Self-Assessment: BOFs for MRCP(UK) and MRCP(I) Part I

Copyright © 2023. Osama Shukir Muhammed Amin.

Copyright Notice:

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the copyright owner in writing:

Email: [email protected]

First Edition: 2009

Second Edition: 2016

Third Edition: 2023

ISBN: 978-1-4478-5767-9

Disclaimer:

This book was written depending on reliable sources. However, while every effort has been made to ensure its accuracy, no responsibility for loss, damage, or injury occasioned on any person acting or refraining from action as a result of information contained herein can be accepted by the author or publisher.

Distributed by Lulu Press, Inc. Northern Carolina, USA.

Dedication

To my lovely family:

Sarah, Awan, and Naz

Acknowledgments

I would like to sincerely thank my patients; their real clinical scenarios were used to generate these questions. Special gratitude goes to my wife Sarah for her endless support and encouragement and her extreme patience.

Osama

Preface

No human being is constituted to know the truth, the whole truth, and nothing but the truth; and even the best of men must be content with fragments, with partial glimpses, never the full fruition, Sir William Osler (1849-1919).

This is the third edition of my book, "Self-Assessment for MRCP(UK) part 1, which was published in 2009. The second edition, entitled Self-Assessment: 650 BOFs for MRCP(UK) and MRCP(I) Part I" was published in late 2016. It has been six years! The third edition has undergone several changes and updates. COVID-19 strikes every chapter.

In authoring this book, I tried my best to include the most common examination themes. You may encounter negative or positive stems. The questions’ objective is to teach, i.e., a rapid review of every subject and theme. This book differs from my book "Get Through MRCP part I; BOFs, which was published in the year 2008 by the Royal Society of Medicine Press in London, and my book MRCP(UK) and MRCP(I) Part I Best of Fives, Volume I", which was published in 2022. The former concentrates mainly on the diagnosis and management, i.e., what is the diagnosis, what is the next best step, what feature is consistent with your preliminary diagnosis, and so on. The latter concentrates on several updates in the management of many diseases, addresses some novel diseases and topics, and focuses on COVID-19. 

Undoubtedly, if you are well-prepared, you will pass the examination very easily. No need to panic when you hear about your colleagues’ experiences. Lack of preparation is the single most common reason for failure. Remember, practice makes perfect. Read and self-assess; that’s it! 

Good luck with your career and exams!

Osama S. M. Amin FRCP

February 1, 2023

Recommended Reading

Penmen et al. Davidson's Principles and Practice of Medicine, 24th edition. London: Churchill Livingstone; 2022.

Feather et al. Kumar and Clark's Clinical Medicine, 10th edition. Philadelphia: Saunders Ltd.; 2020.

Loscalzo et al. Harrison’s Principles of InternalMedicine, 21st edition. New York: McGraw-Hill Professional, 2022.

Goldman et al. Goldman-Cecil Medicine, 2-Volume Set (Cecil Textbook of Medicine), 26th Edition. New York: Elsevier; 2019.

Barrett et al. Ganong’s Review of Medical Physiology, 26th edition. New York: McGraw-Hill Education/Medical; 2019.

Lang TA, Secic M (eds.). How to Report Statistics in Medicine, Annotated Guidelinesfor Authors, Editors, and Reviewers, 2nd edition. Philadelphia: The American College ofPhysicians; 2006.

Table of Content:

Chapter 1: Cardiology

Chapter 2: Clinical hematology and oncology

Chapter 3: Clinical Pharmacology, Therapeutics, and Toxicology

Chapter 4: Clinical Sciences

Chapter 5: Dermatology

Chapter 6: Endocrinology, Diabetes, and Metabolic Diseases

Chapter 7: Gastroenterology and Hepatology

Chapter 8: Infectious Diseases and Genitourinary Medicine

Chapter 9: Neurology, Psychiatry, and Ophthalmology

Chapter 10: Nephrology

Chapter 11: Respiratory Medicine

Chapter 12: Rheumatology and Diseases of the Bones

Chapter One - Cardiology

1) A 65-year-old man visits the physician’s office because of exertional chest pain and frequent palpitations. He is a heavy smoker but does not drink alcohol. The patient’s 12-lead ECG reveals a prominent R-wave in lead V1. All of the following are causes of prominent R-wave in lead V1, except?

