.

Bài 1:
A 48-year-old woman comes to the office with chest pain that has been
occurring over the last several weeks. The pain is not reliably related to
exertion. She is comfortable now. The location of the pain is retrosternal. The
pain is sometimes associated with nausea. There is no shortness of breath and
the pain does not radiate beyond the chest. She has no past medical history.
What is the most likely diagnosis?
A. Gastroesophageal reflux disease (GERD).
B. Unstable angina.
C. Pericarditis.
D. Pneumothorax.
E. Prinzmetal angina

B
E

131. A 55-year-old man has had crushing substernal chest pain on exertion
over the past 6 weeks. He had a myocardial infarction 2 months ago. He takes
nitroglycerin as needed and one aspirin daily. He has smoked two packs of
cigarettes daily for 30 years.
Examination shows normal heart sounds and no carotid or femoral bruits.
Treatment with a β-adrenergic blocking agent is most likely to improve his
symptoms due to which of the following mechanisms?
(A) Decreasing diastolic relaxation
(B) Decreasing myocardial contractility
(C) Dilating the coronary arteries
(D) Peripheral vasodilation
(E) Preventing fibrin and platelet plugs
B

3.A 46-year-old man comes to the emergency department complaining of

weakness and chest tightness on and off over the last 24 hours. He has no past
medical history. He does not use tobacco, alcohol, or illicit drugs. The patient's
father had a myocardial infarction at age 68, and his mother has myasthenia
gravis. An ECG is performed:
This patient should be evaluated for which of the following?
A. Aortic dissection
B. Cushing syndrome
C. High -frequency deafness
D. Hyperthyroidism
E. Nephrotic-range proteinuria
F. Polycystic kidney disease

8.A 78-year-old man is brought to the emergency department after a brief

episode of syncope. Since yesterday, he has been fatigued and lightheaded.
The patient has no chest pain or palpitations. He has a history of hypertension,
stable coronary artery disease, type 2 diabetes mellitus, and hyperlipidemia.
The patient's blood pressure is 82/44 mm Hg. He appears mildly lethargic but
answers questions appropriately. Lungs are clear on auscultation. The patient's
extremities are cold and capillary refill is 3 seconds. ECG is shown In the
Image.
Which of the following Is the most appropriate next step In management of
this patient?
A. Adenosine[6%]
B. Amiodarone[3%]
C. Atropine[64%]
D. Glucagon (9%]
E. Norepinephrine[14%]
A

Which of the following is most likely to benefit a patient’s risk of coronary disease?
A. Administration of estrogen replacement at the time of menopause.
B. Stopping tamoxifen.
C. Stopping aromatase inhibitors.
D. Regular exercise.
E. Relaxation methods such as meditation

Correcting which of the following risk factors for CAD will result in the most
immediate benefit for the patient?

A.Diabetes mellitus.
B.Tobacco smoking.
C.Hypertension.
D.Hyperlipidemia.
E.Weight loss.

1.A 36-year-old woman comes to the ED due to chest pain that started
suddenly while she was shopping at the mall. She also has shortness of breath,
palpitations, and diaphoresis. The pain is retrosternal and radiates to the left
arm. There are no aggravating or relieving factors. She appears to be in mild
discomfort.
On review of systems, the patient reports having had a runny nose, sore throat,
and dry cough for the past 3 days. Her other medical problems include panic
attacks treated with paroxetine and dysfunctional uterine bleeding treated with
estrogen. Family history is significant for her father's sudden death at age 44
from a heart attack. The patient has a 15-pack-year smoking history_ Her
blood pressure is 144/90 mm Hg and pulse is 104/min and regular. Her body
mass index is 29 kg/m2.
Which of the following is the most appropriate initial therapy for this patient?
A.Acetaminophen
B.Aspirin
C.Heparin
D.lbuprofen
E.Lorazepam
F. Oxycodone

A postmenopausal woman develops chest pain immediately on hearing the

news of her
son’s death in a war. She develops acute chest pain, dyspnea, and ST segment
elevation in leads V2 to V4 on ECG. Elevated levels of troponin confirm an
acute MI. Coronary angiography is normal including an absence of vasospasm
on provocative testing. Echocardiography reveals apical left ventricular
“ballooning.”
What is the presumed mechanism of this disorder?
A.Absence of estrogen.
B.Massive catecholamine discharge.
C.Plaque rupture.
D.Platelet activation.
E.Emboli to the coronary arteries.

Which of the following is the most common adverse effect of statin

medications?
A.Rhabdomyolysis.
B.Liver dysfunction.
C.Renal failure.
D.Encephalopathy.
E.Hyperkalemia
B
Which of the following is the most dangerous to a patient in terms of risk for
CAD?

A.Elevated triglycerides.
B.Elevated total cholesterol.
C.Decreased high density lipoprotein (HDL).
D.Elevated low density lipoprotein (LDL).
E.Obesity.
D
A 52-year-old woman with alcoholism comes to the physician after a serum
cholesterol concentration of 290 mg/dL was found on a routine screening. She
drinks a pint of vodka daily. She takes captopril for hypertension and glyburide
for type 2 diabetes mellitus. She also has intermittent episodes of gout.
Fasting serum studies show:
Total cholesterol 252 mg/dL
HDL-cholesterol 80 mg/dL
Triglycerides 300 mg/dL
Glucose 118 mg/dL
Thyroid-stimulating hormone 4.5 μU/mL
Which of the following is the most appropriate next step in management?
(A) Alcohol cessation
(B) Better control of diabetes
(C) Switch from captopril to calcium-channel blocking agent therapy
(D) Gemfibrozil therapy
(E) Thyroid replacement therapy

