-
Question 1
Incorrect
-
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: Paracetamol
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.
-
This question is part of the following fields:
- Cardiology
-
-
Question 2
Incorrect
-
A 55-year-old woman with type II diabetes is urgently sent to the Emergency Department by her General Practitioner (GP). The patient had seen her GP that morning and reported an episode of chest pain that she had experienced the day before. The GP suspected the pain was due to gastro-oesophageal reflux but had performed an electrocardiogram (ECG) and sent a troponin level to be certain. The ECG was normal, but the troponin level came back that afternoon as raised. The GP advised the patient to go to Accident and Emergency, given the possibility of reduced sensitivity to the symptoms of a myocardial infarction (MI) in this diabetic patient.
Patient Normal range
High-sensitivity troponin T 20 ng/l <14 ng/l
What should be done based on this test result?Your Answer: Administer thrombolysis
Correct Answer: Repeat troponin level
Explanation:Management of Suspected Myocardial Infarction
Explanation:
When a patient presents with symptoms suggestive of myocardial infarction (MI), a troponin level should be checked. If the level is only slightly raised, it does not confirm a diagnosis of MI, but neither does it rule it out. Therefore, a repeat troponin level should be performed at least 3 hours after the first level and sent as urgent.
In an MI, cardiac enzymes are released from dead myocytes into the blood, causing enzyme levels to rise and eventually fall as they are cleared from blood. If the patient has had an MI, the repeat troponin level should either be further raised or further reduced. If the level remains roughly constant, then an alternative cause should be sought, such as pulmonary embolism, chronic kidney disease, acute kidney injury, pericarditis, heart failure, or sepsis/systemic infection.
Admission to the Coronary Care Unit (CCU) is not warranted yet. Further investigations should be performed to ascertain whether an admission is needed or whether alternative diagnoses should be explored.
Safety-netting and return to the GP should include a repeat troponin level to see if the level is stable (arguing against an MI) or is rising/falling. A repeat electrocardiogram (ECG) should be performed, and a thorough history and examination should be obtained to identify any urgent diagnoses that need to be explored before the patient is discharged.
Thrombolysis carries a risk for bleeding, so it requires a clear indication, which has not yet been obtained. Therefore, it should not be administered without proper evaluation.
The alanine transaminase (ALT) level has been used as a marker of MI in the past, but it has been since superseded as it is not specific for myocardial damage. In fact, it is now used as a component of liver function tests.
-
This question is part of the following fields:
- Cardiology
-
-
Question 3
Incorrect
-
An overweight 46-year-old Caucasian male patient attends for the results of a health check arranged by your surgery. He smokes 12 cigarettes a day and is trying to cut down. Alcohol intake is 8 units per week. He tells you that his father underwent a ‘triple bypass’ aged 48 years. His results are as follows:
Total cholesterol : HDL ratio 6
HbA1c: 39 mmol/mol
Urea and electrolytes: normal
Estimated glomerular filtration rate (eGFR): 97 ml/min/1.73m2
Liver function tests: normal
Blood pressure (daytime average on 24-h ambulatory monitor): 140/87
Body mass index (BMI): 25
His QRISK2 10-year cardiovascular risk is calculated at 22.7%.
In addition to assisting with smoking cessation and providing lifestyle advice, what is the most appropriate means of managing his risk?Your Answer: Commence atorvastatin 20 mg once a night and recheck cholesterol in 3 months, aiming to titrate the therapy to maintain a total cholesterol of <5; start an angiotensin-converting enzyme (ACE) inhibitor
Correct Answer: Commence atorvastatin 20 mg once a night and start a calcium channel blocker, review after three months
Explanation:Treatment Plan for a Patient with High Cholesterol and Hypertension
Introduction:
This patient has high cholesterol and hypertension, both of which require immediate attention. In this treatment plan, we will discuss the appropriate medications and monitoring for this patient.Treatment Plan for a Patient with High Cholesterol and Hypertension
Medications:
The patient will start taking atorvastatin 20 mg once a night to address their high cholesterol. After three months, their cholesterol and full lipid profile will be rechecked, and the therapy will be titrated to maintain a total cholesterol of <5. If necessary, the dose may be increased to 40 mg once a night. For hypertension, the patient will start taking a calcium channel blocker as they are over the age of 55. The blood pressure will be monitored regularly, and if it rises above 150/90, additional treatment may be necessary. Monitoring:
The patient’s cholesterol and full lipid profile will be rechecked after three months of treatment with atorvastatin. The aim is to see a 40% reduction in non-HDL cholesterol. If this is not achieved, a discussion of adherence, lifestyle measures, and the possibility of increasing the dose will take place.The patient’s blood pressure will also be monitored regularly. If it rises above 150/90, additional treatment may be necessary.
