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Kuwait Board Internal Medicine study materials
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Kuwait Board Internal Medicine practice questions

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Question 1General Internal Medicine and Clinical Reasoning

A 58-year-old man with type 2 diabetes and hypertension presents with sudden-onset severe tearing chest pain radiating to the back. Blood pressure is 190/100 mmHg in the right arm and 150/90 mmHg in the left arm. Chest radiograph shows a widened mediastinum. Which is the most appropriate initial diagnostic study in a hemodynamically stable patient?

  1. CT angiography of the aorta Correct answer.
  2. Transthoracic echocardiography
  3. Coronary angiography
  4. D-dimer assay

Explanation

The interarm blood pressure differential, tearing pain, and widened mediastinum suggest acute aortic dissection. CT angiography of the aorta is the first-line confirmatory study in stable patients because it defines the intimal flap, extent, and involvement of branch vessels rapidly and reliably.

Question 2General Internal Medicine and Clinical Reasoning

Which electrolyte disturbance most characteristically produces peaked T waves, widened QRS complexes, and a sine-wave pattern on the electrocardiogram?

  1. Hyperkalemia Correct answer.
  2. Hypercalcemia
  3. Hypomagnesemia
  4. Hypokalemia

Explanation

Progressive hyperkalemia classically produces tall peaked T waves, then PR prolongation, QRS widening, and ultimately a sine-wave pattern preceding cardiac arrest. These changes reflect slowed myocardial conduction from elevated extracellular potassium.

Question 3General Internal Medicine and Clinical Reasoning

A 24-year-old woman presents with palpitations and is found to have a regular narrow-complex tachycardia at 180 beats per minute. She is hemodynamically stable. Which maneuver is most appropriate as an initial vagal maneuver to terminate the rhythm?

  1. Unilateral eyeball pressure
  2. Carotid sinus massage in a patient without carotid bruit
  3. Rapid intravenous adenosine push as the first step
  4. Valsalva maneuver against a closed glottis Correct answer.

Explanation

A modified Valsalva maneuver is a safe first-line vagal maneuver for stable supraventricular tachycardia and can terminate atrioventricular nodal reentry. It increases intrathoracic pressure and vagal tone without the vascular risks of carotid manipulation.

Question 4General Internal Medicine and Clinical Reasoning

Which finding on arterial blood gas analysis is most consistent with a primary respiratory alkalosis?

  1. High pH with high bicarbonate
  2. Low pH with high carbon dioxide
  3. Low pH with low bicarbonate
  4. High pH with low carbon dioxide Correct answer.

Explanation

A primary respiratory alkalosis is defined by hyperventilation lowering the PaCO2, which raises pH. Renal compensation later lowers bicarbonate, but the primary derangement is a high pH with a low PaCO2.

Question 5General Internal Medicine and Clinical Reasoning

A 68-year-old man with atrial fibrillation on warfarin presents with a large intracerebral hemorrhage. His INR is 4.2. Which agent is most appropriate for urgent reversal of warfarin effect?

  1. Protamine sulfate
  2. Fresh frozen plasma alone
  3. Four-factor prothrombin complex concentrate plus intravenous vitamin K Correct answer.
  4. Platelet transfusion

Explanation

For warfarin-associated major bleeding, guidelines recommend four-factor prothrombin complex concentrate plus intravenous vitamin K for rapid and complete reversal. PCC restores vitamin K-dependent factors faster and with less volume than plasma.

Question 6General Internal Medicine and Clinical Reasoning

Which feature best distinguishes diabetic ketoacidosis from hyperosmolar hyperglycemic state at presentation?

  1. Presence of significant ketonemia and metabolic acidosis Correct answer.
  2. Degree of hyperglycemia alone
  3. Serum sodium concentration
  4. Presence of polyuria

Explanation

Diabetic ketoacidosis is characterized by ketone body accumulation and high-anion-gap metabolic acidosis, whereas hyperosmolar hyperglycemic state has minimal ketosis with profound hyperosmolality. Glucose levels overlap and polyuria occurs in both.