A 55-yo man comes to the office due to worsening cramping in his left leg that
he has noted during his morning exercise routines. He has no chest discomfort,
shorness of breath, palpitations, or syncope. His medical history is
unremarkable and he takes no medications. He is an ex-smoker with a 20-pack-
year history. The patient does not use alcohol or illicit drugs. He exercises
twice a week and eats a low-fat diet.
His father had a myocardial infarction at age 60 and died from a second MI at
age 65. His BP is 145/95 mmHg and pulse is 85/min. His cardiac, pulmonary,
and abdominal examinations are within normal limits. Peripheral pulses are
decreased in the left leg. Ankle-brachial index is 0.65 in the left and 1.1 in the
 right. His ECG is within normal limits. The fasting serum lipid profile shows a
total cholesterol of 220 mg/dl, triglycerides of 150 mgldl, low-density
lipoprotein of 135 mg/dl, and high-density lipoprotein of 50 mg/dL. His fasting
blood glucose is 88 mg/dL.
Which of the following is the most appropriate next step in management of this
patient?
A. Aspirin alone
B. Aspirin and atorastatin
C. Aspirin and fenofibrate
D. Surgical revascularization
E. Warfarin

Diagnostic tests
1/ A 48-year-old woman comes to the office with chest pain that has been occurring over the last several
weeks. The pain is not reliably related to exertion. She is comfortable now.
The location of the pain is retrosternal. She has no hypertension, and the EKG
is normal.
What is the most appropriate next step in management?
a. CK-MB
b. Troponin.
c. Echocardiogram.
d. Exercise tolerance testing
e. Angiography.
f. Cardiac MRI.
h. Holter monitor.


2/A man with atypical chest pain is found to have normal nuclear isotope uptake in his myocardium at
rest. On exercise,
there is decreased uptake in the inferior wall. Two hours after exercise, the
uptake of nuclear isotope returns to
normal.
What is the right thing to do?
A.Coronary angiography.
B.Bypass surgery.
 C.Percutaneous coronary intervention (e.g., angioplasty).
D.Dobutamine echocardiography.
E.Nothing; it is an artifact.

 C
4/A 70-year-old woman comes to the emergency department with crushing substernal chest pain for the
last hour. The
pain radiates to her left arm and is associated with anxiety, diaphoresis, and
nausea. She describes the pain as “sore”
and “dull” and clenches her fist in front of her chest. She has a history of
hypertension.
Which of the following is most likely to be found in this patient?
A. >10 mm Hg decrease in blood pressure on inhalation.
B. Increase in jugular venous pressure on inhalation.
C. Triphasic scratchy sound on auscultation.
D. Continuous “machinery” murmur.
E. S4 gallop.
F. Point of maximal impulse displaced towards the axilla.


5/ A 70-year-old woman comes to the ED with crushing substernal chest pain for the last hour.
Which of the following EKG findings would be associated with the worst
prognosis?
A. ST elevation in leads II, III, aVF.
B. PR interval >200 milliseconds.
C. ST elevation in leads V2-V4.
d. Frequent premature ventricular complexes (PVCs).
E. ST depression in leads V1 and V2.
f. Right bundle branch block (RBBB).
  C

 D

 E
A man comes to the emergency department with chest pain for the last hour that is crushing in quality and
does not change with respiration or the position of his body. An EKG shows
ST segment depression in leads V2 to V4. Aspirin has been given.
What is the most appropriate next step in the management of this patient?
A.Low molecular-weight heparin.
B.Thrombolytics.
C.Glycoprotein IIb/IIIa inhibitor (abciximab).
 D.Nitroglycerin.
E.Morphine.
F.Angioplasty.
G.Metoprolol.

23.A 68-year-old man is recovering in the intensive care unit after CA bypass graft surgery.
Two weeks ago,he was seen in the office for progressive exertional angina and SOB. The patiert
underwent coronary angiography, which indicated severe extensive cororary
artery disease. After discussion about the risks and berefits,he agreed to
proceed with open heart surgery.
The patient has a family history of CAD but no sudden cardiac death, heart failure,or bleeding.
On postoperative day 1, the nurses report that the patient is confused and has had reduced urine output.
Temperature is 35.6 C (96 F), BP is 80/50 mm Hg, pulse is 118/min and
regular, and respirations are 22/min. There is no drainage from his sternal
wound, and there has been no drainage in the chest tube over the last 4 hours.
The lung fields are clear. No heart murmurs are appreciated. The abdomen is
soft. His extremities are cool. ECG shows sinus tachycardia and nonspecific T-
wave changes. Pulmonary artery catheter readings are as follows: Right atrium
20 mm Hg (normal: 2-8 mm Hg),right ventricle 35/20 mm Hg (normal 15-30
mmHg/ 12-8 mm Hg), and pulmonary capillary wedge pressure 20 mm Hg
(normal: 6- 12 mm Hg).
Which of the following is the most appropriate next step in management of this patient?
A. Blood cultures
B. Coronaryangiogram
C. CT pulmonary angiogram
D. CT scan of the head
E. Dobutamine infusion
F. Echocardiogram
 C
A 70-year-old woman comes to the ED with crushing substernal chest pain for the last hour. An EKG
shows ST segment elevation in V2 to V4. Aspirin has been given to the patient to chew.
What is the most appropriate next step in the management of this patient?
A.CK-MB level.
B.Oxygen.
C.Nitroglycerin sublingual.
D.Morphine.
E.Thrombolytics.
F. Metoprolol.
G.Atorvastatin.
 H. Angioplasty.
I. Troponin level; Lisinopril.


 B

 A
5.A 47-year-old man develops sudden onset of mid-sternal chest pain and diaphoresis during a meeting in
his office. While waiting for emergency medical personnel to arrive, he
complains of dizziness and becomes unresponsive. His coworkers perform
cardiopulmonar resuscitation and he regains consciousness after 60 seconds.
The patient has a history of diet-controlled type 2 diabetes mellitus,
hypertension, and hyperlipidemia.
In the emergefy department, his blood pressure is 142/88 mmHg and pulse is 92/min, ECG shows normal
sinus rhythm, venticular premature complexes, and a 3-mm ST-segment
elevation in leads V1-V3.
What is the most likely primary pathophysiologic mechanism responsible for this patient's syncopal
episode?
A. Asystole
B. Atrial fibrillation
C. Atrio-venticular conduction block
D. Paroxysmal supraventricular tachycardia
E. Pulselesselectical activity
F. Reentrant venticular arrhythmias

