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  • Question 1 - A 70-year-old man experiences an acute myocardial infarction and subsequently develops a bundle...

    Incorrect

    • A 70-year-old man experiences an acute myocardial infarction and subsequently develops a bundle branch block. Which coronary artery is the most probable culprit?

      Your Answer: Acute marginal branch of the right coronary artery

      Correct Answer: Left anterior descending artery

      Explanation:

      Coronary Artery Branches and Their Functions

      The heart is supplied with blood by the coronary arteries, which branch off the aorta. These arteries are responsible for delivering oxygen and nutrients to the heart muscle. Here are some of the main branches of the coronary arteries and their functions:

      1. Left Anterior Descending Artery: This artery supplies the front and left side of the heart, including the interventricular septum. It is one of the most important arteries in the heart.

      2. Acute Marginal Branch of the Right Coronary Artery: This branch supplies the right ventricle of the heart.

      3. Circumflex Branch of the Left Coronary Artery: This artery supplies the left atrium, left ventricle, and the sinoatrial node in some people.

      4. Obtuse Marginal Branch of the Circumflex Artery: This branch supplies the left ventricle.

      5. Atrioventricular Nodal Branch of the Right Coronary Artery: This branch supplies the atrioventricular node. Blockage of this branch can result in heart block.

      Understanding the functions of these coronary artery branches is crucial for diagnosing and treating heart conditions.

    • This question is part of the following fields:

      • Cardiology
      1.9
      Seconds
  • Question 2 - A 56-year-old man presents with non-specific chest pain lasting 6 hours. His ECG...

    Correct

    • A 56-year-old man presents with non-specific chest pain lasting 6 hours. His ECG shows no significant changes, and cardiac enzymes are normal. As the pain becomes sharper and localizes to the left side of his chest over the next 48 hours, he reports that it worsens when lying down and taking deep breaths. The diagnosis is pericarditis.
      What can be said about the pericardium in this case?

      Your Answer: The transverse sinus of the pericardium can be found behind the major vessels emerging from the ventricles, but in front of the superior vena cava

      Explanation:

      Pericardium Layers and Sinuses: Understanding the Anatomy of the Heart’s Protective Membrane

      The pericardium is a protective membrane that surrounds the heart. It consists of two layers: the fibrous pericardium and the serous pericardium. The fibrous pericardium adheres to the heart muscle and is derived from the somatopleuric mesoderm of the body cavity. The visceral layer of the serous pericardium, also known as the epicardium, adheres to the heart muscle and is derived from the splanchnopleuric mesoderm of the body cavity.

      The pericardium also contains two sinuses: the transverse sinus and the oblique sinus. The transverse sinus can be found behind the major vessels emerging from the ventricles, but in front of the superior vena cava. The oblique sinus is the other pericardial sinus.

      It is important to understand the anatomy of the pericardium in order to properly diagnose and treat conditions that affect the heart.

    • This question is part of the following fields:

      • Cardiology
      0.5
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  • Question 3 - You are fast-bleeped to the ward where you find a 46-year-old woman in...

    Correct

    • You are fast-bleeped to the ward where you find a 46-year-old woman in ventricular tachycardia. She had a witnessed syncopal episode while walking to the toilet with nursing staff and currently has a blood pressure of 85/56 mmHg. She is orientated to time, place and person but is complaining of feeling light-headed.
      How would you manage this patient’s ventricular tachycardia?

      Your Answer: Synchronised direct current (DC) cardioversion

      Explanation:

      Treatment Options for Ventricular Tachycardia: Synchronised Cardioversion and Amiodarone

      Ventricular tachycardia is a serious condition that requires immediate treatment. The Resuscitation Council tachycardia guideline recommends synchronised electrical cardioversion as the first-line treatment for unstable patients with ventricular tachycardia who exhibit adverse features such as shock, myocardial ischaemia, syncope, or heart failure. Synchronised cardioversion is timed to coincide with the R or S wave of the QRS complex, reducing the risk of ventricular fibrillation or cardiac arrest.

      Administering an unsynchronised shock could coincide with the T wave, triggering fibrillation of the ventricles and leading to a cardiac arrest. If three attempts of synchronised cardioversion fail to restore sinus rhythm, a loading dose of amiodarone 300 mg iv should be given over 10–20 minutes, followed by another attempt of cardioversion.