2) A 60-year-old man, who has a history of long-standing type II diabetes and hypertension, has been referred by his general practitioner for further evaluation of chest pain. You do a 12-lead ECG, and this reveals ST-segment elevation in leads V5, V6, and I. Which one of the following may result in ST-segment elevation?

3) A 23-year-old male is brought to the Acute and Emergency Department with a 2-hour history of palpitation and dizziness. His previous notes reveal similar attacks. The patient’s QRS complexes during sinus rhythms demonstrate delta waves. The commonest type of arrhythmia in Wolff-Parkinson-White syndrome is?

4) A 15-year-old boy has been experiencing progressive exertional breathlessness over the past several months. He has a Turner syndrome-like phenotype.

You do chromosomal studies and secure the diagnosis of Noonan’s syndrome. The following are seen in Noonan's syndrome, except?

5) A 24-year-old woman presents with transient loss of consciousness which turns out to be due to torsades de pointes ventricular tachycardia. Her 12-lead ECG, in sinus rhythm, shows a QTc interval of 0.56 seconds. All of the following may result in QT-interval prolongation, except?

6) A 20-year-old man visits the cardiology outpatient clinic to consult you about his brother who has hypertrophic cardiomyopathy and the likelihood of himself being affected by this disease. Concerning hypertrophic cardiomyopathy, which one of the following is the correct statement?

7) A 47-year-old uremic man presents with central chest pain that is aggravated by swallowing and taking deep breaths. The patient is incompliant with his hemodialysis program. You consider acute pericarditis. His 12-lead ECG solidifies your clinical impression. Regarding acute pericarditis, which one is the false statement?

8) A 69-year-old man presents with severe substernal chest pain. You examine the patient and do some tests. Your diagnosis is acute myocardial infarction, and you consider thrombolytic therapy. Which one of the following represents an absolute contraindication to thrombolytic therapy in acute ST-segment elevation myocardial infarction?

9) A 66-year-old man takes many daily medications for his blood pressure control. He admits to having had orthostasis symptoms over the past few weeks. You tell him that his postural hypotension is due to dilatation of his blood vessels. All of the following cardiovascular medications have a predominantly venodilating effect, except?

10) A 73-year-old diabetic man complains of ischemic chest pain for 2 hours. You admit him and diagnose unstable angina. You further assess whether he has any high-risk factors. High risk factors in unstable angina are considered to be all of the following, except?

11) A 65-year-old man develops right-sided heart failure because of right coronary artery occlusion. You review the vascular anatomy of the heart. The following statements are correct, except? 

12) A 50-year-old man takes amiodarone tablets because of permanent atrial fibrillation. He has impaired left ventricular systolic function. Which one is the false statement about this cardiac medication?

13) You ask your junior house officer to examine the JVP of this 33-year-old male patient, who is found to have raised JVP. The list of causes of raised JVP includes all of the following, except?

14) A 20-year-old woman presents with resistant hypertension. You a systolic bruit in the inter-scapular area. Concerning coarctation of the aorta, which one of the following is the incorrect statement?

15) A 66-year-old man has dilated cardiomyopathy. You assess him and treat him accordingly. The following medications improve survival figures in chronic congestive heart failure, except?

16) A 34-year-old woman presents with a fever and skin rash. She was diagnosed with combined mitral valve disease a few years ago. Examination reveals a new aortic regurgitation and Osler's nodes. Regarding infective endocarditis, which one is the wrong statement?

17) A 22-year-old man consults you before a scheduled dental extraction. He has combined mitral and aortic regurgitations due to rheumatic etiology. You educate him regarding the prophylaxis of infective endocarditis. The following cardiac lesions are associated with a moderate to high risk of infective endocarditis, except?

18) A 30-year-old woman was admitted to the general medical ward and had been receiving treatment for infective endocarditis. She had severe rheumatic reflux. With respect to the treatment of infective endocarditis, which one of the following statements is the incorrect one?

19) A 37-year-old female presents with progressive exercise intolerance and dry cough. After examining her, you think that she has mitral valve disease. You arrange for echocardiography. The latter reveals severe mitral stenosis. Regarding lone mitral stenosis, all of the following are true, except?

20) A 63-year-old man presents with exertional breathlessness. Examination reveals a systolic ejection murmur of grade III/VI at the aortic region. The murmur radiates to the right carotid. With regard to aortic stenosis, all of the following are true, except?