A 76-year-old man is admitted to the coronary care unit after an episode of substernal chest pain. His
other medical problems include hyperension, hypertipidemia, and type 2
diabetes mellitus. He has a history of a diverticular bleed 2 years ago.
After initial workup, cardiac catheterization is performed and shows 70% left main coronary artery
stenosis, 90% proximal lef anterior descending arery stenosis, and 80% right
coronararter stersis. Antiplatelet agents are stopped, and the patient is
continued on a heparin drip in preparation for coronary arterbypass surgery the
next day. Five hours after the catheterization, his blood pressure is 75/60
mmHg and pulse is 120/min and regular. He complains of some generalized
weakness and back pain but denies chest pain, shortness of breath, nausea, and
abdominal discomfort.
On physical examination, he appears diaphoretic and clammy. Neck veins are flat. Heart sounds are
normal, and the chest is clear to auscultation. The right groin arterial puncture
site is mildly tender, without any swelling or bruits. He receives 1000 ml of
normal saline with symptomatic improvement. His blood pressure is 96/60 mm
Hg and pulse is 85/min. His repeat electrocardiogram (ECG) is unchanged
from the initial ECG at presentation.
Which of the following is the most appropriate next step in managing this patient?
A. CT scan of the abdomen and pelvis without contrast
B. CT scan of chest with contrast
C. Nasogastric tube placement
D. Transthoracic echocardiogram
E. Urgent coronary arterbypass surger
B

D
B

A
A

3.A 37-yo woman comes to the clinic due to occasional episodes of nocturnal substemal chest pain that
wake her during sleep. The pain is occasionally associated with
sweating,palpitations,and n.usea but no dyspnea. The pain episodes resolve
spontaneously afer 10-15 minutes. She leads a sedentary lifestyle but states
that she can climb 2 flights of stairs without any discomfort. The patient has no
history of hypertension or diabetes. She smokes half a pack of cigarettes daily.
She does not use alcohol or illicit drugs.
BP is 134/70 mm Hg, pulse is 75/min and regular, and respirations are 14/min. There is no jugular venous
distension. The thyroid is normal. There is no carotid bruit. Heart sounds are
normal without murmurs. Lungs are clear. Extremities have no edema.
Extended ambulatory ECG monitoring shows transient ST-segment elevation
in leads I, aVL,and V4-V6 during her episodes of pain. She is referred for
coronary angiogram,which shows no significant coronary obstruction.
Which of the following is the best treatment for this patient?
Aspirin and rosuvastatin
B Cilostazol
C Diltiazem
D Lorazepam
E Omeprazole
F. Propranolol
G Ranolazine

5.A 47-yo man develops sudden onset of mid-sternal chest pain and
diaphoresis during a meeting in his office. While waiting for emergency
medical personnel to arrive, he complains of dizziness and becomes
unresponsive. His coworkers perform cardiopulmonar resuscitation and he
regains consciousness afer 60 seconds. The patient has a history of diet-
controlled type 2 diabetes mellitus, hypertension, and hyperlipidemia.
In the emergefy department, his blood pressure is 142/88 mmHg and pulse is 92/min, ECG shows normal
sinus rhythm, venticular premature complexes, and a 3-mm ST-segment
elevation in leads V1-V3.
What is the most likely primary pathophysiologic mechanism responsible for this patient's syncopal
episode?
A. Asystole
B. Atrial fibrillation
C. Atrio-venticular conduction block
D. Paroxysmal supraventricular tachycardia
E. Pulselesselectical activity
F. Reentrant venticular arrhythmias

A 70-year-old woman comes to the emergency department with crushing substernal chest pain for the last
hour. An EKG shows ST segment elevation in V2 to V4.
What is the most appropriate next step in the management of this patient?
A. CK-MB level.
B.Oxygen.
C. Nitroglycerin sublingual.
D. Aspirin.
E. Thrombolytics.
F. Metoprolol.
G. Atorvastatin;
H Angioplasty.

Bài 2: congestive
Which of the following is the most common cause of death from CHF?

A.Pulmonary edema.
B.Myocardial infarction.
C.Arrhythmia/sudden death.
E.Emboli.
F.Myocardial rupture.
heart failure

A 74-year-old African American man with a history of dilated cardiomyopathy

secondary to MI in the past is seen in the office for routine evaluation. He is
asymptomatic and is maintained on lisinopril, furosemide, metoprolol, aspirin,
and digoxin. Lab tests reveal a persistently elevated potassium level. The EKG
is unchanged.
What is the best management?
A.Switch lisinopril to candesartan.
B.Stop lisinopril.
C.Start kayexalate.
D.Refer for dialysis.
E. Switch lisinopril to hydralazine and nitroglycerin


A 46-yo man comes to the physician with exertional dyspnea and dry cough.
He also has occasional episodes of suffocating nighttime cough that is only
relieved by sitting up. Past medical history is significant for MI 6 months ago
and hypercholesterolemia.
Current medications:metoprolol, aspirin, rosuvastatin. The patient does not use
tobacco or illicit drugs but drinks alcohol on social occasions. His father died
of a stroke and his mother has type2 DM. His BP is 150/100 mmHg and pulse
is 60/min. Chest examination shows bibasilar crackles. The cardiac apex is
palpated in the left sixth intercostal space. Bilateral pitting leg edema is
present.
Which of the following is most likely to be associated with this patient's condition?
A. Constriction of the efferent renal arterioles[56%]
B. Decreased intraglomerular pressure[15%]
C. Decreased renal venous pressure[4%]
D. Decreased plasma colloid pressure[11%]
E. High sodium delivery to the distal tubule[6%)
F. Increased renal blood flow[4%)
A

A 62-yo man comes to the physician because of a 2-month history of

progressive fatigue and ankle swelling. He had an anterior MI 3 years ago and
has had shortness of breath with mild exertion since then. Current medications
include abetalol and daily aspirin. He has smoked one-half pack of cigarettes
daily for 30 years.
His pulse is 100/min and regular, respirations are 20/min, and BP is 130/75
mm Hg. There are jugular venous pulsations 5 cm above the sternal angle.
Crackles are heard at both lung bases. Cardiac examination shows an S3
gallop. There is edema from the midtibia to the ankle bilaterally.
Further evaluation of this patient is most likely to show which of the following
findings?
(A) Decreased pulmonary capillary wedge pressure
(B) Impaired contractility of the left ventricle
(C) Prolapse of the mitral valve
(D) Thrombosis of the superior vena cava
(E) Ventricular septal defect

