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  • Question 1 - A 67-year-old woman visits her GP for a routine hypertension check-up. She has...

    Incorrect

    • A 67-year-old woman visits her GP for a routine hypertension check-up. She has been on amlodipine for a year and her blood pressure is under control, but she frequently experiences ankle swelling. The swelling is more pronounced towards the end of the day since she started taking amlodipine. The GP decides to switch her medication to a diuretic. Which diuretic targets the sodium-chloride transporter in the distal tubule?

      Your Answer: Mannitol (osmotic diuretic)

      Correct Answer: Bendroflumethiazide (thiazide diuretic)

      Explanation:

      Thiazide diuretics are medications that work by blocking the thiazide-sensitive Na+-Cl− symporter, which inhibits sodium reabsorption at the beginning of the distal convoluted tubule (DCT). This results in the loss of potassium as more sodium reaches the collecting ducts. While thiazide diuretics are useful in treating mild heart failure, loop diuretics are more effective in reducing overload. Bendroflumethiazide was previously used to manage hypertension, but recent NICE guidelines recommend other thiazide-like diuretics such as indapamide and chlorthalidone.

      Common side effects of thiazide diuretics include dehydration, postural hypotension, and electrolyte imbalances such as hyponatremia, hypokalemia, and hypercalcemia. Other potential adverse effects include gout, impaired glucose tolerance, and impotence. Rare side effects may include thrombocytopenia, agranulocytosis, photosensitivity rash, and pancreatitis.

      It is worth noting that while thiazide diuretics may cause hypercalcemia, they can also reduce the incidence of renal stones by decreasing urinary calcium excretion. According to current NICE guidelines, the management of hypertension involves the use of thiazide-like diuretics, along with other medications and lifestyle changes, to achieve optimal blood pressure control and reduce the risk of cardiovascular disease.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 2 - A 72-year-old man is admitted to the renal ward with acute kidney injury...

    Incorrect

    • A 72-year-old man is admitted to the renal ward with acute kidney injury following 3 days of diarrhoea and vomiting. Laboratory results reveal that his potassium levels are below normal limits, likely due to his gastrointestinal symptoms. You review his medications to ensure that none are exacerbating the situation and discover that he is taking diuretics for heart failure management. Which of the following diuretics is linked to hypokalaemia?

      Your Answer:

      Correct Answer: Bumetanide

      Explanation:

      Hypokalaemia may be caused by loop diuretics such as bumetanide. It is important to note that spironolactone, triamterene, eplerenone, and amiloride are potassium-sparing diuretics and are more likely to cause hyperkalaemia. In this case, the patient has been admitted to the hospital with acute kidney injury (AKI) due to diarrhoea and vomiting, which are also possible causes of hypokalaemia. It is important to manage all of these factors. Symptoms of hypokalaemia include fatigue, muscle weakness, myalgia, muscle cramps, constipation, hyporeflexia, and in rare cases, paralysis.

      Loop Diuretics: Mechanism of Action and Clinical Applications

      Loop diuretics, such as furosemide and bumetanide, are medications that inhibit the Na-K-Cl cotransporter (NKCC) in the thick ascending limb of the loop of Henle. By doing so, they reduce the absorption of NaCl, resulting in increased urine output. Loop diuretics act on NKCC2, which is more prevalent in the kidneys. These medications work on the apical membrane and must first be filtered into the tubules by the glomerulus before they can have an effect. Patients with poor renal function may require higher doses to ensure sufficient concentration in the tubules.

      Loop diuretics are commonly used in the treatment of heart failure, both acutely (usually intravenously) and chronically (usually orally). They are also indicated for resistant hypertension, particularly in patients with renal impairment. However, loop diuretics can cause adverse effects such as hypotension, hyponatremia, hypokalemia, hypomagnesemia, hypochloremic alkalosis, ototoxicity, hypocalcemia, renal impairment, hyperglycemia (less common than with thiazides), and gout. Therefore, careful monitoring of electrolyte levels and renal function is necessary when using loop diuretics.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 3 - A 32-year-old woman who is 34 weeks pregnant with her first baby is...

    Incorrect

    • A 32-year-old woman who is 34 weeks pregnant with her first baby is worried about the possibility of her child having a congenital heart defect. She was born with patent ductus arteriosus (PDA) herself and wants to know what treatment options are available for this condition.

      What treatment will you recommend if her baby is diagnosed with PDA?

      Your Answer:

      Correct Answer: The baby receives indomethacin as a neonate

      Explanation:

      The preferred treatment for patent ductus arteriosus (PDA) in neonates is indomethacin or ibuprofen, administered after birth. While PDA is more common in premature infants, a family history of heart defects can increase the risk. Diagnosis typically occurs during postnatal baby checks, often due to the presence of a murmur or symptoms of heart failure. Doing nothing is not a recommended approach, as spontaneous closure is rare. Surgery may be necessary if medical management is unsuccessful. Prostaglandin E1 is not the best answer, as it is typically used in cases where PDA is associated with another congenital heart defect. Indomethacin or ibuprofen are not given to the mother during the antenatal period.

      Understanding Patent Ductus Arteriosus

      Patent ductus arteriosus is a type of congenital heart defect that is generally classified as ‘acyanotic’. However, if left uncorrected, it can eventually result in late cyanosis in the lower extremities, which is termed differential cyanosis. This condition is caused by a connection between the pulmonary trunk and descending aorta. Normally, the ductus arteriosus closes with the first breaths due to increased pulmonary flow, which enhances prostaglandins clearance. However, in some cases, this connection remains open, leading to patent ductus arteriosus.

      This condition is more common in premature babies, those born at high altitude, or those whose mothers had rubella infection in the first trimester. The features of patent ductus arteriosus include a left subclavicular thrill, continuous ‘machinery’ murmur, large volume, bounding, collapsing pulse, wide pulse pressure, and heaving apex beat.

      The management of patent ductus arteriosus involves the use of indomethacin or ibuprofen, which are given to the neonate. These medications inhibit prostaglandin synthesis and close the connection in the majority of cases. If patent ductus arteriosus is associated with another congenital heart defect amenable to surgery, then prostaglandin E1 is useful to keep the duct open until after surgical repair. Understanding patent ductus arteriosus is important for early diagnosis and management of this condition.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 4 - A 50-year-old male is diagnosed with hypertension with a blood pressure reading of...

