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Question 1
Correct
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A 65-year-old man arrives at the Emergency Department complaining of central crushing chest pain that spreads to his arm and jaw. Upon examination, his ECG reveals ST elevation in leads II, III, and aVF, with reciprocal changes in I and aVL. Based on this information, which of the following vessels is most likely obstructed?
Your Answer: Right coronary artery
Explanation:Differentiating Myocardial Infarctions Based on ECG Changes
Myocardial infarction (MI) is a serious condition that requires prompt diagnosis and treatment. Electrocardiogram (ECG) changes can help differentiate the location of the MI and guide appropriate management. Here are the ECG changes expected in different types of MI:
Right Coronary Artery (RCA) Infarction: An inferior MI affects the RCA in 80% of cases, with ST elevation in leads II, III, and aVF, and reciprocal changes in leads I and aVL.
Left Circumflex Artery (LCX) Infarction: LCX infarction presents with ST elevation in leads I, aVL, V5, and V6 (lateral leads), and reciprocal changes in the inferior leads II, III, and aVF.
Left Coronary Artery (LCA) Infarction: If the clot is in the LCA before bifurcation, ST changes are expected in leads I, aVL, and V1–V6 (anterolateral leads).
Posterior Descending Artery (PDA) Infarction: PDA infarction gives ECG changes in keeping with a posterior MI, such as ST depression in the anterior leads.
Left Anterior Descending Artery (LAD) Infarction: LAD runs in the anterior of the heart, almost parallel to the septum, and then lateralizes. Therefore, in an LAD infarction, ST changes are expected in leads V1–V6 (anteroseptal leads).
In conclusion, recognizing the ECG changes in different types of MI can help clinicians make an accurate diagnosis and provide appropriate treatment.
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This question is part of the following fields:
- Cardiology
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Question 2
Incorrect
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A 68-year-old man presents with severe epigastric pain and nausea. He reports not having a bowel movement in 3 days, despite normal bowel habits prior to this. The patient has a history of coronary stents placed after a heart attack 10 years ago. He has been asymptomatic since then and takes aspirin for his cardiac condition and NSAIDs for knee arthritis. He has not consumed alcohol in the past 5 years due to a previous episode of acute gastritis.
On examination, there is mild tenderness over the epigastrium but no guarding. Bowel sounds are normal. An erect CXR and abdominal X-ray are unremarkable. Blood gases and routine blood tests (FBC, U&E, LFTs) are normal, with a normal amylase. Upper GI endoscopy reveals gastric erosions.
What is the most important differential diagnosis to consider for this patient?Your Answer: Duodenal ulcer
Correct Answer: Myocardial infarction
Explanation:Possible Diagnoses for a Patient with Epigastric Pain and History of Cardiac Stents
Introduction:
A patient with a history of cardiac stents presents with epigastric pain. The following are possible diagnoses that should be considered.Myocardial Infarction:
Due to the patient’s history of cardiac stents, ruling out a myocardial infarction (MI) is crucial. An electrocardiogram (ECG) should be performed early to treat any existing cardiac condition without delay.Duodenal Ulcer:
A duodenal ulcer would have likely been visualized on an oesophagogastroduodenoscopy (OGD). However, a normal erect CXR and absence of peritonitis exclude a perforated duodenal ulcer.Acute Gastritis:
Given the patient’s history of aspirin and NSAID use, as well as the gastric erosions visualized on endoscopy, acute gastritis is the most likely diagnosis. However, it is important to first exclude MI as a cause of the patient’s symptoms due to their history of MI and presentation of epigastric pain.Pancreatitis:
Pancreatitis is unlikely, given the normal amylase. However, on occasion, this can be normal in cases depending on the timing of the blood test or whether the pancreas has had previous chronic inflammation.Ischaemic Bowel:
Ischaemic bowel would present with more generalized abdominal pain and metabolic lactic acidosis on blood gas. Therefore, it is less likely to be the cause of the patient’s symptoms. -
This question is part of the following fields:
- Cardiology
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Question 3
Incorrect
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A 49-year-old man presents to the Emergency Department with complaints of chest pain and pain in his left shoulder. He had spent the previous 2 h shoveling snow, but had to stop because of the pain. He admits to several prior episodes of chest pain under similar circumstances. No ST segment changes are seen on the electrocardiogram (ECG). The patient is given sublingual nitroglycerin, which relieves his pain, and is admitted for an overnight stay. The following morning, serum cardiac enzymes are within normal limits and no ECG changes are seen.