A 32-year-old woman comes to the clinic due to progressively worsening

dyspnea a month after returning from a vacation in Texas. The symptoms
started with SOB on exertion and have progressed to the point that she now
wakes during the night with a choking sensation that improves only with
sitting up. The patient has had a very active lifestyle for years,but currently she
is markedly limited in her activities. She has no associated chest pain, skin
rash, or joint pain. The patient has no significant medical history. Family
historis significant for thyroid cancer in her aunt and lung cancer in her father.
There is no family history of CAD, HF, or sudden cardiac death. She does not
use illicit drugs. The patient currently lives in New York City. Temperature is
37.2C (99 F), BP is 110/70 mm Hg, pulse is 96/min, and respirations are
14/min. Bilateral pitting ankle edema is present. The liver is enlarged 2cm
below the right costal margin. Lung auscultation reveals decreased breath
sounds at the bases bilaterally. Cardiac examination reveals the presence of a
S3. Chest x-ray reveals an enlarged cardiac silhouette, small bilateral pleural
effusions.ECG shows nonspecific ST segment changes.
Which of the following is the most likely cause of this patient's symptoms?
A. Atherosclerosis
B. Coccidioidomycosis
C. Connective tissue disease
D. Hypothyroidism
E. Lyme disease
F. Viral infection

A 74-year-old woman comes to the emergency department with the acute onset
of shortness of breath, respiratory rate of 38 per minute, rales to her apices, S3
gallop, and jugulovenous distension.
What is the best initial step in the management of this patient?
A.Oximeter.
B. Echocardiography.
C. Intravenous furosemide
D. Ramipril.
E. Metoprolol.
F. Nesiritide.

A 65-yo female is admitted to the hospital with increasing SOB, weight gain
and lower extremity edema. She has a history of hyperension, nonischemic
cardiomyopathy with an EF of 30%, and hyperlipidemia. Her home
medications include oral aspirin, digoxin, Furosemide, metoprolol, lisinopril
and atorvastatin. She is started on intravenous furosemide. On day three of
hospitalization telemetry reveals six beats of wide complex ventricular
tachycardia. Physical examination now shows decreased leg edema and clear
lungs.
Which of the following is the most appropnate next step in the management of
this patient's tachycardia?
A. Add spironolactone
B. Add metolazone
 C. Measure serum electrolytes
D. Discontmue atorvastatm
E. Discontinue metoprolol

A 32-yo woman comes to the ED due to progressive weakness and SOB over
the last several weeks. The patient has had no chest pain, palpitations,or
syocope. She has not had any recent upper respiratory infection. Medical
history is significant for migraine headaches for which she takes ibuprofen a
few times per week. She does not take any other over-the-counter or
prescription medications. The patient has had 2 cesarean sections, most
recently 2 years ago. She has smoked a pack of cigarettes a day since age 17
and uses methamphetamine. The patient has no family history of heart disease
or sudden cardiac death. Temperature is 36.1 C, BP is 88/60mmHg, pulse
is105/min and regular, and respirations are 22/min. Pulse oximetry is 91% on
room air. She is sitting upright in bed and appears uncomfortable.
Examination reveals diffuse crackles throughout the lung fields and dullness to
percussion at the right lung base. Apical impulse is palpated along the lefl
anterior axillary line. There is an extra low-pitched sound in early diastole,best
heard with the bell of the stethoscope placed on the apex. The patient's legs are
cool and pulses are diminished. There is 1+ bilateral peripheral edema.
Laboratory results are as follows:
Na+:134; K+:4.0; chloride:100; bicarbonate:18; BUN:40; creatinine:1.9;
calcium:8.6; glucose:80.
Pregnancy test is negative. In addition to other appropriate therapy, the patient
is given an intravenous medication that acts by primarily stimulating beta-1
adrenergic receptors.
Which of the following is the most likely mechanism by which this medication
may improve her condition?
A. Decrease in heart rate
B. Decrease in lefventncular end-systolicvolume
C. Decrease in myocardial oxygen demand
D. Increase in cardiac aferload
E. lncrease in cardIacpreload
F. lncrease in leftventncular end-diastolicvolume
G. lncrease in pulmonaryvascular resistance
H. lncrease in systemicvascular resistance

Bài 3: hypertension
B

A 30-year-old woman comes to the physician because of intermittent throbbing

headaches, sweating, and pallor over the past 3 months. She has had several
blood pressure measurements that fluctuate from 110/80 mm Hg to 160/108
mm Hg. Her pulse is 100/min, and blood pressure now is 138/88 mm Hg.
Serum studies show:
Na+ 140 mEq/L
Cl- 110 mEq/L
K+ 4.5 mEq/L
HCO3- 26 mEq/L
Urea nitrogen 14 mg/dL
Creatinine 1 mg/dL
Which of the following is the most likely location of the abnormality?
(A) Adrenal cortex
(B) Adrenal medulla
(C) Aorta
(D) Renal arterioles
(E) Renal glomeruli
(F) Thyroid gland

A 74-year-old man comes to the office to establish care. The patient has no
complaints and states he has been in good health. He has not been to a primary
care provider for several years.
Medical history includes right knee osteoarthritis, for which he occasionally
takes ibuprofen/ He does not use tobacco or alcohol. His blood pressure is
165/75 mm Hg and pulse is 70/min. Examination shows a 2/6 systolic ejection
murmur at the right sternal border without radiation. Peripheral pulses are full
without delay_ ECG reveals left ventricular hyperrophy with secondary ST-
segment and T wave changes. Echocardiogram shows moderate left ventricular
hyperrophy without any significant now abnormalities. The ejection fraction is
60%.
Which of the following is the most likely cause of hyperension in this patient?
A. Aortic insufficiency
B. Elevated plasma renin activity
C. lncreased cardiac output
D. lncreased intravascular volume
E. Rigidity of the arterial wall

