-
Question 1
Incorrect
-
A 27-year-old man comes to the clinic complaining of headache, dizziness, and claudication. Upon measuring his blood pressure, it is found that he has hypertension in his upper limbs and hypotension in his lower limbs. What other finding is most likely to be present in this case?
Your Answer: Vasculitis involving the aortic arch
Correct Answer: Notching of the inferior margins of the ribs
Explanation:Common Causes of Cardiovascular Disorders in Adults
Cardiovascular disorders are a leading cause of morbidity and mortality in adults. Among the most common causes of these disorders are aortic coarctation, patent ductus arteriosus, aortic valvular stenosis, pulmonary valvular stenosis, and vasculitis involving the aortic arch.
Notching of the Inferior Margins of the Ribs: Aortic Coarctation
Aortic coarctation is caused by stenosis in the aortic arch, leading to hypertension proximal to and hypotension distal to the stenotic segment. Enlarged intercostal arteries produce notching of the inferior margins of the ribs, which is diagnostic of this condition.Chronic Cor Pulmonale: Patent Ductus Arteriosus
Patent ductus arteriosus leads to shunting of blood from the aorta to the pulmonary artery, eventually causing chronic cor pulmonale and right-sided heart failure.Systolic Hypotension: Aortic Valvular Stenosis
Aortic valvular stenosis is caused by a congenitally malformed valve, usually a valve with two cusps or a single cusp. It manifests with systolic hypotension, recurrent syncope, and hypertrophy/dilation of the left ventricle.Chronic Cor Pulmonale and Heart Failure: Pulmonary Valvular Stenosis
Pulmonary valvular stenosis is a rare form of congenital heart disease that leads to chronic cor pulmonale and heart failure.Ischemia in the Upper Body: Vasculitis Involving the Aortic Arch
Vasculitis involving the aortic arch is found in Takayasu arthritis, causing chronic inflammatory changes in the aortic arch and its branches. This condition leads to stenosis of these arteries, resulting in signs and symptoms of ischemia in the upper part of the body. It is also known as pulseless disease due to weak or absent radial pulses. -
This question is part of the following fields:
- Cardiology
-
-
Question 2
Correct
-
A patient comes to your general practice with deteriorating shortness of breath and ankle swelling. You have been treating them for a few years for their congestive cardiac failure, which has been gradually worsening. Currently, the patient is at ease when resting, but standing up and walking a few steps cause their symptoms to appear. According to the New York Heart Association (NYHA) classification, what stage of heart failure are they in?
Your Answer: III
Explanation:Understanding NYHA Classification for Heart Failure Patients
The NYHA classification system is used to assess the severity of heart failure symptoms in patients. Class I indicates no limitation of physical activity, while class IV indicates severe limitations and symptoms even at rest. This patient falls under class III, with marked limitation of physical activity but no symptoms at rest. It is important for healthcare professionals to understand and use this classification system to properly manage and treat heart failure patients.
-
This question is part of the following fields:
- Cardiology
-
-
Question 3
Correct
-
A 55-year-old woman with type II diabetes is urgently sent to the Emergency Department by her General Practitioner (GP). The patient had seen her GP that morning and reported an episode of chest pain that she had experienced the day before. The GP suspected the pain was due to gastro-oesophageal reflux but had performed an electrocardiogram (ECG) and sent a troponin level to be certain. The ECG was normal, but the troponin level came back that afternoon as raised. The GP advised the patient to go to Accident and Emergency, given the possibility of reduced sensitivity to the symptoms of a myocardial infarction (MI) in this diabetic patient.
Patient Normal range
High-sensitivity troponin T 20 ng/l <14 ng/l
What should be done based on this test result?Your Answer: Repeat troponin level
Explanation:Management of Suspected Myocardial Infarction
Explanation:
When a patient presents with symptoms suggestive of myocardial infarction (MI), a troponin level should be checked. If the level is only slightly raised, it does not confirm a diagnosis of MI, but neither does it rule it out. Therefore, a repeat troponin level should be performed at least 3 hours after the first level and sent as urgent.
In an MI, cardiac enzymes are released from dead myocytes into the blood, causing enzyme levels to rise and eventually fall as they are cleared from blood. If the patient has had an MI, the repeat troponin level should either be further raised or further reduced. If the level remains roughly constant, then an alternative cause should be sought, such as pulmonary embolism, chronic kidney disease, acute kidney injury, pericarditis, heart failure, or sepsis/systemic infection.
Admission to the Coronary Care Unit (CCU) is not warranted yet. Further investigations should be performed to ascertain whether an admission is needed or whether alternative diagnoses should be explored.
Safety-netting and return to the GP should include a repeat troponin level to see if the level is stable (arguing against an MI) or is rising/falling. A repeat electrocardiogram (ECG) should be performed, and a thorough history and examination should be obtained to identify any urgent diagnoses that need to be explored before the patient is discharged.
Thrombolysis carries a risk for bleeding, so it requires a clear indication, which has not yet been obtained. Therefore, it should not be administered without proper evaluation.
The alanine transaminase (ALT) level has been used as a marker of MI in the past, but it has been since superseded as it is not specific for myocardial damage. In fact, it is now used as a component of liver function tests.
-
This question is part of the following fields:
- Cardiology
-
-
Question 4
Incorrect
-
A 16-year-old boy is discovered following a street brawl with a stab wound on the left side of his chest to the 5th intercostal space, mid-clavicular line. He has muffled heart sounds, distended neck veins, and a systolic blood pressure of 70 mmHg. What is the most accurate description of his condition?
Your Answer:
Correct Answer: Beck’s triad
Explanation:Medical Triads and Laws
There are several medical triads and laws that are used to diagnose certain conditions. One of these is Beck’s triad, which consists of muffled or distant heart sounds, low systolic blood pressure, and distended neck veins. This triad is associated with cardiac tamponade.
