CHAPTER

The Heart 12
PBD9 Chapter 12 and PBD8 Chapter 12: The Heart

BP9 Chapter 10 and BP8 Chapter 11: Heart

1 An 82-year-old woman has had increasing fatigue for sounds. On physical examination, pulse is 77/min and BP
the past 2 years. During this time, she has experienced par- is 110/80 mm Hg. He does not have anginal pain. His liver
oxysmal dizziness and syncope. On physical examination, span is increased to 14 cm. He has pitting edema to his knees.
she is afebrile. Her pulse is 44/min, respirations are 16/min, Jugular venous distention is noted to the angle of the jaw at
and blood pressure is 100/65 mm Hg. On auscultation, the 45-degree elevation of his head while lying down. Which of
lungs are clear, and no murmurs are heard. An echocardio- the following is most likely causing his heart disease?
gram shows a normal-sized heart with normal valve motion A Atrial myxoma
and estimated ejection fraction of 50%. After parasympathetic B Essential hypertension
(vagal) stimulation, the heart rate slows and becomes irregu- C Hyperlipidemia
lar. An abnormality involving which of the following is most D Rheumatic fever
likely to be present in this patient? E Smoking
A Atrioventricular node
B Bundle of His 4 A 62-year-old woman has had increasing dyspnea for
C Left bundle branch the past 2 years. She now awakens at night with air hunger
D Parasympathetic ganglion and cough productive of frothy sputum. On examination, she
E Right bundle branch has rales in all lung fields. Her point of maximal impulse is
F Sinoatrial node strong and displaced laterally. Echocardiography shows a de-
G Sympathetic ganglion creased ejection fraction of 30% with concentric increase in left
ventricular wall size. The valves appear normal. Which of the
2 A neonate developing normally has a newborn checkup. underlying diseases does she have?
On physical examination, there is a systolic murmur. Echocar- A Amyloidosis
diography reveals a muscular defect of the intraventricular B Cardiomyopathy
septum. A checkup 30 years later fails to reveal either a mur- C Hypertension
mur or a flow defect between the ventricles. Which of the fol- D Myocarditis
lowing cells most likely proliferated and led to disappearance E Pericarditis
of the defect?
A Adipocytes 5 A 41-year-old woman has been awakened at night with
B Conduction cells “air hunger” for the past year. She notes sleeping better while
C Endothelial cells sitting up in bed. Her serum B-type natriuretic peptide is >400
D Fibroblasts pg/mL (very high). What cardiac disease best explains her
E Mesothelial cells condition?
F Stem cells A Atrial myxoma
B Fibrinous pericarditis
3 A 66-year-old man has had cough and worsening short- C Giant cell myocarditis
ness of breath for 3 years. On examination, there is dullness D Libman-Sacks endocarditis
to percussion at both lung bases and poorly audible breath E Rheumatic valvulitis
163
164 UNIT II Diseases of Organ Systems

6 A 50-year-old man has had increasing abdominal dis-

comfort and swelling of his legs for the past 2 years. He has
smoked cigarettes for 35 years. On physical examination, he
has jugular venous distention, even when sitting up. The liver
is enlarged and tender and can be palpated 10 cm below the
right costal margin. Pitting edema is observed on the lower
extremities. A chest radiograph shows bilateral diaphragmat-
ic flattening, pleural effusions, and increased lucency of lung
fields. Thoracentesis on the right side yields 500 mL of clear
fluid with few cells. Which of the following is most likely to be
the underlying disease in this patient?
A Acute myocardial infarction
B Chronic bronchitis
C Primary pulmonary hypertension
D Pulmonary valve stenosis
E Tricuspid valve stenosis
10 A 5-year-old child is not as active as other children his
7 An infant born at term is noted to have cyanosis during age. During the past 8 months, the child has had multiple epi-
the first week of life. On examination a heart murmur is aus- sodes of respiratory difficulty following exertion. On physical
cultated. Abnormal findings with echocardiography include examination, his temperature is 37° C, pulse is 81/min, respi-
an overriding aorta, ventricular septal defect, right ventricular rations are 19/min, and blood pressure is 95/60 mm Hg. On
thickening, and pulmonic stenosis involving the fetal heart. auscultation, a loud holosystolic murmur is audible. There
This infant is most likely to have an inherited mutation involv- are diffuse crackles over the lungs bilaterally, with dullness
ing which of the following genes? to percussion at the bases. A chest radiograph shows a promi-
A β-Myosin heavy chain (β-MHC) nent left heart border, pulmonary interstitial infiltrates, and
B Fibrillin 1 (FBN1 ) blunting of the costodiaphragmatic recesses. The representa-
C KCNQ1 tive gross appearance of the child’s heart is shown in the fig-
D NOTCH2 ure. Which of the following additional pathologic conditions
E Transthyretin (TTR) would most likely develop in this child?
A Aortic regurgitation
8 Following an uncomplicated pregnancy, a term infant B Coronary atherosclerosis
appears normal at birth, but at 1 day of life the infant develops C Nonbacterial thrombotic endocarditis
respiratory distress. On physical examination the infant has D Pulmonary hypertension
tachypnea, tachycardia, and cyanosis. There is an S1 ejection E Restrictive cardiomyopathy
click and a split S2 with prominent P sound. A radiograph
shows normal heart size but prominent hilar vascular mark- 11 A 3-year-old child is developing normally. Physical
ings. Echocardiography shows a small left atrium, large right examination reveals a low-pitched cardiac murmur. An echo-
atrium, normally sized ventricles, widely patent foramen ova- cardiogram shows the presence of an ostium secundum, with
le, and normally positioned aorta and pulmonary trunk. What a 1-cm defect. Which of the following abnormalities is most
type of congenital heart disease does this infant most likely likely to be found in this child?
have? A Cyanosis at rest
A Atrial septal defect B Left-to-right shunt
B Coarctation of the aorta, preductal type C Mural thrombosis
C Patent ductus arteriosus D Pericardial effusion
D Tetralogy of Fallot E Pulmonary hypertension
E Total anomalous pulmonary venous connection