A 63-yo woman comes to the office due to leg swelling that is especially
bothersome in the evening. Her symptoms have gradually worsened over the
last year. Her medical problems include hypertension treated with lisinopril
and obstructive sleep apnea for which she uses continuous positive airway
pressure during sleep. She was hospitalized 2 years ago for a chest infection
that was treated with antibiotics. The patient has smoked a pack of cigarettes
daily for 30 years and does not drink alcohol. BP is 160/90 mmHg and pulse is
80/min. BMI is 32 kg/m2. Jugular venous pulsation is seen 2 cm above the
sternal angle with the head of the bed elevated to 45°.
Chest examination shows bilateral scattered wheezes and prolonged
expirations. Her abdomen is soft and nondistended. She has bilateral 2+ pitting
edema in her lower extremities to the midshin with dilated and tortuous
superficial veins. A small ulcer is noted on the left medial ankle. All peripheral
pulses are palpable.
Which of the following is most likely to relieve this patient's current
symptoms?
A. Daily furosemide
B. Dietary sodium restriction
C. Frequent leg elevation
D. lmprove control hypertension
E. Smoking cessation

A 77-yo man is brought to the physician because of a 12-hour history of word-

finding difficulty and weakness and sensory loss of the right arm and leg. He
has no history of similar symptoms. He has type 2 DM, hypertension, and
atrial fibrillation. Current medications include metformin, lisinopril, and
aspirin.
He is alert. His pulse is 80/min and irregular, respirations are 16/min, and BP
is 170/90 mmHg. He follows commands but has nonfluent aphasia. There is
moderate weakness and decreased sensation of the right upper and lower
extremities. Deep tendon reflexes are 2+bilaterally. Babinski sign is present on
the right. His serum glucose concentration is 162 mg/dL.
Which of the following is the most appropriate next step in diagnosis?
(A) Carotid duplex ultrasonography
(B) CT scan of the head
(C) EEG
(D) Lumbar puncture
(E) Cerebral angiography

A 40-year-old man comes to the emergency department with slowly

progressive headaches, dyspnea, and blurry vision over the last 2 days. His
other medical problems include hypertension treated with hydrochlorothiazide
and lisinopril for the past 2 years. He has been noncompliant with his medical
regimen and physician follow-ups. He smokes 1 pack a day and occasionally
consumes alcohol. On initial evaluation, his BP is 220/140 mm Hg and pulse is
75/min.
Which of the following establishes the diagnosis of malignanl hyprtension in
this patient?
A. Left ventricular hypertrophy on electroardiogram
B. Reduced glomerular filtration rate
C. Papilledema and retinal hemorrhages
D. Diastolic blood pressure >120 mmHg
E. Pulmonary congesion on chest x-ray

A 36-year-old man comes to the physician for a routine pre-employment

physical. He has no complaints except for occasiooal morning headaches. His
father died suddenly at age 54. The patient's blood pressure is 175/103 mmHg
in the right arm and 180/105 in the left, and pulse is 82/min. The lungs are
clear bilaterally and heart sounds are normal. Bilateral, nontender, upper
abdominal masses are palpated on examination. His hemoglobin level is 15.2
g/dl and creatinine concentration is 0.8 mg/dL.
Which of the following is the most appropriate next step in evaluating this
patient's condition?
A. 24-hour urine cortisol
B. Adominal ultrasound
C. captopril-enhanced radionuclide renal scan
D. Plasma aldosterone/renin ratio
E. Urine metanephrines

A 50-yo woman presents to your office complaining of lower extremity edema

that started several weeks ago, and slowly progressed thereafter. Her past
medical history is signifiant ror hypertension, treated with metoprolol for 2
years. Amlodipine was added recently because of inadequate control of BP
with metoprolol alone.
She does not smoke or consume alcohol. She has no known drug allergies.
Her BP is 130/80 mmHg and her heart rate is 64/min The physical examination
reveal bilateral symmetric 3+ pitting edema of both lower extremities, without
any skin changes or varicosities. Her neck vein pulsation is normal. Other
physical findings are within normal limits. Her laboratory studies reveal the
following : Serum albumin 45g/dl; Total serumbllirubin 08mg/dl; Serum Na+
140mEqlL; Serum K+ 4.0mEq/L; Serum creatinine 0.8mg/dl. Urinalysis is
within normal limits.
What Is the most likely cause of the edema in this patient?
A. Heart faiIure
B. Liver disease
C. Renal disease
D. Venous insufficiency
E. Side effect of her medIcatIons

An 8O-yo woman is brought to the emergency deparment due to a day of

lethargy and confusion.The patient's medical issues include hypertension,type
2DM,coronary artery disease, peripheral vascular disease,and previous stroke.
She smoked cigarettes for 30 years but quit after a myocardial infarction
10years ago. The patient has been bedbound for the past 2 years due to a
stroke. Temperature is 36.8 C, BP is 74/48 mmHg, pulse is 124/min, and
respirations are 24/min. She has a sacral decubitus ulcer with purulent drainage
and surrounding erythema. On bilateral lower extremities, changes of chronic
venous stasis are present. Neurologic examination shows a confused patient
who is unable to follow instructions. Laboratory results are as follows:
Serum chemistry: Na+ 134 mEq/l, K+ 4.2mEqll, Chloride 100mEq/l,
Bicarbonate 19 mEq/L, Blood urea nitrogen 20 mg/dl, Creatinine 2.2mg/dl,
Glucose 250mg/dl.
Invasive hemodynamte monitoring reveals the pulmonary capillary wedge
pressure is 6 mmHg (normal 6-12 mmHg) and mixed venous oxygen
saturation is 82% (normal: 60%-80%).
Which or the followmg findings would most likely be associated with this
patients hypotension?
A. Decreased cardiac contractility
B. lncreased intrapericardial pressure
C. Loss of vagal tone
D. Mineralocorticoid deficIency
E. Reduced cardiac aflerload
A 67-yo woman comes to the physician because of dizziness for 6 weeks.
When she stands up suddenly, she becomes light-headed and has to steady
herself for approximately 1 to 2 minutes before she is able to walk. She has
hypertension and type 2 diabetes mellitus. Current medications include
glyburide, a diuretic, a β-adrenergic blocking agent, and an ACE inhibitor.
Her pulse is 55/min. Her BP is 110/70 mmHg in the right arm and 70/50
mmHg in the left arm while supine; her BP is 70/50 mmHg in the right arm
and 50/30 mmHg in the left arm immediately after standing. Neurologic
examination shows no focal findings. An ECG shows sinus bradycardia with
no evidence of ischemia. Carotid duplex ultrasonography shows reverse flow
in the left vertebral artery with no evidence of occlusion.
Which of the following is the most appropriate next step in management?
(A) Cardiac stress scintigraphy
(B) Adjusting her medication regimen
(C) Warfarin therapy
(D) Transesophageal echocardiography
(E) Coronary arteriography

