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Question 1
Correct
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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: 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.
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This question is part of the following fields:
- Cardiology
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Question 2
Correct
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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: 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 3
Incorrect
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A 51-year-old man passed away from a massive middle cerebral artery stroke. He had no previous medical issues. Upon autopsy, it was discovered that his heart weighed 400 g and had normal valves and coronary arteries. The atria and ventricles were not enlarged. The right ventricular walls were normal, while the left ventricular wall was uniformly hypertrophied to 20-mm thickness. What is the probable reason for these autopsy results?
Your Answer: Hypertrophic obstructive cardiomyopathy
Correct Answer: Essential hypertension
Explanation:Differentiating Cardiac Conditions: Causes and Risks
Cardiac conditions can have varying causes and risks, making it important to differentiate between them. Essential hypertension, for example, is characterized by uniform left ventricular hypertrophy and is a major risk factor for stroke. On the other hand, atrial fibrillation is a common cause of stroke but does not cause left ventricular hypertrophy and is rarer with normal atrial size. Hypertrophic obstructive cardiomyopathy, which is more common in men and often has a familial tendency, typically causes asymmetric hypertrophy of the septum and apex and can lead to arrhythmogenic or unexplained sudden cardiac death. Dilated cardiomyopathies, such as idiopathic dilated cardiomyopathy, often have no clear precipitant but cause a dilated left ventricular size, increasing the risk for a mural thrombus and an embolic risk. Finally, tuberculous pericarditis is difficult to diagnose due to non-specific features such as cough, dyspnoea, sweats, and weight loss, with typical constrictive pericarditis findings being very late features with fluid overload and severe dyspnoea. Understanding the causes and risks associated with these cardiac conditions can aid in their proper diagnosis and management.
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This question is part of the following fields:
- Cardiology
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Question 4
Correct
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A 27-year-old man comes to the clinic complaining of headache, dizziness, and claudication. Upon measuring his blood pressure, it is found that he has hypertension in his upper limbs and hypotension in his lower limbs. What other finding is most likely to be present in this case?
Your Answer: Notching of the inferior margins of the ribs
Explanation:Common Causes of Cardiovascular Disorders in Adults
Cardiovascular disorders are a leading cause of morbidity and mortality in adults. Among the most common causes of these disorders are aortic coarctation, patent ductus arteriosus, aortic valvular stenosis, pulmonary valvular stenosis, and vasculitis involving the aortic arch.
Notching of the Inferior Margins of the Ribs: Aortic Coarctation
Aortic coarctation is caused by stenosis in the aortic arch, leading to hypertension proximal to and hypotension distal to the stenotic segment. Enlarged intercostal arteries produce notching of the inferior margins of the ribs, which is diagnostic of this condition.Chronic Cor Pulmonale: Patent Ductus Arteriosus
Patent ductus arteriosus leads to shunting of blood from the aorta to the pulmonary artery, eventually causing chronic cor pulmonale and right-sided heart failure.Systolic Hypotension: Aortic Valvular Stenosis
Aortic valvular stenosis is caused by a congenitally malformed valve, usually a valve with two cusps or a single cusp. It manifests with systolic hypotension, recurrent syncope, and hypertrophy/dilation of the left ventricle.Chronic Cor Pulmonale and Heart Failure: Pulmonary Valvular Stenosis
Pulmonary valvular stenosis is a rare form of congenital heart disease that leads to chronic cor pulmonale and heart failure.Ischemia in the Upper Body: Vasculitis Involving the Aortic Arch
Vasculitis involving the aortic arch is found in Takayasu arthritis, causing chronic inflammatory changes in the aortic arch and its branches. This condition leads to stenosis of these arteries, resulting in signs and symptoms of ischemia in the upper part of the body. It is also known as pulseless disease due to weak or absent radial pulses. -
This question is part of the following fields:
- Cardiology
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Question 5
Correct
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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: 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.