9 A 77-year-old woman fell and fractured her ankle. She

has spent most of her time in bed for the past 16 days. She
develops sudden chest pain, dyspnea, and diaphoresis. On
examination she has left thigh swelling and tenderness. A
chest CT shows areas of decreased attenuation in the right and
left pulmonary arteries. A day later she has difficulty speak-
ing. MR angiography shows focal occlusion of a left middle
cerebral artery branch. Which of the following cardiac abnor-
malities is she most likely to have?
A Atrial myxoma
B Infective endocarditis
C Nonbacterial thrombotic endocarditis
D Patent foramen ovale
E Ventricular aneurysm
 CHAPTER 12 The Heart 165

12 A 2-year-old child had an illness 1 year ago character-

ized by a high fever. Staphylococcus epidermidis was cultured
from the blood. The child was given antibiotic therapy and
recovered. Now on physical examination, a harsh, waxing
and waning, machinery-like murmur is heard on auscultation
of the upper chest. A chest radiograph shows prominence of
the pulmonary arteries. Echocardiography shows all cardiac
valves to be normal in configuration. Laboratory studies show
normal arterial oxygen saturation level. Which of the follow-
ing congenital heart diseases is most likely to explain these
findings?
A Aortic atresia
B Aortic coarctation
C Atrial septal defect
D Patent ductus arteriosus
E Tetralogy of Fallot
F Total anomalous pulmonary venous return

13 A 5-year-old girl who is below the 5th percentile for

height and weight for age has exhibited easily fatigability
since infancy. On physical examination, she appears cyanotic.
Her temperature is 37° C, pulse is 82/min, respirations are
16/min, and blood pressure is 105/65 mm Hg. Pulse oximetry
shows decreased oxygen saturation. One month later, she has
fever and obtundation. A cerebral CT scan shows a right pari-
etal, ring-enhancing, 3-cm lesion. Which of the following con-
genital heart diseases is the most likely diagnosis?
A Atrial septal defect
B Bicuspid aortic valve
C Coarctation of the aorta
D Patent ductus arteriosus
E Truncus arteriosus
F Ventricular septal defect 15 A 27-year-old woman gives birth to a term infant after
an uncomplicated pregnancy and delivery. The infant is cya-
14 In a clinical study of tetralogy of Fallot, patients are ex- notic at birth. Two months later, physical examination shows
amined before surgery to determine predictors observed on the infant to be at the 37th percentile for height and weight.
echocardiography that correlate with the severity of the dis- The representative gross appearance of the infant’s heart is
ease and the need for more careful monitoring. A subset of shown in the figure. What is the most likely diagnosis?
patients is found to have more severe congestive heart failure, A Aortic stenosis
poor exercise tolerance, and decreased arterial oxygen satura- B Pulmonic stenosis
tion levels. Which of the following is most likely to predict a C Tetralogy of Fallot
worse clinical presentation for these patients? D Transposition of the great vessels
A Degree of pulmonary stenosis E Truncus arteriosus
B Diameter of the tricuspid valve
C Presence of an atrial septal defect 16 A 15-year-old boy complains of pain in his legs when he
D Size of the ventricular septal defect runs more than 300 m. Physical examination shows tempera-
E Thickness of the left ventricle ture, 36.8° C; pulse, 76/min; respirations, 22/min; and blood
pressure, 165/90 mm Hg. The radial pulses are 4+, and the
dorsalis pedis pulses are 1+. Arterial blood gas measurement
shows a normal oxygen saturation level. Which of the follow-
ing congenital cardiovascular anomalies is most likely to be
present in this patient?
A Aortic valve stenosis
B Coarctation of the aorta
C Patent ductus arteriosus
D Transposition of the great arteries
E Tricuspid valve atresia
166 UNIT II Diseases of Organ Systems

