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ABPTS CCS study materials
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ABPTS CCS practice questions

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Question 1Cardiovascular system examination, evaluation, and clinical decision-making

A 70-year-old man with dyspnea has a low-pitched extra sound at the apex, heard with the bell while he is in the left lateral decubitus position. The sound occurs just after S2. Which heart sound is this?

  1. S4
  2. S1
  3. S3 Correct answer.
  4. S2

Explanation

S3 is a low-pitched early diastolic sound generated by rapid ventricular filling and is best heard at the apex with the bell in the left lateral decubitus position. It follows S2 and is associated with volume overload or reduced ventricular compliance. S4 occurs late in diastole, immediately before S1.

Question 2Cardiovascular system examination, evaluation, and clinical decision-making

Which jugular venous waveform is absent in a patient with atrial fibrillation?

  1. c wave
  2. v wave
  3. a wave Correct answer.
  4. y descent

Explanation

The a wave is produced by right atrial contraction and is therefore absent when atrial fibrillation eliminates effective atrial systole. The c wave reflects tricuspid valve closure and the v wave reflects atrial filling during systole. The y descent reflects tricuspid valve opening and atrial emptying.

Question 3Cardiovascular system examination, evaluation, and clinical decision-making

A blood pressure cuff that is too small for a patient's upper arm will most likely produce which measurement error?

  1. Falsely high systolic and diastolic pressures Correct answer.
  2. Falsely low systolic and diastolic pressures
  3. An isolated increase in diastolic pressure only
  4. No change in pressure readings

Explanation

An undersized cuff requires higher inflation pressure to occlude the brachial artery, so both systolic and diastolic readings are falsely elevated. Cuff bladder length should be about 80% and width about 40% of arm circumference. An oversized cuff tends to produce falsely low readings.

Question 4Cardiovascular system examination, evaluation, and clinical decision-making

Normal splitting of the second heart sound (S2) is expected to widen during which maneuver?

  1. Inspiration Correct answer.
  2. Expiration
  3. Standing
  4. The Valsalva maneuver

Explanation

Inspiration decreases intrathoracic pressure and increases venous return to the right heart, prolonging right ventricular ejection and delaying pulmonary valve closure. This widens the normal split between aortic and pulmonary components of S2. Expiration has the opposite effect and narrows the split.

Question 5Cardiovascular system examination, evaluation, and clinical decision-making

Which carotid pulse contour is most characteristic of severe aortic stenosis?

  1. Parvus et tardus Correct answer.
  2. Bounding and collapsing
  3. Bisferiens
  4. Pulsus alternans

Explanation

Severe aortic stenosis obstructs left ventricular outflow, producing a low-amplitude (parvus) and delayed (tardus) carotid upstroke. The pulse pressure is often narrow. Bounding and collapsing pulses suggest aortic regurgitation.

Question 6Cardiovascular system examination, evaluation, and clinical decision-making

Which ECG finding is the most specific indicator of acute transmural myocardial ischemia?

  1. ST-segment elevation in contiguous leads Correct answer.
  2. First-degree AV block
  3. Peaked T waves
  4. Sinus tachycardia

Explanation

ST-segment elevation in anatomically contiguous leads is the hallmark of acute transmural injury and should prompt urgent reperfusion evaluation. Peaked T waves can be an early sign but are less specific. AV block and sinus tachycardia are nonspecific findings.

Question 7Cardiovascular system examination, evaluation, and clinical decision-making

A patient with heart failure reports marked limitation of physical activity. He is comfortable at rest, but less than ordinary activity causes fatigue and dyspnea. Which NYHA functional class does this describe?

  1. Class II
  2. Class IV
  3. Class I
  4. Class III Correct answer.

Explanation

NYHA class III is marked limitation of activity, with symptoms on less than ordinary activity and comfort at rest. Class II is slight limitation with symptoms on ordinary activity. Class IV describes symptoms at rest.

Question 8Cardiovascular system examination, evaluation, and clinical decision-making

Which physical examination finding most directly suggests right heart failure?