A 47-year-old woman comes to the physician because of persistent

nonproductive cough for 6 weeks. She has not had fever or weight loss. She
has hypertension treated with enalapril for the past 3 months. She does not
smoke. There is no history of lung disease.
She weighs 54 kg (120 lb) and is 163 cm (64 in) tall. Her temperature is 37°C
(98.6°F), BP is 130/80 mmHg, pulse is 70/min, and respirations are 12/min.
Examination and an x-ray of the chest show no abnormalities.
Which of the following is the most likely mechanism of this patient's cough?
(A) Decreased plasma renin activity
(B) Decreased serum angiotensin II concentrations
(C) Increased serum angiotensin I concentrations
(D) Increased serum bradykinin concentrations
(E) Increased serum histamine concentrations
A

During a routine examination, a 32-year-old man has a BP of 120/80 mmHg.

He is concerned because his father, grandfather, and two uncles have
hypertension. He works as a systems programmer for a large computer
company and frequently has to meet tight deadlines. He has smoked one pack
of cigarettes daily for 10 years. He is 4.5 kg (10 lb) overweight and drinks
three cups of coffee daily.
Which of the following measures is most likely to reduce this patient's risk for
hypertension over the next 5 years?
(A) Increase intake of dietary fiber
(B) Restrict caffeine
(C) Stress management
(D) Weight loss
E

E
H

C
E

Bài 5/ Cardiomyopathy
A

D
A 15-year-old boy collapses suddenty while playing basketball with his friends
.The boy played basketball every weekend without any symptoms and was in
his usual state of health prior to this event. He has no known past medical
history and takes no medications. Family history is significant for a maternal
uncle who died at age 25 for unknown reasons. Cardiopulmonary resuscitation
is unsuccessful and the patient is pronounced dead.
Post-mortem examination would most likely show which of the following?
A. Abnormal brain mass
B. Coronary atheroclerosis
C. Hypertrophic cardiomyopathy
D. Mutation in the LQT1 gene
E. No underlying disease
F. Pulmonary embolus
G. Ruptured aortic aneurysm

A 78-year-old man with a history of lung cancer comes to the ED with several
days of increasing shortness of breath. He became somewhat lightheaded
today, and that is what has brought him to the hospital. On physical
examination, he has a BP of 106/70; pulse of 112; jugulovenous distention;
and the lungs are clear to auscultation. The BP drops to 92/58 on inhalation.
Which of the following is the most appropriate to confirm the diagnosis?
A.EKG.
B.Chest x-ray.
C.Echocardiogram.
D.Right heart catheterization.
E.Cardiac MRI.

16.A 34-yo woman comes to the ED with difficulty breathing and dizziness.
An arterial line is placed and her BP tracing is shown below:
Which of the following is most appropriate ?
A. Aortic regurgitation
B. Lobar pneumonia
C. Mitral stenosis
D. Panic attack
E. Severe asthma
An 18-yo man is brought to the ED 10 minutes after he sustained a stab wound
to his chest. On arrival, he is unresponsive to painful stimuli.
His pulse is 130/min, respirations are 8/min and shallow, and palpable systolic
blood pressure is 60 mm Hg. He is intubated and mechanically ventilated, and
infusion of 0.9% saline is begun. After 5 minutes, his pulse is 130/min, and BP
is 70/40 mmHg. Examination shows a 2-cm wound at the left sixth intercostal
space at the midclavicular line. There is jugular venous distention. Breath
sounds are normal. The trachea is at the midline. Heart sounds are not audible.
Which of the following is the most appropriate next step in management?
(A) Chest x-ray
(B) Echocardiography
(C) Bronchoscopy
(D) Pericardiocentesis
(E) Placement of a right chest tube
C

A
D
D
4.A 56-year-old man comes to the ED due to 5 days of dyspnea. He wakes up
during the night with difficulty breathing that keeps him from going back to
sleep. He has never had these symptoms before. The patient's medical history
is signifcant for long-standing hypertension and noncompliance with his
antihypertensive therapy. He was diagnosed with deep-vein thrombosis 8 years
ago after surgery for a tibial fracture; he received 6 months of anticoagulatton.
He has a 30 pack-year smoking history. BP is 182/109 mmHg and pulse is
110/min and regular. Oxygen saturation is 90% on room air. Lung auscultation
shows bibasilar crackles and scattered whezes.
Which of the following is the most appropriate next step in management of this
patient?
A.Albuterol and corticosteroids
B. Intravenous amiodarone
C. lntravenous digoxin
D. Intravenous furosemide
E. lntravenous metoproloI
F. Therapeutic anticoagulatIon

A 46-yo man comes to the physician with exertional dyspnea and dry cough.
He also has occasional episodes of suffocating nighttime cough that is only
relieved by sitting up. Past medical history is significant for MI 6 months ago
and hypercholesterolemia.
 Current medications:metoprolol, aspirin, rosuvastatin. The patient does not use
tobacco or illicit drugs but drinks alcohol on social occasions. His father died
of a stroke and his mother has type2 DM. His BP is 150/100 mmHg and pulse
is 60/min. Chest examination shows bibasilar crackles. The cardiac apex is
palpated in the left sixth intercostal space. Bilateral pitting leg edema is
present.
Which of the following is most likely to be associated with this patient's
condition?
A. Constriction of the efferent renal arterioles
B. Decreased intraglomerular pressure
C. Decreased renal venous pressure
D. Decreased plasma colloid pressure
E. High sodium delivery to the distal tubule
F. Increased renal blood flow