17 A 21-year-old primigravida gives birth at term to a 2800- 20 A 56-year-old man experiences episodes of severe sub-
g infant with no apparent external anomalies. The next day, the sternal chest pain every time he performs a task that requires
infant develops increasing respiratory distress and cyanosis. moderate exercise. The episodes have become more frequent
Echocardiography reveals a slitlike left ventricular chamber, and severe over the past year, but they can be relieved by sub-
small left atrium, and atretic aortic and mitral valves. Through lingual nitroglycerin. On physical examination, he is afebrile,
which of the following structures could blood from the lungs his pulse is 78/min and regular, and there are no murmurs
most likely have reached the infant’s systemic circulation? or gallops. Laboratory studies show creatinine, 1.1 mg/dL;
A Anomalous venous return glucose, 130 mg/dL; and total serum cholesterol, 223 mg/
B Foramen ovale dL. Which of the following cardiac lesions is most likely to be
C Patent ductus arteriosus present in this man?
D Right fourth aortic arch A Calcific aortic stenosis
E Truncus arteriosus B Coronary atherosclerosis
F Ventricular septal defect C Restrictive cardiomyopathy
D Rheumatic mitral stenosis
18 A 60-year-old man has had angina on exertion for the E Serous pericarditis
past 6 years. A coronary angiogram performed 2 years ago F Viral myocarditis
showed 75% stenosis of the left circumflex coronary artery
and 50% stenosis of the right coronary artery. For the past 21 A retrospective study of myocardial infarction is per-
3 weeks, the frequency and severity of his anginal attacks have formed to analyze patterns of cardiac injury. One pattern of
increased, and pain sometimes occurs even when he is lying in injury involves the posterior left ventricular wall and septum.
bed. On physical examination, his blood pressure is 110/80 mm Which of the following pathologic abnormalities is most likely
Hg, and pulse is 85/min with irregular beats. An ECG shows to produce this pattern?
ST segment elevation. Laboratory studies show serum glucose, A Ascending aortic dissection
188 mg/dL; creatinine, 1.2 mg/dL; and troponin I, 1.5 ng/mL. B Left anterior descending arterial plaque rupture
Which of the following is most likely to explain these findings? C Left circumflex arterial vasculitis
A Atheromatous plaque fissure with thrombosis D Right coronary sinus embolization
B Constrictive pericarditis with calcification E Right posterior descending arterial thrombosis
C Endomyocardial fibrosis
D Extensive myocardial fiber hypertrophy
E Left ventricular mural thrombosis
F Mitral valve prolapse with regurgitation

22 A 48-year-old woman has had increasing dyspnea for

the past 2 days. She experiences sudden cardiac arrest. The
representative light microscopic appearance of her left ven-
tricular free wall is shown in the figure. Which of the following
is the most likely diagnosis?
19 A 37-year-old woman has the sudden onset of chest A Acute rheumatic myocarditis
pain. On examination she is afebrile but tachycardic and hypo- B Cardiomyopathy
tensive. An ECG shows ST segment elevation and pathologic C Myocardial infarction
Q waves. The representative microscopic appearance of her D Septic embolization
left circumflex artery is shown in the figure. Which of the fol- E Viral myocarditis
lowing underlying conditions is she most likely to have?
A Acute myelogenous leukemia
B Chronic alcoholism
C Diabetes mellitus
D Marfan syndrome
E Polyarteritis nodosa
 CHAPTER 12 The Heart 167

23 A study of ischemic heart disease analyzes cases of in-

dividuals hospitalized with acute chest pain in which myo-
cardial infarction was documented at autopsy. The gross and
microscopic appearances of the hearts are correlated with the
degree of coronary atherosclerosis and its complications, clinical
symptoms, and therapies given before death. Hemorrhage and
contraction bands in necrotic myocardial fibers are most likely
to be seen with infarction in which of the following settings?
A Acute coronary vasculitis
B Anti-arrhythmic drug usage
C Angioplasty with stent placement
D Septic embolization
E Thrombolytic therapy