  1. Bibasilar crackles
  2. Jugular venous distension Correct answer.
  3. An S3 sound at the apex
  4. A displaced apical impulse

Explanation

Jugular venous distension reflects elevated right atrial pressure and is a direct bedside sign of right heart failure. Bibasilar crackles and an S3 are more typical of left heart failure. A displaced apical impulse suggests left ventricular enlargement.

Question 9Cardiovascular system examination, evaluation, and clinical decision-making

Paradoxical splitting of the second heart sound is most likely in which condition?

  1. Right bundle branch block
  2. Atrial septal defect
  3. Pulmonary stenosis
  4. Severe aortic stenosis Correct answer.

Explanation

Paradoxical splitting occurs when left ventricular ejection is delayed enough that the aortic component of S2 follows the pulmonary component, so the split is heard in expiration and narrows with inspiration. Severe aortic stenosis is a classic cause. RBBB, ASD, and pulmonary stenosis typically cause wide or fixed splitting.

Question 10Cardiovascular system examination, evaluation, and clinical decision-making

Pulsus paradoxus is defined as an inspiratory fall in systolic blood pressure exceeding which threshold?

  1. 20 mmHg
  2. 10 mmHg Correct answer.
  3. 5 mmHg
  4. 15 mmHg

Explanation

Pulsus paradoxus is an exaggerated inspiratory drop in systolic pressure greater than 10 mmHg. It is classically associated with cardiac tamponade but also occurs in severe asthma and constrictive pericarditis. A normal inspiratory fall is usually less than 10 mmHg.

Question 11Cardiovascular system examination, evaluation, and clinical decision-making

A rise in jugular venous pressure during inspiration is called which sign, and is most associated with which condition?

  1. Friedreich sign; aortic regurgitation
  2. Kussmaul sign; constrictive pericarditis Correct answer.
  3. Duroziez sign; mitral stenosis
  4. Cannon a wave; complete heart block

Explanation

Kussmaul sign is a paradoxical rise in JVP with inspiration, caused by impaired right ventricular filling in constrictive pericarditis, restrictive cardiomyopathy, or right ventricular infarction. Cannon a waves occur with AV dissociation. Friedreich and Duroziez signs are arterial findings.

Question 12Cardiovascular system examination, evaluation, and clinical decision-making

On ECG, the PR interval progressively lengthens until a P wave is not followed by a QRS complex. Which rhythm does this describe?

  1. Third-degree AV block
  2. First-degree AV block
  3. Mobitz I second-degree AV block Correct answer.
  4. Mobitz II second-degree AV block

Explanation

Mobitz I (Wenckebach) AV block shows progressive PR prolongation followed by a dropped QRS. Mobitz II has constant PR intervals before dropped beats. Third-degree block shows complete AV dissociation, and first-degree block shows a constant prolonged PR.

Question 13Cardiovascular system examination, evaluation, and clinical decision-making

Which finding during exercise treadmill testing is an absolute indication to stop the test?

  1. A drop in systolic blood pressure of 15 mmHg from baseline Correct answer.
  2. Heart rate at 85% of the age-predicted maximum
  3. ST-segment depression of 0.5 mm
  4. Achieving 5 METs of exercise

Explanation

A fall in systolic blood pressure of more than 10 mmHg from baseline during exercise, especially with other ischemic signs, is an absolute indication to terminate testing. ST depression of 0.5 mm is not a stopping criterion by itself. Reaching target heart rate or a modest workload does not require termination.

Question 14Cardiovascular system examination, evaluation, and clinical decision-making

Which symptom pattern is most consistent with typical angina and therefore raises the pretest probability of obstructive coronary artery disease?

  1. Chest burning relieved by antacids
  2. Substernal pressure provoked by exertion and relieved within minutes by rest Correct answer.
  3. Sharp pain lasting several hours and worse with breathing
  4. Pain reproduced by palpation of the chest wall

Explanation

Typical angina is substernal discomfort provoked by exertion or emotional stress and relieved by rest or nitroglycerin within minutes. This pattern substantially increases the pretest probability of obstructive CAD. Positional, pleuritic, or reproducibly tender pain is more consistent with noncardiac causes.