Which one of the following is the most likely diagnosis?Your Answer: Prinzmetal variant angina
Correct Answer: Stable (typical) angina
Explanation:Differentiating Types of Angina
When a patient presents with chest pain, it is important to differentiate between the different types of angina. In the case of a patient who has experienced chest pain triggered by heavy physical labor without characteristic ECG changes, and without rise in serum cardiac enzymes, it is likely that they are experiencing stable (typical) angina. This is not the patient’s first episode, and the pain is not becoming progressively worse with less severe triggers, ruling out unstable (crescendo) angina. Additionally, the fact that the pain was triggered by physical activity rather than occurring at rest rules out Prinzmetal variant angina. Subendocardial infarction and transmural infarction can also be ruled out as both would result in elevated cardiac enzyme levels and characteristic ECG changes, such as ST depression or ST elevation and Q waves, respectively. Therefore, based on the patient’s presentation, stable (typical) angina is the most likely diagnosis.
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This question is part of the following fields:
- Cardiology
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Question 4
Incorrect
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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: Interventricular septum
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.
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This question is part of the following fields:
- Cardiology
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Question 5
Incorrect
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A 25-year-old woman attends a new patient health check at the General Practice surgery she has recently joined. She mentions she occasionally gets episodes of palpitations and light-headedness and has done so for several years. Her pulse is currently regular, with a rate of 70 bpm, and her blood pressure is 110/76 mmHg. A full blood count is sent, which comes back as normal. The general practitioner requests an electrocardiogram (ECG), which shows a widened QRS complex with a slurred upstroke and a shortened PR interval.
Which of the following is the most likely diagnosis?Your Answer: Mobitz type II atrioventricular block
Correct Answer: Wolff–Parkinson–White syndrome
Explanation:Common Cardiac Conditions and Their ECG Findings
Wolff-Parkinson-White syndrome is a condition that affects young people and is characterized by episodes of syncope and palpitations. It is caused by an accessory pathway from the atria to the ventricles that bypasses the normal atrioventricular node. The ECG shows a slurred upstroke to the QRS complex, known as a delta wave, which reflects ventricular pre-excitation. Re-entry circuits can form, leading to tachyarrhythmias and an increased risk of ventricular fibrillation.
Hypertrophic cardiomyopathy is an inherited condition that presents in young adulthood and is the most common cause of sudden cardiac death in the young. Symptoms include syncope, dyspnea, palpitations, and abnormal ECG findings, which may include conduction abnormalities, arrhythmias, left ventricular hypertrophy, and ST or T wave changes.
First-degree heart block is characterized by a prolonged PR interval and may be caused by medication, electrolyte imbalances, or post-myocardial infarction. It may also be a normal variant in young, healthy individuals.
Ebstein’s anomaly typically presents in childhood and young adulthood with fatigue, palpitations, cyanosis, and breathlessness on exertion. The ECG shows right bundle branch block and signs of atrial enlargement, such as tall, broad P waves.
Mobitz type II atrioventricular block is a type of second-degree heart block that is characterized by a stable PR interval with some non-conducted beats. It often progresses to complete heart block. Mobitz type I (Wenckebach) block, on the other hand, is characterized by a progressively lengthening PR interval, followed by a non-conducted beat and a reset of the PR interval back to a shorter value.