Question 7General Internal Medicine and Clinical Reasoning

A 45-year-old woman has a thyroid-stimulating hormone level below the assay detection limit with an elevated free T4. She has a diffuse goiter and mild ophthalmopathy. Which diagnosis is most likely?

  1. Subacute thyroiditis
  2. Graves disease Correct answer.
  3. Exogenous levothyroxine excess
  4. Toxic multinodular goiter

Explanation

Suppressed TSH with elevated free T4 confirms thyrotoxicosis, and diffuse goiter with ophthalmopathy is characteristic of Graves disease, caused by TSH receptor-stimulating antibodies. Ophthalmopathy is highly specific and points away from other causes.

Question 8General Internal Medicine and Clinical Reasoning

A patient with decompensated heart failure has a serum sodium of 128 mmol/L after aggressive diuresis. Which mechanism best explains this hyponatremia?

  1. Severe hypertriglyceridemia
  2. Non-osmotic release of antidiuretic hormone due to reduced effective circulating volume Correct answer.
  3. Primary polydipsia
  4. Adrenal insufficiency

Explanation

In heart failure, reduced effective arterial volume triggers non-osmotic ADH release, causing water retention and dilutional hyponatremia. The total body sodium is usually increased, but water excess predominates.

Question 9General Internal Medicine and Clinical Reasoning

Which antibiotic is the preferred oral agent for initial treatment of a nonpurulent lower-extremity cellulitis in an otherwise healthy adult in an area with low methicillin-resistant Staphylococcus aureus prevalence?

  1. Azithromycin
  2. Trimethoprim-sulfamethoxazole
  3. Doxycycline
  4. Cephalexin Correct answer.

Explanation

Nonpurulent cellulitis is most often caused by beta-hemolytic streptococci and methicillin-susceptible Staphylococcus aureus, so a first-generation cephalosporin such as cephalexin is appropriate first-line therapy. MRSA coverage is reserved for purulent infection or high local prevalence.

Question 10General Internal Medicine and Clinical Reasoning

A 30-year-old man presents with sudden-onset right-sided pleuritic chest pain and dyspnea after a long flight. He is tachycardic and hypoxic. Which finding on computed tomography pulmonary angiography directly confirms acute pulmonary embolism?

  1. Bilateral pleural effusions
  2. Elevated D-dimer
  3. Right ventricular enlargement
  4. Intraluminal filling defect within a contrast-opacified pulmonary artery Correct answer.

Explanation

CT pulmonary angiography directly demonstrates pulmonary embolism as an intraluminal filling defect in a contrast-filled pulmonary artery. Other findings such as right ventricular dilation are supportive but not diagnostic.

Question 11General Internal Medicine and Clinical Reasoning

Which spirometric pattern is expected in a patient with chronic obstructive pulmonary disease?

  1. Reduced FEV1/FVC ratio that does not fully reverse with bronchodilator Correct answer.
  2. Normal FEV1/FVC ratio with reduced diffusion capacity
  3. Reversible airflow obstruction with a normal FEV1/FVC ratio
  4. Increased FEV1/FVC ratio with reduced total lung capacity

Explanation

COPD is defined by persistent airflow limitation with a post-bronchodilator FEV1/FVC ratio below 0.70. The obstruction is not fully reversible, which distinguishes it from asthma.

Question 12General Internal Medicine and Clinical Reasoning

A 55-year-old woman with a history of gallstones presents with severe epigastric pain radiating to the back, vomiting, and elevated serum lipase three times the upper limit of normal. Which is the most likely diagnosis?

  1. Acute pancreatitis Correct answer.
  2. Perforated peptic ulcer
  3. Acute mesenteric ischemia
  4. Acute cholecystitis

Explanation

Epigastric pain radiating to the back with vomiting and lipase elevation greater than three times the upper limit of normal meets diagnostic criteria for acute pancreatitis, and gallstones are the likely cause.

Question 13General Internal Medicine and Clinical Reasoning

Which serologic finding is most specific for systemic lupus erythematosus?