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This question is part of the following fields:
- Cardiology
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Question 6
Correct
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In a 25-year-old woman undergoing a routine physical examination for a new job, a mid-systolic ejection murmur is discovered in the left upper sternal border. The cardiac examination reveals a significant right ventricular cardiac impulse and wide and fixed splitting of the second heart sound. An electrocardiogram (ECG) shows a right axis deviation, and a chest X-ray shows enlargement of the right ventricle and atrium. What is the most probable diagnosis?
Your Answer: Atrial septal defect
Explanation:Cardiac Abnormalities and their Clinical Findings
Atrial Septal Defect:
Atrial septal defect is characterized by a prominent right ventricular cardiac impulse, a systolic ejection murmur heard best in the pulmonic area and along the left sternal border, and fixed splitting of the second heart sound. These findings are due to an abnormal left-to-right shunt through the defect, which creates a volume overload on the right side. Small atrial septal defects are usually asymptomatic.Pulmonary Valve Stenosis:
Pulmonary valve stenosis causes an increased right ventricular pressure which results in right ventricular hypertrophy and pulmonary artery dilation. A crescendo–decrescendo murmur may be heard if there is a severe stenosis. Right atrial enlargement would not be present.Mitral Regurgitation:
Mitral regurgitation would also present with a systolic murmur; however, left atrial enlargement would be seen before right ventricular enlargement.Mitral Stenosis:
Mitral stenosis would present with an ‘opening snap’ and a diastolic murmur.Aortic Stenosis:
Aortic stenosis is also associated with a systolic ejection murmur. However, the murmur is usually loudest at the right sternal border and radiates upwards to the jugular notch. Aortic stenosis is associated with left ventricular hypertrophy.Clinical Findings of Common Cardiac Abnormalities
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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 25-year-old man visits his general practitioner (GP), as he is concerned that he may have inherited a heart condition. He is fit and well and has no history of any medical conditions. However, his 28-year-old brother has recently been diagnosed with hypertrophic cardiomyopathy (HCM) after collapsing when he was playing football. The patient’s father died suddenly when he was 42, which the family now thinks might have been due to the same condition.
Which of the following signs is most likely to be found in a patient with this condition?Your Answer:
Correct Answer: Ejection systolic murmur decreased by squatting
Explanation:Understanding the Ejection Systolic Murmur in Hypertrophic Cardiomyopathy: Decreased by Squatting
Hypertrophic cardiomyopathy (HCM) is a condition characterized by asymmetrical hypertrophy of both ventricles, with the septum hypertrophying and causing an outflow obstruction of the left ventricle. This obstruction leads to an ejection systolic murmur and reduced cardiac output. However, interestingly, this murmur can be decreased by squatting, which is not typical for most heart murmurs.
Squatting affects murmurs by increasing afterload and preload, which usually makes heart murmurs louder. However, in HCM, the murmur intensity is decreased due to increased left ventricular size and reduced outflow obstruction. Other findings on examination may include a jerky pulse and a double apex beat.
While HCM is often asymptomatic, it can present with dyspnea, angina, and syncope. Patients are also at risk of sudden cardiac death, most commonly due to ventricular arrhythmias. Poor prognostic factors include syncope, family history of sudden death, onset of symptoms at a young age, ventricular tachycardia on Holter monitoring, abnormal blood pressure response during exercise, and septal thickness greater than 3 cm on echocardiogram.
In summary, understanding the ejection systolic murmur in HCM and its unique response to squatting can aid in the diagnosis and management of this condition.
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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 30-year-old woman with rheumatic fever has ongoing shortness of breath following her infection. You suspect she may have mitral stenosis.
What is the most suitable surface anatomical landmark to listen for this murmur?Your Answer:
Correct Answer: At the apex beat
Explanation:Surface Locations for Cardiac Auscultation
Cardiac auscultation is a crucial part of a physical examination to assess the heart’s function. The surface locations for cardiac auscultation are essential to identify the specific valve sounds. Here are the surface locations for cardiac auscultation:
1. Apex Beat: The mitral valve is best heard over the palpated apex beat. If it cannot be felt, then it should be assumed to be in the fifth intercostal space, mid-clavicular line.
