Valvular heart disease US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Valvular heart disease. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Valvular heart disease US Medical PG Question 1: A 58-year-old female presents to her primary care physician with complaints of chest pain and palpitations. A thorough past medical history reveals a diagnosis of rheumatic fever during childhood. Echocardiography is conducted and shows enlargement of the left atrium and narrowing of the mitral valve opening. Which of the following should the physician expect to hear on cardiac auscultation?
- A. Continuous, machine-like murmur
- B. Holosystolic murmur that radiates to the axilla
- C. Opening snap following S2 (Correct Answer)
- D. High-pitched, blowing decrescendo murmur in early diastole
- E. Mid-systolic click
Valvular heart disease Explanation: ***Opening snap following S2***
- The patient's history of **rheumatic fever** and echocardiographic findings of **left atrial enlargement** and **mitral valve narrowing** (mitral stenosis) are classic for this condition.
- An **opening snap** is a high-pitched, sharp sound that occurs shortly after **S2** (the second heart sound) and is pathognomonic for **mitral stenosis**, caused by the sudden tensing of the stenotic mitral valve leaflets as they open during diastole.
- The **S2-OS interval** indicates severity: a shorter interval suggests more severe stenosis.
*Continuous, machine-like murmur*
- This type of murmur is characteristic of a **patent ductus arteriosus (PDA)**, which is a congenital heart defect.
- The patient's symptoms and echocardiographic findings are not consistent with PDA.
*Holosystolic murmur that radiates to the axilla*
- This murmur describes **mitral regurgitation**, which is a leaky mitral valve. While rheumatic fever can cause mitral regurgitation, the echocardiogram shows **narrowing** of the mitral valve, not leakage.
- The radiation to the axilla is classical for the regurgitant jet flowing into the left atrium during systole.
*High-pitched, blowing decrescendo murmur in early diastole*
- This murmur is typical for **aortic regurgitation**, indicating a leaky aortic valve.
- The patient's presentation and echocardiogram findings specifically point to **mitral valve involvement** rather than aortic valve issues.
*Mid-systolic click*
- A **mid-systolic click** is characteristic of **mitral valve prolapse**, often followed by a late systolic murmur.
- The echocardiogram findings of **mitral valve narrowing** are not consistent with mitral valve prolapse.
Valvular heart disease US Medical PG Question 2: A 72-year-old man presents to his primary care physician for a general checkup. The patient works as a farmer and has no concerns about his health. He has a past medical history of hypertension and obesity. His current medications include lisinopril and metoprolol. His temperature is 99.5°F (37.5°C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a murmur after S2 over the left sternal border. The patient demonstrates a stable gait and 5/5 strength in his upper and lower extremities. Which of the following is another possible finding in this patient?
- A. Murmur that radiates to the carotids
- B. Wedge pressure lower than expected
- C. Femoral artery murmur (Correct Answer)
- D. Rumbling heard at the cardiac apex
- E. Audible click heard at the cardiac apex
Valvular heart disease Explanation: ***Femoral artery murmur***
- A murmur heard after S2 over the left sternal border in an elderly patient suggests **aortic regurgitation (AR)**.
- In AR, a **femoral artery murmur (Duroziez's sign)** can be heard, characterized by a systolic murmur over the femoral artery with proximal compression and a diastolic murmur with distal compression.
*Murmur that radiates to the carotids*
- A murmur radiating to the carotids is characteristic of **aortic stenosis**, which typically presents as a systolic murmur, not a diastolic one as heard in this patient.
- Aortic stenosis is also associated with a **crescendo-decrescendo murmur**, in contrast to the diastolic murmur described.
*Wedge pressure lower than expected*
- This patient likely has **aortic regurgitation**, which increases **left ventricular end-diastolic pressure** and, consequently, **pulmonary capillary wedge pressure (PCWP)**.
- A lower than expected wedge pressure would be inconsistent with the volume overload often seen in significant AR.
*Rumbling heard at the cardiac apex*
- A rumbling murmur at the cardiac apex is characteristic of **mitral stenosis**, which is typically preceded by an opening snap.