Conclusion:
This treatment plan addresses both the patient’s high cholesterol and hypertension. By starting atorvastatin and a calcium channel blocker, we can reduce their risk of developing cardiovascular disease. Regular monitoring will ensure that the patient’s cholesterol and blood pressure are under control. -
This question is part of the following fields:
- Cardiology
-
-
Question 4
Correct
-
A first-year medical student is participating in a bedside teaching session and is instructed to listen to the patient's heart. The student places the stethoscope over the patient's fourth left intercostal space just lateral to the sternum.
What heart valve's normal sounds would be best detected with the stethoscope positioned as described?Your Answer: Tricuspid
Explanation:Auscultation of Heart Valves: Locations and Sounds
The human heart has four valves that regulate blood flow. These valves can be heard through auscultation, a medical technique that involves listening to the sounds produced by the heart using a stethoscope. Here are the locations and sounds of each valve:
Tricuspid Valve: This valve is located on the right side of the heart and can be heard at the left sternal border in the fourth intercostal space. The sound produced by this valve is a low-pitched, rumbling noise.
Aortic Valve: The aortic valve is located on the left side of the heart and can be heard over the right sternal border at the second intercostal space. The sound produced by this valve is a high-pitched, clicking noise.
Pulmonary Valve: This valve is located on the right side of the heart and can be heard over the left sternal border at the second intercostal space. The sound produced by this valve is a high-pitched, clicking noise.
Thebesian Valve: The Thebesian valve is located in the coronary sinus and its closure cannot be auscultated.
Mitral Valve: This valve is located on the left side of the heart and can be heard by listening at the apex, in the left mid-clavicular line in the fifth intercostal space. The sound produced by this valve is a low-pitched, rumbling noise.
In summary, auscultation of heart valves is an important diagnostic tool that can help healthcare professionals identify potential heart problems. By knowing the locations and sounds of each valve, healthcare professionals can accurately diagnose and treat heart conditions.
-
This question is part of the following fields:
- Cardiology
-
-
Question 5
Incorrect
-
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: Aspirin
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.
-
This question is part of the following fields:
- Cardiology
-
-
Question 6
Incorrect
-
A 56-year-old, 80 kg woman arrives at the Emergency Department complaining of chest pain that began 5 hours ago. She has no known allergies and is not taking any regular medications. Her electrocardiogram shows T-wave inversion in lateral leads but no ST changes, and her serum troponin level is significantly elevated. What is the appropriate combination of drugs to administer immediately?
Your Answer: Clopidogrel 300 mg, fondaparinux 2.5 mg
Correct Answer: Aspirin 300 mg, prasugrel 60 mg, fondaparinux 2.5 mg
Explanation:For patients with different combinations of medications, the appropriate treatment plan may vary. In general, aspirin should be given as soon as possible and other medications may be added depending on the patient’s condition and the likelihood of undergoing certain procedures. For example, if angiography is not planned within 24 hours of admission, a loading dose of aspirin and prasugrel with fondaparinux may be given. If PCI is planned, unfractionated heparin may be considered. The specific dosages and medications may differ based on the patient’s individual needs and risk factors.
-
This question is part of the following fields:
- Cardiology
-
-
Question 7
Incorrect
-
A 56-year-old Caucasian man presents to his General Practitioner (GP) for routine health screening. He has a background history of obesity (BMI 31 kg/m2), impaired glucose tolerance and he used to smoke. His blood pressure is 162/100 mmHg. It is the same in both arms. There is no renal bruit and he does not appear cushingoid. He does not take regular exercise. At his previous appointment his blood pressure was 168/98 mm/Hg and he has been testing his BP at home. Average readings are 155/95 mmHg. He does not drink alcohol. His father had a heart attack at age 58. Blood results are listed below:
Investigation Result Normal value
HbA1C 46 mmol/l < 53 mmol/mol (<7.0%)
Potassium 4.1 mmol/l 3.5–5 mmol/l
Urea 7 mmol/l 2.5–6.5 mmol/l
Creatinine 84 µmol/l 50–120 µmol/l
Total cholesterol 5.2 mmol/l < 5.2 mmol/l
High-density lipoprotein (HDL) 1.1 mmol/l > 1.0 mmol/l
Low density-lipoprotein (LDL) 3 mmol/l < 3.5 mmol/l
Triglycerides 1.1 mmol/l 0–1.5 mmol/l
Thyroid Stimulating Hormone (TSH) 2 µU/l 0.17–3.2 µU/l
Free T4 16 pmol/l 11–22 pmol/l
What is the most appropriate next step in management of this patient?Your Answer: Commence spironolactone
Correct Answer: Commence ACE inhibitor
Explanation:Treatment for Stage 2 Hypertension: Commencing ACE Inhibitor
Stage 2 hypertension is a serious condition that requires prompt treatment to reduce the risk of a cardiac event. According to NICE guidelines, ACE inhibitors or ARBs are the first-line treatment for hypertension. This man, who has multiple risk factors for hypertension, including age, obesity, and physical inactivity, should commence pharmacological treatment. Lifestyle advice alone is not sufficient in this case.
