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THE CARDIOVASCULAR SYSTEM JAMEEL AL-ATA, M.D. Assistant Professor & Consultant Pediatric Cardiologist King Abdulaziz University Hospital 1. The finding of substernal thrust on palpation of the precordium is most likely to be associated with which one of the following? a. Left ventricular hypertrophy b. Right ventricular hypertrophy c. An ejection click d. Systemic hypertension e. Pericardial effusion 2. A still murmur is a. An early diastolic murmur signifying mitral stenosis b. An innocent murmur that disappears on jugular pressure c. An innocent, musical, vibratory ejection murmur heard best when the patient is in the recumbent position d. An innocent, blowing, early systolic murmur that increases in intensity on expiration e. A blowing diastolic murmur most frequently heard in the newborn period 3. Electrocardiograms are useful in the diagnosis of each of the following EXCEPT a. b. c. d. e. Congenital heart disease Rheumatic heart disease Electrolyte disorders Endocrine and metabolic disease Prematurity 4. Each of the following is a critical congenital heart disease of the neonate EXCEPT a. b. c. d. e. Transposition of the great vessels Hypoplastic left heart syndrome Right ventricular outflow obstruction Coarctation of the aorta Endocardial fibroelastosis 5. Congenital rubella syndrome is associated with which of the following? a. Patent ductus arteriosus (PDA) and branch pulmonary artrery stenosis b. Ventricular septal defect (VSD) and PDA c. Atrial septal defect (ASD) and PDA d. VSD and ASD e. VSD and pulmonary artery stenosis 6. Which of the following is the most common congenital heart defect in infants and children (excluding the neonatal period)? a. ASD b. VSD c. PDA d. Coarctation of the aorta e. Tetralogy of Fallot 7. Tetralogy of Fallot consists of each of the following cardiac malformations EXCEPT a. Pulmonary stenosis b. VSD c. ASD d. Dextroposition of the aorta e. Right ventricular hypertrophy 8. Each of the following statements about transposition of the great arteries is true EXCEPT a. It is the primary cause of death from cyanotic congenital heart disease in the first year of life b. Congestive heart failure occurs by 4 months of age when a VSD is present c. A VSD, PDA, and/or an ASD must be present for the newborn to survive d. The electrocardiogram is often normal initially in the newborn period e. More females than males are affected 9. In recent years the development of which of the following has improved the survival rate of infants with transposition of the great arteries? a. Rashkind procedure (balloon atrial septostomy) b. Echocardiography c. Blalock-Taussig procedure (subclavian pulmonary anastomosis) d. Brock procedure (infundibular resection) e. Home oxygen availability 10. Which one of the following is NOT present in tricuspid atresia? a. Left axis deviation on electrocardiogram b. Patent foramen ovale c. Right ventricular hypoplasia d. Split second heart sound e. Diminished pulmonary vascularity on plain anteroposterior chest film 11. Which of the following statements regarding ventricular septal defect is correct? a. It is most easily diagnosed at birth b. Congestive heart failure usually develops within the first month of life c. The defect is usually small and closes spontaneously d. Surgery should usually be performed within the first six months to prevent subacute bacterial endocarditis e. Pulmonary hypertension will develop rapidly if the defect is not treated surgically 12. Which one of the following statements about atrial septal defect is true? a. The murmur is caused by rapid flow from the left atrium to the right atrium b. The second heart sound is variably split c. High flow through the pulmonary artery causes a palpable thrill at the upper left sternal border d. The defect is a patent foramen ovale e. It causes heart failure in 50% of infants with the defect 13. Which of the following is the most serious atrial septal defect? a. Ostium primum defect b. Ostium secundum defect c. Endocardial cushion defect with common atrioventricular canal d. Patent foramen ovale 14. A diastolic as well as a systolic murmur in a child with a patent ductus arteriosus generally indicates which one of the following? a. Normal or only slightly elevated pulmonary arterial pressure b. Pulmonary hypertension c. Systemic hypotension d. Mitral stenosis e. Tricuspid stenosis 15. The majority of coarctations of the aorta occur a. Between the origin of the right subclavian artery and the right carotid artery b. Between the right and left carotid arteries c. Between the left carotid artery and the left subclavian artery d. Below the left subclavian artery e. At the level of the diaphragm 16. In total anomalous pulmonary venous return, the anomalous vein most often enters the a. Coronary sinus b. Left superior vena cava c. Right superior vena cava d. Portal vein e. Ductus venosus 17. The syndrome of idiopathic hypercalcemia, hypertelorism, and mental retardation is associated with which one of the following? a. Supravalvular aortic stenosis b. Valvular aortic stenosis c. Subvalvular aortic stenosis d. Aortic insufficiency e. Patent ductus arteriosus QUESTIONS 18-19 A teenage girl comes to the clinic complaining that her “heart beats fast sometimes”. She is otherwise well, healthy, and doing well in school. She denies taking any drugs, and she does not smoke cigarettes. Physical examination is unremarkable. Pulse rate is 80 per minute. You decide to do an electrocardiogram. 