    Incorrect

    • A 50-year-old male is diagnosed with hypertension with a blood pressure reading of 180/100 mmHg during ambulatory blood pressure monitoring. The physician prescribes Ramipril, an ACE inhibitor. What is the most frequent adverse effect associated with this medication?

      Your Answer:

      Correct Answer: A dry cough

      Explanation:

      Hypotension, particularly on the first dose, and deterioration of renal function are common side effects of ACE inhibitors in patients. Although angioedema is a rare side effect of ACE inhibitors, oedema is typically associated with calcium channel blockers. Diuretics may cause excessive urine output, while shortness of breath and headaches are uncommon.

      Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.

      While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.

      Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.

      The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 5 - A 45-year-old patient presents to the emergency department with increasing dyspnea on exertion...

    Incorrect

    • A 45-year-old patient presents to the emergency department with increasing dyspnea on exertion and swelling in both legs. A recent outpatient echocardiogram revealed a left ventricular ejection fraction of 31%. During chest examination, an extra heart sound is detected just prior to the first.

      What is the cause of this additional heart sound?

      Your Answer:

      Correct Answer: Atria contracting forcefully to overcome an abnormally stiff ventricle

      Explanation:

      The presence of S4, which sounds like a ‘gallop rhythm’, can be heard after S2 and in conjunction with a third heart sound. However, if the ventricles are contracting against a stiffened aorta, it would not produce a significant heart sound during this phase of the cardiac cycle. Any sound that may be heard in this scenario would occur between the first and second heart sounds during systole, and it would also cause a raised pulse pressure and be visible on chest X-ray as calcification. Delayed closure of the aortic valve could cause a split second heart sound, but it would appear around the time of S2, not before S1. On the other hand, retrograde flow of blood from the right ventricle into the right atrium, known as tricuspid regurgitation, would cause a systolic murmur instead of an additional isolated heart sound. This condition is often caused by infective endocarditis in intravenous drug users or a history of rheumatic fever.

      Heart sounds are the sounds produced by the heart during its normal functioning. The first heart sound (S1) is caused by the closure of the mitral and tricuspid valves, while the second heart sound (S2) is due to the closure of the aortic and pulmonary valves. The intensity of these sounds can vary depending on the condition of the valves and the heart. The third heart sound (S3) is caused by the diastolic filling of the ventricle and is considered normal in young individuals. However, it may indicate left ventricular failure, constrictive pericarditis, or mitral regurgitation in older individuals. The fourth heart sound (S4) may be heard in conditions such as aortic stenosis, HOCM, and hypertension, and is caused by atrial contraction against a stiff ventricle. The different valves can be best heard at specific sites on the chest wall, such as the left second intercostal space for the pulmonary valve and the right second intercostal space for the aortic valve.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 6 - A 73-year-old woman is admitted to the acute surgical unit with profuse vomiting....

    Incorrect

    • A 73-year-old woman is admitted to the acute surgical unit with profuse vomiting. Admission bloods show the following:

      Na+ 131 mmol/l
      K+ 2.2 mmol/l
      Urea 3.1 mmol/l
      Creatinine 56 mol/l
      Glucose 4.3 mmol/l

      What ECG feature is most likely to be seen in this patient?

      Your Answer:

      Correct Answer: U waves

      Explanation:

      Hypokalaemia, a condition characterized by low levels of potassium in the blood, can be detected through ECG features. These include the presence of U waves, small or absent T waves (which may occasionally be inverted), a prolonged PR interval, ST depression, and a long QT interval. The ECG image provided shows typical U waves and a borderline PR interval. To remember these features, one user suggests the following rhyme: In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 7 - A 25-year-old man has a cannula inserted into his cephalic vein. What is...

    Incorrect

    • A 25-year-old man has a cannula inserted into his cephalic vein. What is the structure through which the cephalic vein passes?

      Your Answer:

      Correct Answer: Clavipectoral fascia

      Explanation:

      Preserving the cephalic vein is important for creating an arteriovenous fistula in patients with end stage renal failure, as it is a preferred vessel for this purpose. The vein travels through the calvipectoral fascia, but does not pass through the pectoralis major muscle, before ending in the axillary vein.

      The Cephalic Vein: Path and Connections

      The cephalic vein is a major blood vessel that runs along the lateral side of the arm. It begins at the dorsal venous arch, which drains blood from the hand and wrist, and travels up the arm, crossing the anatomical snuffbox. At the antecubital fossa, the cephalic vein is connected to the basilic vein by the median cubital vein. This connection is commonly used for blood draws and IV insertions.

      After passing through the antecubital fossa, the cephalic vein continues up the arm and pierces the deep fascia of the deltopectoral groove to join the axillary vein. This junction is located near the shoulder and marks the end of the cephalic vein’s path.

      Overall, the cephalic vein plays an important role in the circulation of blood in the upper limb. Its connections to other major veins in the arm make it a valuable site for medical procedures, while its path through the deltopectoral groove allows it to contribute to the larger network of veins that drain blood from the upper body.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 8 - Samantha is a 63-year-old female who has just been diagnosed with hypertension. Her...

    Incorrect

    • Samantha is a 63-year-old female who has just been diagnosed with hypertension. Her physician informs her that her average blood pressure is influenced by various bodily processes, such as heart function, nervous system activity, and blood vessel diameter. Assuming an average cardiac output (CO) of 4L/min, Samantha's mean arterial pressure (MAP) is recorded at 140mmHg during her examination.

      What is Samantha's systemic vascular resistance (SVR) based on these measurements?

      Your Answer:

      Correct Answer: 35 mmhgâ‹…minâ‹…mL-1

      Explanation:

      The equation used to calculate systemic vascular resistance is SVR = MAP / CO. For example, if the mean arterial pressure (MAP) is 140 mmHg and the cardiac output (CO) is 4 mL/min, then the SVR would be 35 mmHgâ‹…minâ‹…mL-1. Although the theoretical equation for SVR is more complex, it is often simplified by assuming that central venous pressure (CVP) is negligible. However, in reality, MAP is typically measured directly or indirectly using arterial pressure measurements. The equation for calculating MAP at rest is MAP = diastolic pressure + 1/3(pulse pressure), where pulse pressure is calculated as systolic pressure minus diastolic pressure.