It is important to note that beta blockers are not considered first-line treatment due to their side-effect profile. Spironolactone is used as fourth-line treatment in resistant hypertension or in the setting of hyperaldosteronism. If cholesterol-lowering treatment were commenced, a statin would be first line. However, in this case, the patient’s cholesterol is normal, so a fibrate is not indicated.
In summary, commencing an ACE inhibitor is the appropriate course of action for this patient with stage 2 hypertension.
-
This question is part of the following fields:
- Cardiology
-
-
Question 8
Incorrect
-
During a routine GP check-up, a 33-year-old woman is found to have a mid-diastolic rumbling murmur accompanied by a loud first heart sound. What valvular abnormality is likely causing this?
Your Answer: Pulmonary stenosis
Correct Answer: Mitral stenosis
Explanation:Valvular Murmurs
Valvular murmurs are a common topic in medical exams, and it is crucial to have a good of them. The easiest way to approach them is by classifying them into systolic and diastolic murmurs. If the arterial valves, such as the aortic or pulmonary valves, are narrowed, ventricular contraction will cause turbulent flow, resulting in a systolic murmur. On the other hand, if these valves are incompetent, blood will leak back through the valve during diastole, causing a diastolic murmur.
Similarly, the atrioventricular valves, such as the mitral and tricuspid valves, can be thought of in the same way. If these valves are leaky, blood will be forced back into the atria during systole, causing a systolic murmur. If they are narrowed, blood will not flow freely from the atria to the ventricles during diastole, causing a diastolic murmur.
Therefore, a diastolic murmur indicates either aortic/pulmonary regurgitation or mitral/tricuspid stenosis. The loud first heart sound is due to increased force in closing the mitral or tricuspid valve, which suggests stenosis. the different types of valvular murmurs and their causes is essential for medical professionals to diagnose and treat patients accurately.
-
This question is part of the following fields:
- Cardiology
-
-
Question 9
Incorrect
-
A typically healthy and fit 35-year-old man presents to the Emergency Department (ED) with palpitations that have been ongoing for 4 hours. He reports no chest pain, has a National Early Warning Score (NEWS) of 0, and the only physical finding is an irregularly irregular pulse. An electrocardiogram (ECG) confirms that the patient is experiencing atrial fibrillation. The patient has no notable medical history.
What is the most suitable course of action?Your Answer: Anticoagulation therapy with warfarin
Correct Answer: Medical cardioversion (amiodarone or flecainide)
Explanation:Management of Atrial Fibrillation: Treatment Options and Considerations
Atrial fibrillation (AF) is a common cardiac arrhythmia that requires prompt management to prevent complications. The following are the treatment options and considerations for managing AF:
Investigations for Reversible Causes
Before initiating any treatment, the patient should be investigated for reversible causes of AF, such as hyperthyroidism and alcohol. Blood tests (TFTs, FBC, U and Es, LFTs, and coagulation screen) and a chest X-ray should be performed.Medical Cardioversion
If no reversible causes are found, medical cardioversion is the most appropriate treatment for haemodynamically stable patients who present within 48 hours of the onset of AF. Amiodarone or flecainide can be used for this purpose.DC Cardioversion
DC cardioversion is indicated for haemodynamically unstable patients, including those with shock, syncope, myocardial ischaemia, and heart failure. It is also appropriate if medical cardioversion fails.Anticoagulation Therapy with Warfarin
Patients who remain in persistent AF for over 48 hours should have their CHA2DS2 VASc score calculated. If the score is equal to or greater than 1 for men or equal to or greater than 2 for women, anticoagulation therapy with warfarin should be initiated.Radiofrequency Ablation
Radiofrequency ablation is not a suitable treatment for acute AF.24-Hour Three Lead ECG Tape
Sending the patient home with a 24-hour three lead ECG tape and reviewing them in one week is not necessary as the diagnosis of AF has already been established.In summary, the management of AF involves investigating for reversible causes, considering medical or DC cardioversion, initiating anticoagulation therapy with warfarin if necessary, and avoiding radiofrequency ablation for acute AF.
-
This question is part of the following fields:
- Cardiology
-
-
Question 10
Correct
-
A 25-year-old man comes to the Emergency Department complaining of gastroenteritis. He has experienced severe cramps in his left calf and has vomited five times in the last 24 hours. Blood tests reveal hypokalaemia, and an electrocardiogram (ECG) is performed. Which ECG change is most commonly linked to hypokalaemia?