  1. Antinuclear antibody
  2. Antihistone antibody
  3. Anti-double-stranded DNA antibody Correct answer.
  4. Rheumatoid factor

Explanation

Anti-double-stranded DNA antibodies are highly specific for systemic lupus erythematosus and correlate with disease activity and lupus nephritis. Antinuclear antibody is sensitive but not specific.

Question 14General Internal Medicine and Clinical Reasoning

A 72-year-old man with chronic kidney disease has a hemoglobin of 8.5 g/dL, normal mean corpuscular volume, low reticulocyte count, and transferrin saturation of 15% with ferritin of 40 ng/mL. What is the most appropriate next step?

  1. Blood transfusion to a target hemoglobin of 12 g/dL
  2. Iron supplementation before considering erythropoiesis-stimulating agents Correct answer.
  3. Oral vitamin B12 and folate replacement
  4. Immediate erythropoiesis-stimulating agent therapy

Explanation

Anemia of chronic kidney disease requires adequate iron stores before erythropoiesis-stimulating agents are effective. A transferrin saturation below 20% with low ferritin indicates iron deficiency, so iron repletion should come first.

Question 15General Internal Medicine and Clinical Reasoning

Which clinical feature is most characteristic of a nephrotic syndrome rather than a nephritic syndrome?

  1. Hematuria with red cell casts
  2. Heavy proteinuria with hypoalbuminemia and edema Correct answer.
  3. Rapid rise in serum creatinine
  4. Hypertension and oliguria

Explanation

Nephrotic syndrome is defined by proteinuria greater than 3.5 g per day, hypoalbuminemia, edema, and hyperlipidemia due to glomerular podocyte injury. Nephritic syndrome instead features hematuria, red cell casts, hypertension, and variable renal impairment.

Question 16General Internal Medicine and Clinical Reasoning

A 60-year-old smoker presents with a 3 cm cavitating upper-lobe lung mass and hemoptysis. Which paraneoplastic syndrome is most associated with squamous cell carcinoma of the lung?

  1. Cushing syndrome from ectopic ACTH
  2. Hyponatremia from ectopic ADH
  3. Carcinoid syndrome
  4. Hypercalcemia from parathyroid hormone-related peptide Correct answer.

Explanation

Squamous cell carcinoma of the lung classically secretes parathyroid hormone-related peptide, causing hypercalcemia. Small cell carcinoma is more associated with ectopic ACTH and ADH production.

Question 17General Internal Medicine and Clinical Reasoning

Which finding on cerebrospinal fluid analysis is most consistent with bacterial meningitis?

  1. Normal cell count with elevated protein
  2. Neutrophilic pleocytosis with low glucose and high protein Correct answer.
  3. Lymphocytic pleocytosis with normal glucose
  4. Lymphocytic pleocytosis with very high glucose

Explanation

Bacterial meningitis typically produces a neutrophilic predominance, low cerebrospinal fluid glucose relative to serum, and elevated protein. Viral meningitis more often shows lymphocytic pleocytosis with normal glucose.

Question 18General Internal Medicine and Clinical Reasoning

A 65-year-old man with hypertension presents with sudden painless loss of vision in one eye. Fundoscopy shows a pale retina with a cherry-red spot at the macula. Which diagnosis is most likely?

  1. Central retinal artery occlusion Correct answer.
  2. Central retinal vein occlusion
  3. Anterior ischemic optic neuropathy
  4. Retinal detachment

Explanation

A pale, opaque retina with a cherry-red spot at the fovea indicates central retinal artery occlusion, where the fovea remains perfused by choroidal circulation while surrounding retina becomes ischemic. Vision loss is sudden and painless.

Question 19General Internal Medicine and Clinical Reasoning

Which is the most appropriate initial pharmacologic therapy for a patient with newly diagnosed type 2 diabetes and no contraindications, in the absence of atherosclerotic cardiovascular disease or heart failure?

  1. Metformin with lifestyle modification Correct answer.
  2. Pioglitazone as first-line therapy
  3. A sulfonylurea as first-line therapy
  4. Basal insulin alone

Explanation

Metformin combined with lifestyle modification remains the recommended first-line therapy for most patients with newly diagnosed type 2 diabetes without cardiovascular or heart failure indications. It is effective, weight-neutral, inexpensive, and has a favorable safety profile.