2. Fifth Intercostal Space, Mid-Axillary Line: This location is too lateral to hear a mitral valve lesion in a non-dilated ventricle.
3. Second Intercostal Space, Left of the Sternum: The pulmonary valve is located in the second intercostal space, left of the sternum.
4. Fourth Intercostal Space, Left of the Sternum: The tricuspid valve is located in the fourth intercostal space, left of the sternum.
5. Xiphisternum: The xiphisternum is not used as a marker for cardiac auscultation, though it is used to guide echocardiography for certain standard views.
Knowing the surface locations for cardiac auscultation is crucial to identify the specific valve sounds and assess the heart’s function accurately.
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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 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 10
Incorrect
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A 65-year-old insurance broker with mitral stenosis is seen in the Cardiology Clinic. He reports increasing shortness of breath on exertion and general fatigue over the past six months. Additionally, he notes swelling in his feet and ankles at the end of the day. What is the first-line intervention for symptomatic mitral stenosis with a mobile undistorted mitral valve and no left atrial thrombus or mitral regurgitation?
Your Answer:
Correct Answer: Balloon valvuloplasty
Explanation:Treatment Options for Mitral Valve Disease
Mitral valve disease can be managed through various treatment options depending on the severity and type of the condition. Balloon valvuloplasty is the preferred option for symptomatic patients with mitral stenosis, while mitral valve repair is the preferred surgical management for mitral regurgitation. Aortic valve replacement is an option if the aortic valve is faulty. Mitral valve replacement with a metallic valve requires high levels of anticoagulation, and therefore repair is preferred if possible. The Blalock–Taussig shunt is a surgical method for palliation of cyanotic congenital heart disease. Mitral valve repair may be considered in patients with mitral stenosis if the valve anatomy is unsuitable for balloon valvuloplasty. However, if the patient has severe symptomatic mitral stenosis with signs of heart failure, mitral valve replacement would be the first line of treatment.
Treatment Options for Mitral Valve Disease
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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 72-year-old man is admitted to hospital with exertional chest pain. He reports that this has only begun in the past few days, particularly when climbing hills. The pain is not present when he is at rest.
What is the gold standard test that you will request for this patient from the following tests?Your Answer:
Correct Answer: Computed tomography (CT) coronary angiogram
Explanation:Investigating Cardiac Chest Pain: Recommended Tests
When a patient presents with cardiac chest pain, it is important to conduct appropriate investigations to determine the underlying cause. The following tests are recommended:
Computed Tomography (CT) Coronary Angiogram: This non-invasive test uses CT scanning to detect any evidence of coronary artery disease and determine its extent. It is considered the gold standard test for investigating cardiac chest pain.
Angiogram: Before undergoing an angiogram, the patient should first have an exercise tolerance test (ETT) to assess real-time cardiac function during exertion. If the patient experiences ischaemic changes and reduced exercise tolerance, an angiogram may be necessary.
Chest X-ray: A chest X-ray is not a priority investigation for cardiac chest pain, as it does not aid in diagnosis unless there is evidence of associated heart failure or pleural effusions.
Full Blood Count: While anaemia could contribute to angina, a full blood count is not a first-line investigation for cardiac chest pain.
Troponin: Troponin levels may be raised in cases of myocardial damage, but are not necessary for managing angina. The recurring pain and relief with rest indicate angina, rather than a myocardial infarction (MI), which would present with crushing chest pain and dyspnoea that is not alleviated by rest.
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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 50-year-old male smoker presents with a 6-hour history of gradual-onset central chest pain. The chest pain is worse on inspiration and relieved by leaning forward. He reports recently suffering a fever which he attributed to a viral illness. He has no significant past medical history; however, both his parents suffered from ischaemic heart disease in their early 60s. An electrocardiogram (ECG) reveals PR depression and concave ST-segment elevation in most leads. He is haemodynamically stable.
