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  • Question 1 - A 50-year-old man undergoes a workplace medical and has an ECG performed. What...

    Incorrect

    • A 50-year-old man undergoes a workplace medical and has an ECG performed. What is the electrophysiological basis of the T wave on a typical ECG?

      Your Answer: Ventricular depolarisation

      Correct Answer: Ventricular repolarisation

      Explanation:

      The T wave on an ECG indicates ventricular repolarisation and is typically positive in all leads except AvR and V1. Abnormal T wave findings may suggest strain, bundle branch block, ischaemia/infarction, hyperkalaemia, Prinzmetal angina, or early STEMI. The P wave represents atrial depolarisation, while atrial repolarisation is hidden by the QRS complex. The PR interval is determined by the duration of conduction delay through the atrioventricular node. Finally, the QRS complex indicates ventricular depolarisation.

    • This question is part of the following fields:

      • Cardiology
      1.2
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  • Question 2 - A 29-year-old man with valvular heart disease is urgently admitted with fever, worsening...

    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: Electrocardiogram (ECG)

      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
      1.1
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  • Question 3 - A 50-year-old patient with hypertension arrives at the Emergency Department complaining of central...

    Incorrect

    • A 50-year-old patient with hypertension arrives at the Emergency Department complaining of central chest pain that feels heavy. The pain does not radiate, and there are no other risk factors for atherosclerosis. Upon examination, the patient's vital signs are normal, including pulse, temperature, and oxygen saturation. The patient appears sweaty, but cardiovascular and respiratory exams are unremarkable. The patient experiences tenderness over the sternum at the site of the chest pain, and the resting electrocardiogram (ECG) is normal.

      What is the most appropriate course of action for managing this patient?

      Your Answer: Discharge the patient if serial resting ECGs are normal

      Correct Answer: Arrange a 12-h troponin T assay before deciding whether or not to discharge the patient

      Explanation:

      Management of Chest Pain in a Patient with Risk Factors for Cardiac Disease

      Chest pain is a common presenting complaint in primary care and emergency departments. However, it is important to consider the possibility of an acute coronary syndrome in patients with risk factors for cardiac disease. Here are some management strategies for a patient with chest pain and risk factors for cardiac disease:

      Arrange a 12-h troponin T assay before deciding whether or not to discharge the patient. A normal troponin assay would make a diagnosis of acute coronary syndrome unlikely, but further investigation may be required to determine if the patient has underlying coronary artery disease.

      Do not discharge the patient with a diagnosis of costochondritis based solely on chest wall tenderness. This should only be used in low-risk patients with tenderness that accurately reproduces the pain they have been feeling on minimal palpation.

      Do not discharge the patient if serial resting ECGs are normal. A normal ECG does not rule out an acute cardiac event.

      Admit the patient to the Coronary Care Unit for monitoring and further assessment only if the 12-h troponin comes back elevated.

      Do not discharge the patient and arrange an outpatient exercise tolerance test until further investigation has been done to rule out an acute cardiac event.

      In summary, it is important to consider the possibility of an acute coronary syndrome in patients with chest pain and risk factors for cardiac disease. Further investigation, such as a 12-h troponin assay, may be required before deciding on appropriate management strategies.

    • This question is part of the following fields:

      • Cardiology
      0.9
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  • Question 4 - What are the clinical signs that indicate a child has acute rheumatic fever...

    Incorrect

    • What are the clinical signs that indicate a child has acute rheumatic fever carditis?

      Your Answer: Reduced respiratory rate

      Correct Answer: Pericardial rub

      Explanation:

      Acute Rheumatic Fever

      Acute rheumatic fever is a condition that occurs after a bacterial infection and is caused by pathogenic antibodies. It is characterized by a systemic inflammatory response that affects the heart, joints, and skin. The condition is triggered by antibodies that cross-react with cardiac tissue, which can lead to pancarditis, arthritis, and intra-dermal inflammation. The diagnosis of acute rheumatic fever is based on a combination of clinical and investigatory findings, which are known as the revised Jones criteria.

      The pancarditis associated with acute rheumatic fever can cause a sustained tachycardia, which is particularly prominent at night. Conduction abnormalities, including prolonged PR interval, are also common. Pericarditis may be detected clinically with a pericardial rub, and patients may exhibit features of congestive cardiac failure, such as cardiomegaly. Several murmurs are recognized in patients with acute rheumatic fever, including aortic regurgitation, mitral regurgitation, and the Carey Coombs murmur.

      In summary, acute rheumatic fever is a serious condition that can have significant effects on the heart, joints, and skin. Early diagnosis and treatment are essential to prevent complications and improve outcomes. The revised Jones criteria provide guidance for clinicians in making an accurate diagnosis and initiating appropriate treatment.

    • This question is part of the following fields:

      • Cardiology
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  • Question 5 - A 54-year-old man, with a family history of ischaemic heart disease, has been...

    Incorrect

    • A 54-year-old man, with a family history of ischaemic heart disease, has been diagnosed with angina. His total cholesterol level is 6.5 mmol/l. He has been prescribed a statin and given dietary advice. What dietary modification is most likely to lower his cholesterol level?

      Your Answer: Replace polyunsaturated fats with saturated fats

      Correct Answer: Replace saturated fats with polyunsaturated fats

      Explanation:

      Lowering Cholesterol Levels: Dietary Changes to Consider

      To lower cholesterol levels, it is important to make dietary changes. One effective change is to replace saturated fats with polyunsaturated fats. Saturated fats increase cholesterol levels, while unsaturated fats lower them. It is recommended to reduce the percentage of daily energy intake from fat, with a focus on reducing saturated fats. Increasing intake of foods such as pulses, legumes, root vegetables, and unprocessed cereals can also help lower cholesterol. Using a margarine containing an added stanol ester can increase plant stanol intake, which can also reduce cholesterol. However, reducing intake of dairy products and meat alone may not be as effective as replacing them with beneficial unsaturated fats. It is important to avoid replacing polyunsaturated fats with saturated fats, as this can raise cholesterol levels.