Question 20General Internal Medicine and Clinical Reasoning

A 40-year-old woman presents with fatigue, weight gain, cold intolerance, and constipation. Examination shows bradycardia and delayed relaxation of deep tendon reflexes. Which laboratory pattern confirms primary hypothyroidism?

  1. Low TSH with low free T4
  2. Elevated TSH with high free T4
  3. Low TSH with high free T4
  4. Elevated TSH with low free T4 Correct answer.

Explanation

Primary hypothyroidism is confirmed by an elevated TSH with a low free T4, reflecting failure of the thyroid gland with appropriate pituitary compensation. The clinical features described are classic for hypothyroidism.

Question 21General Internal Medicine and Clinical Reasoning

A patient with advanced cirrhosis develops confusion, asterixis, and elevated ammonia. Which precipitant should be sought and corrected first in the clinical assessment?

  1. Hyperkalemia
  2. Vitamin D deficiency
  3. Hyperthyroidism
  4. Gastrointestinal bleeding Correct answer.

Explanation

Gastrointestinal bleeding is a common and reversible precipitant of hepatic encephalopathy because blood protein is broken down to ammonia in the gut. Identifying and treating precipitants such as bleeding, infection, constipation, and electrolyte disturbance is central to management.

Question 22General Internal Medicine and Clinical Reasoning

Which statement about the interpretation of a diagnostic test with high sensitivity is correct?

  1. A highly sensitive test always has a high positive predictive value
  2. Sensitivity depends on the prevalence of disease in the population
  3. A highly sensitive test is most useful for ruling out disease when the result is negative Correct answer.
  4. A highly sensitive test is most useful for confirming disease when the result is positive

Explanation

Sensitivity is the probability of a positive test among those with disease, so a highly sensitive test yields few false negatives and a negative result effectively excludes disease. Positive predictive value, not sensitivity, depends on prevalence.

Question 23General Internal Medicine and Clinical Reasoning

A 70-year-old man is admitted with community-acquired pneumonia. Which feature best predicts a higher mortality risk when applying the CURB-65 score?

  1. History of well-controlled hypertension
  2. Temperature of 38.5 degrees Celsius
  3. Productive cough with purulent sputum
  4. Blood urea nitrogen above 7 mmol/L Correct answer.

Explanation

CURB-65 assigns one point each for confusion, urea above 7 mmol/L, respiratory rate of 30 or more, low blood pressure, and age 65 or older. Elevated urea reflects dehydration or renal impairment and independently predicts higher mortality.

Question 24General Internal Medicine and Clinical Reasoning

A 35-year-old woman with a history of recurrent kidney stones has a serum calcium of 11.2 mg/dL and an inappropriately normal parathyroid hormone level. Which is the most likely diagnosis?

  1. Familial hypocalciuric hypercalcemia
  2. Primary hyperparathyroidism Correct answer.
  3. Vitamin D intoxication
  4. Malignancy-associated hypercalcemia

Explanation

Hypercalcemia with a nonsuppressed or elevated parathyroid hormone level points to parathyroid-dependent hypercalcemia, most commonly primary hyperparathyroidism, which also causes recurrent calcium stones. Malignancy and vitamin D excess suppress parathyroid hormone.

Question 25Cardiology

A 58-year-old man with no prior cardiac history presents with sudden-onset tearing chest pain radiating to the back. Blood pressure is 168/94 mmHg in the right arm and 142/80 mmHg in the left arm. Which of the following is the most appropriate initial diagnostic imaging study in this patient?

  1. Urgent CT angiography of the aorta Correct answer.
  2. Exercise stress testing
  3. Transthoracic echocardiography
  4. Coronary angiography

Explanation

A significant interarm blood pressure difference with tearing chest pain radiating to the back suggests acute aortic dissection, and CT angiography of the aorta is the first-line confirmatory study because it rapidly defines the intimal flap, extent of involvement, and branch vessel compromise. Immediate imaging must not be delayed for other tests when dissection is suspected.