What is the most appropriate management?Your Answer:
Correct Answer: Ibuprofen
Explanation:Treatment Options for Acute Pericarditis: Understanding the Clinical Scenario
Acute pericarditis can be caused by a variety of factors, including infection, inflammation, and metabolic issues. The condition is typically characterized by gradual-onset chest pain that worsens with inspiration and lying flat, but improves with leaning forward. ECG findings often show concave ST-segment elevation and PR depression in certain leads, along with reciprocal changes in others.
Understanding Treatment Options for Acute Pericarditis
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This question is part of the following fields:
- Cardiology
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Question 13
Incorrect
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A 60-year-old man presents to cardiology outpatients after being lost to follow-up for 2 years. He has a significant cardiac history, including two previous myocardial infarctions, peripheral vascular disease, and three transient ischemic attacks. He is also a non-insulin-dependent diabetic. During examination, his JVP is raised by 2 cm, and he has peripheral pitting edema to the mid-calf bilaterally and bilateral basal fine inspiratory crepitations. His last ECHO, performed 3 years ago, showed moderately impaired LV function and mitral regurgitation. He is currently taking bisoprolol, aspirin, simvastatin, furosemide, ramipril, and gliclazide. Which medication, if added, would provide prognostic benefit?
Your Answer:
Correct Answer: Spironolactone
Explanation:Heart Failure Medications: Prognostic and Symptomatic Benefits
Heart failure is a prevalent disease that can be managed with various medications. These medications can be divided into two categories: those with prognostic benefits and those with symptomatic benefits. Prognostic medications help improve long-term outcomes, while symptomatic medications provide relief from symptoms.
Prognostic medications include selective beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II antagonists, and spironolactone. In the RALES trial, spironolactone was shown to reduce all-cause mortality by 30% in patients with heart failure and an ejection fraction of less than 35%.
Symptomatic medications include loop diuretics, digoxin, and vasodilators such as nitrates and hydralazine. These medications provide relief from symptoms but do not improve long-term outcomes.
Other medications, such as nifedipine, sotalol, and naftidrofuryl, are used to manage other conditions such as angina, hypertension, and peripheral and cerebrovascular disorders, but are not of prognostic benefit in heart failure.
Treatment for heart failure can be tailored to each individual case, and heart transplant remains a limited option for certain patient groups. Understanding the benefits and limitations of different medications can help healthcare providers make informed decisions about the best course of treatment for their patients.
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This question is part of the following fields:
- Cardiology
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Question 14
Incorrect
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A 54-year-old patient is evaluated in the Pre-Assessment Clinic before undergoing elective surgery for varicose veins. The patient is in good health, with the only significant medical history being well-controlled hypertension with lisinopril. During the examination, the clinician hears an early opening snap in diastole when listening to the patient's heart. What is the most probable cause of this finding?
Your Answer:
Correct Answer: Mitral stenosis
Explanation:Common Heart Murmurs and Their Characteristics
Heart murmurs are abnormal sounds heard during a heartbeat and can indicate underlying heart conditions. Here are some common heart murmurs and their characteristics:
Mitral Stenosis: This condition causes a mid-diastolic murmur that is best heard with the bell of the stethoscope over the apex while the patient is lying in the left lateral position. Severe mitral stenosis can also cause a quiet first heart sound and an early opening snap.
Pulmonary Stenosis: Pulmonary stenosis causes an ejection systolic murmur.
Ventricular Septal Defect: This condition causes a pan-systolic murmur.
Mitral Valve Prolapse: Mitral valve prolapse may cause a mid-systolic click, followed by a late systolic murmur.
Right Bundle Branch Block: This condition is a cause of wide splitting of the second heart sound.
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This question is part of the following fields:
- Cardiology
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Question 15
Incorrect
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A 42-year-old man felt dizzy at work and later had a rhythm strip (lead II) performed in the Emergency Department. It reveals one P wave for every QRS complex and a PR interval of 240 ms.