21) A 34-year-old man presents with palpitations and orthopnea. You detect bilateral pitting ankle edema. You finally diagnose congestive heart failure and you discuss the treatment plan with the patient. Regarding the objectives of medical treatment of heart failure, all of the following statements are correct, except?

22) A 59-year-old man, who has long-standing poorly controlled hypertension, presents with exercise intolerance. Transthoracic echocardiography reveals concentric left ventricular hypertrophy and moderate diastolic dysfunction. He asks what his diastolic heart failure type entails. Regarding diastolic heart failure, which one of the following is the correct statement?

23) A 19-year-old male patient has been referred for further assessment of high blood pressure. He denies a family history of such a condition. He is on no medications and takes no illicit drugs. He neither smokes nor drinks alcohol. After a thorough history taking and examination, you consider secondary causes of his hypertension. Secondary hypertension is suspected in the presence of all of the following, except?

24) A 55-year-old man visits you as part of the regular check-up of his hypertension and diabetes. He takes many daily medications and herbal remedies. He enquires about his long-term outlook. Regarding long-standing hypertension, choose the most correct statement:

25) A 67-year-old man presents with a 3-hour history of central chest pain that is associated with nausea and breathlessness. The list of risk factors for ischemic heart disease does not include which one of the following?

26) A 76-year-old man presents with many complaints. He has long-standing poorly controlled hypertension. Complications of long-standing hypertension include all of the following, except?

27) A 60-year-old female presents with a mitral stenosis-like picture. Her echocardiography reveals a mass within the heart. You repeat the examination and review the echocardiography findings. You finally diagnose cardiac myxoma. Regarding atrial myxoma, which one is the false statement?

28) A 44-year-old man receives a beta-blocker for his essential hypertension. All of the following beta-blockers are non-cardioselective, except?

29) An undergraduate medical student asks for your help to examine the JVP of a patient who has congestive heart failure. You demonstrate the examination sequences and discuss the various abnormalities with him. Which of the following you have not told him?

30) You are reviewing an ECG strip of one of your medical ward patients. His PR interval is 0.04 seconds. Short PR-interval occurs in:

31) One of your junior house officers asks about the characteristics of Q waves in ECGs. Deep and permanent Q-wave may be seen in? 

32) A 16-year-old male has coarctation of the aorta. He has surfed the internet and read about his disease. He is afraid that his anomaly may have additional fearful associations. All of the following are commonly associated with coarctation, except?

33) A 66-year-old man is brought to the Emergency Room because of a few hours of crushing chest pain. You suspect acute myocardial infarction. With respect to the medical treatment of acute myocardial infarction, all of the following are true, except?

34) A 55-year-old man, who sustained acute anterior wall myocardial infarction 1 week ago, will be discharged home today. You educate him about his medications and tell him about the importance of regular visits. Regarding secondary prophylaxis of myocardial infarction, which one is the wrong statement?

35) A 66-year-old man presents with attacks of severe substernal chest pain upon exertion. These pains are relieved by rest and sublingual nitroglycerin. You consider chronic stable angina and you order exercise ECG testing. Contraindication to this mode of cardiac testing encompasses all of the following, except?

36) A 61-year-old man is due to do exercise ECG testing using a treadmill. The following findings reflect a strongly positive exercise ECG testing, except?

37) Your colleague consults you about this 22-year-old young man, who has abnormal exercise ECG. You interview the patient and examine him. You review the ECG trace. Finally, you tell the patient that he has false positive results. Causes of false positive exercise ECG testing include all of the following, except?

38) One of your junior house officers asks you about the causes of electromechanical dissociation of the heart because one of his patients developed this. All of the following can cause electromechanical dissociation, except?

39) You educate this 65-year-old man about the use of ACE inhibitors following his myocardial infarction. He will be discharged today. Which one of the following is the incorrect statement regarding the use of ACE inhibitors in post-myocardial infarction?

40) A 55-year-old man is not compliant with his antihypertensive medication because this medication makes him urinate a lot during work. Regarding the treatment of hypertension with diuretics, all of the following are true, except?

41) A 30-year-old female presents with progressive exercise intolerance and exertional chest pain. Further work-up has revealed primary pulmonary hypertension. With respect to this disease, which one is the false statement?