      Amiodarone is the first-line treatment for uncompromised patients with tachycardia. A loading dose of 300 mg is given iv, followed by an infusion of 900 mg over 24 hours. Digoxin and metoprolol are not recommended for the treatment of ventricular tachycardia. Digoxin is used for atrial fibrillation, while metoprolol should be avoided in patients with significant hypotension, as it can further compromise the patient’s condition.

    • This question is part of the following fields:

      • Cardiology
      32.9
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  • Question 4 - A 66-year-old patient visits her General Practitioner (GP) with complaints of chest pain...

    Incorrect

    • A 66-year-old patient visits her General Practitioner (GP) with complaints of chest pain and shortness of breath when climbing stairs. She reports no other health issues. During the examination, the GP notes a slow-rising pulse, a blood pressure reading of 130/100 mmHg, and detects a murmur on auscultation.
      What is the most probable type of murmur heard in this patient?

      Your Answer: Early diastolic murmur (EDM)

      Correct Answer: Ejection systolic murmur (ESM)

      Explanation:

      Common Heart Murmurs and Their Associations

      Heart murmurs are abnormal sounds heard during a heartbeat. They can be innocent or pathological, and their characteristics can provide clues to the underlying condition. Here are some common heart murmurs and their associations:

      1. Ejection systolic murmur (ESM): This murmur is associated with aortic stenosis and is related to the ventricular outflow tract. It may be innocent in children and high-output states, but pathological causes include aortic stenosis and sclerosis, pulmonary stenosis, and hypertrophic obstructive cardiomyopathy.

      2. Mid-diastolic murmur: This murmur is commonly associated with tricuspid or mitral stenosis and starts after the second heart sound and ends before the first heart sound. Rheumatic fever is a common cause of mitral valve stenosis.

      3. Pansystolic murmur: This murmur is associated with mitral regurgitation and is of uniform intensity that starts immediately after S1 and merges with S2. It is also found in tricuspid regurgitation and ventricular septal defects.

      4. Early diastolic murmur (EDM): This high-pitched murmur occurs in pulmonary and aortic regurgitation and is caused by blood flowing through a dysfunctional valve back into the ventricle. It may be accentuated by asking the patient to lean forward.

      5. Continuous murmur: This murmur is commonly associated with a patent ductus arteriosus (PDA), a connection between the aorta and the pulmonary artery. It causes a continuous murmur, sometimes described as a machinery murmur, heard throughout both systole and diastole.

    • This question is part of the following fields:

      • Cardiology
      129.4
      Seconds
  • Question 5 - A 72-year-old man has been hospitalized with crushing chest pain. An ECG trace...

    Incorrect

    • A 72-year-old man has been hospitalized with crushing chest pain. An ECG trace shows ischaemia of the inferior part of the heart. What is the term that best describes the artery or arterial branch that provides blood supply to the inferior aspect of the heart?

      Your Answer: Right coronary artery

      Correct Answer: Posterior interventricular branch

      Explanation:

      Coronary Artery Branches and Circulation Dominance

      The coronary artery is responsible for supplying blood to the heart muscles. It branches out into several smaller arteries, each with a specific area of the heart to supply. Here are some of the main branches of the coronary artery:

      1. Posterior Interventricular Branch: This branch supplies the inferior aspect of the heart, with ischaemic changes presenting in leads II, III and aVF. In 90% of the population, it arises as a branch of the right coronary artery, while in 10%, it arises as a branch of the left coronary artery.

      2. Circumflex Branch: This branch supplies the anterolateral area of the heart.

      3. Left Coronary Artery: This artery gives off two branches – the left anterior descending artery supplying the anteroseptal and anteroapical parts of the heart, and the circumflex artery supplying the anterolateral heart. In 10% of the population, the left coronary artery gives off a left anterior interventricular branch that supplies the inferior part of the heart.

      4. Marginal Branch: This branch is a branch of the right coronary artery supplying the right ventricle.

      5. Right Coronary Artery: This artery branches out into the marginal artery and, in 90% of the population, the posterior interventricular branch. These individuals are said to have a right dominant circulation.

      Understanding the different branches of the coronary artery and the circulation dominance can help in diagnosing and treating heart conditions.

    • This question is part of the following fields:

      • Cardiology
      21.4
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  • Question 6 - A 40-year-old man presents with pyrexia, night sweats and has recently noticed changes...