What does this rhythm strip reveal?Your Answer:
Correct Answer: First-degree heart block
Explanation:Understanding Different Types of Heart Block
Heart block is a condition where the electrical signals that control the heartbeat are disrupted, leading to an abnormal heart rhythm. There are different types of heart block, each with its own characteristic features.
First-degree heart block is characterized by a prolonged PR interval, but with a 1:1 ratio of P waves to QRS complexes. This type of heart block is usually asymptomatic and does not require treatment.
Second-degree heart block can be further divided into two types: Mobitz type 1 and Mobitz type 2. Mobitz type 1, also known as Wenckebach’s phenomenon, is characterized by a progressive lengthening of the PR interval until a QRS complex is dropped. Mobitz type 2, on the other hand, is characterized by intermittent P waves that fail to conduct to the ventricles, leading to intermittent dropped QRS complexes. This type of heart block often progresses to complete heart block.
Complete heart block, also known as third-degree heart block, occurs when there is no association between P waves and QRS complexes. The ventricular rate is often slow, reflecting a ventricular escape rhythm as the ventricles are no longer controlled by the sinoatrial node pacemaker. This type of heart block requires immediate medical attention.
Understanding the different types of heart block is important for proper diagnosis and treatment. If you experience any symptoms of heart block, such as dizziness, fainting, or chest pain, seek medical attention right away.
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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 55-year-old woman has been suffering from significant pain in her lower limbs when walking more than 200 meters for the past six months. During physical examination, her legs appear pale and cool without signs of swelling or redness. The palpation of dorsalis pedis or posterior tibial pulses is not possible. The patient has a body mass index of 33 kg/m2 and has been smoking for 25 pack years. What is the most probable vascular abnormality responsible for these symptoms?
Your Answer:
Correct Answer: Atherosclerosis
Explanation:Arteriosclerosis and Related Conditions
Arteriosclerosis is a medical condition that refers to the hardening and loss of elasticity of medium or large arteries. Atherosclerosis, on the other hand, is a specific type of arteriosclerosis that occurs when fatty materials such as cholesterol accumulate in the artery walls, causing them to thicken. This chronic inflammatory response is caused by the accumulation of macrophages and white blood cells, and is often promoted by low-density lipoproteins. The formation of multiple plaques within the arteries characterizes atherosclerosis.
Medial calcific sclerosis is another form of arteriosclerosis that occurs when calcium deposits form in the middle layer of walls of medium-sized vessels. This condition is often not clinically apparent unless it is severe, and it is more common in people over 50 years old and in diabetics. It can be seen as opaque vessels on radiographs.
Lymphatic obstruction, on the other hand, is a blockage of the lymph vessels that drain fluid from tissues throughout the body. This condition may cause lymphoedema, and the most common reason for this is the removal or enlargement of the lymph nodes.
It is important to understand these conditions and their differences to properly diagnose and treat patients.
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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 28-year-old male presents with a blood pressure reading of 170/100 mmHg. Upon examination, he exhibits a prominent aortic ejection click and murmurs are heard over the ribs anteriorly and over the back. Additionally, he reports experiencing mild claudication with exertion and has feeble pulses in his lower extremities. What is the most probable diagnosis?
Your Answer:
Correct Answer: Coarctation of the aorta
Explanation:Coarctation of the Aorta: Symptoms and Diagnosis
Coarctation of the aorta is a condition that can present with various symptoms. These may include headaches, nosebleeds, cold extremities, and claudication. However, hypertension is the most typical symptom. A mid-systolic murmur may also be present over the anterior part of the chest, back, spinous process, and a continuous murmur may also be heard.
One important radiographic finding in coarctation of the aorta is notching of the ribs. This is due to erosion by collaterals. It is important to diagnose coarctation of the aorta early on, as it can lead to serious complications such as heart failure, stroke, and aortic rupture.
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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 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:
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.