- The patient's murmur is heard after S2 (diastolic) at the left sternal border, not the apex, making mitral stenosis less likely.
*Audible click heard at the cardiac apex*
- An audible click at the cardiac apex is typically associated with **mitral valve prolapse**, often followed by a mid-systolic murmur.
- This finding is not consistent with the diastolic murmur heard after S2 at the left sternal border.
Valvular heart disease US Medical PG Question 3: A 47-year-old man presents for a routine physical examination as part of an insurance medical assessment. He has no complaints and has no family history of cardiac disease or sudden cardiac death. His blood pressure is 120/80 mm Hg, temperature is 36.7°C (98.1°F), and pulse is 75/min and is regular. On physical examination, he appears slim and his cardiac apex beat is of normal character and non-displaced. On auscultation, he has a midsystolic click followed by a late-systolic high-pitched murmur over the cardiac apex. On standing, the click and murmur occur earlier in systole, and the murmur is of increased intensity. While squatting, the click and murmur occur later in systole, and the murmur is softer in intensity. Echocardiography of this patient will most likely show which of the following findings?
- A. Left atrial mass arising from the region of the septal fossa ovalis
- B. Doming of the mitral valve leaflets in diastole
- C. Prolapse of a mitral valve leaflet of ≥2 mm above the level of the annulus in systole (Correct Answer)
- D. Retrograde blood flow into the right atrium
- E. High pressure gradient across the aortic valve
Valvular heart disease Explanation: ***Prolapse of a mitral valve leaflet of ≥2 mm above the level of the annulus in systole***
- The clinical presentation with a **midsystolic click** followed by a **late-systolic high-pitched murmur over the cardiac apex** is characteristic of **mitral valve prolapse (MVP)**.
- The changes in the click and murmur timing and intensity with **standing (earlier, louder)** and **squatting (later, softer)** are classic findings, reflecting changes in left ventricular volume that affect the onset of valve prolapse.
*Left atrial mass arising from the region of the septal fossa ovalis*
- This description is highly suggestive of a **myxoma**, typically found in the left atrium, which can cause symptoms of **obstructive heart failure** or **embolism**.
- A myxoma would not typically present with the characteristic **midsystolic click** and **late-systolic murmur** that changes with position.
*Doming of the mitral valve leaflets in diastole*
- **Doming of the mitral valve leaflets in diastole** is characteristic of **mitral stenosis**, where the valve fails to open properly.
- Mitral stenosis would present with a **diastolic murmur**, not a midsystolic click and late-systolic murmur.
*Retrograde blood flow into the right atrium*
- **Retrograde blood flow into the right atrium** indicates **tricuspid regurgitation**, which would typically manifest as a **holosystolic murmur** best heard at the lower left sternal border, often with prominent jugular venous pulsations.
- This finding is inconsistent with the patient's auscultatory findings at the cardiac apex.
*High pressure gradient across the aortic valve*
- A **high pressure gradient across the aortic valve** signifies **aortic stenosis**, which is characterized by a **systolic ejection murmur** best heard at the right upper sternal border with radiation to the carotids.
- This condition would not produce a midsystolic click or a late-systolic murmur at the apex.
Valvular heart disease US Medical PG Question 4: A 32-year-old male presents for a new patient visit. He states that he is in good health but has had decreasing exercise tolerance and increased levels of shortness of breath over the past 5 years. He believed that it was due to aging; he has not seen a doctor in 10 years. On auscultation, you note an early diastolic decrescendo blowing murmur that radiates along the left sternal border. In the United States, what is the most likely cause of this patient's condition?
- A. Connective tissue disease
- B. Congenital bicuspid aortic valve (Correct Answer)
- C. Syphilis
- D. Rheumatic heart disease
- E. Myxomatous degeneration
Valvular heart disease Explanation: ***Congenital bicuspid aortic valve***
- The patient's age (32 years old), progressive symptoms of **aortic regurgitation** (decreasing exercise tolerance, shortness of breath, early diastolic decrescendo murmur), and location of the murmur are highly suggestive of a **bicuspid aortic valve**.
- This is the **most common congenital heart defect**, affecting 1-2% of the population, and is the leading cause of **aortic stenosis** and **aortic insufficiency** in younger adults in developed countries.