Bài 6/ Valvular heart disease

A 52-year-old woman has had dyspnea and hemoptysis for 1 month. She has a
history of rheumatic fever as a child and has had a cardiac murmur since early
adulthood.
Her temperature is 36.7°C (98°F), pulse is 130/min and irregularly irregular,
respirations are 20/min, and BP is 98/60 mm Hg. Jugular venous pressure is
not increased. Bilateral crackles are heard at the lung bases. There is an
opening snap followed by a low-pitched diastolic murmur at the third left
intercostal space. An x-ray of the chest shows left atrial enlargement, a straight
left cardiac border, and pulmonary venous engorgement.
Which of the following is the most likely explanation for these findings?
(A) Aortic valve insufficiency
(B) Aortic valve stenosis
(C) Mitral valve insufficiency
(D) Mitral valve stenosis
(E) Tricuspid valve insufficiency
B

A
E

A 48-year-old Caucasian male presents to your office complaining of progressive exertonaldyspnea. It

has become especially bothersome over the past two moriths. Presently, he
becomes short of breath after climbing one flight of stairs. He denies any
significant problems in the past. He is not taking any medications and he
denies smoking or drinking alcohol. His temperature is 37.2°C (98.9°F), pulse
is 78/min, blood pressure is 130/75 mm of Hg and respirations are 14/min.
Chest examination reveals a harsh systolic murmur that is best heard at the
right second intercostal space with radiation along the carotid arteries. An S4 is
heard at the apex. Based on these findings, what is the most likely cause of this
patient's symptoms?
A. Hypertrophiccardiomyopathy
B. Myxomatous valvedegeneration
C. Rheumatic heart disease
D. Bicuspid aoric valve
E. Senile calcific aortic stenosis
 C

A healthy 4-year-old girl is brought for a well-child examination. A grade 2/6

systolic ejection murmur is heard along the upper left sternal border. S2 is
widely split and does not vary with respiration. A soft mid-diastolic murmur is
 heard along the lower left sternal border. Examination shows no other
abnormalities.
Which of the following is the most likely diagnosis?
(A) Aortic stenosis
(B) Atrial septal defect
(C) Coarctation of the aorta
(D) Mitral valve prolapse
(E) Patent ductus arteriosus
(F) Pulmonary stenosis
(G) Tetralogy of Fallot
(H) Transposition of the great arteries
(I) Ventricular septal defect
(J) Normal heart

B
D

A 24-yo woman comes to the office due to pressure-like, substernal chest pain
that occurs when she exercises. The patient began noticing the pain
approximately 6 months ago when she started to exercise to lose weight. Prior
to that, her lifestyle was largely sedentary. She has no associated nausea,
vomiting, diaphoresis, dyspnea, palpitations, or syncope. The patient has no
significant past medical history but was told as a child that she has a
"murmur." She has no significant family history of heart disease.
BP is 130/70mm Hg on the right and 105/55mmHg on the left, and pulse is
72/min and regular. BMI is 29kg/m2. A palpable thrill is present in the
suprasternal notch. There is a loud midsystolic murmur best heard at the first
right intercostal space. The lungs are clear to auscultation.
What is the most likely cause of this patient's chest pain?
A.Anomalous origin of the right coronar arery
B.Atherosclerotic narrowing of the coronaries
C.Increased myocardial oxygen demand
D.Stretching ofthe papillary muscles
E.Systolic anterior motion of the mitral valve

Bài 7/ Nephrology
Diabetic patient is evaluated with a UA that shows no protein.
Microalbuminuria is detected (level between 30 and 300 mg per 24 hours).
What is the next best step in the management of this patient?
A.Enalapril.
B.Kidney biopsy.
C.Hydralazine.
D.Renal consultation.
E.Low-protein diet.
F.Repeat UA annually and treat when trace protein is detected

A woman is admitted to the hospital with trauma and dark urine. The dipstick
is markedly positive for blood.
What is the best initial test to confirm the etiology?
A.Microscopic examination of the urine.
b.Cystoscopy.
C.Renal ultrasound.
D.Renal/bladder CT scan.
E.Abdominal x-ray.
F.Intravenous pyelogram.

A 24-year-old woman comes to the physician because of a 24-hour history of

right flank pain, burning micturition and high-grade fever
with chills. Her temperature is 38.9° C (102° F), blood pressure is 90/60
mmHg, pulse is 130/min, and respirations are 20/min.
Physical examination shows costovertebral angle tenderness.
Which of the following is the most likely urine dipstick finding in this
patient?
A Positive for nitrites and esterase
B. Positive for nitrites only
C. Positive for esterase only
D. Negative for both esterase and nitrites

A 20-year-old African American man comes for a screening test for sickle cell.
He is found to be heterozygous (trait or AS) for sickle cell.
What is the best advice for him?
A.Nothing needed until he has a painful crisis.
B.Avoid dehydration.
C.Hydroxyurea.
E.Folic acid supplementation.
F.Pneumococcal vaccination

A 57-year-old man comes to the physician for 2 episodes of blood in his urine.
He also complains of fatigue and fever for the last 4 weeks. He has no other
medical problems and takes no medications. The patient has a 50-pack-year
smoking history but does not use alcohol or illicit drugs. His father died from a
blood disorder, but the patient is unsure of the specific name. Vital signs are
within normal limits. Examination shows a left-sided varicocele that fails to
empty when the patient is recumbent. The remainder of the examination shows
no abnormalities.
Laboratory results are as follows:
Hemoglobin 18.0 g/dl; WBCs 7,400/µL; Platelets 580,000/µL
Urinalysis >10 RBCs/hpf
Which of the following is the most appropriate diagnostic procedure?
A Chest x-ray
B. Abdominal CT scan
C. Urine cytology
D. Serum alpha-fetoprotein levels
E. Ultrasound of the testicles
F Bone marrow biopsy

A 46-yo man comes to the ED due to intermittent severe right flank pain over
the past few days. He has had decreased urination over the last week but has
also noted occasional episodes of high urine output along with a feeling of
generalized weakness. The patient has a history of chronic back pain for which
he takes oxycodone daily, and he underwent a left total nephrectomy following
a motor vehicle accident 25 years ago. He was recently started on low-dose
lisinopril for a new diagnosis of hypertension. There is no family history of
renal disease. On physical examination, BP is 145/86 mmHg and heart rate is
86/min. Laborator results are as follows:
Serum chemistry: Potassium 3.4 mEq/L; Creatinine 1.7 mg/dl
Urinalysis: Protein trace; White blood cells 4/hpf; Red blood cells 2/hpf; Casts
none
Which of the following is the most likely cause of this patient's symptoms?
A. Adrenal tumor
B. Glomerulonephritis
C. Inherited renal disease
D. Interstitial nephritis
E. Renal artery stenosis
F. Urinary outflow obstruction