Your Answer: Prominent U waves
Explanation:ECG Changes Associated with Hypo- and Hyperkalaemia
Hypokalaemia, or low levels of potassium in the blood, can cause various changes in an electrocardiogram (ECG). One of the most prominent changes is the appearance of U waves, which follow T waves and usually have the same direction. Hypokalaemia can also cause increased amplitude and width of P waves, prolonged PR interval, T wave flattening and inversion, ST depression, and Q-T prolongation in severe cases.
On the other hand, hyperkalaemia, or high levels of potassium in the blood, can cause peaked T waves, which represent ventricular repolarisation. Hyperkalaemia is also associated with widening of the QRS complex, which can lead to life-threatening ventricular arrhythmias. Flattening of P waves and prolonged PR interval are other ECG changes seen in hyperkalaemia.
It is important to note that some of these ECG changes can overlap between hypo- and hyperkalaemia, such as prolonged PR interval. Therefore, other clinical and laboratory findings should be considered to determine the underlying cause of the ECG changes.
-
This question is part of the following fields:
- Cardiology
-
-
Question 11
Incorrect
-
A 65-year-old male with a nine year history of type 2 diabetes is currently taking metformin 1 g twice daily and gliclazide 160 mg twice daily. He has gained weight over the past year and his HbA1c has worsened from 59 to 64 mmol/mol (20-42). The doctor is considering treating him with either insulin or pioglitazone. The patient is curious about the potential side effects of pioglitazone.
What is a common side effect of pioglitazone therapy?Your Answer: Photosensitivity rash
Correct Answer: Fluid retention
Explanation:Common Side Effects of Diabetes Medications
Pioglitazone, a medication used to treat diabetes, can lead to fluid retention in approximately 10% of patients. This side effect can be worsened when taken with other drugs that also cause fluid retention, such as NSAIDs and calcium antagonists. Additionally, weight gain associated with pioglitazone is due to both fat accumulation and fluid retention. It is important to note that pioglitazone is not recommended for patients with cardiac failure.
Metformin, another commonly prescribed diabetes medication, can cause lactic acidosis as a side effect. This is a known risk and should be monitored closely by healthcare providers.
Sulphonylureas, a class of medications used to stimulate insulin production, may cause a rash that is sensitive to sunlight.
Finally, statins and fibrates, medications used to lower cholesterol levels, have been associated with myositis, a condition that causes muscle inflammation and weakness. It is important for patients to be aware of these potential side effects and to discuss any concerns with their healthcare provider.
-
This question is part of the following fields:
- Cardiology
-
-
Question 12
Incorrect
-
A 42-year-old man is admitted with a 30-min history of severe central ‘crushing’ chest pain radiating down the left arm. He is profusely sweating and looks ‘grey’. The electrocardiogram (ECG) shows sinus tachycardia and 3-mm ST elevation in V3–V6.
Which of the following is the most appropriate treatment?Your Answer: Give the patient aspirin, ticagrelor and low molecular weight heparin
Correct Answer: Give the patient aspirin, ticagrelor and low-molecular-weight heparin, followed by a primary percutaneous coronary intervention (PCI)
Explanation:Treatment Options for ST Elevation Myocardial Infarction (STEMI)
When a patient presents with a ST elevation myocardial infarction (STEMI), prompt and appropriate treatment is crucial. The gold standard treatment for a STEMI is a primary percutaneous coronary intervention (PCI), which should be performed as soon as possible. In the absence of contraindications, all patients should receive aspirin, ticagrelor, and low-molecular-weight heparin before undergoing PCI.
Delaying PCI by treating the pain with sublingual glyceryl trinitrate (GTN), aspirin, and oxygen, and reviewing the patient in 15 minutes is not recommended. Similarly, giving the patient aspirin, ticagrelor, and low molecular weight heparin without performing PCI is incomplete management.
Thrombolysis therapy can be performed on patients without access to primary PCI. However, if primary PCI is available, it is the preferred treatment option.
It is important to note that waiting for cardiac enzymes is not recommended as it would only result in a delay in definitive management. Early and appropriate treatment is crucial in improving outcomes for patients with STEMI.
-
This question is part of the following fields:
- Cardiology
-
-
Question 13
Correct
-
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: 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
-
-
Question 14
Incorrect
-
A 55-year-old man comes in with a sudden onset of severe central chest pain that has been going on for an hour. He has no significant medical history. His vital signs are stable with a heart rate of 90 bpm and blood pressure of 120/70 mmHg. An electrocardiogram reveals 5 mm of ST-segment elevation in the anterior leads (V2–V4). He was given aspirin (300 mg) and diamorphine (5 mg) in the ambulance. What is the definitive treatment for this patient?