    • This question is part of the following fields:

      • Cardiology
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  • Question 6 - A 16-year-old girl is referred to cardiology outpatients with intermittent palpitations. She describes...

    Incorrect

    • A 16-year-old girl is referred to cardiology outpatients with intermittent palpitations. She describes occasional spontaneous episodes of being abnormally aware of her heart. She says her heart rate is markedly increased during episodes. She has no significant medical or family history. She is on the oral contraceptive pill. ECG is performed. She is in sinus rhythm at 80 beats per min. PR interval is 108 ms. A slurring slow rise of the initial portion of the QRS complex is noted; QRS duration is 125 ms.
      What is the correct diagnosis?

      Your Answer: Hyperthyroidism

      Correct Answer: Wolff–Parkinson–White syndrome

      Explanation:

      Understanding Wolff-Parkinson-White Syndrome: An Abnormal Congenital Accessory Pathway with Tachyarrhythmia Episodes

      Wolff-Parkinson-White (WPW) syndrome is a rare condition with an incidence of about 1.5 per 1000. It is characterized by the presence of an abnormal congenital accessory pathway that bypasses the atrioventricular node, known as the Bundle of Kent, and episodes of tachyarrhythmia. While the condition may be asymptomatic or subtle, it can increase the risk of sudden cardiac death.

      The presence of a pre-excitation pathway in WPW results in specific ECG changes, including shortening of the PR interval, a Delta wave, and QRS prolongation. The ST segment and T wave may also be discordant to the major component of the QRS complex. These features may be more pronounced with increased vagal tone.

      Upon diagnosis of WPW, risk stratification is performed based on a combination of history, ECG, and invasive cardiac electrophysiology studies. Treatment is only offered to those who are considered to have significant risk of sudden cardiac death. Definitive treatment involves the destruction of the abnormal electrical pathway by radiofrequency catheter ablation, which has a high success rate but is not without complication. Patients who experience regular tachyarrhythmias may be offered pharmacological treatment based on the specific arrhythmia.

      Other conditions, such as first-degree heart block, pulmonary embolism, hyperthyroidism, and Wenckebach syndrome, have different ECG findings and are not associated with WPW. Understanding the specific features of WPW can aid in accurate diagnosis and appropriate management.

    • This question is part of the following fields:

      • Cardiology
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  • Question 7 - A 66-year-old patient with a history of heart failure is given intravenous fluids...

    Correct

    • A 66-year-old patient with a history of heart failure is given intravenous fluids while on the ward. You receive a call from a nurse on the ward reporting that the patient is experiencing increasing shortness of breath. Upon examination, you order an urgent chest X-ray.
      What finding on the chest X-ray would be most indicative of pulmonary edema?

      Your Answer: Patchy perihilar shadowing

      Explanation:

      Interpreting Chest X-Ray Findings in Heart Failure

      Chest X-rays are commonly used to assess patients with heart failure. Here are some key findings to look out for:

      – Patchy perihilar shadowing: This suggests alveolar oedema, which can arise due to fluid overload in heart failure. Intravenous fluids should be given slowly, with frequent re-assessment for signs of peripheral and pulmonary oedema.
      – Cardiothoracic ratio of 0.5: A ratio of >0.5 on a postero-anterior (PA) chest X-ray may indicate heart failure. A ratio of 0.5 or less is considered normal.
      – Patchy shadowing in lower zones: This may suggest consolidation caused by pneumonia, which can complicate heart failure.
      – Prominent lower zone vessels: In pulmonary venous hypertension, there is redistribution of blood flow to the non-dependent upper lung zones, leading to larger vessels in the lower zones.
      – Narrowing of the carina: This may suggest enlargement of the left atrium, which sits directly under the carina in the chest.

    • This question is part of the following fields:

      • Cardiology
      0.7
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  • Question 8 - A 45-year-old man visits his GP for a routine check-up. He reports feeling...

    Incorrect

    • A 45-year-old man visits his GP for a routine check-up. He reports feeling well today but has a history of chronic respiratory tract infections and lung issues. He is immunocompetent.
      During the examination, his temperature and blood pressure are normal. His heart rate is regular and his breathing is effortless. The GP detects a diastolic murmur with a snap that is most audible at the right fifth intercostal space in the mid-clavicular line.
      What is the most probable diagnosis?

      Your Answer: Asthma

      Correct Answer: Primary ciliary dyskinesia

      Explanation:

      Possible Diagnosis for a Patient with Chronic Respiratory Infections and a Heart Murmur

      Primary Ciliary Dyskinesia: A Congenital Syndrome of Ciliary Dysfunction

      The patient described in the case likely has primary ciliary dyskinesia, also known as Kartagener’s syndrome, which is a congenital syndrome of ciliary dysfunction. This disorder affects the proper beating of Ciliary, leading to the accumulation of infectious material within the respiratory tree and abnormal cell migration during development, resulting in situs inversus. Additionally, abnormal Ciliary can lead to non-motile sperm and infertility.