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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 63-year-old man presents with increasing shortness of breath on exertion. On examination, bibasilar wet pulmonary crackles are noted with mild bilateral lower limb pitting oedema. His jugular vein is slightly distended. An S4 sound is audible on cardiac auscultation. An electrocardiogram (ECG) shows evidence of left ventricular (LV) hypertrophy. Chest radiography shows bilateral interstitial oedema without cardiomegaly.
Which one of the following findings is most likely to be found in this patient?Your Answer:
Correct Answer: Impaired LV relaxation – increased LV end-diastolic pressure – normal LV end-systolic volume
Explanation:Understanding the Different Types of Left Ventricular Dysfunction in Heart Failure
Left ventricular (LV) dysfunction can result in heart failure, which is a clinical diagnosis that can be caused by systolic or diastolic dysfunction, or both. Diastolic dysfunction is characterized by impaired LV relaxation, resulting in increased LV end-diastolic pressure but normal LV end-systolic volume. This type of dysfunction can be caused by factors such as LV hypertrophy from poorly controlled hypertension. On the other hand, impaired LV contraction results in systolic dysfunction, which is characterized by LV dilation, increased LV end-systolic and end-diastolic volumes, and increased LV end-diastolic pressure. It is important to differentiate between these types of LV dysfunction in order to properly diagnose and manage heart failure.
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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 75-year-old man presents to his General Practitioner with chest pain. The man reports the pain as crushing in nature, exacerbated by exertion, particularly when climbing stairs in his home. The pain is typically relieved by rest, but he has experienced several episodes while watching television in the past two weeks. He has no other medical history and is generally in good health.
What is the most suitable course of action?Your Answer:
Correct Answer: Refer to hospital for admission for observation and urgent elective angiogram
Explanation:Appropriate Management for a Patient with Unstable Angina
Unstable angina is a serious condition that requires urgent medical attention. In the case of a patient displaying textbook signs of unstable angina, such as crushing chest pain occurring at rest, admission to the hospital is necessary. Sending the patient home with only glyceryl trinitrate (GTN) spray is not appropriate, as the patient is at high risk of having a myocardial infarction (MI). Instead, the patient should be seen by Cardiology for consideration of an urgent elective angiogram.
Prescribing ramipril and simvastatin is not indicated unless there is evidence of hypertension. Lifestyle advice, including exercise recommendation, is also not appropriate for a patient with unstable angina. The immediate problem should be addressed first, which is the need for an angiogram.
It is important to differentiate between unstable and stable angina. Unstable angina presents with symptoms at rest, indicating a significant worsening of the patient’s cardiac disease. On the other hand, stable angina only presents with symptoms on exertion.
Sending the patient for percutaneous coronary intervention (PCI) is not necessary unless there is evidence of an MI. The pain experienced due to angina will alleviate itself most commonly at rest, unless the angina is unstable. Therefore, an urgent elective angiogram is the appropriate management for a patient with unstable angina.
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This question is part of the following fields:
- Cardiology
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Question 21
Incorrect
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An 82-year-old man presents with increasing shortness of breath, tiredness, intermittent chest pain and leg swelling for the last 6 months. His past medical history includes hypertension, gout and a previous myocardial infarction 5 years ago. His current medications are as follows:
diltiazem 60 mg orally (po) twice daily (bd)
spironolactone 100 mg po once daily (od)
allopurinol 100 mg po od
paracetamol 1 g po four times daily (qds) as required (prn)
lisinopril 20 mg po od.
Given this man’s likely diagnosis, which of the above medications should be stopped?Your Answer:
Correct Answer: Diltiazem
Explanation:Medications for Heart Failure: Uses and Contraindications
Diltiazem is a calcium channel blocker that can treat angina and hypertension, but it should be stopped in patients with chronic heart disease and heart failure due to its negative inotropic effects.
Spironolactone can alleviate leg swelling and is one of the three drugs that have been shown to reduce mortality in heart failure, along with ACE inhibitors and β-blockers.
Allopurinol is safe to use in heart failure patients as it is used for the prevention of gout and has no detrimental effect on the heart.