Question 15Cardiovascular system examination, evaluation, and clinical decision-making

Which combination of findings best supports a diagnosis of heart failure with preserved ejection fraction (HFpEF)?

  1. LVEF 55% with elevated left-sided filling pressures Correct answer.
  2. LVEF 45% with a large anterior myocardial infarction
  3. LVEF 60% with severe aortic stenosis
  4. LVEF 30% with global hypokinesis

Explanation

HFpEF requires symptoms and signs of heart failure with a preserved LVEF (generally ≥50%) and evidence of elevated left ventricular filling pressures or diastolic dysfunction. A low LVEF indicates HFrEF. Severe aortic stenosis and prior large MI are separate structural causes that may lead to different phenotypes.

Question 16Cardiovascular system examination, evaluation, and clinical decision-making

On a chest radiograph of a patient with acute decompensated heart failure, which finding reflects pulmonary venous hypertension?

  1. Hyperinflation of the lungs
  2. A unilateral pleural effusion
  3. Cephalization of pulmonary vessels Correct answer.
  4. A widened mediastinum

Explanation

Cephalization, or upper-lobe pulmonary vascular prominence, reflects redistribution of blood flow due to elevated pulmonary venous pressure. It is an early radiographic sign of pulmonary congestion. Hyperinflation suggests obstructive lung disease, and a widened mediastinum has other causes.

Question 17Cardiovascular system examination, evaluation, and clinical decision-making

A holosystolic murmur at the apex that radiates to the axilla is most consistent with which lesion?

  1. Aortic stenosis
  2. Mitral regurgitation Correct answer.
  3. Mitral stenosis
  4. Tricuspid regurgitation

Explanation

Mitral regurgitation produces a holosystolic murmur at the apex that radiates toward the axilla because the regurgitant jet is directed into the left atrium. Aortic stenosis radiates to the carotids. Tricuspid regurgitation radiates to the right sternal border and increases with inspiration.

Question 18Cardiovascular system examination, evaluation, and clinical decision-making

Which murmur description is most typical of aortic stenosis?

  1. Early diastolic decrescendo murmur at the left sternal border
  2. Crescendo-decrescendo systolic murmur at the right upper sternal border radiating to the carotids Correct answer.
  3. Holosystolic murmur at the apex radiating to the axilla
  4. Mid-diastolic rumble at the apex

Explanation

Aortic stenosis produces a crescendo-decrescendo systolic ejection murmur best heard at the right upper sternal border, with radiation to the carotids. The murmur peaks later and becomes softer as stenosis worsens and flow falls. An early diastolic murmur suggests aortic regurgitation.

Question 19Cardiovascular system examination, evaluation, and clinical decision-making

Which ECG criterion is commonly used to identify left ventricular hypertrophy?

  1. S in V1 plus R in V5 or V6 greater than 35 mm Correct answer.
  2. QTc greater than 440 ms
  3. R in V1 plus S in V6 greater than 35 mm
  4. PR interval greater than 200 ms

Explanation

The Sokolow-Lyon criterion for LVH is an S wave in V1 plus an R wave in V5 or V6 greater than 35 mm. Other criteria include the Cornell voltage. PR prolongation indicates AV conduction delay, and QTc prolongation reflects repolarization abnormality.

Question 20Cardiovascular system examination, evaluation, and clinical decision-making

Orthostatic hypotension is defined as which change when a patient moves from supine to standing?

  1. A fall in systolic blood pressure of at least 10 mmHg
  2. A fall in systolic blood pressure of at least 20 mmHg or diastolic blood pressure of at least 10 mmHg Correct answer.
  3. A fall in heart rate of at least 20 beats per minute
  4. A rise in diastolic blood pressure of at least 10 mmHg

Explanation

Orthostatic hypotension is a sustained fall of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing or head-up tilt. It reflects impaired baroreflex function or volume depletion. Symptoms may include dizziness and syncope.