      Other Possible Diagnoses

      Although the GP noticed a diastolic murmur suggestive of mitral stenosis, the patient does not have symptoms of congestive heart failure. Asthma could be associated with chronic lung and respiratory tract infections, but it would not explain the heart murmur. Squamous cell lung cancer is less likely in a man who is 40 years old with a normal respiratory examination and would not explain the heart murmur. Idiopathic pulmonary hypertension usually causes progressive breathlessness, a dry cough, and fine inspiratory crepitations on examination, rather than the picture here.

    • This question is part of the following fields:

      • Cardiology
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  • Question 9 - A 54-year-old patient is evaluated in the Pre-Assessment Clinic before undergoing elective surgery...

    Incorrect

    • A 54-year-old patient is evaluated in the Pre-Assessment Clinic before undergoing elective surgery for varicose veins. The patient is in good health, with the only significant medical history being well-controlled hypertension with lisinopril. During the examination, the clinician hears an early opening snap in diastole when listening to the patient's heart. What is the most probable cause of this finding?

      Your Answer: Ventricular septal defect

      Correct Answer: Mitral stenosis

      Explanation:

      Common Heart Murmurs and Their Characteristics

      Heart murmurs are abnormal sounds heard during a heartbeat and can indicate underlying heart conditions. Here are some common heart murmurs and their characteristics:

      Mitral Stenosis: This condition causes a mid-diastolic murmur that is best heard with the bell of the stethoscope over the apex while the patient is lying in the left lateral position. Severe mitral stenosis can also cause a quiet first heart sound and an early opening snap.

      Pulmonary Stenosis: Pulmonary stenosis causes an ejection systolic murmur.

      Ventricular Septal Defect: This condition causes a pan-systolic murmur.

      Mitral Valve Prolapse: Mitral valve prolapse may cause a mid-systolic click, followed by a late systolic murmur.

      Right Bundle Branch Block: This condition is a cause of wide splitting of the second heart sound.

    • This question is part of the following fields:

      • Cardiology
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  • Question 10 - A patient in their 60s was diagnosed with disease of a heart valve...

    Incorrect

    • A patient in their 60s was diagnosed with disease of a heart valve located between the left ventricle and the ascending aorta. Which of the following is most likely to describe the cusps that comprise this heart valve?

      Your Answer: Anterior and septal cusps

      Correct Answer: Right, left and posterior cusps

      Explanation:

      Different Cusps of Heart Valves

      The heart has four valves that regulate blood flow through the chambers. Each valve is composed of cusps, which are flaps that open and close to allow blood to pass through. Here are the different cusps of each heart valve:

      Aortic Valve: The aortic valve is made up of a right, left, and posterior cusp. It is located at the junction between the left ventricle and the ascending aorta.

      Mitral Valve: The mitral valve is usually the only bicuspid valve and is composed of anterior and posterior cusps. It is located between the left atrium and the left ventricle.

      Tricuspid Valve: The tricuspid valve has three cusps – anterior, posterior, and septal. It is located between the right atrium and the right ventricle.

      Pulmonary Valve: The pulmonary valve is made up of right, left, and anterior cusps. It is located at the junction between the right ventricle and the pulmonary artery.

      Understanding the different cusps of heart valves is important in diagnosing and treating heart conditions.

    • This question is part of the following fields:

      • Cardiology
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  • Question 11 - A 68-year-old man comes in with bilateral ankle swelling. During the examination, an...

    Correct

    • A 68-year-old man comes in with bilateral ankle swelling. During the examination, an elevated jugular venous pressure (JVP) of 7 cm above the sternal angle and large V waves are observed. Upon listening to the heart, a soft pansystolic murmur is heard at the left sternal edge. What is the most probable diagnosis?

      Your Answer: Tricuspid regurgitation

      Explanation:

      Common Heart Murmurs and Their Characteristics

      Tricuspid Regurgitation: This condition leads to an elevated jugular venous pressure (JVP) with large V waves and a pan-systolic murmur at the left sternal edge. Other features include pulsatile hepatomegaly and left parasternal heave.

      Tricuspid Stenosis: Tricuspid stenosis causes a mid-diastolic murmur.

      Pulmonary Stenosis: This condition produces an ejection systolic murmur.

      Mitral Regurgitation: Mitral regurgitation causes a pan-systolic murmur at the apex, which radiates to the axilla.

      Aortic Stenosis: Aortic stenosis causes an ejection systolic murmur that radiates to the neck.

      Mitral Stenosis: Mitral stenosis causes a mid-diastolic murmur at the apex, and severe cases may have secondary pulmonary hypertension (a cause of tricuspid regurgitation).

      These common heart murmurs have distinct characteristics that can aid in their diagnosis.

    • This question is part of the following fields:

      • Cardiology
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  • Question 12 - A 47-year-old woman is admitted with central chest pain of 18 hours’ duration...

    Incorrect

    • A 47-year-old woman is admitted with central chest pain of 18 hours’ duration and shortness of breath. Her troponin is elevated, and her electrocardiogram (ECG) shows changes in leads V2–V6. While undergoing initial management in preparation for primary percutaneous coronary intervention (primary PCI), she deteriorates suddenly and goes into cardiac arrest. Efforts to resuscitate her are unsuccessful. At post-mortem, rupture of the left ventricular cardiac wall is evident at the apex.
      Which is the most likely blood vessel to have been involved in the infarct?

      Your Answer: The posterior interventricular artery

      Correct Answer: The anterior interventricular (left anterior descending) artery

      Explanation:

      Coronary Arteries and Their Blood Supply to the Heart

      The heart is supplied with blood by the coronary arteries. There are four main coronary arteries that provide blood to different parts of the heart.

      The anterior interventricular artery, also known as the left anterior descending artery, supplies blood to the apex of the heart, as well as the anterior part of the interventricular septum and adjacent anterior walls of the right and left ventricles.