A patient with extremely severe myeloma with a plasmacytoma is admitted for

combination chemotherapy. Two days later, the creatinine rises.
What is the most likely cause?
A.Cisplatin.
B.Hyperuricemia.
C.Bence-Jones proteinuria.
D.Hypercalcemia.
E.Hyperoxaluria

A 38-year-old woman comes to the physician because of a low-grade fever and

generalized rash for 4 days. She is currently receiving cefazolin therapy for
chronic osteomyelitis. Her temperature is 38.2°C (100.8°F), BP is 150/108
mmHg, and pulse is 100/min. There is a faint diffuse maculopapular rash.
Examination of the back shows no costovertebral angle tenderness. Cardiac
and pulmonary examinations show no abnormalities. Laboratory studies show:
Eosinophils are found in the urine sediment.
Which of the following is the most likely explanation for these findings?
(A) Acute tubular necrosis
(B) Fibromuscular dysplasia
(C) Interstitial nephropathy
(D) Polyarteritis nodosa
(E) Pyelonephritis
(F) Wegener's granulomatosis

Leukocyte count 10,800/mm3

Segmented neutrophils 60%
Bands 8%; Eosinophils 4%
Lymphocytes 20%
Monocytes 8%
Serum
Urea nitrogen 20 mg/dL
Creatinine 1.6mg/dl
Urine
WBC 12/hpf; RBC 8/hpf
RBC casts none
WBC casts rare

A patient develops ATN from gentamicin. She is vigorously hydrated and

treated with high doses of diuretic, lowdose dopamine, and calcium acetate as
 a phosphate binder. Urine output increases but she still progresses to endstage
renal failure. She also becomes deaf.
What caused her hearing loss?
A.Hydrochlorothiazide.
B.Dopamine.
C.Furosemide.
D.Chlorthalidone.
E.Calcium acetate
C

113.An asymptomatic 52-year-old man comes for a follow-up examination 1

month after he passed renal calculi. He has a history of renal calculi 2 years
ago. Serum uric acid and calcium concentrations and urinary oxalate excretion
are within normal limits. Urinary calcium excretion is increased.
In order to avoid recurrence of renal calculi, Which of the following is the
most appropriate pharmacotherapy for this patient?
(A) Bicarbonate
(B) Calcium lactate
(C) Methenamine mandelate
(D) Probenecid
(E) Thiazide diuretic
E

A
C

Bài 8/ Glomerular Diseases

B

A
A 22-yo man comes to the urgent care clinic complaining of dark urine he
noticed earlier this morning. He is recovering from an upper respiratory tract
infection that stared 4 days ago. The patient's temperature is 37.1C, BP is
145/92 mmHg, pulse is 80/min, and respirations are 14/min. Physical
examination shows no skin rash and no joint abnormalities. Laboratory results
are as follows:
Urinalysis
Glucose Negative; Protein 1+; Ketones Negative; Leukocyte esterase
Negative;
Nitrites Negative; White blood cells 3-6/hpf; Red blood cells 30-50/hpf; Casts
Red blood cells
Serum chemistry
Na+ 138 mEq/L; K+ 4.5 mEq/L; HCO3- 22 mEq/L; BUN 18 mg/dL;
creatinine 1.4 mg/dl
Serum complement levels (C3 and C4) are within normal limits, and other
serological workup is pending. Which of the following is the most likely
diagnosis?
A. Acute interstitial nephritis
B. Acute postinfectious glomerulonephritis
D. Anti-glomerular basement membrane disease
E. Benign recurrent hematuria
F. Goodpasture's syndrome
G. Henoch-Schonlein purpura
H. lgA nephropathy

A 5-year-old boy is brought to the physician due to a 1-week history of

generalized edema, fatigue, and abdominal pain Otherwise, he has been well
and his medical history is unremarkable. The patient takes a daily multivitamin
and no other medications. BP is 92/55 mmHg and pulse is 90/min. Periorbital
edema and 1 + pretibial edema are found on examination. The scrotum is
mildly swollen but nontender. Abdominal examination is unremarkable.
Urinalysis results are as follows:
Specific gravity 1.028; pH 5; Protein 4+; Blood negative; Casts none; Crystals
none.
Which of the following light microscopy findings would be expected if a
kidney biopsy were performed?
A Crescent formation
B. Diffuse thickening of basement membrane
C. Mesangial hypercellularity
D. Normal findings
E. Subepithelial spikes
B

A 28-yo woman comes to the ED due to worsening headaches. She was first
evaluated for headache 4 weeks ago. At that time, examination was
unremarkable and her BP was 132/86 mmHg. The patient was advised to take
ibuprofen. However, she continues to have worsening headache and reports
fatigue. The patient has no fever, nausea, vomiting, abdominal pain, chest pain,
or dyspnea. She was treated for sunburn on the face and arms 6 months ago
and for sinus infection 4 weeks ago. The patient does not use tobacco, alcohol,
or illicit drugs. Temperature is 37.2 C, BP is 170/110 mmHg, pulse is 82/min,
and respirations are 14/min. Examination shows bilateral pitting ankle edema.
Normal heart and vesicular breath sounds are heard on auscultation. The
abdomen is soft and nontender.
Laboratory results are as follows:
Complete blood count: Hb 11 g/dL; Platelets 75,000/mm3; Leukocytes
7,500/mm3
Serum chemistry: Blood urea nitrogen 40 mg/dL; Creatinine 2.5 mg/dL
Urinalysis: Protein 3+; Bacteria none; RBCs 20-30/hpf ; Casts erythrocyte
casts: erythrocyte casts
Immunologic and rheumatologic studies: C3 (complement) 30 mg/dl (88-
206mg/dl)
Which of the following is the most likely diagnosis?
A. Drug-induced interstitial nephritis
B. Granulomatosis with angiitis
C. Hemolytic uremic syndrome
D. Hypertensive emergency
E. Poststreptococcal glomerulonephritis
F. Systemic lupus erythematosus