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This question is part of the following fields:
- Cardiology
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Question 6
Incorrect
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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: Rheumatic heart disease
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.
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This question is part of the following fields:
- Cardiology
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Question 7
Incorrect
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A 38-year-old man presents to the Emergency Department with a 2-day history of flu-like symptoms. He reports experiencing sharp central chest pain that worsens with coughing and improves when he sits forwards. Upon examination, he is found to be tachycardic and has a temperature of 39 °C. A third heart sound is heard upon auscultation. What is the most probable cause of this patient's chest pain?
Your Answer: Myocardial ischaemia
Correct Answer: Pericarditis
Explanation:Differential Diagnosis of Chest Pain: Pericarditis, Aortic Dissection, Myocardial Ischaemia, Oesophageal Reflux, and Pneumonia
Chest pain is a common presenting symptom in clinical practice. It can be caused by a variety of conditions, including pericarditis, aortic dissection, myocardial ischaemia, oesophageal reflux, and pneumonia.
Pericarditis is an acute inflammation of the pericardial sac, which contains the heart. It typically presents with central or left-sided chest pain that is relieved by sitting forwards and worsened by coughing and lying flat. Other signs include tachycardia, raised temperature, and pericardial friction rub. Investigations include blood tests, electrocardiography, chest X-ray, and echocardiography. Treatment aims to address the underlying cause and manage symptoms, such as analgesia and bed rest.
Aortic dissection is characterized by central chest or epigastric pain radiating to the back. It is associated with Marfan syndrome, and symptoms of this condition should be sought when assessing patients.
Myocardial ischaemia is unlikely in a 35-year-old patient without risk factors such as illegal drug use or family history. Ischaemic pain is typically central and heavy/’crushing’ in character, with radiation to the jaw or arm.
Oesophageal reflux disease (GORD) typically presents with chest pain associated with reflux after eating. Patients do not typically have a fever or history of recent illness.
Pneumonia is a possible cause of chest pain, but it is unlikely in the absence of a productive cough. Pleuritic chest pain associated with pneumonia is also unlikely to be relieved by sitting forward, which is a classical sign of pericarditis.
In conclusion, a thorough history and examination, along with appropriate investigations, are necessary to differentiate between the various causes of chest pain and provide appropriate management.
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This question is part of the following fields:
- Cardiology
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Question 8
Incorrect
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A 57-year-old man comes to the Emergency Department with severe crushing pain in his chest and left shoulder that has been ongoing for 2 hours. Despite taking sublingual nitroglycerin, the pain persists, and his electrocardiogram shows ST elevation in multiple leads. Due to preexisting renal impairment, primary percutaneous intervention (PCI) is not an option, and he is started on medical management in the Coronary Care Unit. The following day, his serum cardiac enzymes are found to be four times higher than the upper limit of normal, and his electrocardiographic changes remain.
What is the most probable diagnosis?Your Answer: Subendocardial infarction
Correct Answer: Transmural infarction
Explanation:Differentiating Types of Myocardial Infarction and Angina
When a patient presents with elevated serum cardiac enzymes and typical myocardial pain, it is likely that a myocardial infarction has occurred. If the ST elevation is limited to a few leads, it is indicative of a transmural infarction caused by the occlusion of a coronary artery. On the other hand, severely hypotensive patients who are hospitalized typically experience a more generalized subendocardial infarction.
Unstable angina, which is characterized by chest pain at rest or with minimal exertion, does not cause a rise in cardiac enzymes or ST elevation. Similarly, Prinzmetal angina, which is caused by coronary artery spasm, would not result in a marked increase in serum enzymes.
Stable angina, which is chest pain that occurs with exertion and is relieved by rest or medication, is not associated with ST elevation or a rise in cardiac enzymes.
Subendocardial infarction, which affects most ECG leads, usually occurs in the setting of shock. It is important to differentiate between the different types of myocardial infarction and angina in order to provide appropriate treatment and management.