*Connective tissue disease*
- While connective tissue diseases such as **Marfan syndrome** or **Ehlers-Danlos syndrome** can cause aortic root dilation and regurgitation, they are less common than a bicuspid aortic valve as a primary cause of isolated aortic regurgitation in this age group.
- These conditions typically present with other systemic features (e.g., arachnodactyly, skin hyperextensibility) that are not mentioned in the patient's history.
*Syphilis*
- **Syphilitic aortitis** can cause aortic root dilation and aortic regurgitation, typically as a late-stage manifestation of **tertiary syphilis**.
- While possible, it is less common in developed countries today due to effective antibiotic treatment, and the patient's asymptomatic progression over 5 years might suggest a congenital rather than an infectious cause in this context.
*Rheumatic heart disease*
- **Rheumatic fever** is a common cause of valvular heart disease globally, but its incidence has significantly declined in developed countries due to improved hygiene and antibiotic use for **streptococcal infections**.
- While it can affect the aortic valve, it more commonly affects the **mitral valve** and usually presents with symptoms earlier in life or with a history of recurrent fevers.
*Myxomatous degeneration*
- **Myxomatous degeneration** primarily affects the **mitral valve**, leading to **mitral valve prolapse** and regurgitation.
- While it can sometimes affect the aortic valve, it is a less common cause of isolated aortic regurgitation and often presents with different clinical features or imaging findings.
Valvular heart disease US Medical PG Question 5: A 28-year-old primigravida presents to the office with complaints of heartburn while lying flat on the bed at night and mild constipation that started a couple of weeks ago. She is 10 weeks pregnant, as determined by her last menstrual period. Her first menstruation was at 13 years of age and she has always had regular 28-day cycles. Her past medical history is insignificant. She does not smoke cigarettes or drink alcohol and does not take any medications. Her father died of colon cancer at 70 years of age, while her mother has diabetes and hypertension. Her vital signs include: temperature 36.9℃ (98.4℉), blood pressure 98/52 mm Hg, pulse 113/minute, oxygen saturation 99%, and respiratory rate 12 /minute. The physical examination was unremarkable, except for a diastolic murmur heard over the apex. Which of the following is considered abnormal in this woman?
- A. Decreased vascular resistance
- B. Diastolic murmur (Correct Answer)
- C. Tachycardia
- D. Increased cardiac output
- E. Low blood pressure
Valvular heart disease Explanation: ***Diastolic murmur***
- Diastolic murmurs in pregnancy are **never normal** and always require further investigation to rule out significant **cardiac pathology**, such as valvular stenosis or regurgitation.
- While physiological changes in pregnancy can lead to systolic murmurs, **diastolic murmurs** are considered pathological.
*Decreased vascular resistance*
- **Peripheral vasodilation** due to hormonal changes (**progesterone**) is a normal physiological adaptation in early pregnancy, leading to decreased systemic vascular resistance.
- This decrease helps accommodate the **increased blood volume** and cardiac output, contributing to a slight drop in blood pressure.
*Tachycardia*
- An **increased heart rate** is a normal physiological response in pregnancy, typically seen as early as the first trimester.
- This compensatory mechanism helps maintain **cardiac output** in the face of decreased systemic vascular resistance and increased blood volume.
*Increased cardiac output*
- **Cardiac output increases** significantly during pregnancy, primarily due to increases in both heart rate and stroke volume, to meet the metabolic demands of the mother and fetus.
- This increase begins in the **first trimester** and peaks in the second trimester, remaining elevated until delivery.
*Low blood pressure*
- A **mild decrease in blood pressure**, particularly the diastolic pressure, is common in early pregnancy due to generalized vasodilation.
- The given blood pressure (98/52 mm Hg) is within the expected physiological range for a healthy pregnant woman in her first trimester.
Valvular heart disease US Medical PG Question 6: A patient with a history of Tetralogy of Fallot is being evaluated for long-term complications. This patient is at greatest risk of damage to which of the following cardiovascular structures?