Another law is Courvoisier’s law, which states that if a patient has a palpable gallbladder that is non-tender and is associated with painless jaundice, the cause is unlikely to be gallstones.
Meigs syndrome is a triad of ascites, pleural effusion, and a benign ovarian tumor.
Cushing’s syndrome is a set of signs and symptoms that occur due to prolonged use of corticosteroids, including hypertension and central obesity. However, this is not relevant to the patient in the question as there is no information about steroid use and the blood pressure is low.
Finally, Charcot’s triad is used in ascending cholangitis and consists of right upper quadrant pain, jaundice, and fever.
-
This question is part of the following fields:
- Cardiology
-
-
Question 5
Incorrect
-
A 58-year-old man experiences a myocardial infarction (MI) that results in necrosis of the anterior papillary muscle of the right ventricle. This has led to valve prolapse. Which structure is most likely responsible for the prolapse?
Your Answer:
Correct Answer: Anterior and posterior cusps of the tricuspid valve
Explanation:Cusps and Papillary Muscles of the Tricuspid and Mitral Valves
The tricuspid and mitral valves are important structures in the heart that regulate blood flow between the atria and ventricles. These valves are composed of cusps and papillary muscles that work together to ensure proper function.
The tricuspid valve has three cusps: anterior, posterior, and septal. The papillary muscles of the right ventricle attach to these cusps, with the anterior papillary muscle connecting to both the anterior and posterior cusps.
The mitral valve, located between the left atrium and ventricle, has only two cusps: anterior and posterior.
The posterior and septal cusps of the tricuspid valve attach to the posterior papillary muscle of the right ventricle, while the anterior and septal cusps attach to the septal papillary muscle.
Understanding the anatomy and function of these cusps and papillary muscles is crucial in diagnosing and treating heart conditions such as mitral valve prolapse and tricuspid regurgitation.
-
This question is part of the following fields:
- Cardiology
-
-
Question 6
Incorrect
-
A 55-year-old woman has been suffering from significant pain in her lower limbs when walking more than 200 meters for the past six months. During physical examination, her legs appear pale and cool without signs of swelling or redness. The palpation of dorsalis pedis or posterior tibial pulses is not possible. The patient has a body mass index of 33 kg/m2 and has been smoking for 25 pack years. What is the most probable vascular abnormality responsible for these symptoms?
Your Answer:
Correct Answer: Atherosclerosis
Explanation:Arteriosclerosis and Related Conditions
Arteriosclerosis is a medical condition that refers to the hardening and loss of elasticity of medium or large arteries. Atherosclerosis, on the other hand, is a specific type of arteriosclerosis that occurs when fatty materials such as cholesterol accumulate in the artery walls, causing them to thicken. This chronic inflammatory response is caused by the accumulation of macrophages and white blood cells, and is often promoted by low-density lipoproteins. The formation of multiple plaques within the arteries characterizes atherosclerosis.
Medial calcific sclerosis is another form of arteriosclerosis that occurs when calcium deposits form in the middle layer of walls of medium-sized vessels. This condition is often not clinically apparent unless it is severe, and it is more common in people over 50 years old and in diabetics. It can be seen as opaque vessels on radiographs.
Lymphatic obstruction, on the other hand, is a blockage of the lymph vessels that drain fluid from tissues throughout the body. This condition may cause lymphoedema, and the most common reason for this is the removal or enlargement of the lymph nodes.
It is important to understand these conditions and their differences to properly diagnose and treat patients.
-
This question is part of the following fields:
- Cardiology
-
-
Question 7
Incorrect
-
A 28-year-old man presents with chest pain, 5/10 in intensity, which is aggravated by breathing deeply and improved by leaning forward. The chest pain is not radiating. He has a mild fever but denies nausea, vomiting, cough or haemoptysis. He has self-medicated for a common cold and sore throat 5 days previously. On the electrocardiogram (ECG), there is diffuse, mild ST segment elevation (on leads II, aVF and V2–V6) and PR depression.
Which of the following findings is most likely to be observed on physical examination?Your Answer:
Correct Answer: Triphasic systolic and diastolic rub
Explanation:Common Heart Murmurs and Their Characteristics
Pericarditis: Triphasic Systolic and Diastolic Rub
Pericarditis is characterized by pleuritic chest pain that improves by leaning forward. A pericardial friction rub, with a scratchy, rubbing quality, is the classic cardiac auscultatory finding of pericarditis. It is often a high-pitched, triphasic systolic and diastolic murmur due to friction between the pericardial and visceral pericardium during ventricular contraction, ventricular filling, and atrial contraction.Mitral Regurgitation: High-Pitched Apical Pan-Systolic Murmur Radiating to the Axilla
A high-pitched apical pan-systolic murmur radiating to the axilla is heard in mitral regurgitation.Coarctation of the Aorta: Continuous Systolic and Diastolic Murmur Obscuring S2 Sound and Radiating to the Back
A continuous systolic and diastolic murmur obscuring S2 sound and radiating to the back is heard in coarctation of the aorta.Mitral Stenosis: Apical Opening Snap and Diastolic Rumble
An apical diastolic rumble and opening snap are heard in mitral stenosis.Aortic Regurgitation: Soft-Blowing Early Diastolic Decrescendo Murmur, Loudest at the Third Left Intercostal Space
A soft-blowing early diastolic decrescendo murmur, loudest at the second or third left intercostal space, is heard in aortic regurgitation. -
This question is part of the following fields:
- Cardiology
-
-
Question 8
Incorrect
-
A 65-year-old man presents with shortness of breath and is noted to have an irregular pulse. He reports intermittent palpitations over the past two months, which come on around four to five times weekly and are troublesome. He has diet-controlled type II diabetes mellitus and hypertension, for which he takes amlodipine. An electrocardiogram (ECG) confirms atrial fibrillation (AF) with a rate of 82 bpm. He has no chest pain and is not in overt cardiac failure. He is otherwise well and enjoys hill walking.