      Cardiovascular physiology involves the study of the functions and processes of the heart and blood vessels. One important measure of heart function is the left ventricular ejection fraction, which is calculated by dividing the stroke volume (the amount of blood pumped out of the left ventricle with each heartbeat) by the end diastolic LV volume (the amount of blood in the left ventricle at the end of diastole) and multiplying by 100%. Another key measure is cardiac output, which is the amount of blood pumped by the heart per minute and is calculated by multiplying stroke volume by heart rate.

      Pulse pressure is another important measure of cardiovascular function, which is the difference between systolic pressure (the highest pressure in the arteries during a heartbeat) and diastolic pressure (the lowest pressure in the arteries between heartbeats). Factors that can increase pulse pressure include a less compliant aorta (which can occur with age) and increased stroke volume.

      Finally, systemic vascular resistance is a measure of the resistance to blood flow in the systemic circulation and is calculated by dividing mean arterial pressure (the average pressure in the arteries during a heartbeat) by cardiac output. Understanding these measures of cardiovascular function is important for diagnosing and treating cardiovascular diseases.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 9 - A 45-year-old man undergoes a routine medical exam and his blood pressure is...

    Incorrect

    • A 45-year-old man undergoes a routine medical exam and his blood pressure is measured at 155/95 mmHg, which is unusual as it has been normal for the past five annual check-ups. What could be the reason for this sudden change?

      Your Answer:

      Correct Answer: An undersized blood pressure cuff

      Explanation:

      Ensuring Accurate Blood Pressure Measurements

      Blood pressure is a crucial physiological measurement in medicine, and it is essential to ensure that the values obtained are accurate. Inaccurate readings can occur due to various reasons, such as using the wrong cuff size, incorrect arm positioning, and unsupported arms. For instance, using a bladder that is too small can lead to an overestimation of blood pressure, while using a bladder that is too large can result in an underestimation of blood pressure. Similarly, lowering the arm below heart level can lead to an overestimation of blood pressure, while elevating the arm above heart level can result in an underestimation of blood pressure.

      It is recommended to measure blood pressure in both arms when considering a diagnosis of hypertension. If there is a difference of more than 20 mmHg between the readings obtained from both arms, the measurements should be repeated. If the difference remains greater than 20 mmHg, subsequent blood pressures should be recorded from the arm with the higher reading. By following these guidelines, healthcare professionals can ensure that accurate blood pressure measurements are obtained, which is crucial for making informed medical decisions.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 10 - A 59-year-old woman presents to a respiratory clinic with worsening breathlessness and a...

    Incorrect

    • A 59-year-old woman presents to a respiratory clinic with worsening breathlessness and a recent diagnosis of pulmonary hypertension. The decision is made to initiate treatment with bosentan. Can you explain the mechanism of action of this medication?

      Your Answer:

      Correct Answer: Endothelin antagonist

      Explanation:

      Bosentan, a non-selective endothelin antagonist, is used to treat pulmonary hypertension by blocking the vasoconstrictive effects of endothelin. However, it may cause liver function abnormalities, requiring regular monitoring. Endothelin agonists would worsen pulmonary vasoconstriction and are not suitable for treating pulmonary hypertension. Guanylate cyclase stimulators like riociguat work with nitric oxide to dilate blood vessels and treat pulmonary hypertension. Sildenafil, a phosphodiesterase inhibitor, selectively reduces pulmonary vascular tone to treat pulmonary hypertension.

      Understanding Endothelin and Its Role in Various Diseases

      Endothelin is a potent vasoconstrictor and bronchoconstrictor that is secreted by the vascular endothelium. Initially, it is produced as a prohormone and later converted to ET-1 by the action of endothelin converting enzyme. Endothelin interacts with a G-protein linked to phospholipase C, leading to calcium release. This interaction is thought to be important in the pathogenesis of many diseases, including primary pulmonary hypertension, cardiac failure, hepatorenal syndrome, and Raynaud’s.

      Endothelin is known to promote the release of angiotensin II, ADH, hypoxia, and mechanical shearing forces. On the other hand, it inhibits the release of nitric oxide and prostacyclin. Raised levels of endothelin are observed in primary pulmonary hypertension, myocardial infarction, heart failure, acute kidney injury, and asthma.

      In recent years, endothelin antagonists have been used to treat primary pulmonary hypertension. Understanding the role of endothelin in various diseases can help in the development of new treatments and therapies.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 11 - With respect to the basilic vein, which statement is not true? ...

    Incorrect

    • With respect to the basilic vein, which statement is not true?

      Your Answer:

      Correct Answer: Its deep anatomical location makes it unsuitable for use as an arteriovenous access site in fistula surgery

      Explanation:

      A basilic vein transposition is a surgical procedure that utilizes it during arteriovenous fistula surgery.

      The Basilic Vein: A Major Pathway of Venous Drainage for the Arm and Hand

      The basilic vein is one of the two main pathways of venous drainage for the arm and hand, alongside the cephalic vein. It begins on the medial side of the dorsal venous network of the hand and travels up the forearm and arm. Most of its course is superficial, but it passes deep under the muscles midway up the humerus. Near the region anterior to the cubital fossa, the basilic vein joins the cephalic vein.

      At the lower border of the teres major muscle, the anterior and posterior circumflex humeral veins feed into the basilic vein. It is often joined by the medial brachial vein before draining into the axillary vein. The basilic vein is continuous with the palmar venous arch distally and the axillary vein proximally. Understanding the path and function of the basilic vein is important for medical professionals in diagnosing and treating conditions related to venous drainage in the arm and hand.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 12 - The vertebral artery passes through which of the following structures, except for what?...

    Incorrect

    • The vertebral artery passes through which of the following structures, except for what?

      Your Answer:

      Correct Answer: Intervertebral foramen

      Explanation:

      The vertebral artery does not travel through the intervertebral foramen, but instead passes through the foramina found in the transverse processes of the cervical vertebrae.