Your Answer: Clopidogrel (75 mg)
Correct Answer: Percutaneous coronary intervention
Explanation:Treatment Options for ST-Elevation Myocardial Infarction
ST-elevation myocardial infarction (MI) is a serious condition that requires prompt treatment to save the myocardium. The two main treatment options are primary percutaneous coronary intervention (PCI) and fibrinolysis. Primary PCI is the preferred option for patients who present within 12 hours of symptom onset and can undergo the procedure within 120 minutes of the time when fibrinolysis could have been given.
In addition to PCI or fibrinolysis, patients with acute MI should receive dual antiplatelet therapy with aspirin and a second anti-platelet drug, such as clopidogrel or ticagrelor, for up to 12 months. Patients undergoing PCI should also receive unfractionated heparin or low-molecular-weight heparin, such as enoxaparin.
While glycoprotein IIb/IIIa inhibitors like tirofiban may be used to reduce the risk of immediate vascular occlusion in intermediate- and high-risk patients undergoing PCI, they are not the definitive treatment. Similarly, fibrinolysis with tissue plasminogen activator should only be given if primary PCI cannot be delivered within the recommended timeframe.
Overall, prompt and appropriate treatment is crucial for patients with ST-elevation myocardial infarction to improve outcomes and prevent further complications.
-
This question is part of the following fields:
- Cardiology
-
-
Question 15
Incorrect
-
A 68-year-old woman came to the Heart Failure Clinic complaining of shortness of breath. During the examination, a loud pansystolic murmur was heard throughout her chest. The murmur was more audible during inspiration than expiration, and it was difficult to determine where it was loudest. Additionally, she had distended neck veins and an elevated jugular venous pressure (JVP). What is the most probable diagnosis?
Your Answer:
Correct Answer: Tricuspid regurgitation (TR)
Explanation:Differentiating Heart Murmurs: A Guide
Heart murmurs are abnormal sounds heard during a heartbeat and can indicate underlying heart conditions. Here is a guide to differentiating some common heart murmurs:
Tricuspid Regurgitation (TR)
TR presents with a loud pan-systolic murmur audible throughout the chest, often loudest in the tricuspid area. The most common cause is heart failure, with regurgitation being functional due to myocardial dilation. Patients may have raised JVPs, distended neck veins, and signs of right-sided heart failure.Aortic Sclerosis
Aortic sclerosis is a loud murmur early in systole, with normal S1 and S2. It does not affect pulse pressure, and there is no radiation to the right carotid artery. Right-sided murmurs are louder on inspiration.Aortic Stenosis
Aortic stenosis is a mid-systolic ejection murmur, heard best over the aortic area or right second intercostal space, with radiation into the right carotid artery. It may reduce pulse pressure to <40 mmHg, and S2 may be diminished. Pulmonary Stenosis
Pulmonary stenosis gives a crescendo-decrescendo ejection systolic murmur, loudest over the pulmonary area. It is not pan-systolic, and S2 splitting is widened due to prolonged pulmonic ejection.Mitral Regurgitation
Mitral regurgitation is a pan-systolic murmur heard best over the mitral area, radiating to the axilla. It is not increased on inspiration.Remember to listen carefully to S1 and S2, check for radiation, and consider associated symptoms to differentiate heart murmurs.
-
This question is part of the following fields:
- Cardiology
-
-
Question 16
Incorrect
-
A 45-year-old man is referred to the Cardiology Clinic for a check-up. On cardiac auscultation, an early systolic ejection click is found. A blowing diastolic murmur is also present and best heard over the third left intercostal space, close to the sternum. S1 and S2 heart sounds are normal. There are no S3 or S4 sounds. He denies any shortness of breath, chest pain, dizziness or episodes of fainting.
What is the most likely diagnosis?Your Answer:
Correct Answer: Bicuspid aortic valve without calcification
Explanation:Differentiating between cardiac conditions based on murmurs and clicks
Bicuspid aortic valve without calcification is a common congenital heart malformation in adults. It is characterized by an early systolic ejection click and can also present with aortic regurgitation and/or stenosis, resulting in a blowing early diastolic murmur and/or systolic ejection murmur. However, if there is no systolic ejection murmur, it can be assumed that there is no valvular stenosis or calcification. Bicuspid aortic valves are not essentially associated with stenosis and only become symptomatic later in life when significant calcification is present.
On the other hand, a bicuspid aortic valve with significant calcification will result in aortic stenosis and an audible systolic ejection murmur. This can cause chest pain, shortness of breath, dizziness, or syncope. The absence of a systolic murmur in this case excludes aortic stenosis.