42) A 66-year-old man, who admits to smoking heavily for 45 years, presents with bilateral pitting leg edema and cyanosis. After conducting a proper examination and doing some investigations, you diagnose cor pulmonale. Regarding cor pulmonale, which one is the wrong statement?

43) You have been asked to examine a 70-year-old man with COPD. He presents with excessive daytime somnolence and poor concentration. The patient’s lips are a little bit blue and his outstretched hands are shaky. There is a bounding radial pulse. You intend to examine further to confirm your preliminary diagnosis. What would examine? 

44) A 65-year-old hemiplegic man presents with shortness of breath and bloody sputum. His right calf is swollen and tender. A preliminary diagnosis of pulmonary thromboembolism is made. Which one is the false statement with respect to pulmonary thromboembolism?

45) A 55-year-old man presents to the Emergency Room with sudden severe retrosternal chest pain, 8 days after undergoing right-sided total hip replacement. You do chest X-rays and you examine them carefully. Chest X-ray findings in pulmonary thromboembolism encompass all of the following, except?

46) A 40-year-old female presents with dyspnea and tachypnea 5 days after giving birth to a healthy-looking full-term girl. You do ECG for her in addition to other investigations. Regarding ECG changes in acute pulmonary thromboembolism, which one of the following is uncommonly seen?

47) A 30-year-old man receives therapy for pulmonary thromboembolism, which has developed 7 days after a road traffic accident. Regarding the treatment of pulmonary thromboembolism, which one is the incorrect statement?

48) A 66-year-old man, who underwent left knee joint replacement 9 days ago, presents with right-sided pleuritic chest pain. Chest X-ray film reveals an elevated right hemidiaphragm and small basal liner opacities. Pulmonary thromboembolism is your final diagnosis. General measures in acute pulmonary thromboembolic events include all of the following, except?

49) A 30-year-old pregnant woman visits the physician’s office to ask about the possibility of having a child with a heart anomaly. With respect to the incidence of various congenital heart diseases, all of the following anomalies and their corresponding incidence are correct, except?

50) A 6-year-old child has been referred to the cardiology department. The referral letter states that the child has a congenital heart anomaly. Regarding congenital heart diseases, all of the following are correct, except?

51) A 20-year-old female has primary amenorrhea, a webbed neck, and wide carrying angles. She presents with hypertension and a cardiac murmur. You consider Turner’s syndrome. Turner’s syndrome may be associated with all of the following, except?

52) A 39-year-old man presents with head nodding and palpitations. Examination reveals an early blowing diastolic murmur down the left sternal border. You diagnose aortic regurgitation. The following are important clinical clues to the underlying etiology of this type of valvular reflux, except?

53) A 30-year-old female presents with progressive dyspnea and hemoptysis. Examination reveals apical, mid-diastolic, rumbling murmur. Her echocardiographic study confirms mitral stenosis. With respect to this valvular narrowing, all of the following are true, except?

54) You examine a 5-year-old boy and find a pansystolic murmur in the left lower sternal border, which can be heard all over the precordium. You do investigations to uncover the origin of this non-benign murmur. ECG findings in uncomplicated congenital heart disease include all of the following, except?

55) A 4-year-old child has pansystolic murmur and productive cough. His chest is full of crackles. You do a chest X-ray examination. With respect to the findings in the chest X-ray film of patients with congenital heart disease, which one is the correct statement?

56) A 36-year-old man has recurrent attacks of troublesome supraventricular tachycardia, for which he has been prescribed daily amiodarone. This medication can cause?

57) A 23-year-old man, who has rheumatic mitral regurgitation, presents with frequent palpitations and exercise intolerance. After examining him carefully, you find many signs which reflect severe mitral reflux. You have not detected which one of the following?

58) A 45-year-old man, who was reasonably healthy, complains of palpitation over the past 3 weeks. His 12-lead ECG reveals fast atrial fibrillation. Transthoracic echocardiography is normal apart from the irregularity of the cardiac beats. You prescribe medication to control his heart rate. What else you would prescribe? 

59) A 66-year-old man presents with central chest pain that is crushing in nature and radiating to the left shoulder for the past 4 hours. He has hypertension and type II diabetes. His past notes show high blood lipids. Which one of the following is not given as part of his medical treatment?