Question 26Cardiology

Which electrocardiographic finding is most characteristic of acute pericarditis?

  1. Sawtooth flutter waves at 300 per minute
  2. Diffuse concave ST-segment elevation with PR depression Correct answer.
  3. Deep symmetric T-wave inversion in leads V2 to V4
  4. Localized convex ST elevation with reciprocal depression

Explanation

Acute pericarditis classically produces widespread concave-upward ST elevation in most leads together with PR-segment depression, reflecting diffuse epicardial inflammation. The changes are not confined to a single coronary territory and lack reciprocal ST depression.

Question 27Cardiology

A 70-year-old woman with permanent atrial fibrillation has a CHA2DS2-VASc score of 4. She has no contraindications to anticoagulation. Which long-term antithrombotic strategy offers the best stroke prevention?

  1. Dual antiplatelet therapy
  2. No antithrombotic therapy
  3. Oral anticoagulation alone Correct answer.
  4. Aspirin monotherapy

Explanation

Oral anticoagulation is the standard for stroke prevention in nonvalvular atrial fibrillation when the CHA2DS2-VASc score is 2 or higher in women, and a direct oral anticoagulant is generally preferred over warfarin. Antiplatelet agents do not provide adequate protection and add bleeding risk.

Question 28Cardiology

Which physical examination finding is most specific for severe aortic stenosis?

  1. Loud S2 at the base
  2. Bounding peripheral pulses
  3. Slow-rising, low-amplitude carotid pulse Correct answer.
  4. Wide pulse pressure

Explanation

Severe aortic stenosis limits stroke volume and produces a delayed, low-amplitude carotid upstroke known as pulsus parvus et tardus. This finding reflects fixed outflow obstruction rather than the hyperdynamic circulation seen in regurgitant lesions.

Question 29Cardiology

A 62-year-old man with heart failure and reduced ejection fraction is stable on guideline-directed therapy. Which medication has been shown to reduce mortality in this population?

  1. Ivabradine
  2. Digoxin
  3. Amlodipine
  4. Sacubitril-valsartan Correct answer.

Explanation

Sacubitril-valsartan reduced cardiovascular death and heart failure hospitalization compared with enalapril in patients with reduced ejection fraction and is a cornerstone of guideline-directed therapy. Its benefit on hard outcomes distinguishes it from agents used mainly for symptom control.

Question 30Cardiology

A 55-year-old man presents with palpitations and a regular narrow-complex tachycardia at 180 beats per minute. He is hemodynamically stable. Which maneuver is the most appropriate first step to terminate the arrhythmia?

  1. Intravenous amiodarone
  2. Intravenous digoxin
  3. Synchronized DC cardioversion
  4. Vagal maneuvers such as the Valsalva maneuver Correct answer.

Explanation

A regular narrow-complex tachycardia in a stable patient is most often atrioventricular nodal reentrant tachycardia, and vagal maneuvers increase vagal tone to slow conduction through the atrioventricular node and terminate the reentry circuit. They are safe, quick, and noninvasive, so they precede drug therapy.

Question 31Cardiology

Which laboratory marker is most useful for detecting myocardial injury in a patient presenting 6 hours after the onset of chest pain?

  1. Creatine kinase total
  2. High-sensitivity cardiac troponin Correct answer.
  3. Lactate dehydrogenase
  4. Myoglobin

Explanation

High-sensitivity cardiac troponin is the preferred biomarker for myocardial injury because it is highly specific to cardiac myocytes and rises within hours of injury, remaining elevated for days. Serial measurements demonstrate the rise and fall required to diagnose acute myocardial infarction.

Question 32Cardiology

A 68-year-old man with an anterior ST-elevation myocardial infarction is treated with primary percutaneous coronary intervention. Six hours later he develops acute pulmonary edema with bilateral crackles and an S3 gallop. Which complication is most likely responsible?

  1. Left ventricular free wall rupture
  2. Acute pericardial tamponade
  3. Acute severe mitral regurgitation from papillary muscle rupture Correct answer.
  4. Rupture of the interventricular septum

Explanation

Papillary muscle rupture typically follows an inferior or anterior infarction and produces sudden severe mitral regurgitation with a new murmur, flash pulmonary edema, and cardiogenic shock. The abrupt onset of pulmonary edema hours after reperfusion fits this mechanical complication.