24 A 50-year-old man with diabetes mellitus and hyperten-

sion has had pain in the left shoulder and arm for the past
12 hours. Over the next 6 hours, he develops shortness of
breath, which persists for 2 days. On day 3, he visits the phy-
sician. On physical examination, his temperature is 37.1° C,
pulse is 82/min, respirations are 18/min, and blood pressure
is 160/100 mm Hg. Laboratory studies show total creatine
kinase (CK) activity within reference range, but the troponin
I level is elevated. He continues to experience dyspnea for the
next 3 days. On day 7 after the onset of shoulder pain, he has a
cardiac arrest and is resuscitated. Cardiac imaging now shows
a large fluid collection around the heart. Which of the follow-
ing complications has he most likely developed?
A Aortic valvular perforation
B Hemopericardium
C Left ventricular aneurysm 27 A 69-year-old man with metabolic syndrome had chest
D Papillary muscle rupture pain and an elevated serum troponin I level 1 year ago. He
E Pericarditis was treated in the hospital with anti-arrhythmic agents for
1 week. An echocardiogram showed an ejection fraction
25 A 45-year-old man experiences crushing substernal of 28%. He now has markedly reduced exercise tolerance.
chest pain after arriving at work one morning. Over the next On physical examination, his temperature is 37° C, pulse is
4 hours, the pain persists and begins to radiate to his left arm. 68/min, respirations are 17/min, and blood pressure is
He becomes diaphoretic and short of breath, but waits until 130/80 mm Hg. Diffuse crackles are heard on auscultation of
the end of his 8-hour shift to go to the hospital. An elevated the lungs. The representative gross appearance of his heart is
serum value of which of the following laboratory tests would shown in the figure. Which of the following complications of
be most useful for diagnosis of this patient on admission to the this disease is the patient most likely to develop?
hospital? A Atrial myxoma
A ALT B Cardiac tamponade
B AST C Constrictive pericarditis
C CK-MB fraction D Hypertrophic cardiomyopathy
D C-reactive protein E Infective endocarditis
E LDH-1 F Systemic thromboembolism
F Lipase
28 A 72-year-old man with poorly controlled diabetes mel-
26 A 19-year-old man suddenly collapses and is brought to litus has worsening exercise tolerance for 5 years. For the past
the emergency department. His vital signs are temperature, year he has had chest pain with minimal exertion. On physi-
37.1° C; pulse, 84/min; respirations, 18/min; and blood pres- cal examination he has bilateral pulmonary rales and pitting
sure, 80/40 mm Hg. Laboratory findings include hemoglobin, edema of his legs. He has an irregular heart rate. A chest
13.5 g/dL; platelet count, 252,000/mm3; WBC count, 7230/ radiograph shows prominent right and left heart borders. Echo-
mm3; serum glucose, 73 mg/dL; and creatinine, 1.2 mg/dL. cardiography shows decreased left ventricular ejection fraction
The total creatine kinase (CK) level is elevated, with a CK-MB (25%) with diminished wall motion. Laboratory studies show
fraction of 10%. Which of the following underlying conditions an elevated serum B-type natriuretic peptide. Which of the fol-
is most likely to be present in this patient? lowing pathologic findings is most likely present in this man?
A DiGeorge syndrome A Critical coronary stenosis
B Down syndrome B Left atrial mural thrombus
C Familial hypercholesterolemia C Hypertrophic cardiomyopathy
D Hereditary hemochromatosis D Mitral and tricuspid valve thickening
E Marfan syndrome E Pericardial fibrinohemorrhagic exudate
168 UNIT II Diseases of Organ Systems

29 A 68-year-old woman has had increasing dyspnea and

orthopnea for the past year. She does not report any chest
pain. On physical examination, her temperature is 37° C, pulse
is 77/min, respirations are 20/min, and blood pressure is
140/90 mm Hg. On auscultation of the chest, diffuse crack-
les are heard in all lung fields. No murmurs or gallops are
heard, and the heart rate is regular. A chest radiograph shows
prominent right and left heart borders. Coronary angiography
shows 90% occlusion of the left anterior descending artery.
Echocardiography shows no valvular abnormalities, but there
is decreased left ventricular wall motion and an ejection frac-
tion of 32%. Laboratory studies show serum glucose of 81 mg/
dL, creatinine of 1.6 mg/dL, total cholesterol of 280 mg/dL,
triglyceride of 169 mg/dL, and troponin I of 1 ng/mL. Which
of the following pharmacologic agents is most likely to be ben-
eficial in the treatment of this patient?
A Amiodarone 32 A 59-year-old man has experienced chronic fatigue for the
B Alteplase past 18 months. On physical examination, he is afebrile. A chest
C Glyburide radiograph shows bilateral pulmonary edema and a prominent
D Nitroglycerin left heart border. The representative gross appearance of his
E Propranolol heart is shown in the figure. Laboratory studies show serum
F Simvastatin glucose, 74 mg/dL; total cholesterol, 189 mg/dL; total protein,
7.1 g/dL; albumin, 5.2 g/dL; creatinine, 6.1 mg/dL; and urea
30 A 50-year-old man has sudden onset of severe subster- nitrogen, 58 mg/dL. What is the most likely diagnosis?
nal chest pain that radiates to the neck. On physical examina- A Chronic alcoholism
tion, he is afebrile, but has tachycardia, hyperventilation, and B Diabetes mellitus
hypotension. No cardiac murmurs are heard on auscultation. C Hemochromatosis
Emergent coronary angiography shows a thrombotic occlusion D Pneumoconiosis
of the left circumflex artery and areas of 50% to 70% narrowing E Systemic hypertension
in the proximal circumflex and anterior descending arteries.
Which of the following complications of this disease is most
likely to occur within 1 hour of these events?
A Myocardial rupture
B Pericarditis
C Valvular insufficiency
D Ventricular fibrillation
E Thromboembolism

31 A study of persons receiving emergent medical services

is conducted. It is observed that 5% of persons with sudden
cardiac arrest who receive cardiopulmonary resuscitation sur-
vive. Which of the following is the most likely mechanism for
cardiac arrest in these survivors?
A Arrhythmia
B Infarction
C Inflammation
D Valve failure 33 A 56-year-old man has worsening cough and orthopnea
E Ventricular rupture for the past 2 years. On physical examination, he has dullness
to percussion at both lung bases and diffuse crackles in the
upper lung fields. He is afebrile. Echocardiography shows
marked left ventricular hypertrophy and severe aortic steno-
sis. The representative gross appearance of the opened heart
is shown in the figure. A coronary angiogram shows no sig-
nificant coronary arterial narrowing. Which of the following
underlying conditions best accounts for his findings?
A Congenital anomaly
B Diabetes mellitus
C Infective endocarditis
D Marfan syndrome
E Systemic hypertension
 CHAPTER 12 The Heart 169