      Anatomy of the Vertebral Artery

      The vertebral artery is a branch of the subclavian artery and can be divided into four parts. The first part runs to the foramen in the transverse process of C6 and is located anterior to the vertebral and internal jugular veins. On the left side, the thoracic duct is also an anterior relation. The second part runs through the foramina of the transverse processes of the upper six cervical vertebrae and is accompanied by a venous plexus and the inferior cervical sympathetic ganglion. The third part runs posteromedially on the lateral mass of the atlas and enters the sub occipital triangle. It then passes anterior to the edge of the posterior atlanto-occipital membrane to enter the vertebral canal. The fourth part passes through the spinal dura and arachnoid, running superiorly and anteriorly at the lateral aspect of the medulla oblongata. At the lower border of the pons, it unites to form the basilar artery.

      The anatomy of the vertebral artery is important to understand as it plays a crucial role in supplying blood to the brainstem and cerebellum. Any damage or blockage to this artery can lead to serious neurological complications. Therefore, it is essential for healthcare professionals to have a thorough understanding of the anatomy and function of the vertebral artery.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 13 - A 63-year-old man arrives at the emergency department with sudden and severe chest...

    Incorrect

    • A 63-year-old man arrives at the emergency department with sudden and severe chest pain that began an hour ago. He experiences nausea and sweating, and the pain spreads to his left jaw and arm. The patient has a medical history of essential hypertension and type 2 diabetes mellitus. He is a current smoker with a 30 pack years history and drinks about 30 units of alcohol per week. He used to work as a lorry driver but is now retired. An electrocardiogram in the emergency department reveals ST segment elevations in leads II, III, and aVF, and a blood test shows elevated cardiac enzymes. The man undergoes a percutaneous coronary intervention and is admitted to the coronary care unit. After two weeks, he is discharged. What is the complication that this man is most likely to develop on day 7 after his arrival at the emergency department?

      Your Answer:

      Correct Answer: Cardiac tamponade

      Explanation:

      The patient’s symptoms suggest that he may have experienced an ST elevation myocardial infarction in the inferior wall of his heart. There are various complications that can arise after a heart attack, and the timing of these complications can vary.

      1. Ventricular arrhythmia is a common cause of death after a heart attack, but it typically occurs within the first 24 hours.
      2. Ventricular septal defect, which is caused by a rupture in the interventricular septum, is most likely to occur 3-5 days after a heart attack.
      3. This complication is autoimmune-mediated and usually occurs several weeks after a heart attack.
      4. Cardiac tamponade can occur when bleeding into the pericardial sac impairs the heart’s contractile function. This complication is most likely to occur 5-14 days after a heart attack.
      5. Mural thrombus, which can result from the formation of a true ventricular aneurysm, is most likely to occur at least two weeks after a heart attack. Ventricular pseudoaneurysm, on the other hand, can occur 3-14 days after a heart attack.

      Understanding Cardiac Tamponade

      Cardiac tamponade is a medical condition where there is an accumulation of pericardial fluid under pressure. This condition is characterized by several classical features, including hypotension, raised JVP, and muffled heart sounds, which are collectively known as Beck’s triad. Other symptoms of cardiac tamponade include dyspnea, tachycardia, an absent Y descent on the JVP, pulsus paradoxus, and Kussmaul’s sign. An ECG can also show electrical alternans.

      It is important to differentiate cardiac tamponade from constrictive pericarditis, which has different characteristic features such as an absent Y descent, X + Y present JVP, and the absence of pulsus paradoxus. Constrictive pericarditis is also characterized by pericardial calcification on CXR.

      The management of cardiac tamponade involves urgent pericardiocentesis. It is crucial to recognize the symptoms of cardiac tamponade and seek medical attention immediately to prevent further complications.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 14 - A 42-year-old man arrives at the emergency department with complaints of palpitations and...

    Incorrect

    • A 42-year-old man arrives at the emergency department with complaints of palpitations and dizziness. He has been experiencing vomiting and diarrhoea for the past week and has also been suffering from muscle weakness and cramps for the last three days. The possibility of hypokalaemia is suspected, and an ECG is ordered. What ECG sign is indicative of hypokalaemia?

      Your Answer:

      Correct Answer: Small or inverted T waves

      Explanation:

      Hypokalaemia, a condition characterized by low levels of potassium in the blood, can be detected through ECG features. These include the presence of U waves, small or absent T waves (which may occasionally be inverted), a prolonged PR interval, ST depression, and a long QT interval. The ECG image provided shows typical U waves and a borderline PR interval. To remember these features, one user suggests the following rhyme: In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 15 - A patient in their 60s develops complete heart block in hospital after experiencing...

    Incorrect

    • A patient in their 60s develops complete heart block in hospital after experiencing a myocardial infarction. Their ECG displays a heart rate of 37 beats per minute and desynchronisation of atrial and ventricular contraction. What is the most probable coronary artery that is occluded in heart block during a myocardial infarction, indicating damage to the AV node?

      Your Answer:

      Correct Answer: RIght coronary artery

      Explanation:

      The atrioventricular node is most likely supplied by the right coronary artery.

      The left coronary artery gives rise to the left anterior descending and circumflex arteries.

      An anterior myocardial infarction is caused by occlusion of the left anterior descending artery.

      The coronary sinus is a venous structure that drains blood from the heart and returns it to the right atrium.

      Understanding Coronary Circulation

      Coronary circulation refers to the blood flow that supplies the heart with oxygen and nutrients. The arterial supply of the heart is divided into two main branches: the left coronary artery (LCA) and the right coronary artery (RCA). The LCA originates from the left aortic sinus, while the RCA originates from the right aortic sinus. The LCA further divides into two branches, the left anterior descending (LAD) and the circumflex artery, while the RCA supplies the posterior descending artery.

      The LCA supplies the left ventricle, left atrium, and interventricular septum, while the RCA supplies the right ventricle and the inferior wall of the left ventricle. The SA node, which is responsible for initiating the heartbeat, is supplied by the RCA in 60% of individuals, while the AV node, which is responsible for regulating the heartbeat, is supplied by the RCA in 90% of individuals.

      On the other hand, the venous drainage of the heart is through the coronary sinus, which drains into the right atrium. During diastole, the coronary arteries fill with blood, allowing for the delivery of oxygen and nutrients to the heart muscles. Understanding the coronary circulation is crucial in the diagnosis and management of various heart diseases.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 16 - During ward round, you have been presented with an ECG of a 50-year-old...

