1. HARVEY®Simulation Exam VCU Internal Medicine M3 Clerkship IMSPE Exam

2. Harvey Question #1 A 50 year-old man who hasn’t seen a physician in 15 years presents to your office for establishment of regular care and to update his health maintenance. He denies known medical problems and feels well overall. His vital signs reveal a blood pressure of 153/95 mm Hg, a heart rate of 77/min, a respiratory rate of 16/min, and a temperature of 37.2 Celsius. You auscultate his heart. What is the abnormal finding and its most likely cause? A. Physiologic S3, no underlying disease B. S4, due to essential hypertension C. S3, due to chronic systolic heart failure D. Fixed splitting of S2, due to atrial septal defect E. S4, due to hypertrophic obstructive cardiomyopathy (HOCM)

3. Harvey Question #2 A 75 year-old man presents to your office complaining of exertional near-syncope over the past several months, with progressive worsening. He has no exertional chest pain or dyspnea, and otherwise has felt well. He has a history of well-controlled hypertension but no diabetes or known coronary artery disease. His blood pressue is 128/75 mm Hg and his heart rate is 84/min. You auscultate his heart. Identify the abnormal findings and their most likely cause. A. Systolic murmur loudest at the apex with an S3, due to mitral regurgitation B. Diastolic murmur loudest at the apex, due to mitral stenosis C. Systolic murmur loudest at the left lower sternal border, due to tricuspid regurgitation D. Systolic murmur loudest at the right upper sternal border with S4 at the apex, due to aortic stenosis E. Diastolic murmur loudest at the right upper sternal border with S4 at the apex, due to aortic regurgitation

4. Harvey Question #3 A 65 year-old man with multiple medical problems presents to the emergency department complaining of progressive dyspnea on exertion, orthopnea, and lower extremity edema over the past several days. He has no chest pain. He has poorly- controlled hypertension and diabetes, at least partly due to non- adherence to his medications. On initial examination, his blood pressure is 148/88 mm Hg, his heart rate is 112/min, his respiratory rate is 24/min, and his pulse oximetry is 92% on room air. You auscultate his heart and lungs. Identify the abnormal findings and match them with the most likely problem. A. Holosystolic murmur heard best at the apex, with S3 and S4; and inspiratory crackles, due to systolic heart failure and mitral regurgitation B. Holosystolic murmur heard best at left lower sternal border, with S3 and S4, due to severe pulmonary hypertension and triscuspid regurgitation C. Holosystolic murmur heard best at left lower sternal border and the apex, no S3 or S4, with inspiratory crackles, due to ventricular septal defect D. Diastolic murmur heard best at the apex with an S4, due to mitral stenosis E. Systolic murmur heard best at the left upper sternal border due to pulmonic stenosis

5. Harvey Question #4 A 55 year-old woman presents complaining of several days of progressively worsening chest pain that is severe in nature. She has some mild dyspnea as well but can’t really tell if it’s any worse on exertion. She has hypertension and diabetes, both of which have been well- controlled. She recently had a productive cough about 2-3 weeks ago that has since resolved. You auscultate her heart. What is the most likely diagnosis based on your findings? A. Acute mitral regurgitation due to acute myocardial infarction B.Diastolic heart failure due to long-standing hypertension C.Mitral stenosis due to previously undiagnosed rheumatic heart disease D.Aortic regurgitation due to endocarditis E.Acute pericarditis due to recent viral infection

6. Harvey Question #5 A 25 year-old man presents to your office for a physical examination; he would like to know if it’s safe for him to begin a strenuous exercise program. He is not aware of any medical problems as a child, and he feels well currently. He has no chest pain or dyspnea with his current level of activity (walking several blocks at a time, climbing 1 flight of stairs). His blood pressure is 115/75 mm Hg, his heart rate is 68/min, his respiratory rate is 15/min, and he appears generally comfortable and in no acute distress. You auscultate his heart. What should you tell him about your findings? A.Normal cardiac auscultation, no limitations on exercise B.Systolic murmur heard at right upper sternal border, concerning for aortic stenosis, he should not exercise until an echocardiogram has been obtained C.S4 heard at the apex, concerning for hypertrophic obstructive cardiomyopathy, he should not exercise until an echocardiogram has been obtained D.S3 heard at the apex, no limitations on exercise E.S3 heard at the apex, concerning for left ventricular dysfunction, he needs to see a cardiologist prior to beginning any exercise program

7. Harvey Question #6 A 52 year-old woman presents complaining of progressively worsening dyspnea on exertion. Symptoms have been occurring for several months. Years ago she was told she had a heart murmur but was told she didn’t need to worry about it because she was feeling well at that time. Her vital signs are a blood pressure of 160/65 mm Hg, a heart rate of 92/min, a respiratory rate of 22/min, and a pulse oximetry of 96% on room air at rest. You auscultate her heart. What are the abnormal findings and the most likely diagnosis? A. Diastolic murmur best heard at the apex due to mitral stenosis from prior rheumatic heart disease B. Systolic murmur heard throughout the chest but loudest at the right upper sternal border, due to aortic stenosis C. Systolic murmur at the right upper sternal border, diastolic murmur heard throughout the chest but loudest at the left lower sternal border, due to aortic regurgitation D. Systolic murmur best heard at the left lower sternal border due to tricuspid regurgitation from severe pulmonary hypertension E. Diastolic murmur heard best at the left upper sternal border to the pulmonic regurgitation