What is the appropriate new pharmacological therapy for the patient’s condition?Your Answer:
Correct Answer: Bisoprolol and apixaban
Explanation:Drug combinations for treating atrial fibrillation: A guide
Atrial fibrillation (AF) is a common heart condition that requires treatment to control heart rate and prevent stroke. Here are some drug combinations that may be used to manage AF:
Bisoprolol and apixaban: This combination is recommended for patients who need both rate control and anticoagulation. Bisoprolol is a standard ß-blocker used for rate control, while apixaban is an anticoagulant that lowers the risk of stroke.
Digoxin and warfarin: Digoxin may be used for rate control in elderly patients with non-paroxysmal AF who lead a sedentary lifestyle. However, in this scenario, bisoprolol is a better choice for rate control since the patient enjoys hill walking. Warfarin is appropriate for anticoagulation.
Bisoprolol and aspirin: Aspirin monotherapy is no longer recommended for stroke prevention in patients with AF. Bisoprolol should be used as first line for rate control.
Digoxin and aspirin: Similar to the previous combination, aspirin monotherapy is no longer recommended for stroke prevention in patients with AF. Digoxin may be used for rate control in elderly patients with non-paroxysmal AF who lead a sedentary lifestyle. However, in this scenario, bisoprolol is a better choice for rate control since the patient enjoys hill walking.
Warfarin alone: Even though the patient’s heart rate is currently controlled, he has a history of symptomatic paroxysmal episodes of AF and will need an agent for rate control, as well as warfarin for anticoagulation.
In summary, the choice of drug combination for managing AF depends on the patient’s individual needs and preferences, as well as their risk factors for stroke. It is important to discuss the options with a healthcare professional to make an informed decision.
-
This question is part of the following fields:
- Cardiology
-
-
Question 9
Incorrect
-
A 42-year-old man presents to the Emergency Department with severe central chest pain. The pain is exacerbated by lying down, relieved by sitting forward, and radiates to the left shoulder. He has recently undergone two cycles of radiotherapy for prostate cancer. Upon examination, his blood pressure is 96/52 mmHg (normal <120/80 mmHg), his jugular venous pressure (JVP) is elevated, and his pulse is 98 bpm, which appears to fade on inspiration. Heart sounds are faint. The electrocardiogram (ECG) reveals low-voltage QRS complexes.
What is the most appropriate initial management for this condition?Your Answer:
Correct Answer: Urgent pericardiocentesis
Explanation:The patient is experiencing cardiac tamponade, which is caused by fluid in the pericardial sac compressing the heart and reducing ventricular filling. This is likely due to pericarditis caused by recent radiotherapy. Beck’s triad of low blood pressure, raised JVP, and muffled heart sounds are indicative of tamponade. Urgent pericardiocentesis is necessary to aspirate the pericardial fluid using a 20 ml syringe and 18G needle under echocardiographic guidance. An ECG should be obtained to rule out MI and PE. GTN spray is used to manage MI, but it is not part of the treatment for tamponade. DC cardioversion is used for unstable cardiac arrhythmias, not tamponade. A fluid challenge with 1 liter of sodium chloride is not recommended as it may worsen the tamponade. LMWH is used to manage pulmonary embolus, but it is not appropriate for tamponade and may worsen the condition if the cause is haemopericardium.
-
This question is part of the following fields:
- Cardiology
-
-
Question 10
Incorrect
-
A foundation year 1 (FY1) doctor on the cardiology wards is teaching a group of first year medical students. She asks the students to work out the heart rate of a patient by interpreting his ECG taken during an episode of tachycardia.
What is the duration, in seconds, of one small square on an ECG?Your Answer:
Correct Answer: 0.04 seconds
Explanation:Understanding ECG Time Measurements
When reading an electrocardiogram (ECG), it is important to understand the time measurements represented on the grid paper. The horizontal axis of the ECG represents time, with each small square measuring 1 mm in length and representing 40 milliseconds (0.04 seconds). A large square on the ECG grid has a length of 5 mm and represents 0.2 seconds. Five large squares covering a length of 25 mm on the grid represent 1 second of time. It is important to note that each small square has a length of 1 mm and equates to 40 milliseconds, not 4 seconds. Understanding these time measurements is crucial for accurately interpreting an ECG.
-
This question is part of the following fields:
- Cardiology
-
-
Question 11
Incorrect
-
A 70-year-old patient comes to her doctor for a routine check-up. During the examination, her blood pressure is measured in both arms, and the readings are as follows:
Right arm 152/100
Left arm 138/92
What should be the next step in managing this patient's condition?Your Answer:
Correct Answer: Ask the patient to start ambulatory blood pressure monitoring
Explanation:Proper Management of High Blood Pressure Readings
In order to properly manage high blood pressure readings, it is important to follow established guidelines. If a patient displays a blood pressure of over 140/90 in one arm, the patient should have ambulatory blood pressure monitoring (ABPM) in order to confirm the presence or lack of hypertension, in accordance with NICE guidelines.
It is important to note that a diagnosis of hypertension cannot be made from one blood pressure recording. However, if hypertension is confirmed, based upon the patients’ age, amlodipine would be the antihypertensive of choice.
When measuring blood pressure in both arms (as it should clinically be done), the higher of the two readings should be taken. Asking the patient to come back in one week to re-record blood pressure sounds reasonable, but it is not in accordance with the NICE guidelines.
Lastly, it is important to note that considering the patients’ age, ramipril is second line and should not be the first choice for treatment. Proper management of high blood pressure readings is crucial for the overall health and well-being of the patient.
