx test result is most likely?
1 Metabolic alkalosis
2 Low serum aldosterone to plasma renin activity ratio
3 Hyponatremia
4 Increased erythrocyte sedimentation rate
5 Hypoglycemia - -The correct response is metabolic alkalosis.
This patient is demonstrating signs and symptoms consistent with primary hyperaldosteronism,
which is most commonly caused by a unilateral adrenocortical adenoma (Conn's syndrome), but
in a minority of patients, it is caused by adrenal hyperplasia.
-A 40-year-old man presents with atrial flutter with 2:1 atrioventricular (AV) conduction, giving
him a pulse of 150 per minute, which is perfectly regular. His blood pressure is 70/40 mm Hg.
He takes no medications regularly. You plan to provide him with urgent direct current
cardioversion with conscious sedation. What would be an appropriate level of energy for
cardioversion in order to restore sinus rhythm in this patient?
1. 10 Joules
2. 15 Joules
3. 50 Joules
4. 200 Joules
5. 300 Joules
6. 360 Joules - -Of all of the arrhythmias, both supraventricular and ventricular, atrial flutter is
the easiest to cardiovert back to a regular sinus rhythm. Direct cardioversion is usually successful
with low energy - 25 to 100 Joules. There is no need to apply especially high energies such as
200 Joules, 300 Joules, or 360 Joules as the initial energy for cardioversion in case of atrial
flutter, as higher energies have a greater probability of causing burns or broken bones. On the
other hand, 10 or 15 Joules is unlikely to result in a successful cardioversion.
*50*
,-A 48-year-old man is brought to the ER complaining of difficulty breathing, fatigue, and
intermittent chest pain for the past month. On further questioning, he states that the breathing
seems to worsen when lying down. On physical exam, you note elevated respiratory and heart
rates and pale, sweaty skin. On auscultation, rales are noted as well as a 3rd heart sound. Which
of the following is the most likely diagnosis?
1 Right Ventricular failure
2 Pulmonary Embolism
3 Mitral Valve Stenosis
4 Left Ventricular failure
5 Chronic Obstructive Pulmonary Disease (COPD) - -Left Ventricular failure
The clinical picture is suggestive of left ventricular failure (LVF). Clinical presentation includes
dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. The patient may also have hemoptysis,
chest pain, fatigue, nocturia, and confusion. On physical exam, the patient may present with cold,
pale sweaty skin, tachypnea and tachycardia, rales, and 3rd and 4th heart sounds. This is
diagnostically different from right ventricular failure.
Right ventricular failure (RVF) has a clinical picture of shortness of breath, pedal edema, and
abdominal pain. On PE, RVF will present with a S3, jugular venous distention (JVD) and may
have signs of LVF.
-A 41-year-old woman presents for follow-up regarding elevated blood pressure. This is her third
visit to the office, and her blood pressure has been elevated on multiple readings at each visit.
She has a history of eczema but is otherwise healthy. Labs reveal the following:
WBC: 14.5 k/uL
Hgb: 13.5 g/dL
HCT: 41%
PLT: 152 k/uL
Na: 135 mmol/L
K: 2.8 mmol/L
Cl: 99 mmol/L
CO2: 32 mmol/L
BUN: 10 mmol/L
Cr: 1.02 mmol/L
What lab abnormality is most likely to be causing her secondary htn? - -*Hypokalemia is
correct.* Patients with primary hypertension should not have abnormalities in serum electrolytes.
The patient's hypokalemia suggests a secondary cause of hypertension. *The most common
cause of secondary hypertension is renal artery stenosis caused by fibrosmuscular dysplasia.* If
the adult is middle-aged, then the most common secondary cause of hypertension would be
*aldosteronism and a highly recommended initial diagnostic test would be an aldosterone/renin
ratio.*
Age is incorrect. This patient is 41 years old. Secondary hypertension is more likely in patients
under 30 years old or over 50 years old.
, Female gender is incorrect. Primary hypertension is more common in middle-aged males than
middle-aged females. The gender distribution for secondary hypertension varies with the specific
cause of secondary hypertension. Hypokalemia is the most suggestive risk factor of secondary
hypertension in this patient.
Eczema is incorrect. Eczema is not a risk factor for secondary hypertension
Leukocytosis is incorrect. Leukocytosis is not associated with secondary hypertension.
-A 78-year-old man with known left-sided congestive heart failure presents with a complaint of
cough, worsening dyspnea with exertion, and orthopnea. What is the most direct cause of his
symptoms?
1. Tricuspid insufficiency
2. Left ventricular hypertrophy
3 .Decreased peripheral vascular resistance
4. Increased pulmonary venous pressure
5. Mucus plugging - -Increased pulmonary venous pressure
In left-sided congestive heart failure, the predominant feature is *low cardiac output and elevated
pulmonary venous pressure, resulting in dyspnea.* As dyspnea worsens, the patient will also
begin to experience shortness of breath at rest, which is worsened in the supine position.
Tricuspid function is not related to CHF.
Peripheral vascular resistance typically increases in CHF, which is designed to help maintain
perfusion to vital organs.
Mucus plugging is not associated with CHF.
-A 58-year-old woman presents with a 3-month history of postprandial abdominal pain. This
crampy pain occurs 30 minutes after eating, every time. Due to these symptoms, the patient has
lost 30 pounds and is afraid to eat. Her past medical history includes hypertension treated with
enalapril, coronary artery disease for which she has undergone a right coronary artery stent, and
she underwent a carotid endarterectomy for symptomatic carotid stenosis. She has smoked 2
packs of cigarettes a day for 30 years.
What is the best initial test for this patient?
1 Mesenteric angiogram
2 Mesenteric duplex ultrasound
3 Computerized tomography (CT)
4 Magnetic resonance angiography (MRA)
5 Computerized tomography angiography (CTA) - -The symptoms of chronic mesenteric
ischemia have a typical presentation, including a cachectic, middle-aged patient with crampy