    Incorrect

    • A 40-year-old man presents with pyrexia, night sweats and has recently noticed changes to his fingernails. He has no past medical history except he remembers that as a child he was in hospital with inflamed, painful joints, and a very fast heartbeat following a very sore throat.
      What is the most likely diagnosis?

      Your Answer: Pneumonia

      Correct Answer: Infective endocarditis

      Explanation:

      Differential Diagnosis for a Patient with Pyrexia and Splinter Haemorrhages

      The patient’s past medical history suggests a possible case of rheumatic fever, which can lead to valvular damage and increase the risk of infective endocarditis later in life. The current symptoms of pyrexia, night sweats, and splinter haemorrhages point towards a potential diagnosis of infective endocarditis. There are no clinical signs of septic arthritis, hepatitis, or pneumonia. Aortic regurgitation may present with different symptoms such as fatigue, syncope, and shortness of breath, but it is less likely in this case. Overall, the differential diagnosis for this patient includes infective endocarditis as the most probable diagnosis.

    • This question is part of the following fields:

      • Cardiology
      0.8
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  • Question 7 - A 30-year-old woman visits her GP to discuss contraception options, specifically the combined...

    Incorrect

    • A 30-year-old woman visits her GP to discuss contraception options, specifically the combined oral contraceptive pill. She has no medical history, is a non-smoker, and reports no health concerns. During her check-up, her GP measures her blood pressure and finds it to be 168/96 mmHg, which is consistent on repeat testing and in both arms. Upon examination, her BMI is 24 kg/m2, her pulse is 70 bpm, femoral pulses are palpable, and there is an audible renal bruit. Urinalysis is normal, and blood tests reveal no abnormalities in full blood count, urea, creatinine, electrolytes, or thyroid function. What is the most conclusive test to determine the underlying cause of her hypertension?

      Your Answer: 24-hour urine cortisol

      Correct Answer: Magnetic resonance imaging with gadolinium contrast of renal arteries

      Explanation:

      Diagnostic Tests for Secondary Hypertension: Assessing the Causes

      Secondary hypertension is a condition where high blood pressure is caused by an underlying medical condition. To diagnose the cause of secondary hypertension, various diagnostic tests are available. Here are some of the tests that can be done:

      Magnetic Resonance Imaging with Gadolinium Contrast of Renal Arteries
      This test is used to diagnose renal artery stenosis, which is the most common cause of secondary hypertension in young people, especially young women. It is done when a renal bruit is detected. Fibromuscular dysplasia, a vascular disorder that affects the renal arteries, is one of the most common causes of renal artery stenosis in young adults, particularly women.

      Echocardiogram
      While an echocardiogram can assess for end-organ damage resulting from hypertension, it cannot provide the actual cause of hypertension. Coarctation of the aorta is unlikely if there is no blood pressure differential between arms.

      24-Hour Urine Cortisol
      This test is done to diagnose Cushing syndrome, which is unlikely in this case. The most common cause of Cushing syndrome is exogenous steroid use, which the patient does not have. In addition, the patient has a normal BMI and does not have a cushingoid appearance on examination.

      Plasma Metanephrines
      This test is done to diagnose phaeochromocytoma, which is unlikely in this case. The patient does not have symptoms suggestive of it, such as sweating, headache, palpitations, and syncope. Phaeochromocytoma is also a rare tumour, causing less than 1% of cases of secondary hypertension.

      Renal Ultrasound
      This test is a less accurate method for assessing the renal arteries. Renal parenchymal disease is unlikely in this case as urinalysis, urea, and creatinine are normal.

      Diagnostic Tests for Secondary Hypertension: Assessing the Causes

    • This question is part of the following fields:

      • Cardiology
      0.6
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  • Question 8 - A 40-year-old male patient complains of shortness of breath, weight loss, and night...

    Incorrect

    • A 40-year-old male patient complains of shortness of breath, weight loss, and night sweats for the past six weeks. Despite being generally healthy, he is experiencing these symptoms. During the examination, the patient's fingers show clubbing, and his temperature is 37.8°C. His pulse is 88 beats per minute, and his blood pressure is 128/80 mmHg. Upon listening to his heart, a pansystolic murmur is audible. What signs are likely to be found in this patient?