-
This question is part of the following fields:
- Cardiology
-
-
Question 12
Incorrect
-
A 25-year-old man visits his general practitioner (GP), as he is concerned that he may have inherited a heart condition. He is fit and well and has no history of any medical conditions. However, his 28-year-old brother has recently been diagnosed with hypertrophic cardiomyopathy (HCM) after collapsing when he was playing football. The patient’s father died suddenly when he was 42, which the family now thinks might have been due to the same condition.
Which of the following signs is most likely to be found in a patient with this condition?Your Answer:
Correct Answer: Ejection systolic murmur decreased by squatting
Explanation:Understanding the Ejection Systolic Murmur in Hypertrophic Cardiomyopathy: Decreased by Squatting
Hypertrophic cardiomyopathy (HCM) is a condition characterized by asymmetrical hypertrophy of both ventricles, with the septum hypertrophying and causing an outflow obstruction of the left ventricle. This obstruction leads to an ejection systolic murmur and reduced cardiac output. However, interestingly, this murmur can be decreased by squatting, which is not typical for most heart murmurs.
Squatting affects murmurs by increasing afterload and preload, which usually makes heart murmurs louder. However, in HCM, the murmur intensity is decreased due to increased left ventricular size and reduced outflow obstruction. Other findings on examination may include a jerky pulse and a double apex beat.
While HCM is often asymptomatic, it can present with dyspnea, angina, and syncope. Patients are also at risk of sudden cardiac death, most commonly due to ventricular arrhythmias. Poor prognostic factors include syncope, family history of sudden death, onset of symptoms at a young age, ventricular tachycardia on Holter monitoring, abnormal blood pressure response during exercise, and septal thickness greater than 3 cm on echocardiogram.
In summary, understanding the ejection systolic murmur in HCM and its unique response to squatting can aid in the diagnosis and management of this condition.
-
This question is part of the following fields:
- Cardiology
-
-
Question 13
Incorrect
-
What hormone does the heart produce under stressed conditions?
Your Answer:
Correct Answer: B-type natriuretic peptide (BNP)
Explanation:The cardiovascular system relies on a complex network of hormones and signaling molecules to regulate blood pressure, fluid balance, and other physiological processes. Here are some key players in this system:
B-type natriuretic peptide (BNP): This hormone is secreted by the ventricle in response to stretch, and levels are elevated in heart failure.
Angiotensin II: This hormone is produced mostly in the lungs where angiotensin-converting enzyme (ACE) concentrations are maximal.
C-type natriuretic peptide: This signaling molecule is produced by the endothelium, and not the heart.
Nitric oxide: This gasotransmitter is released tonically from all endothelial lined surfaces, including the heart, in response to both flow and various agonist stimuli.
Renin: This enzyme is released from the kidney, in response to reductions in blood pressure, increased renal sympathetic activity or reduced sodium and chloride delivery to the juxtaglomerular apparatus.
Understanding the roles of these hormones and signaling molecules is crucial for managing cardiovascular health and treating conditions like heart failure.
-
This question is part of the following fields:
- Cardiology
-
-
Question 14
Incorrect
-
A 20-year-old man, who recently immigrated to the United Kingdom from Eastern Europe, presents to his general practitioner with a history of intermittent dizzy spells. He reports having limited exercise capacity since childhood, but this has not been investigated before. Upon examination, the patient appears slight, has a dusky blue discoloration to his lips and tongue, and has finger clubbing. A murmur is also heard. The GP refers him to a cardiologist.
The results of a cardiac catheter study are as follows:
Anatomical site Oxygen saturation (%) Pressure (mmHg)
End systolic/End diastolic
Superior vena cava 58 -
Inferior vena cava 52 -
Right atrium (mean) 56 10
Right ventricle 55 105/9
Pulmonary artery - 16/8
Pulmonary capillary wedge pressure - 9
Left atrium 97 -
Left ventricle 84 108/10
Aorta 74 110/80
What is the most likely diagnosis?Your Answer:
Correct Answer: Fallot's tetralogy
Explanation:Fallot’s Tetralogy
Fallot’s tetralogy is a congenital heart defect that consists of four features: ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and an over-riding aorta. To diagnose this condition, doctors look for specific indicators. A step-down in oxygen saturation between the left atrium and left ventricle indicates a right to left shunt at the level of the ventricles, which is a sign of ventricular septal defect. Pulmonary stenosis is indicated by a significant gradient of 89 mmHg across the pulmonary valve, which is calculated by subtracting the right ventricular systolic pressure from the pulmonary artery systolic pressure. Right ventricular hypertrophy is diagnosed by high right ventricular pressures and a right to left shunt, as indicated by the oxygen saturations. Finally, an over-riding aorta is identified by a further step-down in oxygen saturation between the left ventricle and aorta. While this could also occur in cases of patent ductus arteriosus with right to left shunting, the presence of the other features of Fallot’s tetralogy makes an over-riding aorta the most likely cause of reduced oxygen saturation due to admixture of deoxygenated blood from the right ventricle entering the left heart circulation.
-
This question is part of the following fields:
- Cardiology
-
-
Question 15
Incorrect
-
A previously healthy 58-year-old man collapsed while playing with his grandchildren. Although he quickly regained consciousness and became fully alert, his family called an ambulance. The emergency medical team found no abnormalities on the electrocardiogram. Physical examination was unremarkable. However, the patient was admitted to the Coronary Care Unit of the local hospital. During the evening, the patient was noted to have a fast rhythm with a wide complex on his monitor, followed by hypotension and loss of consciousness.
After electrical cardioversion with 200 watt-seconds of direct current, which one of the following may possible therapy include?Your Answer:
Correct Answer: Amiodarone
Explanation:The patient in the scenario is experiencing a fast rhythm with wide complexes, which is likely ventricular tachycardia (VT). As the patient is unstable, electrical cardioversion was attempted first, as recommended by the Resuscitation Council Guideline. If cardioversion fails and the patient remains unstable, intravenous amiodarone can be used as a loading dose of 300 mg over 10-20 minutes, followed by an infusion of 900 mg/24 hours. Amiodarone is a class III anti-arrhythmic agent that prolongs the repolarization phase of the cardiac action potential by blocking potassium efflux. Side-effects associated with amiodarone include deranged thyroid and liver function tests, nausea, vomiting, bradycardia, interstitial lung disease, jaundice, and sleep disorders.