Mixed aortic stenosis and regurgitation can also be ruled out if there is no systolic ejection murmur. An early systolic ejection click without an ejection murmur or with a short ejection murmur is suggestive of a bicuspid aortic valve.
Aortic regurgitation alone will not cause an early systolic ejection click. This is often associated with aortic or pulmonary stenosis or a bicuspid aortic valve.
Lastly, aortic stenosis causes a systolic ejection murmur, while flow murmurs are always systolic in nature and not diastolic.
-
This question is part of the following fields:
- Cardiology
-
-
Question 17
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
-
-
Question 18
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiology
-
-
Question 19
Incorrect
-
A 42-year-old man presents to the Emergency Department with severe central chest pain. The pain is exacerbated by lying down, relieved by sitting forward, and radiates to the left shoulder. He has recently undergone two cycles of radiotherapy for prostate cancer. Upon examination, his blood pressure is 96/52 mmHg (normal <120/80 mmHg), his jugular venous pressure (JVP) is elevated, and his pulse is 98 bpm, which appears to fade on inspiration. Heart sounds are faint. The electrocardiogram (ECG) reveals low-voltage QRS complexes.
What is the most appropriate initial management for this condition?Your Answer:
Correct Answer: Urgent pericardiocentesis
Explanation:The patient is experiencing cardiac tamponade, which is caused by fluid in the pericardial sac compressing the heart and reducing ventricular filling. This is likely due to pericarditis caused by recent radiotherapy. Beck’s triad of low blood pressure, raised JVP, and muffled heart sounds are indicative of tamponade. Urgent pericardiocentesis is necessary to aspirate the pericardial fluid using a 20 ml syringe and 18G needle under echocardiographic guidance. An ECG should be obtained to rule out MI and PE. GTN spray is used to manage MI, but it is not part of the treatment for tamponade. DC cardioversion is used for unstable cardiac arrhythmias, not tamponade. A fluid challenge with 1 liter of sodium chloride is not recommended as it may worsen the tamponade. LMWH is used to manage pulmonary embolus, but it is not appropriate for tamponade and may worsen the condition if the cause is haemopericardium.
-
This question is part of the following fields:
- Cardiology
-
-
Question 20
Incorrect
-
What is the most accurate statement regarding the electrocardiograph?
Your Answer:
Correct Answer: ST depression and tall R waves in leads V1 and V2 are consistent with a diagnosis of a posterior myocardial infarction
Explanation:Common ECG Findings and Their Significance
Electrocardiogram (ECG) is a valuable tool in diagnosing various cardiac conditions. Here are some common ECG findings and their significance:
1. ST depression and tall R waves in leads V1 and V2 are consistent with a diagnosis of a posterior myocardial infarction.
2. Pneumonia causes low-voltage QRS complexes. This can be caused by the dampening effect of extra layers of fat, fluid, or air between the heart and thoracic wall.
3. The corrected QT interval (QTc) is calculated by Bazett’s formula: QTc = QT interval ÷ square root of the RR interval (in seconds).
4. A 2-mm ST elevation in leads II, III, aVF, V4, and V5 is consistent with an anterior myocardial infarction. This suggests an inferior lateral infarction, as opposed to just an inferior myocardial infarction.
5. The S1Q3T3 pattern is seen in up to 20% of patients with a pulmonary embolism. Sinus tachycardia is the most common ECG abnormality seen in patients presenting with pulmonary emboli. Other potential findings include a right ventricular strain pattern, complete and incomplete right bundle branch block (RBBB), and P pulmonale indicating right atrial enlargement.
Understanding these common ECG findings can aid in the diagnosis and management of various cardiac conditions.
-
This question is part of the following fields:
- Cardiology
-
-
Question 21
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiology
-
-
Question 22
Incorrect
-
A young marine biologist was snorkelling among giant stingrays when the tail (barb) of one of the stingrays suddenly pierced his chest. The tip of the barb pierced the right ventricle and the man instinctively removed it in the water. When he was brought onto the boat, there was absence of heart sounds, reduced cardiac output and engorged jugular veins.
What was the most likely diagnosis for the young marine biologist who was snorkelling among giant stingrays and had the tail (barb) of one of the stingrays pierce his chest, causing the tip of the barb to pierce the right ventricle? Upon being brought onto the boat, the young man exhibited absence of heart sounds, reduced cardiac output and engorged jugular veins.Your Answer:
Correct Answer: Cardiac tamponade
Explanation:Differential diagnosis of a patient with chest trauma
When evaluating a patient with chest trauma, it is important to consider various potential diagnoses based on the clinical presentation and mechanism of injury. Here are some possible explanations for different symptoms:
– Cardiac tamponade: If a projectile penetrates the fibrous pericardium, blood can accumulate in the pericardial cavity and compress the heart, leading to decreased cardiac output and potential death.