Question 33Cardiology

A 45-year-old woman has resistant hypertension and episodic headaches with palpitations. Biochemical testing shows elevated plasma metanephrines. Which imaging study is most appropriate to localize the lesion?

  1. Magnetic resonance angiography of the renal arteries
  2. Echocardiography
  3. Renal artery duplex ultrasonography
  4. CT of the abdomen and pelvis Correct answer.

Explanation

Biochemical evidence of pheochromocytoma should be followed by anatomic imaging of the adrenal glands, and CT of the abdomen and pelvis is the preferred initial modality because it detects adrenal and extra-adrenal masses with high sensitivity.

Question 34Cardiology

A 30-year-old man is found to have a blood pressure of 170/105 mmHg in both arms with a systolic murmur. He has a history of premature coronary disease in his father and an uncle. Which lipid disorder is most likely?

  1. Familial chylomicronemia syndrome
  2. Familial hypercholesterolemia Correct answer.
  3. Heterozygous familial hypobetalipoproteinemia
  4. Lipoprotein lipase deficiency

Explanation

Familial hypercholesterolemia causes markedly elevated LDL cholesterol from birth and premature atherosclerotic cardiovascular disease, and it may present with premature hypertension and coronary events in relatives. Tendon xanthomas and a strong family history of early myocardial infarction support the diagnosis.

Question 35Cardiology

A 72-year-old woman with a history of hypertension and diabetes presents with syncope. An electrocardiogram shows a PR interval of 240 ms with a dropped beat after progressively lengthening PR intervals. Which conduction abnormality is present?

  1. First-degree atrioventricular block
  2. Third-degree atrioventricular block
  3. Second-degree atrioventricular block, Mobitz type I Correct answer.
  4. Second-degree atrioventricular block, Mobitz type II

Explanation

Progressive PR prolongation before a nonconducted P wave defines Mobitz type I (Wenckebach) second-degree atrioventricular block, which reflects conduction delay within the atrioventricular node. The pattern differs from Mobitz type II, where PR intervals remain constant before the dropped beat.

Question 36Cardiology

A 60-year-old man with dilated cardiomyopathy has an ejection fraction of 30% and left bundle branch block with a QRS duration of 160 ms. He remains symptomatic despite optimal medical therapy. Which intervention is most likely to improve his symptoms and survival?

  1. Implantable cardioverter-defibrillator alone
  2. Cardiac resynchronization therapy Correct answer.
  3. Amiodarone therapy
  4. Rate-control with a beta blocker

Explanation

Cardiac resynchronization therapy is indicated for symptomatic heart failure with reduced ejection fraction, a wide QRS with left bundle branch morphology, and an ejection fraction of 35% or less despite optimal medical therapy. Resynchronization improves ventricular coordination, symptoms, and survival.

Question 37Cardiology

Which finding on physical examination is most consistent with severe tricuspid regurgitation?

  1. Prominent v wave in the jugular venous pulse Correct answer.
  2. Pulsus paradoxus
  3. Slow-rising carotid pulse
  4. Corrigan sign

Explanation

Severe tricuspid regurgitation transmits right ventricular systole into the right atrium, producing a large v wave in the jugular venous pulse. This finding reflects volume overload of the right atrium during systole.

Question 38Cardiology

A 35-year-old woman has a blood pressure of 158/96 mmHg documented on three occasions in the clinic, with normal home readings. Which diagnosis should be considered first?

  1. Masked hypertension
  2. Secondary hypertension
  3. Malignant hypertension
  4. White coat hypertension Correct answer.

Explanation

Elevated office readings with consistently normal out-of-office measurements define white coat hypertension, in which the clinic setting itself raises blood pressure. Ambulatory or home monitoring is essential to avoid unnecessary treatment.

Question 39Cardiology

A 66-year-old man presents with exertional dyspnea and is found to have a low-flow, low-gradient aortic stenosis with a reduced ejection fraction. Which finding would best confirm that the stenosis is truly severe and that valve replacement is appropriate?