    Incorrect

    • During ward round, you have been presented with an ECG of a 50-year-old female who was admitted with blackouts and a heart rate of 43bpm. On the ECG you note that the QRS complex is narrow but is missing after every other P wave. What is this condition called?

      Your Answer:

      Correct Answer: 2:1 heart block

      Explanation:

      The patient has a bradycardia with a narrow QRS complex, ruling out bundle branch blocks. It is not a first-degree heart block or a Wenckebach heart block. The correct diagnosis is a 2:1 heart block with 2 P waves to each QRS complex.

      Understanding Heart Blocks: Types and Features

      Heart blocks are a type of cardiac conduction disorder that can lead to serious complications such as syncope and heart failure. There are three types of heart blocks: first degree, second degree, and third degree (complete) heart block.

      First degree heart block is characterized by a prolonged PR interval of more than 0.2 seconds. Second degree heart block can be further divided into two types: type 1 (Mobitz I, Wenckebach) and type 2 (Mobitz II). Type 1 is characterized by a progressive prolongation of the PR interval until a dropped beat occurs, while type 2 has a constant PR interval but the P wave is often not followed by a QRS complex.

      Third degree (complete) heart block is the most severe type of heart block, where there is no association between the P waves and QRS complexes. This can lead to a regular bradycardia with a heart rate of 30-50 bpm, wide pulse pressure, and cannon waves in the neck JVP. Additionally, variable intensity of S1 can be observed.

      It is important to recognize the features of heart blocks and differentiate between the types in order to provide appropriate management and prevent complications. Regular monitoring and follow-up with a healthcare provider is recommended for individuals with heart blocks.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 17 - John, a 67-year-old male, is brought to the emergency department by ambulance. The...

    Incorrect

    • John, a 67-year-old male, is brought to the emergency department by ambulance. The ambulance crew explains that the patient has emesis, homonymous hemianopia, weakness of left upper and lower limb, and dysphasia. He makes the healthcare professionals aware he has a worsening headache.

      He has a past medical history of atrial fibrillation for which he is taking warfarin. His INR IS 4.3 despite his target range of 2-3.

      A CT is ordered and the report suggests the anterior cerebral artery is the affected vessel.

      Which areas of the brain can be affected with a haemorrhage stemming of this artery?

      Your Answer:

      Correct Answer: Frontal and parietal lobes

      Explanation:

      The frontal and parietal lobes are partially supplied by the anterior cerebral artery, which is a branch of the internal carotid artery. Specifically, it mainly provides blood to the anteromedial region of these lobes.

      The Circle of Willis is an anastomosis formed by the internal carotid arteries and vertebral arteries on the bottom surface of the brain. It is divided into two halves and is made up of various arteries, including the anterior communicating artery, anterior cerebral artery, internal carotid artery, posterior communicating artery, and posterior cerebral arteries. The circle and its branches supply blood to important areas of the brain, such as the corpus striatum, internal capsule, diencephalon, and midbrain.

      The vertebral arteries enter the cranial cavity through the foramen magnum and lie in the subarachnoid space. They then ascend on the anterior surface of the medulla oblongata and unite to form the basilar artery at the base of the pons. The basilar artery has several branches, including the anterior inferior cerebellar artery, labyrinthine artery, pontine arteries, superior cerebellar artery, and posterior cerebral artery.

      The internal carotid arteries also have several branches, such as the posterior communicating artery, anterior cerebral artery, middle cerebral artery, and anterior choroid artery. These arteries supply blood to different parts of the brain, including the frontal, temporal, and parietal lobes. Overall, the Circle of Willis and its branches play a crucial role in providing oxygen and nutrients to the brain.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 18 - Where are the arterial baroreceptors situated? ...

    Incorrect

    • Where are the arterial baroreceptors situated?

      Your Answer:

      Correct Answer: Carotid sinus and aortic arch

      Explanation:

      The heart has four chambers and generates pressures of 0-25 mmHg on the right side and 0-120 mmHg on the left. The cardiac output is the product of heart rate and stroke volume, typically 5-6L per minute. The cardiac impulse is generated in the sino atrial node and conveyed to the ventricles via the atrioventricular node. Parasympathetic and sympathetic fibers project to the heart via the vagus and release acetylcholine and noradrenaline, respectively. The cardiac cycle includes mid diastole, late diastole, early systole, late systole, and early diastole. Preload is the end diastolic volume and afterload is the aortic pressure. Laplace’s law explains the rise in ventricular pressure during the ejection phase and why a dilated diseased heart will have impaired systolic function. Starling’s law states that an increase in end-diastolic volume will produce a larger stroke volume up to a point beyond which stroke volume will fall. Baroreceptor reflexes and atrial stretch receptors are involved in regulating cardiac output.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 19 - A 47-year-old woman is recuperating in the ICU after undergoing a Whipples surgery....

    Incorrect

    • A 47-year-old woman is recuperating in the ICU after undergoing a Whipples surgery. She has a central venous line inserted. What will cause the 'y' descent on the waveform trace?

      Your Answer:

      Correct Answer: Emptying of the right atrium

      Explanation:

      The JVP waveform consists of 3 upward deflections and 2 downward deflections. The upward deflections include the a wave, which represents atrial contraction, the c wave, which represents ventricular contraction, and the v wave, which represents atrial venous filling. The downward deflections include the x wave, which occurs when the atrium relaxes and the tricuspid valve moves down, and the y wave, which represents ventricular filling. The y descent in the waveform indicates the emptying of the atrium and the filling of the right ventricle.

      The heart has four chambers and generates pressures of 0-25 mmHg on the right side and 0-120 mmHg on the left. The cardiac output is the product of heart rate and stroke volume, typically 5-6L per minute. The cardiac impulse is generated in the sino atrial node and conveyed to the ventricles via the atrioventricular node. Parasympathetic and sympathetic fibers project to the heart via the vagus and release acetylcholine and noradrenaline, respectively. The cardiac cycle includes mid diastole, late diastole, early systole, late systole, and early diastole. Preload is the end diastolic volume and afterload is the aortic pressure. Laplace’s law explains the rise in ventricular pressure during the ejection phase and why a dilated diseased heart will have impaired systolic function. Starling’s law states that an increase in end-diastolic volume will produce a larger stroke volume up to a point beyond which stroke volume will fall. Baroreceptor reflexes and atrial stretch receptors are involved in regulating cardiac output.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 20 - A patient in his late 60s presents with dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea,...