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This question is part of the following fields:
- Cardiology
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Question 9
Incorrect
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A 70-year-old patient comes to her doctor for a routine check-up. During the examination, her blood pressure is measured in both arms, and the readings are as follows:
Right arm 152/100
Left arm 138/92
What should be the next step in managing this patient's condition?Your Answer: Confirm a diagnosis of hypertension and start the patient on verapamil
Correct Answer: Ask the patient to start ambulatory blood pressure monitoring
Explanation:Proper Management of High Blood Pressure Readings
In order to properly manage high blood pressure readings, it is important to follow established guidelines. If a patient displays a blood pressure of over 140/90 in one arm, the patient should have ambulatory blood pressure monitoring (ABPM) in order to confirm the presence or lack of hypertension, in accordance with NICE guidelines.
It is important to note that a diagnosis of hypertension cannot be made from one blood pressure recording. However, if hypertension is confirmed, based upon the patients’ age, amlodipine would be the antihypertensive of choice.
When measuring blood pressure in both arms (as it should clinically be done), the higher of the two readings should be taken. Asking the patient to come back in one week to re-record blood pressure sounds reasonable, but it is not in accordance with the NICE guidelines.
Lastly, it is important to note that considering the patients’ age, ramipril is second line and should not be the first choice for treatment. Proper management of high blood pressure readings is crucial for the overall health and well-being of the patient.
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This question is part of the following fields:
- Cardiology
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Question 10
Incorrect
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A 65-year-old man visits his doctor complaining of a persistent cough with yellow sputum, mild breathlessness, and fever for the past three days. He had a heart attack nine months ago and received treatment with a bare metal stent during angioplasty. Due to his penicillin allergy, the doctor prescribed oral clarithromycin 500 mg twice daily for a week to treat his chest infection. However, after five days, the patient returns to the doctor with severe muscle pains in his thighs and shoulders, weakness, lethargy, nausea, and dark urine. Which medication has interacted with clarithromycin to cause these symptoms?
Your Answer:
Correct Answer: Simvastatin
Explanation:Clarithromycin and its Drug Interactions
Clarithromycin is an antibiotic used to treat various bacterial infections. It is effective against many Gram positive and some Gram negative bacteria that cause community acquired pneumonias, atypical pneumonias, upper respiratory tract infections, and skin infections. Unlike other macrolide antibiotics, clarithromycin is highly stable in acidic environments and has fewer gastric side effects. It is also safe to use in patients with penicillin allergies.
However, clarithromycin can interact with other drugs by inhibiting the hepatic cytochrome P450 enzyme system. This can lead to increased levels of other drugs that are metabolized via this route, such as warfarin, aminophylline, and statin drugs. When taken with statins, clarithromycin can cause muscle breakdown and rhabdomyolysis, which can lead to renal failure. Elderly patients who take both drugs may experience reduced mobility and require prolonged rehabilitation physiotherapy.
To avoid these interactions, it is recommended that patients taking simvastatin or another statin drug discontinue its use during the course of clarithromycin treatment and for one week after. Clarithromycin can also potentially interact with clopidogrel, a drug used to prevent stent thrombosis, by reducing its efficacy. However, clarithromycin does not have any recognized interactions with bisoprolol, lisinopril, or aspirin.
In summary, while clarithromycin is an effective antibiotic, it is important to be aware of its potential drug interactions, particularly with statin drugs and clopidogrel. Patients should always inform their healthcare provider of all medications they are taking to avoid any adverse effects.
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This question is part of the following fields:
- Cardiology
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Question 11
Incorrect
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A 63-year-old diabetic woman presents with general malaise and epigastric pain of 2 hours’ duration. She is hypotensive (blood pressure 90/55) and has jugular venous distension. Cardiac workup reveals ST elevation in leads I, aVL, V5 and V6. A diagnosis of high lateral myocardial infarction is made, and the patient is prepared for percutaneous coronary intervention (PCI).