Question 21Cardiovascular system examination, evaluation, and clinical decision-making

A patient with dilated cardiomyopathy has alternating strong and weak systolic pulses on consecutive beats. This finding is called pulsus alternans and most directly indicates which of the following?

  1. Severe left ventricular systolic dysfunction Correct answer.
  2. Hypertrophic cardiomyopathy with outflow obstruction
  3. Cardiac tamponade
  4. Aortic regurgitation

Explanation

Pulsus alternans is beat-to-beat alternation in pulse amplitude caused by cyclical variation in left ventricular contractility, and it indicates severe LV systolic dysfunction. It is not the same as pulsus paradoxus, which varies with respiration. Tamponade and hypertrophic obstruction produce different pulse patterns.

Question 22Cardiovascular system examination, evaluation, and clinical decision-making

A patient with intermittent chest pain has T-wave inversions in leads V2 and V3 on an ECG obtained while pain-free. This pattern is most concerning for which of the following?

  1. Pulmonary embolism
  2. Acute pericarditis
  3. Critical proximal LAD stenosis Correct answer.
  4. Left ventricular hypertrophy

Explanation

Wellens syndrome consists of deep, symmetrical T-wave inversions or biphasic T waves in the anterior precordial leads during a pain-free interval. It indicates critical proximal left anterior descending artery stenosis and warns of impending anterior MI. Urgent cardiology evaluation is required.

Question 23Cardiovascular system examination, evaluation, and clinical decision-making

Which combination of findings is most consistent with cardiac tamponade?

  1. Kussmaul sign, pericardial knock, and ascites
  2. Pulsus paradoxus, elevated jugular venous pressure, and electrical alternans Correct answer.
  3. Pulsus bisferiens, wide pulse pressure, and left ventricular hypertrophy
  4. Cannon a waves, hypotension, and bradycardia

Explanation

Tamponade causes impaired diastolic filling, producing elevated JVP, pulsus paradoxus, and often electrical alternans on ECG. These findings reflect both hemodynamic compromise and the swinging heart in a large effusion. Kussmaul sign and a pericardial knock are more typical of constrictive pericarditis.

Question 24Cardiovascular system examination, evaluation, and clinical decision-making

Which echocardiographic finding is most useful for distinguishing constrictive pericarditis from restrictive cardiomyopathy?

  1. A large pericardial effusion with tamponade
  2. Severe left ventricular hypertrophy
  3. Respiratory variation in mitral inflow velocity with a septal bounce Correct answer.
  4. Reduced left ventricular ejection fraction

Explanation

Constrictive pericarditis shows exaggerated ventricular interdependence, with respiratory variation in mitral inflow velocities and a septal bounce or shudder. Restrictive cardiomyopathy typically lacks this respiratory variation. LVEF may be normal in both, and hypertrophy is not the key discriminator.

Question 25Cardiovascular system examination, evaluation, and clinical decision-making

A patient with left bundle branch block and suspected stable angina cannot exercise. Which stress testing modality is most appropriate?

  1. Standard exercise ECG testing
  2. Dobutamine stress echocardiography
  3. Vasodilator stress myocardial perfusion imaging Correct answer.
  4. Resting ECG alone

Explanation

LBBB makes the exercise ECG uninterpretable for ischemia because of baseline repolarization abnormalities. Vasodilator stress perfusion imaging is preferred in patients who cannot exercise, whereas dobutamine stress echocardiography can be limited by LBBB-induced septal motion abnormalities and arrhythmia. Resting ECG alone cannot assess inducible ischemia.

Question 26Cardiovascular system examination, evaluation, and clinical decision-making

A clinician is measuring blood pressure in an adult with an arm circumference of 38 cm using a standard adult cuff. Which effect is most likely if the cuff bladder is too small for the arm?

  1. Readings are unaffected because cuff size influences only comfort.
  2. Systolic and diastolic readings are falsely elevated. Correct answer.
  3. Both systolic and diastolic readings are falsely lowered.
  4. Systolic readings are falsely lowered but diastolic readings are unchanged.