  1. A preserved left ventricular ejection fraction on repeat study
  2. A dobutamine stress echocardiogram showing an increase in stroke volume with a rise in mean gradient Correct answer.
  3. A normal coronary angiogram
  4. A resting mean gradient of 20 mmHg

Explanation

Low-flow, low-gradient aortic stenosis with reduced ejection fraction requires dobutamine stress echocardiography to distinguish true severe stenosis from pseudosevere stenosis. An increase in stroke volume with a rise in mean gradient to the severe range confirms contractile reserve and true severity, supporting valve replacement.

Question 40Cardiology

Which electrocardiographic abnormality is most suggestive of left ventricular hypertrophy?

  1. Sokolow-Lyon voltage criteria with a deep S in V1 and tall R in V5 Correct answer.
  2. Prolonged QT interval
  3. Sinus bradycardia at 50 beats per minute
  4. Delta wave with a short PR interval

Explanation

The Sokolow-Lyon criteria combine a deep S wave in V1 with a tall R wave in V5 or V6 to indicate increased left ventricular voltage consistent with hypertrophy. Voltage criteria are supportive and are usually interpreted alongside clinical features and imaging.

Question 41Cardiology

A 24-year-old athlete collapses during a basketball game and is resuscitated. He has a family history of sudden death in a young relative. Which inherited condition should be suspected first?

  1. Mitral valve prolapse
  2. Atrial septal defect
  3. Bicuspid aortic valve
  4. Hypertrophic cardiomyopathy Correct answer.

Explanation

Hypertrophic cardiomyopathy is the most common inherited cause of sudden cardiac death in young athletes and is often associated with a family history of premature sudden death. Dynamic left ventricular outflow obstruction and ventricular arrhythmias underlie the risk.

Question 42Cardiology

A 58-year-old woman with a mechanical mitral valve is being counseled about anticoagulation. Which regimen is recommended?

  1. Aspirin 81 mg daily
  2. A direct oral anticoagulant such as apixaban
  3. Dual antiplatelet therapy
  4. Warfarin with a target INR of 2.5 to 3.5 Correct answer.

Explanation

Patients with mechanical mitral valve prostheses require warfarin with a higher target INR of 2.5 to 3.5 because the mitral position carries a greater thromboembolic risk than the aortic position. Direct oral anticoagulants are not approved for mechanical valves.

Question 43Cardiology

A 64-year-old man with chronic stable angina reports chest tightness that reliably occurs with exertion and resolves within minutes of rest. Which medication improves survival in this setting?

  1. Nicorandil
  2. Ranolazine
  3. A beta blocker after myocardial infarction Correct answer.
  4. Sublingual nitroglycerin as needed

Explanation

Beta blockers reduce myocardial oxygen demand and, in patients with prior myocardial infarction, improve survival, making them the preferred antianginal therapy in that group. Other antianginal agents relieve symptoms but have not consistently shown a mortality benefit.

Question 44Cardiology

A 70-year-old man with severe aortic stenosis, hypertension, and chronic kidney disease develops progressive exertional dyspnea. Which factor most strongly predicts a poor prognosis and prompts consideration of valve replacement?

  1. An echocardiographic aortic valve area of 1.5 cm2
  2. The onset of symptoms attributable to aortic stenosis Correct answer.
  3. A systolic ejection murmur grade of 2/6
  4. A history of well-controlled hypertension

Explanation

Once severe aortic stenosis produces symptoms such as angina, syncope, or exertional dyspnea, the prognosis without intervention is poor, with high mortality within a few years. Symptom onset is the key trigger for aortic valve replacement.

Question 45Cardiology

A 52-year-old man is admitted with a large anterior ST-elevation myocardial infarction and develops hypotension, elevated jugular venous pressure, and clear lungs. Echocardiography shows a large right ventricular infarction. Which initial measure is most appropriate?