Blockage of which of the following arteries is most likely to lead to this type of infarction?Your Answer:
Correct Answer: Left (obtuse) marginal artery
Explanation:Coronary Arteries and their Associated ECG Changes
The heart is supplied with blood by the coronary arteries, and blockages in these arteries can lead to myocardial infarction (heart attack). Different coronary arteries supply blood to different parts of the heart, and the location of the blockage can be identified by changes in the electrocardiogram (ECG) readings.
Left (obtuse) Marginal Artery: This artery supplies the lateral wall of the left ventricle. Blockages in this artery can cause changes in ECG leads I, aVL, V2, V5, and V6, with reciprocal changes in the inferior leads.
Anterior Interventricular (Left Anterior Descending) Artery: This artery supplies the anterior walls of both ventricles and the anterior part of the interventricular septum. Blockages in this artery can cause changes in ECG leads V2-V4, sometimes extending to V1 and V5.
Posterior Interventricular Artery: This artery is a branch of the right coronary artery and supplies the posterior walls of both ventricles. ECG changes associated with blockages in this artery are not specific.
Right (Acute) Marginal Artery: This artery supplies the right ventricle. Blockages in this artery can cause changes in ECG leads II, III, aVF, and sometimes V1.
Right Mainstem Coronary Artery: Inferior myocardial infarction is most commonly associated with blockages in this artery (80% of cases) or the left circumflex artery (20% of cases). ECG changes in this type of infarct are seen in leads II, III, and aVF.
Understanding Coronary Arteries and ECG Changes in Myocardial Infarction
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This question is part of the following fields:
- Cardiology
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Question 12
Incorrect
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A 55-year-old woman visits her GP and mentions her diagnosis of heart failure. She expresses interest in learning about medications that can potentially decrease mortality in heart failure. Which drug has been proven to have this effect?
Your Answer:
Correct Answer: Spironolactone
Explanation:Common Medications for Heart Failure: Benefits and Limitations
Heart failure is a chronic condition that affects millions of people worldwide. While there is no cure for heart failure, medications can help manage symptoms and improve quality of life. Here are some common medications used in the treatment of heart failure, along with their benefits and limitations.
Spironolactone: Recent trials have shown that spironolactone can reduce mortality in severe heart failure. This drug works by antagonizing the deleterious effects of aldosterone on cardiac remodeling, rather than its diuretic effect.
Simvastatin: While statins are effective in reducing morbidity and mortality in patients with coronary artery disease, their beneficial effects in heart failure remain inconclusive.
Atenolol: Atenolol has not been shown to be effective in reducing mortality in heart failure and is not used as part of the condition’s management. However, certain beta-blockers like carvedilol, metoprolol, or bisoprolol are recommended in patients who have been stabilized on diuretic and angiotensin-converting enzyme (ACE-I) therapy.
Furosemide: Furosemide is a mainstay in the treatment of both acute and long-term heart failure, particularly for relieving symptoms of fluid overload. However, there is little data to prove that it improves long-term mortality in patients with chronic congestive cardiac failure (CCF).
Digoxin: Digoxin does not decrease mortality in heart failure. Its use is reserved for patients in atrial fibrillation and those who cannot be controlled on an ACE-I, beta-blocker, and loop diuretic. Some studies suggest a decreased rate in CHF-related hospital admissions.
In conclusion, while these medications can help manage symptoms and improve quality of life in heart failure patients, their limitations should also be considered. It is important to work closely with a healthcare provider to determine the best treatment plan for each individual.
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This question is part of the following fields:
- Cardiology
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Question 13
Incorrect
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What condition would make exercise testing completely unsafe?