      The right marginal artery supplies the anteroinferior aspect of the right ventricle.

      The posterior interventricular artery supplies the interventricular septum and adjacent right and left ventricles on the diaphragmatic surface of the heart, but does not reach the apex.

      The circumflex artery supplies the posterolateral aspect of the left ventricle.

      Finally, the conus branch of the right coronary artery supplies the outflow tract of the right ventricle.

      Understanding the blood supply to different parts of the heart is important in diagnosing and treating heart conditions.

    • This question is part of the following fields:

      • Cardiology
      0.7
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  • Question 13 - A 70-year-old woman was recently diagnosed with essential hypertension and started on a...

    Incorrect

    • A 70-year-old woman was recently diagnosed with essential hypertension and started on a medication to lower her blood pressure. She then stopped taking the medication as she reported ankle swelling. Her blood pressure readings usually run at 160/110 mmHg. She denies any headache, palpitation, chest pain, leg claudication or visual problems. She was diagnosed with osteoporosis with occasional back pain and has been admitted to the hospital for a hip fracture on two occasions over the last 3 years. There is no history of diabetes mellitus, coronary artery disease or stroke. She has no known drug allergy. Her vital signs are within normal limits, other than high blood pressure. The S1 is loud. The S2 is normal. There is an S4 sound without a murmur, rub or gallop. The peripheral pulses are normal and symmetric. The serum electrolytes (sodium, potassium, calcium and chloride), creatinine and urea nitrogen are within normal range.
      What is the most appropriate antihypertensive medication for this patient?

      Your Answer: Prazosin

      Correct Answer: Indapamide

      Explanation:

      The best medication for the patient in the scenario would be indapamide, a thiazide diuretic that blocks the Na+/Cl− cotransporter in the distal convoluted tubules, increasing calcium reabsorption and reducing the risk of osteoporotic fractures. Common side-effects include hyponatraemia, hypokalaemia, hypercalcaemia, hyperglycaemia, hyperuricaemia, gout, postural hypotension and hypochloraemic alkalosis. Prazosin is used for benign prostatic hyperplasia, enalapril is not preferred for patients over 55 years old and can increase osteoporosis risk, propranolol is not a preferred initial treatment for hypertension, and amlodipine can cause ankle swelling and should be avoided in patients with myocardial infarction and symptomatic heart failure.

    • This question is part of the following fields:

      • Cardiology
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  • Question 14 - A 50-year-old man with a long-standing history of hypertension visits his primary care...

    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. During the examination, his temperature is recorded as 37.1 °C, and his blood pressure in the left arm is 174/96 mmHg, with a heart rate of 78 bpm, respiratory rate of 16 breaths per minute, and oxygen saturation of 98% on room air. Bilateral 1+ dorsalis pedis pulses are noted, and his lower extremities feel 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. His 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: Atrial septal defect

      Correct Answer: Coarctation of the aorta

      Explanation:

      The patient’s symptoms suggest coarctation of the aorta, a condition where the aortic lumen narrows just after the branches of the aortic arch. This causes hypertension in the upper extremities and hypotension in the lower extremities, leading to lower extremity claudication. Chest X-rays may show notching of the ribs. Treatment involves surgical resection of the narrowed lumen. Bilateral lower extremity deep vein thrombosis, patent ductus arteriosus, renal artery stenosis, and atrial septal defects are other conditions that can cause different symptoms and require different treatments.

    • This question is part of the following fields:

      • Cardiology
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  • Question 15 - A 28-year-old woman presents to the Emergency department with sudden onset of palpitations....

    Incorrect

    • A 28-year-old woman presents to the Emergency department with sudden onset of palpitations. Upon examination, her pulse rate is found to be 180 bpm and she appears warm and well perfused. Her blood pressure is 135/80 mmHg, respiratory rate is 20/min, and oxygen saturation is 100% on air. Chest auscultation reveals no signs of cardiac failure, but an ECG shows a narrow complex tachycardia. Despite attempts at carotid massage and Valsalva manoeuvre, the rhythm disturbance persists. What is the appropriate initial management?

      Your Answer: IV magnesium

      Correct Answer: IV adenosine

      Explanation:

      Management of Narrow Complex Supraventricular Tachycardia

      When a patient presents with narrow complex supraventricular tachycardia, the initial management would be to administer IV adenosine, provided there are no contraindications such as asthma. This medication creates a transient conduction delay, which may terminate the tachycardia or slow down the heart rate enough to identify the underlying rhythm. This information is crucial in determining the optimal antiarrhythmic therapy for the patient.

      However, if the patient experiences chest pain, hypotension, SBP <90 mmHg, or evidence of cardiac failure, then DC cardioversion would be necessary. It is important to note that if the patient is not haemodynamically compromised, IV adenosine is the preferred initial management for narrow complex supraventricular tachycardia. By following these guidelines, healthcare professionals can effectively manage this condition and provide the best possible care for their patients.

    • This question is part of the following fields:

      • Cardiology
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  • Question 16 - A 32-year-old woman presents with dyspnoea on exertion and palpitations. She has an...

    Incorrect

    • A 32-year-old woman presents with dyspnoea on exertion and palpitations. She has an irregularly irregular and tachycardic pulse, and a systolic murmur is heard on auscultation. An ECG reveals atrial fibrillation and right axis deviation, while an echocardiogram shows an atrial septal defect.
      What is the process of atrial septum formation?