Epinephrine is used in the treatment of acute anaphylaxis and cardiopulmonary resuscitation. It acts on adrenergic receptors, causing bronchodilation and vasoconstriction. Side-effects associated with epinephrine include palpitations, arrhythmias, headache, tremor, and hypertension.
Intravenous propranolol is a non-selective β-adrenergic receptor blocker that has limited use in treating arrhythmias and thyrotoxic crisis. It is contraindicated in patients with severe hypotension, asthma, COPD, bradycardia, sick sinus rhythm, atrioventricular block, and cardiogenic shock. Side-effects associated with propranolol include insomnia, nightmares, nausea, diarrhea, bronchospasm, exacerbation of Raynaud’s, bradycardia, hypotension, and heart block.
Digoxin, a cardiac glycoside extracted from the plant genus Digitalis, can be used in the treatment of supraventricular arrhythmias and heart failure. However, it is of no use in this scenario as the patient is experiencing a broad complex tachycardia. Digoxin has a narrow therapeutic window, and even small changes in dosing can lead to toxicity. Side-effects associated with digoxin include nausea, vomiting, diarrhea, bradycardia, dizziness, yellow vision, and eosinophilia.
Diltiazem, a non-dihydropyridine calcium channel blocker, is normally used for hypertension and prophylaxis and treatment of ang
-
This question is part of the following fields:
- Cardiology
-
-
Question 16
Incorrect
-
A 29-year-old man with valvular heart disease is urgently admitted with fever, worsening shortness of breath and a letter from his GP confirming the presence of a new murmur. During examination, a harsh pansystolic murmur and early diastolic murmur are detected, along with a temperature of 38.3 °C and bilateral fine basal crepitations. Initial blood cultures have been collected.
What is the most pressing concern that needs to be addressed immediately?Your Answer:
Correct Answer: Administration of intravenous antibiotics
Explanation:Prioritizing Interventions in Suspected Infective Endocarditis
When dealing with suspected infective endocarditis, time is of the essence. The following interventions should be prioritized in order to limit valve destruction and improve patient outcomes.
Administration of Intravenous Antibiotics
Prompt initiation of intravenous antibiotics is crucial. An empirical regime of gentamicin and benzylpenicillin may be used until microbiological advice suggests any alternative.Electrocardiogram (ECG)
An ECG provides important diagnostic information and should be performed as part of the initial work-up. However, it does not take priority over antibiotic administration.Echocardiogram (ECHO)
An ECHO should be performed in all patients with suspected infective endocarditis, but it does not take priority over administration of antibiotics. A transoesophageal ECHO is more sensitive and should be considered if necessary.Throat Swab
While a throat swab may be useful in identifying the causative organism of infective endocarditis, it should not take precedence over commencing antibiotics. Careful examination of a patient’s dentition is also crucial to evaluate for a possible infectious source.Administration of Paracetamol
Symptomatic relief is important, but administration of paracetamol should not take priority over antibiotic delivery. Both interventions should be given as soon as possible to improve patient outcomes. -
This question is part of the following fields:
- Cardiology
-
-
Question 17
Incorrect
-
A 55-year-old woman from India visits the general practice clinic, reporting fatigue and tiredness after completing household tasks. During the examination, the physician observes periodic involuntary contractions of her left arm and multiple lumps beneath the skin. The doctor inquires about the patient's medical history and asks if she had any childhood illnesses. The patient discloses that she had a severe throat infection in India as a child but did not receive any treatment.
What is the most frequent abnormality that can be detected by listening to the heart during auscultation?Your Answer:
Correct Answer: An opening snap after S2, followed by a rumbling mid-diastolic murmur
Explanation:Common Heart Murmurs and their Association with Rheumatic Heart Disease
Rheumatic heart disease (RHD) is a condition resulting from untreated pharyngitis caused by group A beta-haemolytic streptococcal infection. RHD can lead to heart valve dysfunction, most commonly the mitral valve, resulting in mitral stenosis. The characteristic murmur of mitral stenosis is a mid-diastolic rumbling murmur that follows an opening snap after S2. Aortic stenosis can also be present in RHD but is less prevalent. Other heart murmurs associated with RHD include a high-pitched blowing diastolic decrescendo murmur, which is associated with aortic regurgitation, and a continuous machine-like murmur that is loudest at S2, consistent with patent ductus arteriosus. A late systolic crescendo murmur with a mid-systolic click is seen in mitral valve prolapse. A crescendo-decrescendo systolic ejection murmur following an ejection click describes the murmur heard in aortic stenosis. It is important to recognize these murmurs and their association with RHD for proper diagnosis and management.
-
This question is part of the following fields:
- Cardiology
-
-
Question 18
Incorrect
-
A 70-year-old man with a history of chronic cardiac failure with reduced ventricular systolic function presents with recent onset of increasing breathlessness, and worsening peripheral oedema and lethargy. He is currently taking ramipril and bisoprolol alongside occasional paracetamol.
What is the most appropriate long-term management?Your Answer:
Correct Answer: Addition of spironolactone
Explanation:For the management of heart failure, first line options include ACE inhibitors, beta-blockers, and aldosterone antagonists. In this case, the patient was already on a beta-blocker and an ACE inhibitor which had been effective. The addition of an aldosterone antagonist such as spironolactone would be the best option as it prevents fluid retention and reduces pressure on the heart. Ivabradine is a specialist intervention that should only be considered after trying all other recommended options. Addition of furosemide would only provide symptomatic relief. Insertion of an implantable cardiac defibrillator device is a late-stage intervention. Encouraging regular exercise and a healthy diet is important but does not directly address the patient’s clinical deterioration.
