USMLE EXAM QUESTIONS WITH
REVISED ANSWERS (VERIFIED
ANSWERS) ALREADY GRADED A+
A 50-year-old man comes to the emergency department due to intermittent palpitations
over the last 6 months. The patient describes them as "very uncomfortable" and says
the episodes occur randomly, last for several hours, and resolve spontaneously or with
sleep. The current episode started an hour ago and has been accompanied by
lightheadedness He has no medical history and says that he does not like seeing
doctors. He is a lifetime nonsmoker The patient drinks beer on weekends He has no
family history of cardiovascular disease Temperature is normal and blood pressure is
122/75 mmHg BMI is 30 kg/m2 Chest examination reveals no murmurs and the lungs
are clear on auscultation There is trace peripheral edema Cardiac rhythm strip obtained
in the emergency department is shown in the exhibit Aberrant electrical activity in which
of the following anatomic structures is the most likely trigger for this patient's current
cond - Answer-C
A 21-year-old man comes to the office due to recurrent heart palpitations that start and
stop abruptly. After initial workup, the physician suspects that there is an abnormal
conduction pathway in this patient's heart that bypasses the atrioventricular node.
Assuming the diagnosis is correct, which part of the patient's ECG is most likely to be
affected during normal sinus rhythm?
A. A
B. B
C. C
D. D
E. E - Answer-B
A72-year-old man with long-standing dyspnea was seen in the clinic after experiencing
an episode of syncope. Physical examination showed weak and slowly rising arterial
pulses. Cardiac auscultation showed a harsh midsystolic murmur best heard at the
second right intercostal space with decreased intensity of the second heart sound
Electrocardiogram and echocardiogram confirmed the diagnosis of severe aortic
stenosis. Two months later the patient comes to the emergency department with
palpitations and increased shortness of breath His blood pressure is 90/60 mm Hg and
his heart rate is 130/min with an irregularly irregular rhythm Electrocardiogram shows
new-on set atrial fibrillation on without significant ST-segment or T-wave changes.
Chest x-ray shows bilateral pulmonary edema Which of the following hemodynamic
changes is most likely associated with this patient's current presentation?
A insidious right ventricular f - Answer-B
,A 77-year-old woman is brought to the emergency department with severe
lightheadedness and near-syncope that began earlier in the day Over the past several
months she has experienced occasional episodes of lightheadedness and feeling
unsteady, which she attributed to ''old age" The patient has not had chest pain
shortness of breath, or lower extremity swelling She was diagnosed with hypertension
10 years ago and has been taking Losartan The patient does not take any other
medications She lives alone and is independent in her daily activities An ECG obtained
in the emergency department is shown in the exhibit Cell degeneration in which of the
following locations is most likely responsible for this patient's current condition?
A Interatrial septum
B Interventricular septum
C Left atrial wall
D Left ventricular free wall
E Right atrial wall - Answer-E
A 62-year-old man with a long history of hypertension comes to the clinic for a routine
physical examination. Blood pressure is 150/90 mm Hg and heart rate is 74;min and
regular. Cardiac auscultation reveals a low-frequency, presystolic sound that
immediately precedes the S1 heart sound and is best heard during expiration when the
patient is lying on his left side. Chest x-ray reveals Extensive calcification around the
mitral and aortic valves Which of the following is the most likely explanation for the
additional heart sound1?
A Increased flow velocity through the aortic valve
B Increased stiffness of the left ventricular wall
C. Rapid passive filling of the ventricles
D. Restricted motion of the aortic valve cusps
E Systolic anterior motion of the mitral valve - Answer-B
A 53-year-old man comes to the office with progressive exertion dyspnea. He has
smoked 2 packs of cigarettes per day for the last 36 years. Physical examination shows
increased anterioposterior diameter of his chest Auscultation reveals decreased breath
sounds and scattered wheezes throughout Ins lungs Exam in a Lion of his extremities is
unremarkable An echocardiogram reveals moderate dilation of the right ventricle and
increased central venous pressure The absence of peripheral edema in this patient is
best explained by which of the following compensatory mechanisms?
A Decreased capillary permeability
B Decreased circulating aldosterone levels
C. Decreased interstitial fluid pressure
D. Increased plasma oncotic pressure
E Increased tissue lymphatic drainage - Answer-E
A 32-year-old woman comes to the emergency department with lightheadedness and
shortness of breath, which started while shopping at a supermarket. During the last 6
months; she had increasing shortness of breath and had to adjust her daily activities
The patient has no other medical problems and does not use tobacco alcohol, or illicit
, drugs. There is no family history of heart disease stroke or blood Clots Her BMI is 25
kg/m2. After initial assessment the patient reports that she feels ''fine." refuses further
evaluation and insists on being discharged She dies a month later At autopsy, her heart
has the following appearance (RV, right ventricle; LV, left ventricle):
Which of the following is l he most likely diagnosis?