      Your Answer:

      Correct Answer: The septum secundum grows down to the right of the septum primum

      Explanation:

      During embryonic development, the septum primum grows down from the roof of the primitive atrium and fuses with the endocardial cushions. It initially has a hole called the ostium primum, which closes as the septum grows downwards. However, a second hole called the ostium secundum develops in the septum primum before fusion can occur. The septum secundum then grows downwards and to the right of the septum primum and ostium secundum. The foramen ovale is a passage through the septum secundum that allows blood to shunt from the right to the left atrium in the fetus, bypassing the pulmonary circulation. This defect closes at birth due to a drop in pressure within the pulmonary circulation after the infant takes a breath. If there is overlap between the foramen ovale and ostium secundum or if the ostium primum fails to close, an atrial septal defect results. This defect does not cause cyanosis because oxygenated blood flows from left to right through the defect.

    • This question is part of the following fields:

      • Cardiology
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  • Question 17 - A 68-year-old man experienced acute kidney injury caused by rhabdomyolysis after completing his...

    Incorrect

    • A 68-year-old man experienced acute kidney injury caused by rhabdomyolysis after completing his first marathon. He was started on haemodialysis due to uraemic pericarditis. What symptom or sign would indicate the presence of cardiac tamponade?

      Your Answer:

      Correct Answer: Pulsus paradoxus

      Explanation:

      Understanding Pericarditis and Related Symptoms

      Pericarditis is a condition characterized by inflammation of the pericardium, the sac surrounding the heart. One of the signs of pericarditis is pulsus paradoxus, which is a drop in systolic blood pressure of more than 10 mmHg during inspiration. This occurs when the pericardial effusion normalizes the wall pressures across all the chambers, causing the septum to bulge into the left ventricle, reducing stroke volume and blood pressure. Pleuritic chest pain is not a common symptom of pericarditis, and confusion is not related to pericarditis or incipient tamponade. A pericardial friction rub is an audible medical sign used in the diagnosis of pericarditis, while a pericardial knock is a pulse synchronous sound that can be heard in constrictive pericarditis. Understanding these symptoms can aid in the diagnosis and management of pericarditis.

    • This question is part of the following fields:

      • Cardiology
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  • Question 18 - In a 25-year-old woman undergoing a routine physical examination for a new job,...

    Incorrect

    • In a 25-year-old woman undergoing a routine physical examination for a new job, a mid-systolic ejection murmur is discovered in the left upper sternal border. The cardiac examination reveals a significant right ventricular cardiac impulse and wide and fixed splitting of the second heart sound. An electrocardiogram (ECG) shows a right axis deviation, and a chest X-ray shows enlargement of the right ventricle and atrium. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Atrial septal defect

      Explanation:

      Cardiac Abnormalities and their Clinical Findings

      Atrial Septal Defect:
      Atrial septal defect is characterized by a prominent right ventricular cardiac impulse, a systolic ejection murmur heard best in the pulmonic area and along the left sternal border, and fixed splitting of the second heart sound. These findings are due to an abnormal left-to-right shunt through the defect, which creates a volume overload on the right side. Small atrial septal defects are usually asymptomatic.

      Pulmonary Valve Stenosis:
      Pulmonary valve stenosis causes an increased right ventricular pressure which results in right ventricular hypertrophy and pulmonary artery dilation. A crescendo–decrescendo murmur may be heard if there is a severe stenosis. Right atrial enlargement would not be present.

      Mitral Regurgitation:
      Mitral regurgitation would also present with a systolic murmur; however, left atrial enlargement would be seen before right ventricular enlargement.

      Mitral Stenosis:
      Mitral stenosis would present with an ‘opening snap’ and a diastolic murmur.

      Aortic Stenosis:
      Aortic stenosis is also associated with a systolic ejection murmur. However, the murmur is usually loudest at the right sternal border and radiates upwards to the jugular notch. Aortic stenosis is associated with left ventricular hypertrophy.

      Clinical Findings of Common Cardiac Abnormalities

    • This question is part of the following fields:

      • Cardiology
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  • Question 19 - You are asked to see a 63-year-old man who has been admitted overnight...

    Incorrect

    • You are asked to see a 63-year-old man who has been admitted overnight following a road traffic accident. He sustained extensive bruising to his chest from the steering wheel. The nurses are concerned as he has become hypotensive and tachycardic. There is a history of a previous inferior myocardial infarction some 7 years ago, but nil else of note. On examination his BP is 90/50 mmHg, pulse is 95/min and regular. He looks peripherally shut down. There are muffled heart sounds and pulsus paradoxus.
      Investigations – arterial blood gas - reveal:
      Investigation Result Normal Value
      pH 7.29 7.35–7.45
      pO2 11.9 kPa 11.2–14.0 kPa
      pCO2 6.1 kPa 4.7–6.0 kPa
      ECG Widespread anterior T wave inversion
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Cardiac tamponade

      Explanation:

      Differential Diagnosis for a Patient with Hypotension, Tachycardia, and Muffled Heart Sounds Following a Road Traffic Accident: Cardiac Tamponade, Myocarditis, NSTEMI, Pericarditis, and STEMI

      A 67-year-old man presents with hypotension, tachycardia, and poor peripheral perfusion following a road traffic accident with a steering wheel injury. On examination, muffled heart sounds and pulsus paradoxus are noted, and an ECG shows widespread anterior T-wave inversion. The patient has a history of inferior wall MI seven years ago. Arterial blood gas analysis reveals respiratory acidosis.

      The differential diagnosis includes cardiac tamponade, myocarditis, NSTEMI, pericarditis, and STEMI. While myocarditis can cause similar symptoms and ECG changes, the presence of muffled heart sounds and pulsus paradoxus suggests fluid in the pericardium and cardiac tamponade. NSTEMI and STEMI can also cause acute onset of symptoms and ECG changes, but the absence of ST elevation and the history of trauma make cardiac tamponade more likely. Pericarditis can cause muffled heart sounds and pulsus paradoxus, but the absence of peripheral hypoperfusion and the presence of non-specific ST-T changes on ECG make it less likely.