-
This question is part of the following fields:
- Cardiology
-
-
Question 19
Incorrect
-
A 65-year-old retiree visits his GP as he is becoming increasingly breathless and tired whilst walking. He has always enjoyed walking and usually walks 3 times a week. Over the past year he has noted that he can no longer manage the same distance that he used to be able to without getting breathless and needing to stop. He wonders if this is a normal part of ageing or if there could be an underlying medical problem.
Which of the following are consistent with normal ageing with respect to the cardiovascular system?Your Answer:
Correct Answer: Reduced VO2 max
Explanation:Ageing and Cardiovascular Health: Understanding the Normal and Abnormal Changes
As we age, our organs may still function normally at rest, but they may struggle to respond adequately to stressors such as exercise or illness. One of the key indicators of cardiovascular health is VO2 max, which measures the maximum rate of oxygen consumption during exercise. In normal ageing, VO2 max may decrease along with muscle strength, making intense exertion more difficult. However, significantly reduced VO2 max, left ventricular ejection fraction (LVEF), or stroke volume are not consistent with normal ageing. Additionally, hypotension or hypertension are not typical changes associated with ageing. Understanding these normal and abnormal changes can help us better monitor and manage our cardiovascular health as we age.
-
This question is part of the following fields:
- Cardiology
-
-
Question 20
Incorrect
-
An adolescent with Down's syndrome is being seen at the cardiology clinic due to a heart murmur detected during a routine check-up. It is known that approximately half of infants with Down's syndrome have congenital heart defects, and the prevalence remains high throughout their lifespan. What are the five most frequent types of congenital heart disease observed in individuals with Down's syndrome? Please list them in order of decreasing incidence, starting with the most common cause and ending with the least common cause.
Your Answer:
Correct Answer: Atrioventricular septal defect, ventricular septal defect, tetralogy of Fallot, atrial septal defect, patent ductus arteriosus
Explanation:Congenital Heart Defects in Down’s Syndrome
Congenital heart defects are common in individuals with Down’s syndrome, with five specific pathologies accounting for approximately 99% of cases. Atrioventricular septal defects and ventricular septal defects occur in roughly a third of cases each, while the remaining third is accounted for by the other three defects. Chromosomal abnormalities, such as trisomy 21, which is commonly associated with Down’s syndrome, can predispose individuals to congenital heart disease. Around 50% of people with Down’s syndrome have one of the five cardiac defects listed above, but the exact cause for this is not yet known.
The development of endocardial cushions is often impaired in individuals with Down’s syndrome, which can lead to defects in the production of the atrial and ventricular septae, as well as the development of the atrioventricular valves. This explains why atrioventricular septal defects are a common congenital defect in Down’s syndrome, as they involve a common atrioventricular orifice and valve. The severity of the defect depends on its size and the positioning of the leaflets of the common atrioventricular valve, which contribute to defining the degree of shunt. Additionally, the type of ventricular septal defects and atrial septal defects that commonly occur in Down’s syndrome can be explained by the impaired development of endocardial cushions. VSDs are usually of the inlet type, while ASDs are more commonly of the prium type, representing a failure of the endocardial cushion to grow in a superior direction.
-
This question is part of the following fields:
- Cardiology
-
-
Question 21
Incorrect
-
A fourth year medical student on a ward round with your team is inquiring about pacemakers.
Which of the following WOULD BE an indication for permanent pacemaker implantation?Your Answer:
Correct Answer: Third degree AV block (complete heart block)
Explanation:Understanding Indications for Permanent Pacemaker Insertion
A third degree AV block, also known as complete heart block, occurs when the atria and ventricles contract independently of each other. This can lead to syncope, chest pain, or signs of heart failure. Definitive treatment is the insertion of a permanent pacemaker. Other arrhythmias that may require permanent pacing include type 2 second-degree heart block (Mobitz II), sick sinus syndrome, and symptomatic slow atrial fibrillation. Ventricular tachycardia and ventricular fibrillation are not indications for pacing. Type 1 second degree (Mobitz I) AV block is a benign condition that does not require specific treatment. It is important to understand these indications for permanent pacemaker insertion for both exam and clinical purposes.
-
This question is part of the following fields:
- Cardiology
-
-
Question 22
Incorrect
-
You are in pre-assessment clinic and request an electrocardiogram (ECG) on a 58-year-old man attending for a radical prostatectomy.
What are the limits of the normal cardiac axis?Your Answer:
Correct Answer: -30 to 90 degrees
Explanation:Understanding ECG Analysis: The Normal Cardiac Axis
ECG analysis is a fundamental concept that is essential to understand early on. One of the key components of ECG analysis is the normal cardiac axis, which ranges from −30 to 90 degrees. If the axis is greater than 90 degrees, it implies right axis deviation, while an axis less than −30 degrees indicates left axis deviation.
To determine the axis, leads I, II, and III of the ECG are typically examined. A normal axis is characterized by upgoing waves in all three leads. In contrast, right axis deviation is indicated by a downgoing wave in lead I and an upgoing wave in leads II and III. Left axis deviation is indicated by an upgoing wave in lead I and a downgoing wave in leads II and III.
While −30 to −90 degrees is considered left axis deviation and not a normal axis, −30 to 60 degrees is a normal axis, but it does not cover the full spectrum of a normal axis. Therefore, the correct answer is -30 to 90 degrees. Understanding the normal cardiac axis is crucial for accurate ECG interpretation and diagnosis.
-
This question is part of the following fields:
- Cardiology
-
-
Question 23
Incorrect
-
A 58-year-old Caucasian man with type II diabetes is seen for annual review. His blood pressure is 174/99 mmHg, and his 24-hour urine collection reveals moderately increased albuminuria (microalbuminuria). Blood results show Na+ 140 mmol/l, K+ 4.0 mmol/l, urea 4.2 mmol/l and creatinine 75 μmol/l.