    Incorrect

    • A patient in his late 60s presents with dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, fatigue, cyanosis. A diagnosis of acute heart failure is made. He is started on diuretics, ACE inhibitors, beta-blockers but shows minimal improvement with medications.

      What should be considered if he continues to fail to improve?

      Your Answer:

      Correct Answer: Continuous positive airway pressure

      Explanation:

      If a patient with acute heart failure does not show improvement with appropriate medication, CPAP should be considered as a viable treatment option.

      Heart failure requires acute management, with recommended treatments including IV loop diuretics such as furosemide or bumetanide. Oxygen may also be given in accordance with British Thoracic Society guidelines to maintain oxygen saturations between 94-98%. Vasodilators such as nitrates should not be routinely given to all patients, but may be considered for those with concomitant myocardial ischaemia, severe hypertension, or regurgitant aortic or mitral valve disease. However, hypotension is a major side-effect and contraindication.

      For patients with respiratory failure, CPAP may be used. In cases of hypotension or cardiogenic shock, treatment can be challenging as loop diuretics and nitrates may exacerbate hypotension. Inotropic agents like dobutamine may be considered for patients with severe left ventricular dysfunction and potentially reversible cardiogenic shock. Vasopressor agents like norepinephrine are typically only used if there is insufficient response to inotropes and evidence of end-organ hypoperfusion. Mechanical circulatory assistance such as intra-aortic balloon counterpulsation or ventricular assist devices may also be used.

      While opiates were previously used routinely to reduce dyspnoea/distress in patients, NICE now advises against routine use due to studies suggesting increased morbidity in patients given opiates. Regular medication for heart failure such as beta-blockers and ACE-inhibitors should be continued, with beta-blockers only stopped if the patient has a heart rate less than 50 beats per minute, second or third degree atrioventricular block, or shock.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 21 - A 45-year-old male with no past medical history is recently diagnosed with hypertension....

    Incorrect

    • A 45-year-old male with no past medical history is recently diagnosed with hypertension. His GP prescribes him lisinopril and orders a baseline renal function blood test, which comes back normal. The GP schedules a follow-up appointment for two weeks later to check his renal function. At the follow-up appointment, the patient's blood test results show:

      Na 137 mmol/l
      K 4.7 mmol/l
      Cl 98 mmol/l
      Urea 12.2 mmol/l
      Creatinine 250 mg/l

      What is the most likely cause for the abnormal blood test results?

      Your Answer:

      Correct Answer: Bilateral stenosis of renal arteries

      Explanation:

      Patients with renovascular disease should not be prescribed ACE inhibitors as their first line antihypertensive medication. This is because bilateral renal artery stenosis, a common cause of hypertension, can go undetected and lead to acute renal impairment when treated with ACE inhibitors. This occurs because the medication prevents the constriction of efferent arterioles, which is necessary to maintain glomerular pressure in patients with reduced blood flow to the kidneys. Therefore, further investigations such as a renal artery ultrasound scan should be conducted before prescribing ACE inhibitors to patients with hypertension.

      Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.

      While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.

      Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.

      The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 22 - The T wave in a typical electrocardiogram is mainly generated by what mechanisms?...

    Incorrect

    • The T wave in a typical electrocardiogram is mainly generated by what mechanisms?

      Your Answer:

      Correct Answer: Ventricular repolarization

      Explanation:

      The Glasgow coma scale is a widely used tool to assess the severity of brain injuries. It is scored between 3 and 15, with 3 being the worst and 15 the best. The scale comprises three parameters: best eye response, best verbal response, and best motor response. The verbal response is scored from 1 to 5, with 1 indicating no response and 5 indicating orientation.

      A score of 13 or higher on the Glasgow coma scale indicates a mild brain injury, while a score of 9 to 12 indicates a moderate injury. A score of 8 or less indicates a severe brain injury. Healthcare professionals rely on the Glasgow coma scale to assess the severity of brain injuries and determine appropriate treatment. The score is the sum of the scores as well as the individual elements. For example, a score of 10 might be expressed as GCS10 = E3V4M3.

      Best eye response:
      1- No eye opening
      2- Eye opening to pain
      3- Eye opening to sound
      4- Eyes open spontaneously

      Best verbal response:
      1- No verbal response
      2- Incomprehensible sounds
      3- Inappropriate words
      4- Confused
      5- Orientated

      Best motor response:
      1- No motor response.
      2- Abnormal extension to pain
      3- Abnormal flexion to pain
      4- Withdrawal from pain
      5- Localizing pain
      6- Obeys commands

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 23 - A 50-year-old man is brought to the hospital after a head-on collision. Upon...

    Incorrect

    • A 50-year-old man is brought to the hospital after a head-on collision. Upon initial resuscitation, a chest X-ray reveals a widened mediastinum. An urgent CT aortogram confirms a traumatic aortic rupture.

      Where is the most probable location for a traumatic aortic rupture to occur?

      Your Answer:

      Correct Answer: Proximal descending aorta distal to origin of left subclavian artery (aortic isthmus)

      Explanation:

      Although the aorta can be ruptured by trauma at any location, the aortic isthmus (the section of the proximal descending aorta located below the left subclavian artery) is the most frequent site of rupture resulting from deceleration injuries.

      Thoracic Aorta Rupture: Causes, Symptoms, Diagnosis, and Treatment

      Thoracic aorta rupture is a life-threatening condition that occurs due to decelerating force, such as a road traffic accident or a fall from a great height. Most people die at the scene, while survivors may have an incomplete laceration at the ligamentum arteriosum of the aorta. The clinical features of thoracic aorta rupture include a contained hematoma and persistent hypotension, which can be detected mainly by history and changes in chest X-rays. The X-ray changes include a widened mediastinum, trachea/esophagus to the right, depression of the left main stem bronchus, widened paratracheal stripe/paraspinal interfaces, obliteration of the space between the aorta and pulmonary artery, and rib fracture/left hemothorax.