      In conclusion, the clinical scenario is most consistent with traumatic cardiac tamponade, which requires urgent echocardiography for confirmation and possible guided pericardiocentesis.

    • This question is part of the following fields:

      • Cardiology
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  • Question 20 - A 70-year-old man presents with severe breathlessness which started this morning and has...

    Incorrect

    • A 70-year-old man presents with severe breathlessness which started this morning and has become gradually worse. The patient denies coughing up any phlegm. He has a history of essential hypertension. On examination, the patient has a blood pressure of 114/75 mmHg and a respiratory rate of 30 breaths per minute. His temperature is 37.1°C. His jugular venous pressure (JVP) is 8 cm above the sternal angle. On auscultation there are fine bibasal crackles and a third heart sound is audible. The patient is an ex-smoker and used to smoke 5–10 cigarettes a day for about 10 years.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Pulmonary oedema

      Explanation:

      Differentiating Pulmonary Oedema from Other Cardiac and Respiratory Conditions

      Pulmonary oedema is a condition characterized by the accumulation of fluid in the lungs due to left ventricular failure. It presents with symptoms such as shortness of breath, raised jugular venous pressure, and a third heart sound. Bi-basal crackles are also a hallmark of pulmonary oedema. However, it is important to differentiate pulmonary oedema from other cardiac and respiratory conditions that may present with similar symptoms.

      Tricuspid regurgitation is another cardiac condition that may present with a raised JVP and a third heart sound. However, it is characterized by additional symptoms such as ascites, a pulsatile liver, peripheral oedema, and a pansystolic murmur. Pneumonia, on the other hand, is a respiratory infection that presents with a productive cough of yellow or green sputum and shortness of breath. Bronchial breath sounds may also be heard upon auscultation.

      Pulmonary embolus is a condition that presents with chest pain, shortness of breath, and signs of an underlying deep vein thrombosis. Pericardial effusion, on the other hand, is characterized by the accumulation of fluid in the pericardial sac surrounding the heart. It may eventually lead to cardiac tamponade, which presents with hypotension, shortness of breath, and distant heart sounds. However, bi-basal crackles are not a feature of pericardial effusion.

      In summary, it is important to consider the specific symptoms and characteristics of each condition in order to accurately diagnose and differentiate pulmonary oedema from other cardiac and respiratory conditions.

    • This question is part of the following fields:

      • Cardiology
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  • Question 21 - A patient presents to the Emergency Department following a fracture dislocation of his...

    Incorrect

    • A patient presents to the Emergency Department following a fracture dislocation of his ankle after a night out drinking vodka red-bulls. His blood pressure is low at 90/50 mmHg. He insists that it is never normally that low.
      Which one of these is a possible cause for this reading?

      Your Answer:

      Correct Answer: Incorrect cuff size (cuff too large)

      Explanation:

      Common Factors Affecting Blood Pressure Readings

      Blood pressure readings can be affected by various factors, including cuff size, alcohol and caffeine consumption, white coat hypertension, pain, and more. It is important to be aware of these factors to ensure accurate readings.

      Incorrect Cuff Size:
      Using a cuff that is too large can result in an underestimation of blood pressure, while a cuff that is too small can cause a falsely elevated reading.

      Alcohol and Caffeine:
      Both alcohol and caffeine can cause a temporary increase in blood pressure.

      White Coat Hypertension:
      Many patients experience elevated blood pressure in medical settings due to anxiety. To obtain an accurate reading, blood pressure should be measured repeatedly on separate occasions.

      Pain:
      Pain is a common cause of blood pressure increase and should be taken into consideration during medical procedures. A significant rise in blood pressure during a procedure may indicate inadequate anesthesia.

      Factors Affecting Blood Pressure Readings

    • This question is part of the following fields:

      • Cardiology
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  • Question 22 - A fourth year medical student on a ward round with your team is...

    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
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  • Question 23 - A 16-year-old boy is discovered following a street brawl with a stab wound...

    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
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  • Question 24 - A 72-year-old woman visits her GP for a routine check-up. During the examination,...

    Incorrect

    • A 72-year-old woman visits her GP for a routine check-up. During the examination, she seems generally healthy but slightly fatigued and experiences some breathlessness at rest. Her pulse is irregularly irregular and measures 72 bpm, while her blood pressure is 126/78 mmHg. Upon further examination, no concerning issues are found. The patient has no significant medical history and is not taking any regular medications.
      What is the probable reason for this woman's development of atrial fibrillation (AF)?

      Your Answer:

      Correct Answer: Lone AF

      Explanation:

      Management of Atrial Fibrillation: The ABCD Approach

      Atrial fibrillation (AF) is a common arrhythmia that can be classified as paroxysmal, persistent, or permanent. Treatment options for AF depend on the classification and can be categorized into rate control, rhythm control, and anticoagulation. The ABCD approach is a useful tool for managing AF.

      A – Anticoagulation: Patients with AF are at an increased risk for thromboembolic disease, and anticoagulation should be considered in high-risk patients where the benefit outweighs the risk of hemorrhage.

      B – Better symptom control: Rate control is aimed at controlling the ventricular response rate to improve symptoms. Rhythm control is aimed at restoring and maintaining sinus rhythm to improve symptoms.

      C – Cardiovascular risk factor management: Management of underlying cardiovascular risk factors such as hypertension, diabetes, and hyperlipidemia can help reduce the risk of AF recurrence and complications.