- A. Cardiac septum
- B. Coronary artery
- C. Temporal artery
- D. Pulmonary valve (Correct Answer)
- E. Cardiac conduction system
Valvular heart disease Explanation: ***Pulmonary valve***
- Patients with **Tetralogy of Fallot** often have severe **pulmonary stenosis**, which can lead to significant long-term damage and insufficiency of the pulmonary valve, frequently requiring replacement.
- The elevated right ventricular pressure from **outflow obstruction** and the **ventricular septal defect** alter flow dynamics, putting continuous strain on the pulmonary valve and the right ventricular outflow tract.
*Cardiac septum*
- While a **ventricular septal defect (VSD)** is a key feature of Tetralogy of Fallot, it is a structural anomaly present from birth and usually does not *suffer additional damage* over time in the same way a valve does, although its size can impact shunt dynamics.
- Damage to the septum itself (beyond the initial defect) is not the primary long-term risk for this cardiovascular structure in Tetralogy of Fallot.
*Coronary artery*
- Anomalies of the **coronary arteries** can occur in Tetralogy of Fallot but are not consistently present and are not the primary structure at greatest risk of *damage* as a direct consequence of the typical hemodynamics of the condition.
- Coronary artery disease is generally a later-life atherosclerotic process and not directly linked to the congenital defect itself.
*Temporal artery*
- The **temporal artery** is an extracardiac artery and is not a cardiovascular structure at risk of damage in Tetralogy of Fallot.
- Conditions like giant cell arteritis affect the temporal artery, which is unrelated to this congenital heart defect.
*Cardiac conduction system*
- While there is a risk of **arrhythmias** in patients with Tetralogy of Fallot, particularly with surgical repairs, the direct *damage* to the cardiac conduction system itself from the pathophysiology is not the greatest risk compared to the structural deterioration of the pulmonary valve.
- Scarring from corrective surgery can predispose to conduction abnormalities, but the primary pathology and greatest unaddressed risk is often related to the right ventricular outflow tract and pulmonary valve.
Valvular heart disease US Medical PG Question 7: A 43-year-old woman presents to the emergency department complaining of palpitations, dry cough, and shortness of breath for 1 week. She immigrated to the United States from Korea at the age of 20. She says that her heart is racing and she has never felt these symptoms before. Her cough is dry and is associated with shortness of breath that occurs with minimal exertion. Her past medical history is otherwise unremarkable. She has no allergies and is not currently taking any medications. She is a nonsmoker and an occasional drinker. She denies illicit drug use. Her blood pressure is 100/65 mm Hg, pulse is 76/min, respiratory rate is 23/min, and temperature is 36.8°C (98.2°F). Her physical examination is significant for bibasilar lung crackles and a non-radiating, low-pitched, mid-diastolic rumbling murmur best heard at the apical region. In addition, she has jugular vein distention and bilateral pitting edema in her lower extremities. Which of the following best describes the infectious agent that led to this patient’s condition?
- A. A bacterium that induces partial lysis of red cells with hydrogen peroxide
- B. A bacterium that requires an anaerobic environment to grow properly
- C. A bacterium that does not lyse red cells
- D. A bacterium that induces heme degradation of the red cells of a blood agar plate
- E. A bacterium that induces complete lysis of the red cells of a blood agar plate with an oxygen-sensitive cytotoxin (Correct Answer)
Valvular heart disease Explanation: ***A bacterium that induces complete lysis of the red cells of a blood agar plate with an oxygen-sensitive cytotoxin***
- This describes **Group A Streptococcus (GAS)**, specifically *Streptococcus pyogenes*, which causes **rheumatic fever** leading to **mitral stenosis**. Mitral stenosis is characterized by a **mid-diastolic rumbling murmur** at the apex, left atrial enlargement causing **palpitations**, and **pulmonary congestion** leading to dyspnea, cough, and bibasilar crackles.
- The delayed onset of symptoms (immigrated at 20, symptoms at 43) is typical for **rheumatic heart disease**, where repeated GAS infections in childhood/adolescence lead to valve damage that manifests years later. GAS produces **streptolysin O**, an **oxygen-labile cytotoxin** responsible for **beta-hemolysis** (complete lysis) on blood agar.