34 A 73-year-old woman had an episode a week ago in 36 A 65-year-old healthy woman has a check of her health
which she became disoriented, had difficulty speaking, and status and the only finding is a midsystolic click on ausculta-
had persisting weakness on the right side of her body. On phys- tion of the heart. Within 5 years she has increasing dyspnea.
ical examination, she is now afebrile with pulse of 68/min, res- Echocardiography now shows mitral regurgitation from pro-
pirations of 15/min, and blood pressure of 130/85 mm Hg. On lapse of a leaflet. Which of the following pathologic changes is
auscultation, the lungs are clear, the heart rate is irregular, and most likely present in this valve?
there is a midsystolic click. A chest CT scan shows a focus of A Destructive vegetations
bright attenuation within the heart. An echocardiogram shows B Dystrophic calcification
that one valvular leaflet appears to balloon upward. The ejec- C Fibrinoid necrosis
tion fraction is estimated to be 55%. Laboratory findings show D Myxomatous degeneration
serum creatine kinase (CK), 100 U/L; glucose, 77 mg/dL; E Rheumatic fibrosis
creatinine, 0.8 mg/dL; calcium, 8.1 mg/dL; and phosphorus,
3.5 mg/dL. Which of the following is the most likely diagnosis? 37 A 35-year-old woman has had palpitations, fatigue,
A Carcinoid heart disease and worsening chest pain during the past year. On physical
B Hyperparathyroidism examination, she is afebrile. Her pulse is 75/min, respirations
C Infective endocarditis are 15/min, and blood pressure is 110/70 mm Hg. Ausculta-
D Mitral annular calcification tion of the chest indicates a midsystolic click with late systolic
E Rheumatic heart disease murmur. A review of systems indicates that the patient has
F Senile calcific stenosis one or two anxiety attacks per month. An echocardiogram is
most likely to show which of the following?
A Aortic valvular vegetations
B Mitral valve prolapse
C Patent ductus arteriosus
D Pulmonic stenosis
E Tricuspid valve regurgitation

38 An 11-year-old boy had a sore throat, no cough, tonsil-

lar exudates, and 38.3° C fever 3 weeks ago, and a throat cul-
ture was positive for group A β-hemolytic Streptococcus. On
the follow-up examination, the child is afebrile. His pulse
is 85/min, respirations are 18/min, and blood pressure is
90/50 mm Hg. On auscultation, a diastolic mitral murmur
is audible, and there are diffuse rales over both lungs. Over
the next 2 days he has several episodes of atrial fibrillation
accompanied by signs of acute left ventricular failure. Which
of the following pathologic changes occurring in this child’s
heart is most likely to be the cause of the left ventricular
failure?
A Amyloidosis
35 A 77-year-old woman has had episodes of syncope B Fibrinous pericarditis
with exertion for the past month. On physical examination, C Mitral valve fibrosis
she is afebrile. Her pulse is 66/min, respirations are 14/min, D Myocarditis
and blood pressure is 125/85 mm Hg. On auscultation, a sys- E Tamponade
tolic ejection murmur is heard. There are a few crackles over F Verrucous endocarditis
the lung bases posteriorly. From the representative gross
appearance of the opened aorta shown in the figure, which of
the following most likely contributed to the development of
this lesion?
A Aging
B Atherosclerosis
C Chromosomal aneuploidy
D Hypercalcemia of malignancy
E Systemic lupus erythematosus
F Tertiary syphilis
170 UNIT II Diseases of Organ Systems