      Your Answer: Cyanosis

      Correct Answer: Splinter haemorrhages

      Explanation:

      Symptoms and Diagnosis of Infective Endocarditis

      This individual has a lengthy medical history of experiencing night sweats and has developed clubbing of the fingers, along with a murmur. These symptoms are indicative of infective endocarditis. In addition to splinter hemorrhages in the nails, other symptoms that may be present include Roth spots in the eyes, Osler’s nodes and Janeway lesions in the palms and fingers of the hands, and splenomegaly instead of cervical lymphadenopathy. Cyanosis is not typically associated with clubbing and may suggest idiopathic pulmonary fibrosis or cystic fibrosis in younger individuals. However, this individual has no prior history of cystic fibrosis and has only been experiencing symptoms for six weeks.

    • This question is part of the following fields:

      • Cardiology
      1.9
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  • Question 9 - You are in pre-assessment clinic and request an electrocardiogram (ECG) on a 58-year-old...

    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: 0 to -90 degrees

      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
      0.8
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  • Question 10 - A 57-year-old male with a history of hypertension for six years presents to...

    Incorrect

    • A 57-year-old male with a history of hypertension for six years presents to the Emergency department with complaints of severe chest pain that radiates to his back, which he describes as tearing in nature. He is currently experiencing tachycardia and hypertension, with a blood pressure reading of 185/95 mmHg. A soft early diastolic murmur is also noted. The ECG shows ST elevation of 2 mm in the inferior leads, and a small left-sided pleural effusion is visible on chest x-ray. Based on the patient's clinical history, what is the initial diagnosis that needs to be ruled out?

      Your Answer: Pulmonary embolism

      Correct Answer: Aortic dissection

      Explanation:

      Aortic Dissection in a Hypertensive Patient

      This patient is experiencing an aortic dissection, which is a serious medical condition. The patient’s hypertension is a contributing factor, and the pain they are experiencing is typical for this condition. One of the key features of aortic dissection is radiation of pain to the back. Upon examination, the patient also exhibits hypertension, aortic regurgitation, and pleural effusion, which are all consistent with this diagnosis. The ECG changes in the inferior lead are likely due to the aortic dissection compromising the right coronary artery. To properly diagnose and treat this patient, it is crucial to thoroughly evaluate their peripheral pulses and urgently perform imaging of the aorta. Proper and timely medical intervention is necessary to prevent further complications and ensure the best possible outcome for the patient.

    • This question is part of the following fields:

      • Cardiology
      0.6
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  • Question 11 - A 25-year-old man presents to the Emergency Department with severe vomiting and diarrhoea...

    Correct

    • A 25-year-old man presents to the Emergency Department with severe vomiting and diarrhoea that has lasted for four days. He has been unable to keep down any fluids and is dehydrated, so he is started on an intravenous infusion. Upon investigation, his potassium level is found to be 2.6 mmol/L (3.5-4.9). What ECG abnormality would you anticipate?

      Your Answer: S-T segment depression

      Explanation:

      Hypokalaemia and Hyperkalaemia

      Hypokalaemia is a condition characterized by low levels of potassium in the blood. This can be caused by excess loss of potassium from the gastrointestinal or renal tract, decreased oral intake of potassium, alkalosis, or insulin excess. Additionally, hypokalaemia can be seen if blood is taken from an arm in which IV fluid is being run. The characteristic ECG changes associated with hypokalaemia include S-T segment depression, U-waves, inverted T waves, and prolonged P-R interval.

      On the other hand, hyperkalaemia is a condition characterized by high levels of potassium in the blood. This can be caused by kidney failure, medications, or other medical conditions. The changes that may be seen with hyperkalaemia include tall, tented T-waves, wide QRS complexes, and small P waves.

      It is important to understand the causes and symptoms of both hypokalaemia and hyperkalaemia in order to properly diagnose and treat these conditions. Regular monitoring of potassium levels and ECG changes can help in the management of these conditions.

    • This question is part of the following fields:

      • Cardiology
      9.6
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  • Question 12 - A 48-year-old man presents to the Emergency Department with chest tightness. His blood...