  1. Cautious intravenous fluid loading Correct answer.
  2. High-dose intravenous furosemide
  3. Sublingual nitroglycerin
  4. Aggressive beta blockade

Explanation

Right ventricular infarction causes hypotension because the right ventricle cannot fill the left ventricle adequately, and cautious fluid loading improves preload and cardiac output. Diuretics, nitrates, and beta blockers reduce preload or contractility and can worsen hypotension.

Question 46Cardiology

A 40-year-old woman has recurrent episodes of palpitations with a heart rate of 220 beats per minute, and an electrocardiogram during an episode shows a narrow-complex tachycardia with a short RP interval and retrograde P waves buried in the terminal QRS. Which mechanism best explains this arrhythmia?

  1. Microreentry within the left atrium
  2. Enhanced automaticity of the sinoatrial node
  3. Abnormal automaticity of the His-Purkinje system
  4. Reentry within the atrioventricular node Correct answer.

Explanation

A narrow-complex tachycardia with retrograde P waves buried in or just after the QRS suggests atrioventricular nodal reentrant tachycardia, which arises from a reentry circuit within the atrioventricular node using a slow and a fast pathway. The short RP interval reflects retrograde atrial activation occurring nearly simultaneously with ventricular activation.

Question 47Cardiology

A 66-year-old man with heart failure and reduced ejection fraction has persistent volume overload despite maximal diuretic therapy. Which combination has been shown to reduce cardiovascular death or heart failure hospitalization in this setting?

  1. Digoxin with diltiazem and a loop diuretic
  2. Amlodipine with hydralazine and a loop diuretic
  3. Sacubitril-valsartan with a mineralocorticoid receptor antagonist and a beta blocker Correct answer.
  4. Ivabradine with verapamil and a loop diuretic

Explanation

Combining sacubitril-valsartan, a mineralocorticoid receptor antagonist, and a beta blocker forms part of the guideline-directed foundation that reduces mortality and heart failure hospitalization in reduced ejection fraction. Each component has demonstrated outcome benefit in randomized trials.

Question 48Cardiology

A 28-year-old man presents with fever, a new holosystolic murmur, and multiple splinter hemorrhages. Blood cultures grow Staphylococcus aureus. Which finding would most strongly support a diagnosis of infective endocarditis with a high risk of embolic complications?

  1. A normal transthoracic echocardiogram
  2. A history of penicillin allergy
  3. A vegetation larger than 10 mm on the anterior mitral leaflet Correct answer.
  4. A platelet count of 150,000 per microliter

Explanation

Large vegetations, particularly those exceeding 10 mm on the mitral valve, are associated with an increased risk of systemic embolization and may prompt consideration of early surgery. Vegetation size and mobility are key echocardiographic predictors of embolic events.

Question 49Pulmonology

A 24-year-old man is brought to the emergency department after a bee sting. He has stridor, diffuse wheeze, and a blood pressure of 78/40 mmHg. Intramuscular epinephrine has been given. Which of the following is the most appropriate immediate next step in airway management?

  1. Give nebulised salbutamol alone
  2. Await response to epinephrine for 30 minutes
  3. Obtain a chest radiograph before any airway intervention
  4. Urgent endotracheal intubation Correct answer.

Explanation

Anaphylaxis with stridor indicates upper airway oedema and impending obstruction, which is a life-threatening emergency. Intramuscular epinephrine is the first drug, but when airway compromise is present, early definitive airway control by endotracheal intubation is required before oedema makes it impossible. Nebulised bronchodilators and imaging are adjuncts that must never delay securing the airway.

Question 50Pulmonology

A 58-year-old man has a spontaneous pneumothorax. Which finding on clinical examination is most characteristic of a tension pneumothorax rather than a simple pneumothorax?

  1. Hyperresonance with normal blood pressure
  2. Reduced breath sounds on the affected side
  3. Pleural rub on auscultation
  4. Tracheal deviation away from the affected side with hypotension Correct answer.

Explanation

Tension pneumothorax produces mediastinal shift, so the trachea deviates away from the affected side, and impaired venous return causes hypotension. Hyperresonance and reduced breath sounds occur in any pneumothorax and are not specific for tension. A pleural rub suggests pleural inflammation rather than a large air collection.