41 A 25-year-old man was found dead at home by the

39 A 14-year-old girl has fever and chest pain 2 weeks after apartment manager, who had been called by the decedent’s
having a mild upper respiratory tract infection. On physical employer because of failure to report to work for the past
examination, her temperature is 37° C, pulse is 90/min, res- 3 days. An external examination by the medical examiner
pirations are 20/min, and blood pressure is 85/45 mm Hg. showed splinter hemorrhages under the fingernails and no
A friction rub is audible on auscultation of the chest. A chest signs of trauma. The gross appearance of the heart at autop-
radiograph shows pulmonary edema. An echocardiogram sy is shown in the figure. Which of the following laboratory
shows small vegetations at the closure line of the mitral and findings is most likely to provide evidence for the cause of his
aortic valves. An endomyocardial biopsy shows focal intersti- disease?
tial aggregates of mononuclear cells enclosing areas of fibri- A Elevated anti–streptolysin O titer
noid necrosis. Her condition improves over the next month. B Positive ANCA serology
The representative gross appearance of the affected heart is C Increased creatine kinase–MB (CK-MB) fraction
shown in the figure. Which of the following cardiac abnormal- D High double-stranded DNA autoantibody titer
ities is most likely to occur in this patient? E Positive blood culture for Staphylococcus aureus
A Constrictive pericarditis
B Dilated cardiomyopathy 42 A 22-year-old previously healthy man undergoes a tooth
C Left ventricular aneurysm extraction, and 4 days later he develops a fever. On physical
D Myxoma examination his temperature is 37.6° C. A high-pitched systolic
E Valvular stenosis murmur is auscultated. A tentative diagnosis of congenital
heart disease is made. In which of the following locations is the
40 A 10-year-old girl develops subcutaneous nodules over congenital anomaly in this man most likely found?
the skin of her arms and torso 3 weeks after a bout of acute A Ascending aorta
pharyngitis. She manifests choreiform movements and begins B Atrial appendage
to complain of pain in her knees and hips, particularly with C Chordae tendineae
movement. A friction rub is heard on auscultation of her chest. D Cusps of valves
An abnormality detected by which of the following serum lab- E Muscular septum
oratory findings is most characteristic of the disease affecting
this girl? 43 A 26-year-old woman has had a fever for 5 days. On
A Antistreptolysin O antibody titer physical examination, her temperature is 38.2° C, pulse is
B Antinuclear antibody titer 100/min, respirations are 19/min, and blood pressure is
C Creatinine level 90/60 mm Hg. A cardiac murmur is heard on auscultation.
D Rapid plasma reagin test Her sensorium is clouded, but there are no focal neurologic
E Troponin I level deficits. Laboratory findings include hemoglobin, 13.1 g/dL;
platelet count, 233,300/mm3; and WBC count, 19,200/mm3.
Blood cultures are positive for gram-positive bacteria. Urinaly-
sis shows hematuria. An echocardiogram shows a 1.5-cm veg-
etation on the mitral valve. Which of the following conditions
is this patient most likely to develop?
A Cerebral arterial mycotic aneurysm
B Dilated cardiomyopathy
C Myxomatous mitral valve degeneration
D Pericardial effusion with tamponade
E Pulmonary abscess
 CHAPTER 12 The Heart 171

44 A 19-year-old man has had a low-grade fever for 48 A 50-year-old man with a history of infective endocar-
3 weeks. On physical examination, his temperature is 38.3° C, ditis has increasing fatigue. He receives a bileaflet tilting disk
pulse is 104/min, respirations are 28/min, and blood pressure mechanical mitral valve prosthesis. After surgery, he is stable,
is 95/60 mm Hg. A tender spleen tip is palpable. There are and an echocardiogram shows no abnormal valvular or ven-
splinter hemorrhages under the fingernails and tender hem- tricular function. Which of the following pharmacologic agents
orrhagic nodules on the palms and soles. A heart murmur should he receive regularly after this surgical procedure?
is heard on auscultation. Which of the following infectious A Aspirin
agents is most likely to be cultured from this patient’s blood? B Ciprofloxacin
A Coxsackievirus B C Cyclosporine
B Mycobacterium tuberculosis D Digoxin
C Pseudomonas aeruginosa E Propranolol
D Viridans streptococci F Warfarin
E Trypanosoma cruzi
49 A 44-year-old, previously healthy man has experienced
45 A 71-year-old woman has had a 10-kg weight loss worsening exercise tolerance accompanied by marked short-
accompanied by severe nausea and vomiting of blood for the ness of breath for the past 6 months. On physical examina-
past 8 months. On physical examination, she is afebrile. Labo- tion, his vital signs are normal. He has diffuse rales in all
ratory studies show hemoglobin, 8.4 g/dL; platelet count, lung fields and pitting edema to the knees. Laboratory stud-
227,100/mm3; and WBC count, 6180/mm3. Biopsy specimens ies show serum sodium, 130 mmol/L; potassium, 4 mmol/L;
obtained by upper gastrointestinal endoscopy show adeno- chloride, 102 mmol/L; CO2, 25 mmol/L; creatinine, 2 mg/dL;
carcinoma of the stomach. CT scan of the abdomen shows and glucose, 120 mg/dL. A 100-mL urine sample is collected.
multiple hepatic masses. CT scan of the head shows a cystic There is 1.3 mmol sodium and 40 mg creatinine in the urine
area in the right frontal lobe. Her condition is stable until sample. A chest radiograph shows cardiomegaly and pul-
2 weeks later, when she develops severe dyspnea. A chest CT monary edema with pleural effusions. An echocardiogram
scan shows areas of decreased pulmonary arterial attenua- shows four-chamber cardiac enlargement and mitral and
tion. Which of the following cardiac lesions is most likely to be tricuspid valvular regurgitation, with an ejection fraction of
present in this woman? 30%. A coronary angiogram shows less than 10% narrowing
A Calcific aortic valvular stenosis of the major coronary arteries. Which of the following is the
B Constrictive pericarditis most likely diagnosis?
C Epicardial metastatic carcinoma A Amyloidosis
D Left ventricular mural thrombosis B Hypercholesterolemia
E Nonbacterial thrombotic endocarditis C Familial cardiomyopathy
D Rheumatic heart disease
46 A 41-year-old woman has had increasing dyspnea for the E Trypanosoma cruzi infection
past week. On physical examination, temperature is 37.3° C,
pulse is 85/min, respirations are 20/min, and blood pressure 50 A 56-year-old man has experienced increased fatigue
is 150/95 mm Hg. There is dullness to percussion over the and decreased exercise tolerance for the past 2 years. On phys-
lung bases. A chest radiograph shows large bilateral pleural ical examination, his temperature is 37° C, pulse is 75/min,
effusions and a normal heart size. Laboratory findings in- respirations are 17/min, and blood pressure is 115/75 mm Hg.
clude serum creatinine, 3.1 mg/dL; urea nitrogen, 29 mg/dL; On auscultation, diffuse crackles are audible. The abdomen is
troponin I, 0.1 ng/mL; WBC count, 3760/mm3; hemoglobin, distended with a fluid wave, and there is bilateral pitting ede-
11.7 g/dL; and positive ANA and anti–double-stranded DNA ma to the knees. A chest radiograph shows pulmonary edema,
antibody test results. Which of the following cardiac lesions is pleural effusions, and marked cardiomegaly. An echocar-
most likely to be present in this patient? diogram shows mild tricuspid and mitral regurgitation and
A Calcific aortic stenosis reduced right and left ventricular wall motion, with an ejec-
B Hemorrhagic pericarditis tion fraction of 30%. He experiences cerebral, renal, and splen-
C Nonbacterial thrombotic endocarditis ic infarctions over the next year. Chronic use of which of the
D Libman-Sacks endocarditis following substances has most likely produced these findings?
E Mural thrombosis A Acetaminophen
F Rheumatic verrucous endocarditis B Cocaine
C Ethanol
47 A 44-year-old woman with rheumatic heart disease D Lisinopril
with aortic stenosis undergoes valve replacement with a bio- E Nicotine
prosthesis. She remains stable for the next 8 years and then F Propranolol
develops diminished exercise tolerance. Which of the follow-
ing complications involving the bioprosthesis has most likely
occurred?
A Embolization
B Hemolysis
C Myocardial infarction
D Paravalvular leak
E Stenosis
172 UNIT II Diseases of Organ Systems