    Incorrect

    • A 48-year-old man presents to the Emergency Department with chest tightness. His blood pressure is 200/105 mmHg and heart rate is 70 bpm. His femoral pulses cannot be felt. Echocardiography reveals cardiomegaly and a left-ventricular ejection fraction of 34%. The patient also has a N-terminal pro-brain natriuretic peptide (NT-proBNP) of 25,000 pg/mL. As a result of the patient’s hypertension and high levels of NT-proBNP, he undergoes coronary angiography to exclude cardiac ischaemia. There is no evidence of myocardial ischaemia, but there are significant arterial findings.
      Which of the following is most likely to be seen on coronary angiography of this patient?

      Your Answer: Aortic aneurysm

      Correct Answer: Stenotic arteries

      Explanation:

      Differentiating Arterial Conditions: Understanding the Symptoms and Causes

      When it comes to arterial conditions, it is important to understand the symptoms and causes in order to make an accurate diagnosis. Here, we will explore several potential conditions and how they may present in a patient.

      Stenotic Arteries:
      Coarctation of the aorta is a potential condition to consider in younger adults with poorly controlled hypertension. Symptoms may include weak or absent femoral pulses, heart failure, and left-ventricular hypertrophy. Angiography may reveal stenosis in the middle and proximal segments of the left anterior descending artery, as well as in the left circumflex artery.

      Thickened Arteries:
      Atherosclerosis, or the build-up of plaque in the arteries, is a risk factor for heart attacks and stroke. However, it is unlikely to explain persistently high blood pressure or an absent femoral pulse.

      Aortic Aneurysm:
      While chronic high blood pressure can increase the risk of an aortic aneurysm, sudden, intense chest or back pain is a more common symptom. Additionally, a patient with an aneurysm would likely have low blood pressure and an elevated heart rate, which is inconsistent with the vitals seen in this presentation.

      Calcified Arteries:
      Calcification of arteries is caused by elevated lipid content and increases with age. While it can increase the risk of heart attack and stroke, it would not explain the absence of a femoral pulse or extremely high blood pressure.

      Patent Foramen Ovale:
      This condition, which predisposes patients to paradoxical emboli, is typically diagnosed on an echocardiogram and is unlikely to cause hypertension. It should be considered in patients who have had a stroke before the age of 50.

      In summary, understanding the symptoms and causes of arterial conditions is crucial for accurate diagnosis and treatment.

    • This question is part of the following fields:

      • Cardiology
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  • Question 13 - 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: Tricuspid regurgitation

      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 14 - A 72-year-old man is admitted to hospital with exertional chest pain. He reports...

    Incorrect

    • A 72-year-old man is admitted to hospital with exertional chest pain. He reports that this has only begun in the past few days, particularly when climbing hills. The pain is not present when he is at rest.
      What is the gold standard test that you will request for this patient from the following tests?

      Your Answer:

      Correct Answer: Computed tomography (CT) coronary angiogram

      Explanation:

      Investigating Cardiac Chest Pain: Recommended Tests

      When a patient presents with cardiac chest pain, it is important to conduct appropriate investigations to determine the underlying cause. The following tests are recommended:

      Computed Tomography (CT) Coronary Angiogram: This non-invasive test uses CT scanning to detect any evidence of coronary artery disease and determine its extent. It is considered the gold standard test for investigating cardiac chest pain.

      Angiogram: Before undergoing an angiogram, the patient should first have an exercise tolerance test (ETT) to assess real-time cardiac function during exertion. If the patient experiences ischaemic changes and reduced exercise tolerance, an angiogram may be necessary.

      Chest X-ray: A chest X-ray is not a priority investigation for cardiac chest pain, as it does not aid in diagnosis unless there is evidence of associated heart failure or pleural effusions.

      Full Blood Count: While anaemia could contribute to angina, a full blood count is not a first-line investigation for cardiac chest pain.

      Troponin: Troponin levels may be raised in cases of myocardial damage, but are not necessary for managing angina. The recurring pain and relief with rest indicate angina, rather than a myocardial infarction (MI), which would present with crushing chest pain and dyspnoea that is not alleviated by rest.

    • This question is part of the following fields:

      • Cardiology
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  • Question 15 - A 55-year-old man presents to the clinic with complaints of chest pain and...

    Incorrect

    • A 55-year-old man presents to the clinic with complaints of chest pain and difficulty breathing. He had been hospitalized four weeks ago for acute coronary syndrome and was discharged on bisoprolol, simvastatin, aspirin, and ramipril. During the examination, a narrow complex tachycardia is observed. What is the absolute contraindication in this scenario?