Which of the following medications would be the most appropriate to use first line to treat the hypertension?Your Answer:
Correct Answer: Ramipril
Explanation:First-line treatment for hypertension in diabetic patients: Ramipril
Ramipril is the first-line treatment for hypertension in diabetic patients due to its ability to reduce proteinuria in diabetic nephropathy, in addition to its antihypertensive effect. Calcium channel blockers, such as amlodipine, may be preferred for pregnant women or patients with hypertension but no significant proteinuria. Bendroflumethiazide may be introduced if first-line therapy is ineffective, while atenolol can be used in difficult-to-treat hypertension where dual therapy is ineffective. Furosemide is usually avoided in type II diabetes due to its potential to interfere with blood glucose levels.
-
This question is part of the following fields:
- Cardiology
-
-
Question 24
Incorrect
-
A woman with known angina currently managed on glyceryl trinitrate (GTN) spray presents to Accident and Emergency with crushing central chest pain. A 12-lead electrocardiogram (ECG) reveals ST depression and flat T waves. She is managed as acute coronary syndrome without ST elevation.
Which one of the following options is most likely to be used in her immediate management?Your Answer:
Correct Answer: Fondaparinux
Explanation:Medications for Acute Coronary Syndrome: Indications and Uses
Acute coronary syndrome (ACS) is a medical emergency that requires prompt and appropriate treatment to prevent further damage to the heart muscle. The management of ACS involves a combination of medications and interventions, depending on the type and severity of the condition. Here are some commonly used medications for ACS and their indications:
1. Fondaparinux: This medication is a factor Xa inhibitor that is used for anticoagulation in ACS without ST-segment elevation. It is usually given along with other drugs such as aspirin, clopidogrel, and nitrates to prevent blood clots and reduce the risk of future cardiovascular events.
2. Warfarin: This medication is used for the treatment and prevention of venous thrombosis and thromboembolism. It is not indicated for the immediate management of ACS.
3. Furosemide: This medication is a diuretic that is used to treat pulmonary edema in patients with heart failure. It is not indicated for ACS as it may cause dehydration.
4. Paracetamol: This medication is not effective as an analgesic option for ACS. Morphine is commonly used for pain relief in ACS.
5. Simvastatin: This medication is a statin that is used for the long-term management of high cholesterol levels. It is not indicated for the initial management of ACS.
In summary, the management of ACS involves a combination of medications and interventions that are tailored to the individual patient’s needs. Prompt and appropriate treatment can help improve outcomes and reduce the risk of future cardiovascular events.
-
This question is part of the following fields:
- Cardiology
-
-
Question 25
Incorrect
-
A 51-year-old man passed away from a massive middle cerebral artery stroke. He had no previous medical issues. Upon autopsy, it was discovered that his heart weighed 400 g and had normal valves and coronary arteries. The atria and ventricles were not enlarged. The right ventricular walls were normal, while the left ventricular wall was uniformly hypertrophied to 20-mm thickness. What is the probable reason for these autopsy results?
Your Answer:
Correct Answer: Essential hypertension
Explanation:Differentiating Cardiac Conditions: Causes and Risks
Cardiac conditions can have varying causes and risks, making it important to differentiate between them. Essential hypertension, for example, is characterized by uniform left ventricular hypertrophy and is a major risk factor for stroke. On the other hand, atrial fibrillation is a common cause of stroke but does not cause left ventricular hypertrophy and is rarer with normal atrial size. Hypertrophic obstructive cardiomyopathy, which is more common in men and often has a familial tendency, typically causes asymmetric hypertrophy of the septum and apex and can lead to arrhythmogenic or unexplained sudden cardiac death. Dilated cardiomyopathies, such as idiopathic dilated cardiomyopathy, often have no clear precipitant but cause a dilated left ventricular size, increasing the risk for a mural thrombus and an embolic risk. Finally, tuberculous pericarditis is difficult to diagnose due to non-specific features such as cough, dyspnoea, sweats, and weight loss, with typical constrictive pericarditis findings being very late features with fluid overload and severe dyspnoea. Understanding the causes and risks associated with these cardiac conditions can aid in their proper diagnosis and management.
-
This question is part of the following fields:
- Cardiology
-
-
Question 26
Incorrect
-
A 25-year-old female with Down's syndrome presents with a systolic murmur on clinical examination. What is the most prevalent cardiac anomaly observed in individuals with Down's syndrome that could account for this murmur?
Your Answer:
Correct Answer: Atrioventricular septal defect
Explanation:Endocardial Cushion Defects
Endocardial cushion defects, also referred to as atrioventricular (AV) canal or septal defects, are a group of abnormalities that affect the atrial septum, ventricular septum, and one or both of the AV valves. These defects occur during fetal development when the endocardial cushions, which are responsible for separating the heart chambers and forming the valves, fail to develop properly. As a result, there may be holes or gaps in the septum, or the AV valves may not close properly, leading to a mix of oxygenated and deoxygenated blood in the heart. This can cause a range of symptoms, including shortness of breath, fatigue, poor growth, and heart failure. Treatment for endocardial cushion defects typically involves surgery to repair the defects and improve heart function.
-
This question is part of the following fields:
- Cardiology
-
-
Question 27
Incorrect
-
During a routine GP check-up, a 33-year-old woman is found to have a mid-diastolic rumbling murmur accompanied by a loud first heart sound. What valvular abnormality is likely causing this?
Your Answer:
Correct Answer: Mitral stenosis
Explanation:Valvular Murmurs
Valvular murmurs are a common topic in medical exams, and it is crucial to have a good of them. The easiest way to approach them is by classifying them into systolic and diastolic murmurs. If the arterial valves, such as the aortic or pulmonary valves, are narrowed, ventricular contraction will cause turbulent flow, resulting in a systolic murmur. On the other hand, if these valves are incompetent, blood will leak back through the valve during diastole, causing a diastolic murmur.