*A bacterium that induces partial lysis of red cells with hydrogen peroxide*
- This describes **alpha-hemolytic** bacteria like *Streptococcus pneumoniae* or *Viridans streptococci*, which cause **partial hemolysis** (greenish discoloration) on blood agar due to **hydrogen peroxide** production.
- While *Viridans streptococci* can cause **infective endocarditis**, the clinical picture of **rheumatic mitral stenosis** is more consistent with a history of recurrent streptococcal pharyngitis (GAS).
*A bacterium that requires an anaerobic environment to grow properly*
- This description typically refers to **anaerobic bacteria**, such as *Clostridium* or *Bacteroides* species.
- These bacteria are generally not associated with the primary cause of acute rheumatic fever or the subsequent development of chronic valvular heart disease like mitral stenosis.
*A bacterium that does not lyse red cells*
- This describes **gamma-hemolytic** (non-hemolytic) bacteria, such as *Enterococcus faecalis* or some *Staphylococcus* species.
- These organisms do not cause the characteristic hemolysis seen with the streptococci responsible for rheumatic fever.
*A bacterium that induces heme degradation of the red cells of a blood agar plate*
- This description is **too vague** and does not specifically identify the organism. While heme degradation occurs with various types of hemolysis, the key distinguishing feature of **Group A Streptococcus** is **complete lysis (beta-hemolysis)** combined with production of the **oxygen-sensitive toxin streptolysin O**.
- This option lacks the specificity needed to identify GAS as the causative agent of rheumatic fever. Both alpha- and beta-hemolytic organisms can degrade heme, but only beta-hemolytic GAS causes rheumatic heart disease.
Valvular heart disease US Medical PG Question 8: A 49-year-old man with a past medical history of hypertension on amlodipine presents to your office to discuss ways to lessen his risk of complications from heart disease. After a long discussion, he decides to significantly decrease his intake of trans fats in an attempt to lower his risk of coronary artery disease. Which type of prevention is this patient initiating?
- A. Secondary prevention
- B. Delayed prevention
- C. Quaternary prevention
- D. Tertiary prevention
- E. Primary prevention (Correct Answer)
Valvular heart disease Explanation: ***Primary prevention***
- This patient is initiating primary prevention by **modifying lifestyle choices** (decreasing trans fats) to **prevent the initial onset of coronary artery disease**, as he has a risk factor (hypertension) but no established heart disease.
- Primary prevention focuses on **preventing disease before it occurs** through health promotion and risk reduction.
*Secondary prevention*
- Secondary prevention involves **early detection and treatment of existing disease** to prevent progression or recurrence.
- Examples include **screening tests** like mammography or **medications for individuals already diagnosed** with a condition.
*Delayed prevention*
- This is **not a recognized category** of prevention in public health or medical practice.
- Prevention stages are typically classified as primary, secondary, tertiary, and sometimes quaternary.
*Quaternary prevention*
- Quaternary prevention aims to **protect patients from medical interventions** that may cause harm, such as over-medicalization or unnecessary procedures.
- It focuses on **reducing the burden of iatrogenic disease** and ensuring appropriate care.
*Tertiary prevention*
- Tertiary prevention focuses on **reducing the impact of an existing disease** or disability through rehabilitation and managing complications.
- It applies to patients who **already have an established disease** and seeks to improve their quality of life and functionality.
Valvular heart disease US Medical PG Question 9: A 14-year-old Caucasian female with a family history of familial hypercholesterolemia commits suicide by drug overdose. Her family decides to donate her organs, and her heart is removed for donation. After removing the heart, the cardiothoracic surgeon notices flat yellow spots on the inside of her aorta. Which of the following cell types predominate in these yellow spots?
- A. Fibroblasts
- B. T-cells
- C. Macrophages (Correct Answer)
- D. Neutrophils
- E. Endothelium
Valvular heart disease Explanation: ***Correct: Macrophages***
- The "flat yellow spots" on the aorta in a familial hypercholesterolemia patient are characteristic of **fatty streaks**, the earliest lesions of atherosclerosis.
- These fatty streaks are primarily composed of **lipid-laden macrophages**, also known as **foam cells**, which have ingested oxidized low-density lipoprotein (LDL).