60) A 65-year-old man presents with hemodynamic collapse and a rapid feeble pulse. One week ago, his general practitioner prescribed atenolol to treat frequent ventricular ectopic beats. His last ECG which was done 2 days ago revealed a regular heart rate of 36 beats per minute. What is the likely cause of his new presentation?

61) A 19-year-old man develops a fever, malaise, and anorexia. A few days later, he develops a dry cough and shortness of breath. Further evaluation reveals Coronavirus disease 2019 (COVID-19). On day 4 of hospitalization, he complains of severe substernal chest pain. ECG shows ST-segment elevation in leads V1-V4. Which one of the following is not a recognized cardiovascular complication of COVID-19?

Chapter One - Answers

1) e. 

The other causes of prominent R-wave in lead V1 are hypertrophic cardiomyopathy and right ventricular hypertrophy. Isolated posterior wall myocardial infarction is rare in clinical practice and is usually associated with inferior wall myocardial infarction; therefore, one should look at leads II, III, and aVF (i.e., for right coronary artery occlusion). Mirror image dextrocardia and wrong lead connections (so-called limb lead reversal) are usually forgotten causes of prominent R waves in lead V1. Rarely, it may be a normal variant.

2) d.

Early repolarization after an episode of angina is associated with ST-segment elevation while the other stems result in ST-segment depression. Causes of ST-segment elevation:

Full-thickness myocardial infarction (ST-segment elevation myocardial infarction or STEMI).

Early repolarization after an attack of angina.

Acute pericarditis and acute myocarditis.

Ventricular aneurysm. 

Transiently during cardiac and coronary angiography.

During Prinzmetal angina or acute Takotsubo cardiomyopathy.

Left bundle branch block (in leads V1-3 only).

Myocardial tumors and traumas.

Hyperkalemia (only leads V1-2).

Brugada syndrome (in leads V1-3 with right bundle branch block pattern).

NB: Takotsubo cardiomyopathy is characterized by transient apical left ventricular dysfunction which mimics myocardial infarction but in the absence of significant coronary artery disease.

3) e. 

Ventricular arrhythmias in Wolff-Parkinson-White (WPW) syndrome are highly atypical and suggest either an alternative diagnosis or a co-existent pathology. The commonest tachycardia is orthodromic (uncommonly antidromic) AV nodal re-entrant tachycardia. A special concern is the development of atrial fibrillation (AF), which may degenerate into ventricular fibrillation. Atrial fibrillation occurs in 10-30% of WPW syndrome patients. Spontaneous AF is more common in patients with anterograde conduction through the accessory pathway and is uncommon in the rare patients with WPW who have only concealed retrograde conduction through the accessory pathway. Patients with accessory pathways that have short antegrade refractory periods are more liable to develop AF. AF originates within the atria, independent of the accessory pathway, but the accessory pathway functions as another route for the conduction of atrial impulses into the ventricles.

4) e. 

Left-sided cardiac lesions are not part of Noonan's syndrome, and their presence suggests an acquired defect, e.g., mitral stenosis following rheumatic fever. The pulmonic valve is typically dysplastic in Noonan’s syndrome. Noonan syndrome is a relatively common autosomal dominant disorder, with an estimated incidence of one in 1000 to 2500 live births. It is characterized by dysmorphic features, proportionate short stature, and heart disease, most commonly pulmonic stenosis and hypertrophic cardiomyopathy. In addition, frequently associated with this syndrome are webbed neck, chest deformity, cryptorchidism, mental retardation, and bleeding diatheses. More than 50% of cases are due to a mutation in the PTPN11 gene on chromosome 12, which encodes the non-receptor protein tyrosine phosphatase SHP-2.

5) d.

The long QT syndrome (LQTS) is a disorder of myocardial repolarization that is characterized by a prolonged QT interval on the electrocardiogram. This syndrome is associated with an increased risk of a characteristic the life-threatening cardiac arrhythmia, torsade de pointes. The primary symptoms in patients with LQTS include palpitations, syncope, seizures, and sudden cardiac death. It may be caused by:

Inherited syndromes (congenital long QT syndromes): Jervell-Lange-Nielsen syndrome (which is autosomal recessive and is associated with sensorineural deafness; its course is highly malignant) and Romano-Ward syndrome (which is autosomal dominant and is a pure cardiac phenotype; its course is generally benign when compared with Jervell-Lange-Nielsen). Most cases result from mutations in various components of the cardiac potassium channels causing delayed phase 3 of cardiac action potential; only LQT3 subtype results from sodium channel mutation causing prolongation of phase 2 of the cardiac action potential.