      D – Disease management: Management of underlying conditions associated with AF, such as valvular heart disease and heart failure, can help improve AF outcomes.

      In summary, the ABCD approach to managing AF involves anticoagulation, better symptom control, cardiovascular risk factor management, and disease management. This approach can help improve outcomes and reduce the risk of complications in patients with AF.

    • This question is part of the following fields:

      • Cardiology
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  • Question 25 - A 50-year-old man with type II diabetes, is having his annual diabetes review....

    Incorrect

    • A 50-year-old man with type II diabetes, is having his annual diabetes review. During this review it is noticed that the man has a heart rate between 38–48 beats/min. On questioning, he mentions that he has noticed occasional palpitations, but otherwise has been asymptomatic.
      An ECG is performed, which shows that on every fourth beat there is a non-conducted P-wave (a P-wave without QRS complex). Otherwise there are no other abnormalities and the PR interval is constant.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Second degree heart block – Mobitz type II

      Explanation:

      Understanding Different Types of Heart Blocks on an ECG

      An electrocardiogram (ECG) is a diagnostic tool used to monitor the electrical activity of the heart. It can help identify different types of heart blocks, which occur when the electrical signals that control the heartbeat are disrupted. Here are some common types of heart blocks and how they appear on an ECG:

      Second Degree Heart Block – Mobitz Type II
      This type of heart block is characterized by a regular non-conducted P-wave on the ECG. It may also show a widened QRS, indicating that the block is in the bundle branches of Purkinje fibers. If a patient is symptomatic with Mobitz type II heart block, permanent pacing is required to prevent progression to third degree heart block.

      Third Degree Heart Block
      An ECG of a third degree heart block would show dissociated P-waves and QRS-waves. This means that the atria and ventricles are not communicating properly, and the heart may beat very slowly or irregularly.

      Atrial Flutter
      Atrial flutter on an ECG would typically show a saw-toothed baseline. This occurs when the atria are beating too quickly and not in sync with the ventricles.

      Ectopic Beats
      Ectopic beats are premature heartbeats that occur outside of the normal rhythm. They would not result in regular non-conducted P-waves on an ECG.

      Second Degree Heart Block – Mobitz Type I
      Mobitz type I heart block would typically show progressive lengthening of the PR interval over several complexes, before a non-conducted P-wave would occur. This type of heart block is usually not as serious as Mobitz type II, but may still require monitoring and treatment.

    • This question is part of the following fields:

      • Cardiology
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  • Question 26 - A 28-year-old man comes to the clinic complaining of intermittent sharp central chest...

    Incorrect

    • A 28-year-old man comes to the clinic complaining of intermittent sharp central chest pains over the past 48 hours. The pain worsens with exertion and when he lies down. He reports no difficulty breathing. The ECG reveals widespread ST elevation.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Pericarditis

      Explanation:

      Distinguishing Pericarditis from Other Cardiac Conditions: A Clinical Overview

      Pericarditis is a common cause of widespread ST elevation, characterized by chest pain that is often pleuritic and relieved by sitting forwards. Other symptoms include dry cough, dyspnoea, and flu-like symptoms, with the most important sign being pericardial rub. It can be caused by viral infections, post-MI, tuberculosis, or uraemia.

      While pulmonary embolism may cause similar pleuritic pain, it would not result in the same ECG changes as pericarditis. Acute MI causes ST elevation in the affected coronary artery territory, with reciprocal ST depression. Hypertrophic cardiomyopathy presents with syncope or pre-syncope, and ECG changes consistent with left ventricular and septal hypertrophy. Ventricular aneurysm is another cause of ST elevation, but the clinical scenario and patient age align with a diagnosis of acute pericarditis.

      In summary, recognizing the unique clinical presentation and ECG changes of pericarditis is crucial in distinguishing it from other cardiac conditions.

    • This question is part of the following fields:

      • Cardiology
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  • Question 27 - A 20-year-old man presents with complaints of palpitations and dizzy spells. Upon performing...

    Incorrect

    • A 20-year-old man presents with complaints of palpitations and dizzy spells. Upon performing an echocardiogram, the diagnosis of hypertrophic obstructive cardiomyopathy (HOCM) is made.
      What will be visualized on the echocardiogram?

      Your Answer:

      Correct Answer: Reduced left ventricular cavity size

      Explanation:

      Echocardiographic Findings in Hypertrophic Obstructive Cardiomyopathy

      Hypertrophic obstructive cardiomyopathy (HOCM) is a condition characterized by thickening of the heart muscle, particularly the septum, which can lead to obstruction of blood flow out of the heart. Echocardiography is a useful tool for diagnosing and monitoring HOCM. Here are some echocardiographic findings commonly seen in HOCM:

      Reduced left ventricular cavity size: Patients with HOCM often have a banana-shaped left ventricular cavity, with reduced size due to septal hypertrophy.

      Increased left ventricular outflow tract gradients: HOCM can cause obstruction of blood flow out of the heart, leading to increased pressure gradients in the left ventricular outflow tract.

      Systolic anterior motion of the mitral leaflet: This is a characteristic finding in HOCM, where the mitral valve moves forward during systole and can contribute to obstruction of blood flow.

      Asymmetrical septal hypertrophy: While some patients with HOCM may have symmetrically hypertrophied ventricles, the more common presentation is asymmetrical hypertrophy, with thickening of the septum.

      Mitral regurgitation: HOCM can cause dysfunction of the mitral valve, leading to mild to moderate regurgitation of blood back into the left atrium.

      Overall, echocardiography plays an important role in the diagnosis and management of HOCM, allowing for visualization of the structural and functional abnormalities associated with this condition.