Your Answer:
Correct Answer: Severe aortic stenosis
Explanation:Contraindications for Exercise Testing
Exercise testing is a common diagnostic tool used to evaluate a patient’s cardiovascular health. However, there are certain conditions that make exercise testing unsafe or inappropriate. These conditions are known as contraindications.
Absolute contraindications for exercise testing include acute myocardial infarction (heart attack) within the past two days, unstable angina, uncontrolled cardiac arrhythmias, symptomatic severe aortic stenosis, uncontrolled heart failure, acute pulmonary embolism or pulmonary infarction, acute myocarditis or pericarditis, and acute aortic dissection. These conditions are considered absolute contraindications because they pose a significant risk to the patient’s health and safety during exercise testing.
Relative contraindications for exercise testing include left main coronary stenosis, moderate stenotic valvular heart disease, electrolyte abnormalities, severe arterial hypertension, tachyarrhythmias or bradyarrhythmias, hypertrophic cardiomyopathy, mental or physical impairment leading to an inability to exercise adequately, and high-degree atrioventricular (AV) block. These conditions are considered relative contraindications because they may increase the risk of complications during exercise testing, but the benefits of testing may outweigh the risks in certain cases.
It is important for healthcare providers to carefully evaluate a patient’s medical history and current health status before recommending exercise testing. If contraindications are present, alternative diagnostic tests may be necessary to ensure the safety and well-being of the patient.
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This question is part of the following fields:
- Cardiology
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Question 14
Incorrect
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An 82-year-old man has been experiencing increasing shortness of breath, tiredness, intermittent chest pain and leg swelling for the past 6 months. He recently underwent an echocardiogram as an outpatient which revealed evidence of heart failure. As the FY1 on the Medical Assessment Unit, you have been tasked with taking the patient's medical history. He has a history of hypertension and gout and is currently taking diltiazem (calcium-channel blocker) 60 mg po bd, furosemide (diuretic) 20 mg po od, Spironolactone 25mg od, allopurinol 100 mg po od, paracetamol 1 g po qds prn, and lisinopril 20 mg po od. Considering his likely diagnosis of heart failure, which medication should be discontinued?
Your Answer:
Correct Answer: Diltiazem
Explanation:Medications for Heart Failure: Understanding their Effects
Heart failure is a complex condition that requires careful management, including the use of various medications. In this context, it is important to understand the effects of each drug and how they can impact the patient’s health. Here is a brief overview of some commonly used medications for heart failure and their effects:
Diltiazem: This calcium-channel blocker can be used to treat angina and hypertension. However, it is advisable to stop calcium-channel blockers in patients with heart disease, as they can reduce the contractility of the heart, exacerbating the condition.
Spironolactone: This drug can help alleviate leg swelling by reducing water retention. It is also one of the three drugs in heart failure that have been shown to reduce mortality, along with ACE inhibitors and b-blockers.
Allopurinol: This medication is used in the prevention of gout long term and has no detrimental effect on the heart.
Paracetamol: This drug does not have an effect on the heart.
Lisinopril: This ACE inhibitor is used in the treatment of hypertension and the prophylactic treatment of angina. Stopping this medication is likely to worsen heart failure. Like spironolactone and b-blockers, ACE inhibitors have been shown to reduce mortality in heart failure, although the mechanisms behind this effect are not fully understood.
In summary, understanding the effects of medications for heart failure is crucial for optimizing patient care and improving outcomes. Healthcare providers should carefully consider each drug’s benefits and risks and tailor treatment to the individual patient’s needs.
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This question is part of the following fields:
- Cardiology
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Question 15
Incorrect
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During a routine GP check-up, a 33-year-old woman is found to have a mid-diastolic rumbling murmur accompanied by a loud first heart sound. What valvular abnormality is likely causing this?