      Your Answer:

      Correct Answer: Verapamil

      Explanation:

      Verapamil and Beta Blockers: A Dangerous Combination

      Verapamil is a type of medication that blocks calcium channels in the heart, leading to a decrease in cardiac output and a slower heart rate. However, it also has negative effects on the heart’s ability to contract, making it a highly negatively inotropic drug. Additionally, it may impair the conduction of electrical signals between the atria and ventricles of the heart.

      According to the British National Formulary (BNF), verapamil should not be given to patients who are already taking beta blockers. This is because the combination of these two drugs can lead to dangerously low blood pressure and even asystole, a condition where the heart stops beating altogether.

      Therefore, it is important for healthcare professionals to carefully consider a patient’s medication history before prescribing verapamil. If a patient is already taking beta blockers, alternative treatments should be considered to avoid the potentially life-threatening consequences of combining these two drugs.

    • This question is part of the following fields:

      • Cardiology
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  • Question 16 - An 85-year-old woman attends her general practice for a medication review. She is...

    Incorrect

    • An 85-year-old woman attends her general practice for a medication review. She is currently taking aspirin, simvastatin, atenolol, captopril and furosemide. The general practitioner (GP) performs an examination and notes an irregular pulse with a rate of 100 bpm. The GP makes a referral to the Cardiology Department with a view to establishing whether this woman’s atrial fibrillation (AF) is permanent or paroxysmal and to obtaining the appropriate treatment for her.
      Which of the following is the most recognised risk factor for the development of AF?

      Your Answer:

      Correct Answer: Alcohol

      Explanation:

      Understanding Risk Factors for Atrial Fibrillation

      Atrial fibrillation (AF) is a common cardiac arrhythmia that can lead to palpitations, shortness of breath, and fatigue. It is most commonly associated with alcohol consumption, chest disease, and hyperthyroidism. Other risk factors include hypertension, pericardial disease, congenital heart disease, cardiomyopathy, valvular heart disease, and coronary heart disease. AF can be classified as paroxysmal, persistent, or permanent, and may be diagnosed incidentally through an electrocardiogram (ECG) finding.

      Once diagnosed, management includes investigating with a 12-lead ECG, echocardiogram, and thyroid function tests. The main objectives are rate control, rhythm control, and reducing the risk of thromboembolic disease. Rhythm control can be achieved through electrical cardioversion or drug therapy, while rate control is managed using medications such as digoxin, β-blockers, or rate-limiting calcium antagonists. Warfarin is indicated for patients with risk factors for stroke, and the risk of ischaemic stroke is calculated using the CHADS2vasc scoring system. Novel oral anticoagulants are also available as an alternative to warfarin in certain patients.

      While hyperthyroidism is a recognized risk factor for AF, obesity and smoking are also associated with an increased risk of developing the condition. Pneumothorax, however, is not a recognized risk factor for AF. Understanding these risk factors can help individuals take steps to reduce their risk of developing AF and manage the condition if diagnosed.

    • This question is part of the following fields:

      • Cardiology
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  • Question 17 - An 80-year-old man is hospitalized with acute coronary syndrome and is diagnosed with...

    Incorrect

    • An 80-year-old man is hospitalized with acute coronary syndrome and is diagnosed with a heart attack. After four days, he experiences another episode of chest pain with non-specific ST-T wave changes on the ECG. Which cardiac enzyme would be the most suitable for determining if this second episode was another heart attack?

      Your Answer:

      Correct Answer: CK-MB

      Explanation:

      Evaluating Chest Pain after an MI

      When a patient experiences chest pain within ten days of a previous myocardial infarction (MI), it is important to evaluate the situation carefully. Troponin T levels remain elevated for ten days following an MI, which can make it difficult to determine if a second episode of chest pain is related to the previous event. To make a diagnosis, doctors will need to evaluate the patient’s creatine kinase (CK)-myoglobin (MB) levels. These markers rise over three days and can help form a diagnostic profile that can help determine if the chest pain is related to a new MI or another condition. By carefully evaluating these markers, doctors can provide the best possible care for patients who are experiencing chest pain after an MI.

    • This question is part of the following fields:

      • Cardiology
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  • Question 18 - A 27-year-old intravenous drug user presents with a systolic murmur that is most...

    Incorrect

    • A 27-year-old intravenous drug user presents with a systolic murmur that is most audible at the fifth costal cartilage on the left sternal edge. What is the most probable anatomical site of the disease causing the murmur?