Explanation

A cuff bladder that is too small for the arm requires a higher inflating pressure to compress the brachial artery, so both systolic and diastolic values are overestimated. The error is clinically important because it can lead to unnecessary treatment. Cuff length and width should match the arm circumference.

Question 27Cardiovascular system examination, evaluation, and clinical decision-making

Which auscultatory finding is most characteristic of a fourth heart sound (S4)?

  1. A low-pitched sound heard just before S1, loudest at the apex. Correct answer.
  2. A fixed split of S2 that widens during inspiration.
  3. A high-pitched sound heard just after S2, loudest at the base.
  4. A mid-diastolic rumble heard at the apex with the bell.

Explanation

An S4 is a late diastolic atrial gallop produced when atrial contraction fills a stiff ventricle. It is low-pitched and best heard at the apex with the bell. An S4 is not a split valve sound and does not occur after S2.

Question 28Cardiovascular system examination, evaluation, and clinical decision-making

Which ECG pattern is most typical of acute pericarditis in a patient without prior cardiac disease?

  1. Focal ST elevation in leads II, III, and aVF with reciprocal depression in I and aVL.
  2. Diffuse concave ST elevation with PR-segment depression. Correct answer.
  3. Deep Q waves in leads V1 through V3 with loss of R-wave progression.
  4. Sawtooth flutter waves at a rate of 300 per minute.

Explanation

Acute pericarditis commonly produces widespread concave ST elevation and PR depression, reflecting diffuse epicardial inflammation. Reciprocal ST depression is limited mainly to aVR and V1. Focal ST elevation with reciprocal changes suggests acute myocardial infarction instead.

Question 29Cardiovascular system examination, evaluation, and clinical decision-making

Which laboratory test is most useful for supporting a diagnosis of acute decompensated heart failure in a patient presenting with dyspnea?

  1. D-dimer.
  2. Serum troponin I.
  3. Serum potassium.
  4. B-type natriuretic peptide. Correct answer.

Explanation

BNP is released by ventricular myocytes in response to wall stretch and is useful when the diagnosis of acute heart failure is uncertain. A low value strongly argues against heart failure, whereas an elevated value requires clinical interpretation. Troponin, D-dimer, and potassium do not directly confirm heart failure.

Question 30Cardiovascular system examination, evaluation, and clinical decision-making

A 28-year-old man has a bounding carotid pulse, a diastolic decrescendo murmur at the left sternal border, and a wide pulse pressure. Which additional peripheral finding is most consistent with the underlying lesion?

  1. An apical impulse that is sustained and displaced laterally.
  2. A visible and palpable head bob synchronized with the heartbeat. Correct answer.
  3. A sustained plateau-like carotid upstroke.
  4. A systolic blood pressure that falls by more than 10 mm Hg during inspiration.

Explanation

Aortic regurgitation produces a rapid upstroke and rapid runoff, causing a wide pulse pressure and water-hammer pulse. The visible head bob with each heartbeat is de Musset sign, a peripheral sign of severe aortic regurgitation. Sustained plateau upstroke and sustained apical impulse point to pressure overload.

Question 31Cardiovascular system examination, evaluation, and clinical decision-making

A patient has a regular jugular venous waveform in which intermittent cannon a waves appear. Which rhythm disturbance is most likely?

  1. Tricuspid regurgitation with a large v wave.
  2. Atrial fibrillation with a rapid ventricular response.
  3. Complete heart block with atrioventricular dissociation. Correct answer.
  4. Sinus tachycardia with a prolonged PR interval.

Explanation

Cannon a waves occur when the right atrium contracts against a closed tricuspid valve, producing intermittent prominent a waves. Complete heart block with AV dissociation allows the atrium to contract during ventricular systole. Atrial fibrillation abolishes organized a waves.

Question 32Cardiovascular system examination, evaluation, and clinical decision-making

A patient with acute chest pain has ST elevation in leads II, III, and aVF. Which coronary artery is most commonly responsible?

  1. Left main coronary artery.
  2. Right coronary artery. Correct answer.
  3. Left anterior descending artery.
  4. Left circumflex artery in all cases.