      The diagnosis of thoracic aorta rupture is usually made through angiography, with CT aortogram being the preferred method. Treatment involves repair or replacement of the ruptured aorta, with endovascular repair being the ideal option. In summary, thoracic aorta rupture is a serious condition that requires prompt diagnosis and treatment to prevent fatal outcomes.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 24 - A 44-year-old woman presents with varicose veins and has a saphenofemoral disconnection, long...

    Incorrect

    • A 44-year-old woman presents with varicose veins and has a saphenofemoral disconnection, long saphenous vein stripping to the ankle, and isolated hook phlebectomies. After the surgery, she experiences numbness above her ankle. What is the probable reason for this?

      Your Answer:

      Correct Answer: Saphenous nerve injury

      Explanation:

      Full length stripping of the long saphenous vein below the knee is no longer recommended due to its relation to the saphenous nerve, while the short saphenous vein is related to the sural nerve.

      The Anatomy of Saphenous Veins

      The human body has two saphenous veins: the long saphenous vein and the short saphenous vein. The long saphenous vein is often used for bypass surgery or removed as a treatment for varicose veins. It originates at the first digit where the dorsal vein merges with the dorsal venous arch of the foot and runs up the medial side of the leg. At the knee, it runs over the posterior border of the medial epicondyle of the femur bone before passing laterally to lie on the anterior surface of the thigh. It then enters an opening in the fascia lata called the saphenous opening and joins with the femoral vein in the region of the femoral triangle at the saphenofemoral junction. The long saphenous vein has several tributaries, including the medial marginal, superficial epigastric, superficial iliac circumflex, and superficial external pudendal veins.

      On the other hand, the short saphenous vein originates at the fifth digit where the dorsal vein merges with the dorsal venous arch of the foot, which attaches to the great saphenous vein. It passes around the lateral aspect of the foot and runs along the posterior aspect of the leg with the sural nerve. It then passes between the heads of the gastrocnemius muscle and drains into the popliteal vein, approximately at or above the level of the knee joint.

      Understanding the anatomy of saphenous veins is crucial for medical professionals who perform surgeries or treatments involving these veins.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 25 - A 20-year-old man undergoes a routine ECG during his employment health check. The...

    Incorrect

    • A 20-year-old man undergoes a routine ECG during his employment health check. The ECG reveals sinus arrhythmia with varying P-P intervals and slight changes in the ventricular rate. The P waves exhibit normal morphology, and the P-R interval remains constant. The patient has a history of asthma and has been using inhalers more frequently due to an increase in running mileage. What is the probable cause of this rhythm, and how would you reassure the patient about the ECG results?

      Your Answer:

      Correct Answer: Ventricular rate changes with ventilation

      Explanation:

      Sinus arrhythmia is a natural occurrence that is commonly observed in young and healthy individuals. It is characterized by a fluctuation in heart rate during breathing, with an increase in heart rate during inhalation and a decrease during exhalation. This is due to a decrease in vagal tone during inspiration and an increase during expiration. The P-R interval remains constant, indicating no heart block, while the varying P-P intervals reflect changes in the ventricular heart rate.

      While anxiety may cause tachycardia, it cannot explain the fluctuation in P-P intervals. Similarly, salbutamol may cause a brief increase in heart rate, but this would not result in varying P-P and P-R intervals. In healthy and fit individuals, there should be no variation in the firing of the sino-atrial node.

      Understanding the Normal ECG

      The electrocardiogram (ECG) is a diagnostic tool used to assess the electrical activity of the heart. The normal ECG consists of several waves and intervals that represent different phases of the cardiac cycle. The P wave represents atrial depolarization, while the QRS complex represents ventricular depolarization. The ST segment represents the plateau phase of the ventricular action potential, and the T wave represents ventricular repolarization. The Q-T interval represents the time for both ventricular depolarization and repolarization to occur.

      The P-R interval represents the time between the onset of atrial depolarization and the onset of ventricular depolarization. The duration of the QRS complex is normally 0.06 to 0.1 seconds, while the duration of the P wave is 0.08 to 0.1 seconds. The Q-T interval ranges from 0.2 to 0.4 seconds depending upon heart rate. At high heart rates, the Q-T interval is expressed as a ‘corrected Q-T (QTc)’ by taking the Q-T interval and dividing it by the square root of the R-R interval.

      Understanding the normal ECG is important for healthcare professionals to accurately interpret ECG results and diagnose cardiac conditions. By analyzing the different waves and intervals, healthcare professionals can identify abnormalities in the electrical activity of the heart and provide appropriate treatment.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 26 - A 33-year-old woman delivers a baby boy in the delivery room. The midwife...

    Incorrect

    • A 33-year-old woman delivers a baby boy in the delivery room. The midwife observes microcephaly, polydactyly, and low-set ears during the neonatal assessment. Trisomy 13 is confirmed through rapid genetic testing. What is the most commonly associated cardiac abnormality with this condition?

      Your Answer:

      Correct Answer: Ventricular septal defect

      Explanation:

      Understanding Ventricular Septal Defect

      Ventricular septal defect (VSD) is a common congenital heart disease that affects many individuals. It is caused by a hole in the wall that separates the two lower chambers of the heart. In some cases, VSDs may close on their own, but in other cases, they require specialized management.

      There are various causes of VSDs, including chromosomal disorders such as Down’s syndrome, Edward’s syndrome, Patau syndrome, and cri-du-chat syndrome. Congenital infections and post-myocardial infarction can also lead to VSDs. The condition can be detected during routine scans in utero or may present post-natally with symptoms such as failure to thrive, heart failure, hepatomegaly, tachypnea, tachycardia, pallor, and a pansystolic murmur.

      Management of VSDs depends on the size and symptoms of the defect. Small VSDs that are asymptomatic may require monitoring, while moderate to large VSDs may result in heart failure and require nutritional support, medication for heart failure, and surgical closure of the defect.

      Complications of VSDs include aortic regurgitation, infective endocarditis, Eisenmenger’s complex, right heart failure, and pulmonary hypertension. Eisenmenger’s complex is a severe complication that results in cyanosis and clubbing and is an indication for a heart-lung transplant. Women with pulmonary hypertension are advised against pregnancy as it carries a high risk of mortality.