Your Answer:
Correct Answer: Mitral stenosis
Explanation:Valvular Murmurs
Valvular murmurs are a common topic in medical exams, and it is crucial to have a good of them. The easiest way to approach them is by classifying them into systolic and diastolic murmurs. If the arterial valves, such as the aortic or pulmonary valves, are narrowed, ventricular contraction will cause turbulent flow, resulting in a systolic murmur. On the other hand, if these valves are incompetent, blood will leak back through the valve during diastole, causing a diastolic murmur.
Similarly, the atrioventricular valves, such as the mitral and tricuspid valves, can be thought of in the same way. If these valves are leaky, blood will be forced back into the atria during systole, causing a systolic murmur. If they are narrowed, blood will not flow freely from the atria to the ventricles during diastole, causing a diastolic murmur.
Therefore, a diastolic murmur indicates either aortic/pulmonary regurgitation or mitral/tricuspid stenosis. The loud first heart sound is due to increased force in closing the mitral or tricuspid valve, which suggests stenosis. the different types of valvular murmurs and their causes is essential for medical professionals to diagnose and treat patients accurately.
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This question is part of the following fields:
- Cardiology
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Question 16
Incorrect
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A 48-year-old woman comes to you for consultation after being seen two days ago for a fall. She has a medical history of type 2 diabetes mellitus, bilateral knee replacements, chronic hypotension, and heart failure, which limits her mobility. Her weight is 120 kg. During her previous visit, her ECG showed that she had AF with a heart rate of 180 bpm. She was prescribed bisoprolol and advised to undergo a 48-hour ECG monitoring. Upon her return, it was discovered that she has non-paroxysmal AF.
What is the most appropriate course of action?Your Answer:
Correct Answer: Start her on digoxin
Explanation:Treatment Options for Atrial Fibrillation in a Patient with Heart Failure
When treating a patient with atrial fibrillation (AF) and heart failure, the aim should be rate control. While bisoprolol is a good choice, it may not be suitable for a patient with chronic low blood pressure. In this case, digoxin would be the treatment of choice. Anticoagulation with a NOAC or warfarin is also necessary. Cardioversion with amiodarone should not be the first line of treatment due to the patient’s heart failure. Increasing the dose of bisoprolol may not be the best option either. Amlodipine is not effective for rate control in AF, and calcium-channel blockers should not be used in heart failure. Electrical cardioversion is not appropriate for this patient. Overall, the treatment plan should be tailored to the patient’s individual needs and medical history.
Managing Atrial Fibrillation and Heart Failure: Treatment Options
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This question is part of the following fields:
- Cardiology
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Question 17
Incorrect
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A 55-year-old man is experiencing chest pain and shortness of breath three weeks after a myocardial infarction that was treated with percutaneous coronary intervention (PCI) for a proximal left anterior descending artery occlusion. On examination, he has a loud friction rub over the praecordium, bilateral pleural effusions on chest x-ray, and ST elevation on ECG. What is the most probable diagnosis?
Your Answer:
Correct Answer: Dressler's syndrome
Explanation:Dressler’s Syndrome
Dressler’s syndrome is a type of pericarditis that typically develops between two to six weeks after a person has experienced an anterior myocardial infarction or undergone heart surgery. This condition is believed to be caused by an autoimmune response to myocardial antigens. In simpler terms, the body’s immune system mistakenly attacks the heart tissue, leading to inflammation of the pericardium, which is the sac that surrounds the heart.
The symptoms of Dressler’s syndrome can vary from person to person, but they often include chest pain, fever, fatigue, and shortness of breath. In some cases, patients may also experience a cough, abdominal pain, or joint pain. Treatment for this condition typically involves the use of nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and manage pain. In severe cases, corticosteroids may be prescribed to help suppress the immune system.
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This question is part of the following fields:
- Cardiology
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Question 18
Incorrect
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A 62-year-old salesman is found to have a blood pressure (BP) of 141/91 mmHg on a routine medical check. Two months later, his BP was 137/89 mmHg. He leads a physically active life, despite being a heavy smoker. He is not diabetic and his cholesterol levels are low. There is no past medical history of note.