– Deep vein thrombosis: This condition involves the formation of a blood clot in a deep vein, often in the leg. However, it does not typically cause the symptoms described in this case.
– Stroke: A stroke occurs when blood flow to the brain is disrupted, usually due to a blockage or rupture of an artery. This is not likely to be the cause of the patient’s symptoms.
– Pulmonary embolism: If a clot from a deep vein thrombosis travels to the lungs and obstructs blood flow, it can cause sudden death. However, given the history of trauma, other possibilities should be considered first.
– Haemothorax: This refers to the accumulation of blood in the pleural cavity around a lung. While it can cause respiratory distress and chest pain, it does not typically affect jugular veins or heart sounds. -
This question is part of the following fields:
- Cardiology
-
-
Question 23
Incorrect
-
What term describes a lack of pulses but regular coordinated electrical activity on an ECG?
Your Answer:
Correct Answer: Pulseless electrical activity (PEA)
Explanation:Causes of Pulseless Electrical Activity
Pulseless Electrical Activity (PEA) occurs when there is a lack of pulse despite normal electrical activity on the ECG. This can be caused by poor intrinsic myocardial contractility or a variety of remediable factors. These factors include hypoxemia, hypovolemia, severe acidosis, tension pneumothorax, pericardial tamponade, hyperkalemia, hypocalcemia, poisoning with a calcium channel blocker, or hypothermia. Additionally, PEA may be caused by a massive pulmonary embolism. It is important to identify and address the underlying cause of PEA in order to improve patient outcomes.
-
This question is part of the following fields:
- Cardiology
-
-
Question 24
Incorrect
-
A 65-year-old retiree visits his GP as he is becoming increasingly breathless and tired whilst walking. He has always enjoyed walking and usually walks 3 times a week. Over the past year he has noted that he can no longer manage the same distance that he used to be able to without getting breathless and needing to stop. He wonders if this is a normal part of ageing or if there could be an underlying medical problem.
Which of the following are consistent with normal ageing with respect to the cardiovascular system?Your Answer:
Correct Answer: Reduced VO2 max
Explanation:Ageing and Cardiovascular Health: Understanding the Normal and Abnormal Changes
As we age, our organs may still function normally at rest, but they may struggle to respond adequately to stressors such as exercise or illness. One of the key indicators of cardiovascular health is VO2 max, which measures the maximum rate of oxygen consumption during exercise. In normal ageing, VO2 max may decrease along with muscle strength, making intense exertion more difficult. However, significantly reduced VO2 max, left ventricular ejection fraction (LVEF), or stroke volume are not consistent with normal ageing. Additionally, hypotension or hypertension are not typical changes associated with ageing. Understanding these normal and abnormal changes can help us better monitor and manage our cardiovascular health as we age.
-
This question is part of the following fields:
- Cardiology
-
-
Question 25
Incorrect
-
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
-
This question is part of the following fields:
- Cardiology
-
-
Question 26
Incorrect
-
Which statement about congenital heart disease is accurate?
Your Answer:
Correct Answer: In Down's syndrome with an endocardial cushion defect, irreversible pulmonary hypertension occurs earlier than in children with normal chromosomes
Explanation:Common Congenital Heart Defects and their Characteristics
An endocardial cushion defect, also known as an AVSD, is the most prevalent cardiac malformation in individuals with Down Syndrome. This defect can lead to irreversible pulmonary hypertension, which is known as Eisenmenger’s syndrome. It is unclear why children with Down Syndrome tend to have more severe cardiac disease than unaffected children with the same abnormality.
ASDs, or atrial septal defects, may close on their own, and the likelihood of spontaneous closure is related to the size of the defect. If the defect is between 5-8 mm, there is an 80% chance of closure, but if it is larger than 8 mm, the chance of closure is minimal.
Tetralogy of Fallot, a cyanotic congenital heart disease, typically presents after three months of age. The murmur of VSD, or ventricular septal defect, becomes more pronounced after one month of life. Overall, the characteristics of these common congenital heart defects is crucial for proper diagnosis and treatment.
-
This question is part of the following fields:
- Cardiology
-
-
Question 27
Incorrect
-
A 55-year-old man presents with sudden onset of severe chest pain and difficulty breathing. The pain started while he was eating and has been constant for the past three hours. It radiates to his back and interscapular region.
The patient has a history of hypertension for three years, alcohol abuse, and is a heavy smoker of 30 cigarettes per day. On examination, he is cold and clammy with a heart rate of 130/min and a blood pressure of 80/40 mm Hg. JVP is normal, but breath sounds are decreased at the left lung base and a chest x-ray reveals a left pleural effusion.