      Your Answer:

      Correct Answer: Tricuspid valve

      Explanation:

      Auscultation of Heart Murmurs and Associated Cardiac Structures

      When listening to heart sounds, the location of the murmur can provide clues about the underlying cardiac structure involved. A pansystolic murmur heard at the left sternal margin at the fifth costal cartilage suggests tricuspid regurgitation, likely caused by infective endocarditis in an intravenous drug user. A ventricular septal defect can be auscultated as a pansystolic murmur, while an atrial septal defect is associated with an ejection systolic murmur and split second heart sound over the pulmonary area. Abnormalities of the mitral valve are heard in the fifth intercostal space at the mid-clavicular line, and the aortic valve can be auscultated at the second intercostal space in the right sternal edge. Understanding the relationship between heart murmurs and associated cardiac structures can aid in diagnosis and management of cardiac conditions.

    • This question is part of the following fields:

      • Cardiology
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  • Question 19 - A 72-year-old man presents to his GP for a routine check-up and is...

    Incorrect

    • A 72-year-old man presents to his GP for a routine check-up and is found to have a systolic murmur heard loudest in the aortic region. The murmur increases in intensity with deep inspiration and does not radiate. What is the most probable abnormality in this patient?

      Your Answer:

      Correct Answer: Pulmonary stenosis

      Explanation:

      Systolic Valvular Murmurs

      A systolic valvular murmur can be caused by aortic/pulmonary stenosis or mitral/tricuspid regurgitation. It is important to note that the location where the murmur is heard loudest can be misleading. For instance, if it is aortic stenosis, the murmur is expected to radiate to the carotids. However, the significant factor to consider is that the murmur is heard loudest on inspiration. During inspiration, venous return to the heart increases, which exacerbates right-sided murmurs. Conversely, expiration reduces venous return and exacerbates left-sided murmurs. To remember this useful fact, the mnemonic RILE (Right on Inspiration, Left on Expiration) can be used.

      If a systolic murmur is enhanced on inspiration, it must be a right-sided murmur, which could be pulmonary stenosis or tricuspid regurgitation. However, in this case, only pulmonary stenosis is an option. systolic valvular murmurs and their characteristics is crucial in making an accurate diagnosis and providing appropriate treatment.

    • This question is part of the following fields:

      • Cardiology
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  • Question 20 - A 50-year-old woman presents with shortness of breath on exertion, and reports that...

    Incorrect

    • A 50-year-old woman presents with shortness of breath on exertion, and reports that she sleeps on three pillows at night to avoid shortness of breath. Past medical history of note includes two recent transient ischaemic attacks which have resulted in transient speech disturbance and minor right arm weakness. Other non-specific symptoms include fever and gradual weight loss over the past few months. On auscultation of the heart you notice a loud first heart sound, and a plopping sound in early diastole. General examination also reveals that she is clubbed.
      Investigations:
      Investigation Result Normal value
      Sodium (Na+) 140 mmol/l 135–145 mmol/l
      Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
      Urea 6.1 mmol/l 2.5–6.5 mmol/l
      Creatinine 100 μmol/l 50–120 µmol/l
      Haemoglobin 101 g/dl
      (normochromic normocytic) 115–155 g/l
      Platelets 195 × 109/l 150–400 × 109/l
      White cell count (WCC) 11.2 × 109/l 4–11 × 109/l
      Erythrocyte sedimentation rate (ESR) 85 mm/h 0–10mm in the 1st hour
      Chest X-ray Unusual intra-cardiac calcification
      within the left atrium

      Which of the following fits best with the likely diagnosis in this case?

      Your Answer:

      Correct Answer: Left atrial myxoma

      Explanation:

      Cardiac Conditions: Differentiating Left Atrial Myxoma from Other Pathologies

      Left atrial myxoma is a cardiac condition characterized by heart sounds, systemic embolization, and intracardiac calcification seen on X-ray. Echocardiography is used to confirm the diagnosis, and surgery is usually curative. However, other cardiac pathologies can present with similar symptoms, including rheumatic heart disease, mitral stenosis, mitral regurgitation, and infective endocarditis. It is important to differentiate between these conditions to provide appropriate treatment. This article discusses the key features of each pathology to aid in diagnosis.

    • This question is part of the following fields:

      • Cardiology
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