Explanation

ST elevation in leads II, III, and aVF localizes injury to the inferior wall. The right coronary artery supplies the inferior wall in most patients, although the left circumflex can occasionally be responsible. Anterior leads V1–V4 reflect the left anterior descending territory.

Question 33Cardiovascular system examination, evaluation, and clinical decision-making

A 62-year-old with sudden tearing chest pain has a blood pressure of 168/94 mm Hg in the right arm and 132/78 mm Hg in the left arm. Which additional finding most increases the likelihood of aortic dissection?

  1. Pain that resolves completely after sublingual nitroglycerin.
  2. A new diastolic murmur at the right upper sternal border. Correct answer.
  3. Pain that is reproduced by palpation of the chest wall.
  4. A pleural friction rub heard at the left lung base.

Explanation

A significant interarm blood pressure difference with abrupt tearing pain raises concern for aortic dissection. Extension of the dissection to the aortic root can cause acute aortic regurgitation, producing a new diastolic murmur. Pain reproduced by palpation or relieved by nitroglycerin is more typical of musculoskeletal or anginal pain.

Question 34Cardiovascular system examination, evaluation, and clinical decision-making

A 70-year-old with calf claudication has an ankle-brachial index of 0.72 in the symptomatic leg. How should this result be interpreted?

  1. It indicates critical limb ischemia requiring immediate revascularization.
  2. It is falsely elevated and should be repeated after exercise.
  3. It is abnormal and consistent with peripheral arterial disease. Correct answer.
  4. It is normal because values above 0.50 exclude disease.

Explanation

An ankle-brachial index of 0.90 or lower is abnormal and supports a diagnosis of peripheral arterial disease. Values between roughly 0.40 and 0.90 usually indicate claudication, while critical limb ischemia is suggested by rest pain or tissue loss and often much lower values. ABI should be interpreted with the clinical picture.

Question 35Cardiovascular system examination, evaluation, and clinical decision-making

Which peripheral finding is most specifically associated with infective endocarditis?

  1. Painless jaundice.
  2. Bilateral pitting edema of the ankles.
  3. A continuous machinery murmur at the left infraclavicular area.
  4. Painful erythematous nodules on the finger pads. Correct answer.

Explanation

Osler nodes are painful erythematous nodules on the finger or toe pads and are a peripheral manifestation of infective endocarditis. Janeway lesions are painless and more often on the palms and soles. A continuous machinery murmur suggests a patent ductus arteriosus.

Question 36Cardiovascular system examination, evaluation, and clinical decision-making

A patient with a permanent pacemaker and left bundle branch block cannot achieve adequate heart rate on a treadmill. Which stress test is most appropriate for evaluating myocardial ischemia?

  1. Hyperventilation provocation testing.
  2. Treadmill exercise ECG without imaging.
  3. Regadenoson perfusion imaging. Correct answer.
  4. Exercise echocardiography with the current pacemaker setting.

Explanation

Exercise ECG is unreliable for ischemia when the baseline ECG has left bundle branch block, and a pacemaker may limit heart-rate response. Vasodilator stress with perfusion imaging, such as regadenoson, avoids exercise and is not limited by LBBB. Exercise echocardiography can be useful in some patients, but pacing and LBBB make it less reliable.

Question 37Cardiovascular system examination, evaluation, and clinical decision-making

A patient with rheumatic heart disease has a low-pitched diastolic rumble at the apex preceded by an opening snap. Which maneuver best augments this murmur?

  1. Valsalva strain.
  2. Standing abruptly from a squatting position.
  3. Rolling onto the left lateral decubitus position. Correct answer.
  4. Sustained handgrip.

Explanation

The murmur of mitral stenosis is a low-pitched diastolic rumble best heard at the apex with the bell. It is augmented by the left lateral decubitus position and by expiration. Maneuvers that reduce preload, such as Valsalva or standing, make the murmur softer.

Question 38Cardiovascular system examination, evaluation, and clinical decision-making

A young athlete has a harsh systolic murmur at the left lower sternal border that becomes louder during Valsalva strain and softer during handgrip. Which diagnosis is most likely?