- In familial hypercholesterolemia, elevated LDL levels accelerate the formation of these macrophage-rich lesions even in young patients.
*Incorrect: Fibroblasts*
- While fibroblasts are involved in the later stages of **atherosclerotic plaque formation** by synthesizing collagen and forming a fibrous cap, they are not the predominant cell type in early fatty streaks.
- Their presence signifies a more advanced, **fibrotic lesion**, not the initial yellow spots.
*Incorrect: T-cells*
- T-cells are involved in the inflammatory response in **atherosclerosis** and are found within plaques, but they are not the dominant cell type forming the bulk of the initial lipid accumulation in fatty streaks.
- They contribute to the **immune-mediated aspects** of plaque progression.
*Incorrect: Neutrophils*
- Neutrophils are primarily involved in **acute inflammation** and bacterial infections.
- They are generally not a prominent cell type in either early or advanced **atherosclerotic lesions** under normal circumstances.
*Incorrect: Endothelium*
- Endothelial cells line the lumen of blood vessels and are crucial in the **initiation of atherosclerosis** by becoming dysfunctional and allowing LDL entry.
- However, they do not constitute the "yellow spots" themselves, which are subendothelial accumulations of lipids and immune cells.
Valvular heart disease US Medical PG Question 10: A 51-year-old man comes to the physician for the evaluation of a 3-week history of fatigue and shortness of breath. One year ago, a screening colonoscopy showed colonic polyps. His brother has a bicuspid aortic valve. On examination, a late systolic crescendo-decrescendo murmur is heard at the right upper sternal border. Laboratory studies show:
Hemoglobin 9.1 g/dL
LDH 220 U/L
Haptoglobin 25 mg/dL (N = 41–165 mg/dL)
Urea nitrogen 22 mg/dL
Creatinine 1.1 mg/dL
Total bilirubin 1.8 mg/dL
A peripheral blood smear shows schistocytes. Which of the following is the most likely cause of this patient's anemia?
- A. Erythrocyte membrane fragility
- B. Fragmentation of erythrocytes (Correct Answer)
- C. Erythrocyte enzyme defect
- D. Gastrointestinal bleeding
- E. Autoimmune destruction of erythrocytes
Valvular heart disease Explanation: ***Fragmentation of erythrocytes***
- The presence of **schistocytes** on peripheral blood smear, along with signs of **hemolysis** (elevated LDH, decreased haptoglobin, elevated bilirubin), points to **microangiopathic hemolytic anemia**.
- The late systolic crescendo-decrescendo murmur at the right upper sternal border, combined with a family history of **bicuspid aortic valve**, strongly suggests **aortic stenosis**, which can cause **shear stress** and fragmentation of red blood cells as they pass through the narrowed valve.
*Erythrocyte membrane fragility*
- While membrane fragility can cause hemolytic anemia, conditions like **hereditary spherocytosis** or **elliptocytosis** would typically present with specific red cell morphologies (spherocytes, elliptocytes) rather than schistocytes.
- There are no other findings in the patient's history or lab results that would specifically suggest a primary membrane defect.
*Erythrocyte enzyme defect*
- Enzyme defects such as **G6PD deficiency** or **pyruvate kinase deficiency** lead to hemolytic anemia but typically do not cause **schistocytes**.
- These conditions are also often associated with specific triggers or presentations not evident here.
*Gastrointestinal bleeding*
- While a history of colonic polyps and anemia could suggest **gastrointestinal bleeding** (leading to iron deficiency anemia), this would typically present as a **microcytic hypochromic anemia** and would not cause **schistocytes**, elevated LDH, or decreased haptoglobin.
- The low hemoglobin could be partially due to blood loss, but the hemolytic markers point to a different primary cause for the anemia.
*Autoimmune destruction of erythrocytes*
- **Autoimmune hemolytic anemia** can cause significant anemia and hemolysis (elevated LDH, decreased haptoglobin, elevated bilirubin).
- However, it typically does not present with **schistocytes** but rather **spherocytes**, and a **direct Coombs test** would be positive, which is not mentioned here.
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