What is the most suitable course of action for managing this patient?Your Answer:
Correct Answer: Lifestyle advice and reassess every year
Explanation:Hypertension Management and Lifestyle Advice
Managing hypertension requires careful consideration of various factors, including cardiovascular risk, age, and other risk factors. The 2011 NICE guidelines recommend further investigation and assessment for those with a BP of 140/90 mmHg or higher and for those at high risk. Once diagnosed, lifestyle advice and annual reassessment are recommended, with drug therapy considered based on the number of risk factors present.
For patients with cardiovascular risk factors, lifestyle advice and education on reducing cardiovascular risk are crucial. This includes support for smoking cessation, as smoking is a significant risk factor for cardiovascular disease. Patients with high risk, such as the elderly or heavy smokers, should be monitored annually.
While pharmacological treatment may be necessary, thiazide diuretics are no longer used first-line for hypertension management. For patients over 55, calcium channel blockers are recommended as first-line treatment. ACE inhibitors would not be used first-line in patients over 55.
In summary, managing hypertension requires a comprehensive approach that considers various factors, including cardiovascular risk, age, and other risk factors. Lifestyle advice and annual reassessment are crucial for patients with hypertension, with drug therapy considered based on the number of risk factors present.
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This question is part of the following fields:
- Cardiology
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Question 19
Incorrect
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A 33-year-old known intravenous drug user presents to your GP clinic with complaints of fatigue, night sweats and joint pain. During the examination, you observe a new early-diastolic murmur. What is the probable causative organism for this patient's condition?
Your Answer:
Correct Answer: Staphylococcus aureus
Explanation:Common Causes of Infective Endocarditis and their Characteristics
Infective endocarditis is a serious condition that can lead to severe complications if left untreated. The most common causative organism of acute infective endocarditis is Staphylococcus aureus, especially in patients with risk factors such as prosthetic valves or intravenous drug use. Symptoms and signs consistent with infective endocarditis include fever, heart murmur, and arthritis, as well as pathognomonic signs like splinter hemorrhages, Osler’s nodes, Roth spots, Janeway lesions, and petechiae.
Group B streptococci is less common than Staphylococcus aureus but has a high mortality rate of 70%. Streptococcus viridans is not the most common cause of infective endocarditis, but it does cause 50-60% of subacute cases. Group D streptococci is the third most common cause of infective endocarditis. Pseudomonas aeruginosa is not the most common cause of infective endocarditis and usually requires surgery for cure.
In summary, knowing the characteristics of the different causative organisms of infective endocarditis can help in the diagnosis and treatment of this serious condition.
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This question is part of the following fields:
- Cardiology
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Question 20
Incorrect
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A 60-year-old man with hypertension and hypercholesterolaemia experienced severe central chest pain lasting one hour. His electrocardiogram (ECG) in the ambulance reveals anterolateral ST segment elevation. Although his symptoms stabilized with medical treatment in the ambulance, he suddenly passed away while en route to the hospital.
What is the probable reason for his deterioration and death?Your Answer:
Correct Answer: Ventricular arrhythmia
Explanation:Complications of Myocardial Infarction
Myocardial infarction (MI) is a serious medical condition that can lead to various complications. Among these complications, ventricular arrhythmia is the most common cause of death. Malignant ventricular arrhythmias require immediate direct current (DC) electrical therapy to terminate the arrhythmias. Mural thrombosis, although it may cause systemic emboli, is not a common cause of death. Myocardial wall rupture and muscular rupture typically occur 4-7 days post-infarction, while papillary muscle rupture is also a possibility. Pulmonary edema, which can be life-threatening, is accompanied by symptoms of breathlessness and orthopnea. However, it can be treated effectively with oxygen, positive pressure therapy, and vasodilators.
Understanding the Complications of Myocardial Infarction
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This question is part of the following fields:
- Cardiology
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