What is the most likely diagnosis?Your Answer:
Correct Answer: Acute aortic dissection
Explanation:Acute Aortic Dissection: Symptoms, Diagnosis, and Imaging
Acute aortic dissection is a medical emergency that causes sudden and severe chest pain. The pain is often described as tearing and may be felt in the front or back of the chest, as well as in the neck. Other symptoms and signs depend on the arteries involved and nearby organs affected. In severe cases, it can lead to hypovolemic shock and sudden death.
A chest x-ray can show a widened mediastinum, cardiomegaly, pleural effusion, and intimal calcification separated more than 6 mm from the edge. However, aortography is the gold standard for diagnosis, which shows the origin of arteries from true or false lumen. CT scan and MRI are also commonly used for diagnosis. Transoesophageal echo (TEE) is best for the descending aorta, while transthoracic echo (TTE) is best for the ascending aorta and arch.
In summary, acute aortic dissection is a serious condition that requires prompt diagnosis and treatment. Symptoms include sudden and severe chest pain, which may be accompanied by other signs depending on the arteries involved. Imaging techniques such as chest x-ray, aortography, CT scan, MRI, TEE, and TTE can aid in diagnosis.
-
This question is part of the following fields:
- Cardiology
-
-
Question 28
Incorrect
-
An adolescent with Down's syndrome is being seen at the cardiology clinic due to a heart murmur detected during a routine check-up. It is known that approximately half of infants with Down's syndrome have congenital heart defects, and the prevalence remains high throughout their lifespan. What are the five most frequent types of congenital heart disease observed in individuals with Down's syndrome? Please list them in order of decreasing incidence, starting with the most common cause and ending with the least common cause.
Your Answer:
Correct Answer: Atrioventricular septal defect, ventricular septal defect, tetralogy of Fallot, atrial septal defect, patent ductus arteriosus
Explanation:Congenital Heart Defects in Down’s Syndrome
Congenital heart defects are common in individuals with Down’s syndrome, with five specific pathologies accounting for approximately 99% of cases. Atrioventricular septal defects and ventricular septal defects occur in roughly a third of cases each, while the remaining third is accounted for by the other three defects. Chromosomal abnormalities, such as trisomy 21, which is commonly associated with Down’s syndrome, can predispose individuals to congenital heart disease. Around 50% of people with Down’s syndrome have one of the five cardiac defects listed above, but the exact cause for this is not yet known.
The development of endocardial cushions is often impaired in individuals with Down’s syndrome, which can lead to defects in the production of the atrial and ventricular septae, as well as the development of the atrioventricular valves. This explains why atrioventricular septal defects are a common congenital defect in Down’s syndrome, as they involve a common atrioventricular orifice and valve. The severity of the defect depends on its size and the positioning of the leaflets of the common atrioventricular valve, which contribute to defining the degree of shunt. Additionally, the type of ventricular septal defects and atrial septal defects that commonly occur in Down’s syndrome can be explained by the impaired development of endocardial cushions. VSDs are usually of the inlet type, while ASDs are more commonly of the prium type, representing a failure of the endocardial cushion to grow in a superior direction.
-
This question is part of the following fields:
- Cardiology
-
-
Question 29
Incorrect
-
You are requested by a nurse to assess a 66-year-old woman on the Surgical Assessment Unit who is 1-day postoperative, having undergone a laparoscopic cholecystectomy procedure for cholecystitis. She has a medical history of type II diabetes mellitus and chronic kidney disease. Blood tests taken earlier in the day revealed electrolyte imbalances with hyperkalaemia.
Which of the following ECG changes is linked to hyperkalaemia?Your Answer:
Correct Answer: Peaked T waves
Explanation:Electrocardiogram (ECG) Changes Associated with Hypo- and Hyperkalaemia
Hypo- and hyperkalaemia can cause significant changes in the ECG. Hypokalaemia is associated with increased amplitude and width of the P wave, T wave flattening and inversion, ST-segment depression, and prominent U-waves. As hypokalaemia worsens, it can lead to frequent supraventricular ectopics and tachyarrhythmias, eventually resulting in life-threatening ventricular arrhythmias. On the other hand, hyperkalaemia is associated with peaked T waves, widening of the QRS complex, decreased amplitude of the P wave, prolongation of the PR interval, and eventually ventricular tachycardia/ventricular fibrillation. Both hypo- and hyperkalaemia can cause prolongation of the PR interval, but only hyperkalaemia is associated with flattening of the P-wave. In hyperkalaemia, eventually ventricular tachycardia/ventricular fibrillation is seen, while AF can occur in hypokalaemia.
-
This question is part of the following fields:
- Cardiology
-
-
Question 30
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiology
-
00
Correct
00
Incorrect
00
:
00
:
00
Session Time
00
:
00
Average Question Time (
Mins)