A Bicuspid aortic valve with acquired aortic stenosis-
B Dilated Cardiomyopathy
C Essential hypertension
D. Myocardial infarction
E Pulmonary arterial hypertension
F Wolff-Farkinson-White syndrome - Answer-E
A 42-year-ald man comes to the emergency department due to acute-onset shortness
of breath. He has no medical conditions and does net use alcohol, tobacco, or illicit
drugs The patient works as a box handler at a warehouse and has excellent exercise
tolerance Family history is insignificant. Blood pressure is 98760 mm Hg and pulse is
112/min and regular A short systolic murmur is heard at the apex. Bilateral crackles are
present on lung auscultation Bedside echocardiography reveals a flail posterior mitral
leaflet due to chordal rupture and severe mitral regurgitation Which of the following best
reflects this patient's left ventricular hemodynamics compared to the normal heart?
A Afterload decrease preload decrease, ejection fraction decrease
B Afterioad decrease, preload increase ejection fraction increase
C Afterioad increase, preload decrease, ejection fraction decrease
D Afterioad increase, preload decrease, ejec - Answer-B
A63-year-old man comes to the office due to exertional dyspnea that has been
progressively worsening over the last 3 weeks. He sleeps in a recliner with his head
elevated because he gets short of breath when Hying flat in bed. Medical history
includes gout dyslipidemia and hypertension Blood pressure is 154/S& rum Hg and
pulse s SS/min Physical examination shows distended jugular veins in the semi-
recumbent position An apical heave 15 present on cardiac examination There is pitting
edema in 1he bilateral lower extremities Levels of which of I he following substances will
be higher in the pulmonary vein compared to the pulmonary artery in this patient?
A Aldosterone
B Angiotensin I
C Angiotensin II
D. Angiotensinase
E Angiotensinogen
F Arginine vasopressin
G Prostaglandin E1
H. Renin - Answer-C
A 45-year-old man comes to clinic due to frequent fibrillation associated with a rapid
ventricular response rate. A radio-frequency ablation procedure is planned. The access
site is the right femoral vein. The ablation catheter is advanced to the left atrium where
radiofrequency energy is used to eliminate an ectopic focus of abnormal electrical
REVISED ANSWERS (VERIFIED
ANSWERS) ALREADY GRADED A+
A 50-year-old man comes to the emergency department due to intermittent palpitations
over the last 6 months. The patient describes them as "very uncomfortable" and says
the episodes occur randomly, last for several hours, and resolve spontaneously or with
sleep. The current episode started an hour ago and has been accompanied by
lightheadedness He has no medical history and says that he does not like seeing
doctors. He is a lifetime nonsmoker The patient drinks beer on weekends He has no
family history of cardiovascular disease Temperature is normal and blood pressure is
122/75 mmHg BMI is 30 kg/m2 Chest examination reveals no murmurs and the lungs
are clear on auscultation There is trace peripheral edema Cardiac rhythm strip obtained
in the emergency department is shown in the exhibit Aberrant electrical activity in which
of the following anatomic structures is the most likely trigger for this patient's current
cond - Answer-C
A 21-year-old man comes to the office due to recurrent heart palpitations that start and
stop abruptly. After initial workup, the physician suspects that there is an abnormal
conduction pathway in this patient's heart that bypasses the atrioventricular node.
Assuming the diagnosis is correct, which part of the patient's ECG is most likely to be
affected during normal sinus rhythm?
A. A
B. B
C. C
D. D
E. E - Answer-B
A72-year-old man with long-standing dyspnea was seen in the clinic after experiencing
an episode of syncope. Physical examination showed weak and slowly rising arterial
pulses. Cardiac auscultation showed a harsh midsystolic murmur best heard at the
second right intercostal space with decreased intensity of the second heart sound
Electrocardiogram and echocardiogram confirmed the diagnosis of severe aortic
stenosis. Two months later the patient comes to the emergency department with
palpitations and increased shortness of breath His blood pressure is 90/60 mm Hg and
his heart rate is 130/min with an irregularly irregular rhythm Electrocardiogram shows
new-on set atrial fibrillation on without significant ST-segment or T-wave changes.
Chest x-ray shows bilateral pulmonary edema Which of the following hemodynamic
changes is most likely associated with this patient's current presentation?