18. Below are five electrocardiograms. Which is most likely to be from this patient? (If you were to have a tracing when she is symptomatic). 19. Reversion of this patient’s electrocardiogram to normal will occur most readily with which of the following? a. Vagal stimulation b. Digoxin c. Quinidine d. D-C cardioversion e. Phenytoin-(Dilantin) 20. The most common underlying factor in children who develop acute bacterial endocarditis is which of the following? a. Congenital heart disease b. Dental surgery c. Streptococcal pharyngitis d. Acute rheumatic fever e. Tonsillectomy 21. Which of the following is the most important procedure in the diagnosis of subacute bacterial endocarditis? a. Complete blood count b. Urinalysis (microscopic) c. Erythrocyte sedimentation rate d. Blood cultures e. Electrocardiogram 22. Which of the following is the most common immediate valvular lesion resulting from acute rheumatic fever? a. Mitral insufficiency b. Mitral stenosis c. Aortic insufficiency d. Aortic stenosis e. Tricuspid insufficiency 23. Evidence that digitalis has had an effect in an infant with congestive heart failure would include each of the following EXCEPT a. Diminished venous pressure b. Decreased liver size c. Decreased P-R interval on electrocardiogram d. Decreased heart rate e. Increased urinary output 24. Pulsus paradoxus is associated with a. b. c. d. e. pericarditis endocarditis Rheumatic fever myocarditis Postperfusion syndrome 25. The combination of tachycardia, enlarged liver, a cardiac gallop without murmurs, and a cranial bruit is most likely a. Congestive heart failure from viral myocarditis b. Congestive heart failure from mucocutaneous lymph node syndrome c. Congestive heart failure from an intracranial hemangioma d. Thyrotoxicosis e. Aneurysm of the circle (intracranial aneurysm) of Willis 26. Potentially curable forms of hypertension in children include each of the following EXCEPT a. Neuroblastoma b. Pheochromocytoma c. Medullary cystic disease d. Renal artery stenosis e. Ingestion of excessive amounts of licorice 27. Each of the following statements about hyperlipidemia in children is true EXCEPT a. Screening programs have not been shown to be cost beneficial b. Cholesterol is the major blood lipid implicated in the pathogenesis of arteriosclerotic heart disease c. Dietary regulation is the most important treatment modality d. Colestipol is the most effective cholesterol-lowering agent available e. Surgical therapy (portocaval shunts) has shown promising results QUESTIONS 28-29 A 16-year old girl comes to your office because of dizziness and throbbing heartaches occurring two or three times a day. She has no other complaints and is otherwise in good health. There is no family history of hypertension. 28. Important other history would include which of the following? (Choose as many as are appropriate). a. Renal trauma b. Immunizations c. Drug use d. Smoking e. Visual problems f. Nocturnal cough g. Personality change h. Excessive sweating 29. There is no history of renal trauma. Immunizations are up to date. She neither smokes nor drinks, but does take oral contraceptives. Her vision is fine, and she has no cough at all. There has been no personality change or excessive sweating. On physical examination you find that blood pressure is 140/100 mm Hg; pulse is 90 per minute; height and weight are in the 25th percentile. The remainder of the physical examination including funduscopic examination and complete neurologic examination, is normal. There are no abdominal bruits, and her thyroid gland is normal. Which one of the following would be indicated at this point? Con’t. (29) a. Repeat blood pressure measurements at least twice over the next few weeks b. Order complete blood count, urinalysis, urine culture, and intravenous urogram c. Measure urinary catecholamines, 17hydroxysteroids, and 7-ketosteroids d. Tell her to discontinue oral contraceptives e. Begin antihypertensive therapy 30. Each of the following is true about hypertension in children EXCEPT a. Essential hypertension is the most common form b. Most newborns with hypertension have hyperthyroidism c. Renal disease if the most likely etiology in childhood if hypertension is secondary d. A discrepancy in renin secretion of greater than 1.5:1 indicates renal involvement on the side with the higher level e. The natural history of essential hypertension is not known 31. The most common cardiac childhood is a. Rhabdomyosarcoma b. Mesothelioma c. Papilloma d. Lipoma e. Myxoma tumor in