51 A 25-year-old man suffers a sudden cardiac arrest. He is most likely show which of the following functional cardiac
resuscitated. On examination his vital signs are normal. Echo- disturbances?
cardiography shows that the left ventricle is normal but there A Dynamic obstruction to ventricular outflow
is marked thinning with dilation of the right ventricle. MR im- B Impaired ventricular diastolic filling
aging of his chest shows extensive fibrofatty replacement of C Increased end-systolic volume
the myocardium, but no inflammation. Which of the following D Mitral and tricuspid valvular insufficiency
is the most likely cause for his findings? E Reduced ejection fraction
A Cardiomyopathy
B Chagas disease 55 A 33-year-old woman from Victoria, British Columbia,
C Hypertension goes to the physician because of increasingly severe dyspnea,
D Long QT syndrome orthopnea, and swelling of the legs for the past 2 weeks. She
E Radiation therapy has no previous history of serious illness or surgery. On physi-
cal examination, her temperature is 37.8° C, pulse is 83/min,
52 A 10-year-old girl who is normally developed has respirations are 20/min, and blood pressure is 100/60 mm Hg.
chronic progressive exercise intolerance. On physical exami- An ECG shows episodes of ventricular tachycardia. An echo-
nation, temperature is 37.1° C, pulse is 70/min, respirations cardiogram shows right and left ventricular dilation, but no
are 14/min, and blood pressure is 100/60 mm Hg. A chest valvular deformities. An endomyocardial biopsy shows focal
radiograph shows cardiomegaly and mild pulmonary edema. myocyte necrosis and lymphocytic infiltrate. Which of the fol-
An echocardiogram shows severe left ventricular hypertrophy lowing organisms most likely caused the infection?
and a prominent interventricular septum. The right ventricle A Coxsackievirus A
is slightly thickened. During systole, the anterior leaflet of the B Mycobacterium kansasii
mitral valve moves into the outflow tract of the left ventricle. C Viridans streptococci
The ejection fraction is abnormally high, and the ventricular D Staphylococcus aureus
volume and cardiac output are both low. Which of the follow- E Toxoplasma gondii
ing is the most likely cause of the cardiac abnormalities in this F Trypanosoma cruzi
patient?
A Autoimmunity against myocardial fibers
B β-Myosin heavy chain gene mutation
C Deposition of amyloid fibrils
D Excessive iron accumulation
E Latent enterovirus infection