Similarly, the atrioventricular valves, such as the mitral and tricuspid valves, can be thought of in the same way. If these valves are leaky, blood will be forced back into the atria during systole, causing a systolic murmur. If they are narrowed, blood will not flow freely from the atria to the ventricles during diastole, causing a diastolic murmur.
Therefore, a diastolic murmur indicates either aortic/pulmonary regurgitation or mitral/tricuspid stenosis. The loud first heart sound is due to increased force in closing the mitral or tricuspid valve, which suggests stenosis. the different types of valvular murmurs and their causes is essential for medical professionals to diagnose and treat patients accurately.
-
This question is part of the following fields:
- Cardiology
-
-
Question 28
Incorrect
-
A 20-year-old female patient visited her doctor complaining of general malaise, lethargy, and fatigue. She couldn't pinpoint when the symptoms started but felt that they had been gradually developing for a few months. During the physical examination, the doctor detected a murmur and referred her to a cardiologist based on the findings. The cardiac catheterization results are as follows:
Anatomical site Oxygen saturation (%) Pressure (mmHg)
End systolic/End diastolic
Superior vena cava 77 -
Right atrium (mean) 79 7
Right ventricle 78 -
Pulmonary artery 87 52/17
Pulmonary capillary wedge pressure - 16
Left ventricle 96 120/11
Aorta 97 120/60
What is the most accurate description of the murmur heard during the chest auscultation of this 20-year-old woman?Your Answer:
Correct Answer: A continuous 'machinery' murmur at the left upper sternal edge with late systolic accentuation
Explanation:Characteristics of Patent Ductus Arteriosus
Patent ductus arteriosus is a condition that is characterized by an unusual increase in oxygen saturation between the right ventricle and pulmonary artery. This is often accompanied by elevated pulmonary artery pressures and a high wedge pressure. These data are typical of this condition and can be used to diagnose it. It is important to note that patent ductus arteriosus can lead to serious complications if left untreated, including heart failure and pulmonary hypertension. Therefore, early detection and treatment are crucial for improving outcomes and preventing long-term complications.
-
This question is part of the following fields:
- Cardiology
-
-
Question 29
Incorrect
-
Which congenital cardiac defect is correctly matched with its associated syndrome from the following options?
Your Answer:
Correct Answer: Turner syndrome and coarctation of the aorta
Explanation:Common Cardiovascular Abnormalities Associated with Genetic Syndromes
Various genetic syndromes are associated with cardiovascular abnormalities. Turner syndrome is linked with coarctation of the aorta, aortic stenosis, bicuspid aortic valve, aortic dilation, and dissection. Marfan syndrome is associated with aortic root dilation, mitral valve prolapse, mitral regurgitation, and aortic dissection. Kartagener syndrome can lead to bicuspid aortic valve, dextrocardia, bronchiectasis, and infertility. However, congenital adrenal hyperplasia is not associated with congenital cardiac conditions. Finally, congenital rubella syndrome is linked with patent ductus arteriosus, atrial septal defect, and pulmonary stenosis.
-
This question is part of the following fields:
- Cardiology
-
-
Question 30
Incorrect
-
A 50-year-old man with a long-standing history of hypertension visits his primary care physician for a routine check-up. He mentions experiencing a painful, burning sensation in his legs when he walks long distances and feeling cold in his lower extremities. He has no history of dyslipidaemia. Upon examination, his temperature is 37.1 °C; the blood pressure in his left arm is 174/96 mmHg, heart rate 78 bpm, respiratory rate 16 breaths per minute, and oxygen saturation 98% on room air. He has 1+ dorsalis pedis pulses bilaterally, and his lower extremities are cool to the touch. Cardiac auscultation does not reveal any murmurs, rubs, or gallops. His abdominal examination is unremarkable, and no bruits are heard on auscultation. Renal function tests show a creatinine level of 71 μmol/l (50–120 μmol/l), which is his baseline. What is the most likely defect present in this patient?
Your Answer:
Correct Answer: Coarctation of the aorta
Explanation:Cardiovascular Conditions: Symptoms and Characteristics
Coarctation of the Aorta, Patent Ductus Arteriosus, Renal Artery Stenosis, Atrial Septal Defect, and Bilateral Lower Extremity Deep Vein Thrombosis are all cardiovascular conditions that have distinct symptoms and characteristics.
Coarctation of the Aorta is characterized by hypertension in the upper extremities and hypotension in the lower extremities. Patients may also experience lower extremity claudication due to low oxygen delivery. Chest X-rays may reveal notching of the ribs. Treatment involves surgical resection of the narrowed lumen.
Patent Ductus Arteriosus refers to a persistent open lumen in the ductus arteriosus, causing a left-to-right shunt. A constant, machine-like murmur is detected on cardiac auscultation. If left untreated, it can lead to Eisenmenger syndrome and reverse to become a cyanotic right-to-left shunt.
Renal Artery Stenosis causes decreased blood flow to the kidneys, leading to fluid retention and hypertension. A bruit is typically heard on auscultation of the abdomen, and creatinine levels may be elevated due to decreased renal perfusion.
Atrial Septal Defect is a congenital abnormality that causes a left-to-right shunt. It can be detected by a fixed, widely split S2 on cardiac auscultation. If left untreated, it can lead to pulmonary hypertension and right heart failure.
Bilateral Lower Extremity Deep Vein Thrombosis refers to blood clots in the deep veins of the legs, causing lower extremity swelling, warmth, and erythema. It does not cause hypertension, claudication, or cool lower extremities. Lower extremity arterial insufficiency may cause claudication.
-
This question is part of the following fields:
- Cardiology
-
00
Correct
00
Incorrect
00
:
00
:
00
Session Time
00
:
00
Average Question Time (
Secs)