A insidious right ventricular f - Answer-B
,A 77-year-old woman is brought to the emergency department with severe
lightheadedness and near-syncope that began earlier in the day Over the past several
months she has experienced occasional episodes of lightheadedness and feeling
unsteady, which she attributed to ''old age" The patient has not had chest pain
shortness of breath, or lower extremity swelling She was diagnosed with hypertension
10 years ago and has been taking Losartan The patient does not take any other
medications She lives alone and is independent in her daily activities An ECG obtained
in the emergency department is shown in the exhibit Cell degeneration in which of the
following locations is most likely responsible for this patient's current condition?
A Interatrial septum
B Interventricular septum
C Left atrial wall
D Left ventricular free wall
E Right atrial wall - Answer-E
A 62-year-old man with a long history of hypertension comes to the clinic for a routine
physical examination. Blood pressure is 150/90 mm Hg and heart rate is 74;min and
regular. Cardiac auscultation reveals a low-frequency, presystolic sound that
immediately precedes the S1 heart sound and is best heard during expiration when the
patient is lying on his left side. Chest x-ray reveals Extensive calcification around the
mitral and aortic valves Which of the following is the most likely explanation for the
additional heart sound1?
A Increased flow velocity through the aortic valve
B Increased stiffness of the left ventricular wall
C. Rapid passive filling of the ventricles
D. Restricted motion of the aortic valve cusps
E Systolic anterior motion of the mitral valve - Answer-B
A 53-year-old man comes to the office with progressive exertion dyspnea. He has
smoked 2 packs of cigarettes per day for the last 36 years. Physical examination shows
increased anterioposterior diameter of his chest Auscultation reveals decreased breath
sounds and scattered wheezes throughout Ins lungs Exam in a Lion of his extremities is
unremarkable An echocardiogram reveals moderate dilation of the right ventricle and
increased central venous pressure The absence of peripheral edema in this patient is
best explained by which of the following compensatory mechanisms?
A Decreased capillary permeability
B Decreased circulating aldosterone levels
C. Decreased interstitial fluid pressure
D. Increased plasma oncotic pressure
E Increased tissue lymphatic drainage - Answer-E
A 32-year-old woman comes to the emergency department with lightheadedness and
shortness of breath, which started while shopping at a supermarket. During the last 6
months; she had increasing shortness of breath and had to adjust her daily activities
The patient has no other medical problems and does not use tobacco alcohol, or illicit
, drugs. There is no family history of heart disease stroke or blood Clots Her BMI is 25
kg/m2. After initial assessment the patient reports that she feels ''fine." refuses further
evaluation and insists on being discharged She dies a month later At autopsy, her heart
has the following appearance (RV, right ventricle; LV, left ventricle):
Which of the following is l he most likely diagnosis?
A Bicuspid aortic valve with acquired aortic stenosis-
B Dilated Cardiomyopathy
C Essential hypertension
D. Myocardial infarction
E Pulmonary arterial hypertension
F Wolff-Farkinson-White syndrome - Answer-E
A 42-year-ald man comes to the emergency department due to acute-onset shortness
of breath. He has no medical conditions and does net use alcohol, tobacco, or illicit
drugs The patient works as a box handler at a warehouse and has excellent exercise
tolerance Family history is insignificant. Blood pressure is 98760 mm Hg and pulse is
112/min and regular A short systolic murmur is heard at the apex. Bilateral crackles are
present on lung auscultation Bedside echocardiography reveals a flail posterior mitral
leaflet due to chordal rupture and severe mitral regurgitation Which of the following best
reflects this patient's left ventricular hemodynamics compared to the normal heart?
A Afterload decrease preload decrease, ejection fraction decrease
B Afterioad decrease, preload increase ejection fraction increase
C Afterioad increase, preload decrease, ejection fraction decrease
D Afterioad increase, preload decrease, ejec - Answer-B
A63-year-old man comes to the office due to exertional dyspnea that has been
progressively worsening over the last 3 weeks. He sleeps in a recliner with his head
elevated because he gets short of breath when Hying flat in bed. Medical history
includes gout dyslipidemia and hypertension Blood pressure is 154/S& rum Hg and
pulse s SS/min Physical examination shows distended jugular veins in the semi-
recumbent position An apical heave 15 present on cardiac examination There is pitting
edema in 1he bilateral lower extremities Levels of which of I he following substances will
be higher in the pulmonary vein compared to the pulmonary artery in this patient?
A Aldosterone
B Angiotensin I
C Angiotensin II
D. Angiotensinase
E Angiotensinogen
F Arginine vasopressin
G Prostaglandin E1
H. Renin - Answer-C
A 45-year-old man comes to clinic due to frequent fibrillation associated with a rapid
ventricular response rate. A radio-frequency ablation procedure is planned. The access
site is the right femoral vein. The ablation catheter is advanced to the left atrium where
radiofrequency energy is used to eliminate an ectopic focus of abnormal electrical