Electrolyte disturbance: hypokalemia, hypomagnesemia, and hypocalcemia. 

Mitral valve prolapse.

4-Rheumatic carditis

Drugs and medications (class Ic and III anti-arrhythmic medications).

Bradycardia-associated (any cause of bradycardia): this is the rationale behind using isoprenaline infusion to treat such cases. However, this is contraindicated in congenital syndromes because of their already increased sympathetic drive.

6) c. 

Hypertrophic cardiomyopathy results from sarcomeric contractile proteins gene mutations. Many types of mutations have been detected, and certain gene mutations predict a poor prognosis. About 50% of cases have a positive family history (25% of idiopathic dilated cardiomyopathy patients display a positive family history). The presence of a left ventricular outflow obstructive element does not predict a gloomy outcome; this form of dynamic obstruction occurs in about 1/3rd of cases. Many cases are totally asymptomatic and are detected by doing echocardiography for some reason or another. On the other extreme, some patients present with sudden death. The asymmetric septal type is the commonest one, but the apical variety is the predominant one in the Far East. There are certain variants that do not have cardiac hypertrophy, at all. The commonest mutations occur in:

Beta myosin heavy chain gene: this is associated with elaborate ventricular hypertrophy.

Troponin gene: there is little or no ventricular hypertrophy, but patients demonstrate abnormal vascular responses (mainly hypotension) upon doing exercise, and there is a high risk of sudden death.

Myosin-binding protein C gene: usually manifests later in life, and is often associated with prominent cardiac dysrhythmia and systemic hypertension.

There is no correlation between the degree of left ventricular (LV) outflow obstruction and symptoms. Some patients with severe LV outflow tract obstruction remain asymptomatic for many years; at the other extreme, cardiac arrest or sudden death may be the initial presentation. However, many patients with hypertrophic cardiomyopathy develop one or more of the following symptoms: dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, chest pain, presyncope/syncope, palpitation, postural lightheadedness, fatigue, and bipedal pitting edema (which is actually rare). These symptoms can be induced by a variety of mechanisms which may include: LV outflow tract obstruction at rest, LV outflow tract obstruction that is present only with provocation (such as exertion or straining), impaired myocardial function in the absence of obstruction, arrhythmias (or conduction delay), and impaired filling due to diastolic dysfunction.

7) b. 

The commonest type of pericarditis is the idiopathic variety. In patients with acute pericarditis in whom no cause is identified (so-called idiopathic pericarditis), the etiology is frequently presumed to be viral or autoimmune. Autoimmune factors may be particularly important in patients with recurrent acute pericarditis. The presence of pericarditis should be suspected in the following clinical settings: persistent high fever in patients with pericardial effusion; unexplained new radiographic cardiomegaly; unexplained hemodynamic deterioration after myocardial infarction, cardiac surgery, or cardiac diagnostic or interventional procedures. The disease rarely progresses to tamponade formation, and most cases follow a benign course. Uremic pericarditis has a risk of hemorrhagic transformation. The occurrence of pericarditis in dialysis patients indicates an inadequate dialysis regimen; it is an indication to do dialysis in end-stage renal disease patients (who are not receiving any form of renal replacement therapy). The resulting rub is usually transient and fluctuating. Generally, the disappearance of the rub reflects a transient phenomenon (which is very common in clinical practice), resolution of the inflammatory process, or fluid collection in the pericardial sac (effusion or tamponade). Tuberculous pericarditis usually presents either as a progressive collection of a large volume of fluid or as a chronic constrictive picture.

8) a. 

Involvement of the right coronary ostium in type A aortic dissection results in right coronary artery occlusion and inferior wall myocardial infarction; thrombolysis is contraindicated. Type A dissection may also cause aortic regurgitation and pericardial tamponade. Proliferative diabetic retinopathy, pregnancy, and easily controllable hypertension are relative contraindications for r-tPA administration. Stem e strongly calls for using r-tPA.

9) a. 

Hydralazine and minoxidil have a pure arteriolar dilating effect. The other stems have combined arteriolar and venodilating effects.

10) e. 

High-risk unstable angina is reflected by the presence of any one of the following:

1- Post-infarct angina.

2- Recurrent chest pain at