      In conclusion, VSD is a common congenital heart disease that requires specialized management. Early detection and appropriate treatment can prevent severe complications and improve outcomes for affected individuals.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 27 - A 65-year-old woman with confirmed heart failure visits her GP with swelling and...

    Incorrect

    • A 65-year-old woman with confirmed heart failure visits her GP with swelling and discomfort in both legs. During the examination, the GP observes pitting edema and decides to prescribe a brief trial of a diuretic. Which diuretic targets the thick ascending limb of the loop of Henle?

      Your Answer:

      Correct Answer: Furosemide (loop diuretic)

      Explanation:

      Loop Diuretics: Mechanism of Action and Clinical Applications

      Loop diuretics, such as furosemide and bumetanide, are medications that inhibit the Na-K-Cl cotransporter (NKCC) in the thick ascending limb of the loop of Henle. By doing so, they reduce the absorption of NaCl, resulting in increased urine output. Loop diuretics act on NKCC2, which is more prevalent in the kidneys. These medications work on the apical membrane and must first be filtered into the tubules by the glomerulus before they can have an effect. Patients with poor renal function may require higher doses to ensure sufficient concentration in the tubules.

      Loop diuretics are commonly used in the treatment of heart failure, both acutely (usually intravenously) and chronically (usually orally). They are also indicated for resistant hypertension, particularly in patients with renal impairment. However, loop diuretics can cause adverse effects such as hypotension, hyponatremia, hypokalemia, hypomagnesemia, hypochloremic alkalosis, ototoxicity, hypocalcemia, renal impairment, hyperglycemia (less common than with thiazides), and gout. Therefore, careful monitoring of electrolyte levels and renal function is necessary when using loop diuretics.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 28 - A 25-year-old man has been diagnosed with an abnormal electrical connection in his...

    Incorrect

    • A 25-year-old man has been diagnosed with an abnormal electrical connection in his heart, resulting in frequent palpitations, dizzy spells, and shortness of breath. Delta waves are also evident on his ECG. Would ablation of the coronary sinus be a viable treatment option for this condition?

      From which embryological structure is the target for this surgery derived?

      Your Answer:

      Correct Answer: Left horn of the sinus venosus

      Explanation:

      The sinus venosus has two horns, left and right. The left horn gives rise to the coronary sinus, while the right horn forms the smooth part of the right atrium. In patients with Wolff-Parkinson-White syndrome, an abnormal conduction pathway exists in the heart. To eliminate this pathway, a treatment called ablation of the coronary sinus is used. This involves destroying the conducting pathway that runs through the coronary sinus, which is formed from the left horn of the sinus venosus during embryonic development.

      During cardiovascular embryology, the heart undergoes significant development and differentiation. At around 14 days gestation, the heart consists of primitive structures such as the truncus arteriosus, bulbus cordis, primitive atria, and primitive ventricle. These structures give rise to various parts of the heart, including the ascending aorta and pulmonary trunk, right ventricle, left and right atria, and majority of the left ventricle. The division of the truncus arteriosus is triggered by neural crest cell migration from the pharyngeal arches, and any issues with this migration can lead to congenital heart defects such as transposition of the great arteries or tetralogy of Fallot. Other structures derived from the primitive heart include the coronary sinus, superior vena cava, fossa ovalis, and various ligaments such as the ligamentum arteriosum and ligamentum venosum. The allantois gives rise to the urachus, while the umbilical artery becomes the medial umbilical ligaments and the umbilical vein becomes the ligamentum teres hepatis inside the falciform ligament. Overall, cardiovascular embryology is a complex process that involves the differentiation and development of various structures that ultimately form the mature heart.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 29 - A 50-year-old man presents to the emergency department with acute chest pain. His...

    Incorrect

    • A 50-year-old man presents to the emergency department with acute chest pain. His ECG reveals ST depression in leads II, III, & aVF, and his troponin levels are elevated. He is diagnosed with NSTEMI and prescribed ticagrelor as part of his treatment plan.

      What is the mechanism of action of ticagrelor?

      Your Answer:

      Correct Answer: Inhibits ADP binding to platelet receptors

      Explanation:

      Clopidogrel and ticagrelor have a similar mechanism of action in that they both inhibit the binding of ADP to platelet receptors. Heparin activates antithrombin III, which in turn inhibits factor Xa and IIa. DOACs like rivaroxaban directly inhibit factor Xa that is bound to the prothrombinase complex and associated with clots. Aspirin works by inhibiting the production of prostaglandins, while warfarin inhibits VKORC1, which is responsible for the activation of vitamin K.

      ADP receptor inhibitors, such as clopidogrel, prasugrel, ticagrelor, and ticlopidine, work by inhibiting the P2Y12 receptor, which leads to sustained platelet aggregation and stabilization of the platelet plaque. Clinical trials have shown that prasugrel and ticagrelor are more effective than clopidogrel in reducing short- and long-term ischemic events in high-risk patients with acute coronary syndrome or undergoing percutaneous coronary intervention. However, ticagrelor may cause dyspnea due to impaired clearance of adenosine, and there are drug interactions and contraindications to consider for each medication. NICE guidelines recommend dual antiplatelet treatment with aspirin and ticagrelor for 12 months as a secondary prevention strategy for ACS.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 30 - A 50-year-old man is having a lymph node biopsy taken from the posterior...

    Incorrect

    • A 50-year-old man is having a lymph node biopsy taken from the posterior triangle of his neck. What structure creates the posterior boundary of this area?

      Your Answer:

      Correct Answer: Trapezius muscle

      Explanation:

      The posterior triangle of the neck is an area that is bound by the sternocleidomastoid and trapezius muscles, the occipital bone, and the middle third of the clavicle. Within this triangle, there are various nerves, vessels, muscles, and lymph nodes. The nerves present include the accessory nerve, phrenic nerve, and three trunks of the brachial plexus, as well as branches of the cervical plexus such as the supraclavicular nerve, transverse cervical nerve, great auricular nerve, and lesser occipital nerve. The vessels found in this area are the external jugular vein and subclavian artery. Additionally, there are muscles such as the inferior belly of omohyoid and scalene, as well as lymph nodes including the supraclavicular and occipital nodes.

    • This question is part of the following fields:

      • Cardiovascular System
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