  1. Mitral regurgitation.
  2. Aortic stenosis.
  3. Hypertrophic cardiomyopathy. Correct answer.
  4. Ventricular septal defect.

Explanation

The murmur of hypertrophic cardiomyopathy is dynamic and typically becomes louder when preload falls, as during Valsalva strain. Increasing afterload with handgrip reduces the gradient and softens the murmur. Aortic stenosis and mitral regurgitation respond differently to these maneuvers.

Question 39Cardiovascular system examination, evaluation, and clinical decision-making

A 72-year-old with an anterior myocardial infarction has a blood pressure of 82/54 mm Hg, cool extremities, and a lactate of 4.2 mmol/L. Which hemodynamic pattern most supports cardiogenic shock rather than hypovolemic shock?

  1. Elevated pulmonary capillary wedge pressure with a low cardiac index. Correct answer.
  2. Low central venous pressure with a marked rise after a fluid bolus.
  3. Narrowed pulse pressure that resolves with passive leg raising.
  4. High cardiac output with low systemic vascular resistance.

Explanation

Cardiogenic shock is characterized by inadequate cardiac output despite adequate or elevated filling pressures. A low cardiac index with a high pulmonary capillary wedge pressure and elevated systemic vascular resistance fits this pattern. Hypovolemic shock typically shows low filling pressures that improve with fluid.

Question 40Cardiovascular system examination, evaluation, and clinical decision-making

A 68-year-old has syncope while sitting quietly. The ECG shows a QTc of 520 ms and there is a family history of sudden cardiac death. Which feature most strongly suggests a cardiac cause of the syncope?

  1. Syncope that occurs only after prolonged standing.
  2. Complete recovery within 30 seconds of lying down.
  3. A prodrome of nausea and diaphoresis before the event.
  4. Abrupt onset without warning plus an abnormal ECG. Correct answer.

Explanation

Cardiac syncope is more likely when loss of consciousness is abrupt without a prodrome, especially with an abnormal ECG or a family history of sudden death. These features identify patients who need urgent cardiac evaluation. Vasovagal syncope usually has warning symptoms, and orthostatic syncope follows standing.

Question 41Pulmonary system examination, evaluation, and clinical decision-making

What is the typical resting respiratory rate for a healthy adult?

  1. 28 to 34 breaths per minute
  2. 22 to 26 breaths per minute
  3. 8 to 10 breaths per minute
  4. 12 to 20 breaths per minute Correct answer.

Explanation

A healthy adult at rest breathes 12 to 20 times per minute; values outside this range are recorded as bradypnea or tachypnea. Because breathing is irregular, the count should cover a full 60 seconds rather than extrapolating from a 15- or 30-second sample.

Question 42Pulmonary system examination, evaluation, and clinical decision-making

A therapist auscultates just below the larynx and hears loud, hollow, high-pitched sounds separated by a brief pause between inspiration and expiration. These are:

  1. fine end-inspiratory crackles
  2. a pleural friction rub
  3. bronchial breath sounds Correct answer.
  4. vesicular breath sounds

Explanation

Bronchial sounds are loud, hollow, and relatively high pitched, with a gap between inspiration and expiration, because they are generated in large airways. They are normal over the trachea and become abnormal when heard over peripheral lung, where they suggest consolidation.

Question 43Pulmonary system examination, evaluation, and clinical decision-making

A patient rescued from a house fire has an SpO2 of 99% on room air but is confused and has cherry-red skin. Which factor most likely makes the oximetry reading falsely reassuring?

  1. Elevated methemoglobin
  2. Poor peripheral perfusion
  3. Darkly pigmented nail polish
  4. Elevated carboxyhemoglobin Correct answer.

Explanation

Carboxyhemoglobin absorbs light much like oxyhemoglobin, so a standard two-wavelength oximeter overestimates arterial saturation in carbon monoxide poisoning. Co-oximetry or blood gas analysis with a co-oximeter is required to detect the true level.