    • This question is part of the following fields:

      • Cardiology
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  • Question 28 - A 68-year-old woman is admitted to the Cardiology Ward with acute left ventricular...

    Incorrect

    • A 68-year-old woman is admitted to the Cardiology Ward with acute left ventricular failure. The patient is severely short of breath.
      What would be the most appropriate initial step in managing her condition?

      Your Answer:

      Correct Answer: Sit her up and administer high flow oxygen

      Explanation:

      Managing Acute Shortness of Breath: Prioritizing ABCDE Approach

      When dealing with acutely unwell patients experiencing shortness of breath, it is crucial to follow the ABCDE approach. The first step is to address Airway and Breathing by sitting the patient up and administering high flow oxygen to maintain normal saturations. Only then should Circulation be considered, which may involve cannulation and administering IV furosemide.

      According to the latest NICE guidelines, non-invasive ventilation should be considered as part of non-pharmacological management if simple measures do not improve symptoms.

      It is important to prioritize the ABCDE approach and not jump straight to administering medication or inserting a urinary catheter. Establishing venous access and administering medication should only be done after ensuring the patient’s airway and breathing are stable.

      If the patient has an adequate systolic blood pressure, iv nitrates such as glyceryl trinitrate (GTN) infusion could be considered to reduce preload on the heart. However, most patients can be treated with iv diuretics, such as furosemide.

      In cases of acute pulmonary edema, close monitoring of urine output is recommended, and the easiest and most accurate method is through catheterization with hourly urine measurements. Oxygen should be given urgently if the patient is short of breath.

      In summary, managing acute shortness of breath requires a systematic approach that prioritizes Airway and Breathing before moving on to Circulation and other interventions.

    • This question is part of the following fields:

      • Cardiology
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  • Question 29 - A 72-year-old man is brought by ambulance to the Accident and Emergency department....

    Incorrect

    • A 72-year-old man is brought by ambulance to the Accident and Emergency department. He is visibly distressed but gives a history of sudden onset central compressive chest pain radiating to his left upper limb. He is also nauseous and very sweaty. He has had previous myocardial infarctions (MI) in the past and claims the pain is identical to those episodes. ECG reveals an anterior ST elevation MI.
      Which of the following is an absolute contraindication to thrombolysis?

      Your Answer:

      Correct Answer: Brain neoplasm

      Explanation:

      Relative and Absolute Contraindications to Thrombolysis

      Thrombolysis is a treatment option for patients with ongoing cardiac ischemia and presentation within 12 hours of onset of pain. However, there are both relative and absolute contraindications to this treatment.

      Absolute contraindications include internal or heavy PV bleeding, acute pancreatitis or severe liver disease, esophageal varices, active lung disease with cavitation, recent trauma or surgery within the past 2 weeks, severe hypertension (>200/120 mmHg), suspected aortic dissection, recent hemorrhagic stroke, cerebral neoplasm, and previous allergic reaction.

      Relative contraindications include prolonged CPR, history of CVA, bleeding diathesis, anticoagulation, blood pressure of 180/100 mmHg, peptic ulcer, and pregnancy or recent delivery.

      It is important to consider these contraindications before administering thrombolysis as they can increase the risk of complications. Primary percutaneous coronary intervention is the preferred treatment option, but if not available, thrombolysis can be a viable alternative. The benefit of thrombolysis decreases over time, and a target time of <30 minutes from admission for commencement of thrombolysis is typically recommended.

    • This question is part of the following fields:

      • Cardiology
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  • Question 30 - A 67-year-old woman arrives at the Emergency Department by ambulance with chest pain...

    Incorrect

    • A 67-year-old woman arrives at the Emergency Department by ambulance with chest pain that began 45 minutes ago. An ECG is performed and shows ST elevation in leads V1-V6, with ST depression in leads III and aVF. The closest facility capable of providing primary PCI is a 2 hour transfer time by ambulance. What is the most appropriate course of action for this patient?

      Your Answer:

      Correct Answer: Administer thrombolysis and transfer for PCI

      Explanation:

      Management of ST Elevation Myocardial Infarction in Remote Locations

      ST elevation myocardial infarction (STEMI) is a medical emergency that requires prompt treatment. Percutaneous coronary intervention (PCI) is the gold standard first-line treatment for STEMI, but in remote locations, the patient may need to be taken to the nearest facility for initial assessment prior to transfer for PCI. In such cases, the most appropriate management strategy should be considered to minimize time delays and optimize patient outcomes.

      Administer Thrombolysis and Transfer for PCI

      In cases where the transfer time to the nearest PCI facility is more than 120 minutes, fibrinolysis prior to transfer should be strongly considered. This is particularly important for patients with anterior STEMI, where time is of the essence. Aspirin, clopidogrel, and low-molecular-weight heparin should also be administered, and the patient should be transferred to a PCI-delivering facility as soon as possible.

      Other Treatment Options

      If PCI is not likely to be achievable within 120 minutes of when fibrinolysis could have been given, thrombolysis should be administered prior to transfer. Analgesia alone is not sufficient, and unfractionated heparin is not the optimum treatment for STEMI.

      Conclusion

      In remote locations, the management of STEMI requires careful consideration of the potential time delays involved in transferring the patient to a PCI-delivering facility. Administering thrombolysis prior to transfer can help minimize delays and improve patient outcomes. Aspirin, clopidogrel, and low-molecular-weight heparin should also be administered, and the patient should be transferred to a PCI-delivering facility as soon as possible.

    • This question is part of the following fields:

      • Cardiology
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SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiology (2/15) 13%
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