53 A 17-year-old girl jumps up for a block in the third

match of a volleyball tournament and suddenly collapses.
She requires cardiopulmonary resuscitation. A similar epi-
sode occurs a month later. She had been healthy all her life
and complained only of limited episodes of chest pain in
games during the current school year. Which of the following
pathologic findings of the heart is most likely to be present in
this girl?
A Extensive myocardial hemosiderin deposition
B Haphazardly arranged hypertrophied septal
myocytes
C Large, friable vegetations with destruction of aortic
valve cusps
D Mitral valvular stenosis with left atrial enlargement 56 A 68-year-old man has become increasingly lethargic
E Tachyzoites within foci of myocardial necrosis and and weak for the past 7 months. On physical examination,
inflammation his temperature is 36.9° C, pulse is 70/min, respirations are
15/min, and blood pressure is 160/105 mm Hg. On ausculta-
54 An 86-year-old man has had increasing dyspnea and tion of his chest, a friction rub is audible. There are no other
reduced exercise tolerance for the past 7 years. On physical remarkable findings. The representative gross appearance of
examination, he is afebrile and has a blood pressure of 135/85 the heart is shown in the figure. Which of the following labo-
mm Hg. An irregularly irregular heart rate averaging 76/min ratory findings is most likely to be reported for this patient?
is audible on auscultation of the chest. Crackles are heard at A Elevated serum anti–streptolysin O titer
the bases of the lungs. A chest radiograph shows mild car- B Elevated plasma renin level
diomegaly and mild pulmonary edema. Echocardiography C Increased blood urea nitrogen level
shows slight right and left ventricular wall thickening with D Increased serum CK-MB level
reduced left and right ventricular wall motion, reduced left E Positive ANA with “rim” pattern
ventricular filling, and an ejection fraction estimated to be F Positive viral serology
25%. An endomyocardial biopsy specimen shows amor-
phous pink-staining deposits between myocardial fibers, but
no inflammation and no necrosis. Echocardiography would
 CHAPTER 12 The Heart 173

57 A 52-year-old woman has had a chronic cough for the 59 A 73-year-old woman has had episodes of chest pain
past 2 years, accompanied by a small amount of occasionally during the past week. She is afebrile. Her pulse is 80/min, res-
blood-streaked, whitish sputum. On physical examination, her pirations are 16/min, and blood pressure is 110/70 mm Hg.
temperature is 37.9° C, pulse is 72/min, respirations are 22/min, On auscultation of the chest, heart sounds seem distant, but
and blood pressure is 125/80 mm Hg. Crackles are heard on the lung fields are clear. Neck veins are distended to the angle
auscultation over the upper lung fields. Heart sounds are faint, of the jaw, even while sitting. There is a darkly pigmented,
and there is a 15 mm Hg inspiratory decline in systolic arterial irregular, 1.2-cm skin lesion on the right shoulder. A chest ra-
pressure. The chest radiograph shows prominent heart borders diograph shows prominent borders on the left and right sides
with a “water bottle” configuration. Pericardiocentesis yields of the heart. Pericardiocentesis yields bloody fluid. Labora-
200 mL of bloody fluid. Infection with which of the following tory findings include a serum troponin I level of 0.3 ng/mL.
organisms is most likely to produce these findings? Which of the following lesions is the most likely cause of these
A Candida albicans findings?
B Coxsackievirus B A Calcific aortic stenosis
C Group A streptococcus B Coronary atherosclerosis
D Mycobacterium tuberculosis C Epicardial metastases
E Staphylococcus aureus D Mitral valvulitis
E Tuberculous pericarditis

60 A 48-year-old, previously healthy woman reports having

suddenly lost consciousness four times in the past 6 months.
In three instances, she was unconsciousness for only a few
minutes. After the fourth episode 1 month ago, she was uncon-
scious for 6 hours and had weakness in her right arm and dif-
ficulty speaking. On physical examination, she is afebrile, and
her blood pressure is normal. No murmurs are auscultated. She
has good carotid pulses with no bruits. Which of the following
cardiac lesions is most likely to be present in this woman?
A Bicuspid aortic valve
B Coronary artery thrombosis
C Left atrial myxoma
D Mitral valve stenosis
E Pericardial effusion

61 A 55-year-old man undergoes orthotopic cardiac trans-

plantation. Two months later, an endomyocardial biopsy
specimen shows focal myocardial cell death with scattered
perivascular lymphocytes and plasma cells. He is treated with
sirolimus. Which of the following pathologic processes best
accounts for these biopsy findings?
A Autoimmunity
B Autophagy
C Ischemia
D Infection
E Rejection

62 A 45-year-old man receives a cardiac allograft for dilated

58 A 31-year-old man experienced chest pain, became in- cardiomyopathy. He has no problems with rejection, but 5 years
creasingly dyspneic and nauseated, and lost consciousness later he has worsening exercise tolerance with increasing dys-
multiple times. Seven days after the appearance of these pnea and peripheral edema. Echocardiography shows a reduced
symptoms, he was found dead in his sleep. External examina- ejection fraction of 35%. Which of the following pathologic
tion of the body by the medical examiner shows no evidence abnormalities has he most likely developed in the allograft?
of trauma. The body is 166 cm (5 ft 5 in) in height and weighs A Amyloidosis
75 kg (BMI 27). The gross appearance of the chest cavity at B Constrictive pericarditis
autopsy with the pericardial sac opened is shown in the figure. C Coronary arteriopathy
What is the most likely underlying cause of his death? D Non-Hodgkin lymphoma
A Coronary atherosclerosis E Toxoplasmosis
B Dilated cardiomyopathy
C Disseminated tuberculosis
D Systemic sclerosis
E Malignant melanoma
F Marfan syndrome
G Takayasu arteritis