Question 44Pulmonary system examination, evaluation, and clinical decision-making

Dullness to percussion over the left posterior base, together with decreased breath sounds and decreased tactile fremitus at that site, most suggests:

  1. acute bronchospasm
  2. emphysema
  3. pneumothorax
  4. pleural effusion Correct answer.

Explanation

Pleural fluid dampens transmission of sound and vibration, producing a dull percussion note with decreased breath sounds and decreased tactile fremitus over the fluid. Air in the pleural space does the opposite, producing hyperresonance and reduced fremitus.

Question 45Pulmonary system examination, evaluation, and clinical decision-making

Which observation made during a resting examination most directly indicates increased work of breathing?

  1. Increased AP chest diameter
  2. Intercostal retractions Correct answer.
  3. Bilateral pedal edema
  4. Digital clubbing

Explanation

Retractions of the intercostal, supraclavicular, or subcostal regions reflect large negative pleural pressures generated by accessory muscles, a direct sign of increased work of breathing. Clubbing, edema, and barrel chest are chronic structural signs that do not track acute effort.

Question 46Pulmonary system examination, evaluation, and clinical decision-making

An arterial blood gas shows pH 7.28, PaCO2 58 mmHg, and HCO3 26 mEq/L. Which interpretation is correct?

  1. Metabolic acidosis
  2. Chronic respiratory acidosis
  3. Acute respiratory acidosis Correct answer.
  4. Metabolic alkalosis

Explanation

An acid pH with an elevated PaCO2 and only a minimal bicarbonate rise indicates acute respiratory acidosis, because metabolic compensation takes days to develop. In acute settings, bicarbonate rises roughly 1 mEq/L for every 10 mmHg increase in PaCO2.

Question 47Pulmonary system examination, evaluation, and clinical decision-making

Which measurement is used to quantify inspiratory muscle strength?

  1. Maximal inspiratory pressure (MIP) Correct answer.
  2. Peak expiratory flow rate (PEFR)
  3. Slow vital capacity (SVC)
  4. Maximal expiratory pressure (MEP)

Explanation

Maximal inspiratory pressure is obtained during a forceful inspiratory effort against an occluded airway, usually starting near residual volume. Values less negative than about -60 cmH2O suggest inspiratory muscle weakness.

Question 48Pulmonary system examination, evaluation, and clinical decision-making

For a patient with COPD and a history of hypercapnia, which SpO2 range is generally targeted during supplemental oxygen titration?

  1. 84% to 87%
  2. 88% to 92% Correct answer.
  3. 80% to 85%
  4. 95% to 100%

Explanation

Guidelines target an SpO2 of 88% to 92% in patients with COPD who are at risk for hypercapnia, preserving oxygen delivery while limiting rises in PaCO2 from blunted hypoxic drive and worsened ventilation-perfusion mismatch. Higher targets are used for most other acute conditions.

Question 49Pulmonary system examination, evaluation, and clinical decision-making

Which spirometry result meets the standard criterion for a positive bronchodilator response?

  1. A 150 mL and 8% increase in FEV1
  2. A 250 mL and 5% increase in FEV1
  3. A 200 mL and 12% increase in FEV1 Correct answer.
  4. A 100 mL and 15% increase in FEV1

Explanation

A positive bronchodilator response requires both an absolute increase of at least 200 mL in FEV1 and a relative increase of at least 12% from baseline. Meeting only one of the two thresholds is not considered significant.

Question 50Pulmonary system examination, evaluation, and clinical decision-making

Post-bronchodilator spirometry shows an FEV1/FVC ratio of 0.64 with FEV1 at 55% of predicted. What does the reduced ratio establish?

  1. Persistent airflow obstruction Correct answer.
  2. An isolated small-airway disease
  3. A restrictive ventilatory defect
  4. Normal age-related decline

Explanation

A post-bronchodilator FEV1/FVC below 0.70 defines persistent airflow obstruction and is the spirometric criterion for COPD in current guidelines. Restriction cannot be diagnosed from spirometry alone and requires measurement of total lung capacity.