Paracetamol does not affect the heart and is safe to use in heart failure patients.
Lisinopril is an ACE inhibitor used to treat hypertension and angina, and stopping it can worsen heart failure. It is also one of the three drugs that have been shown to reduce mortality in heart failure. The mechanism by which ACE inhibitors reduce mortality is not fully understood.
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This question is part of the following fields:
- Cardiology
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Question 22
Incorrect
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A radiologist examined a coronary angiogram of a 75-year-old man with long-standing heart disease and identified stenosis of the right coronary artery resulting in reduced perfusion of the myocardium of the right atrium. Which structure related to the right atrium is most likely to have been impacted by the decreased blood flow?
Your Answer:
Correct Answer: Sinoatrial node
Explanation:Coronary Arteries and their Supply to Cardiac Conduction System
The heart’s conduction system is responsible for regulating the heartbeat. The following are the coronary arteries that supply blood to the different parts of the cardiac conduction system:
Sinoatrial Node
The sinoatrial node, which is the primary pacemaker of the heart, is supplied by the right coronary artery in 60% of cases through a sinoatrial nodal branch.Atrioventricular Node
The atrioventricular node, which is responsible for delaying the electrical impulse before it reaches the ventricles, is supplied by the right coronary artery in 80% of individuals through the atrioventricular nodal branch.Atrioventricular Bundle
The atrioventricular bundle, which conducts the electrical impulse from the atria to the ventricles, is supplied by numerous septal arteries that mostly arise from the anterior interventricular artery, a branch of the left coronary artery.Left Bundle Branch
The left bundle branch, which conducts the electrical impulse to the left ventricle, is supplied by numerous subendocardial bundle arteries that originate from the left coronary artery.Right Bundle Branch
The right bundle branch, which conducts the electrical impulse to the right ventricle, is supplied by numerous subendocardial bundle arteries that originate from the right coronary artery. -
This question is part of the following fields:
- Cardiology
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Question 23
Incorrect
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You are assisting in the anaesthesia of an 80-year-old man for a plastics procedure. He is having a large basal cell carcinoma removed from his nose. He has a history of ischaemic heart disease, having had three stents placed 2 years ago. He is otherwise healthy and still able to walk to the shops. His preoperative electrocardiogram (ECG) showed sinus rhythm. During the procedure, his heart rate suddenly increases to 175 bpm with a narrow complex, and you cannot see P waves on the monitor. You are having difficulty obtaining a blood pressure reading but are able to palpate a radial pulse with a systolic pressure of 75 mmHg. The surgeons have been using lidocaine with adrenaline around the surgical site. What is the next best course of action?
Your Answer:
Correct Answer: 100% O2, synchronised cardioversion, 150-J biphasic shock
Explanation:Treatment Options for a Patient with Narrow-Complex Tachycardia and Low Blood Pressure
When a patient with a history of ischaemic heart disease presents with a narrow-complex tachycardia and low blood pressure, it is likely that they have gone into fast atrial fibrillation. In this case, the first step in resuscitation should be a synchronised direct current (DC) cardioversion with a 150-J biphasic shock. Administering 100% oxygen, a 500 ml Hartmann bolus, and 0.5 mg metaraminol may help increase the patient’s blood pressure, but it does not address the underlying cause of their haemodynamic instability.
Amiodarone 300 mg stat is recommended for patients with narrow-complex tachycardia and haemodynamic instability. However, administering 10 mmol magnesium sulphate is not the first-line treatment for tachycardia unless the patient has torsades de pointes.
Lastly, administering Intralipid® as per guideline for local anaesthetic toxicity is unlikely to be the main source of the patient’s hypotension and does not address their narrow-complex tachycardia. Therefore, it is important to prioritize the synchronised cardioversion and amiodarone administration in this patient’s treatment plan.
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This question is part of the following fields:
- Cardiology
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Question 24
Incorrect
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A 55-year-old man presents to the clinic with complaints of chest pain and difficulty breathing. He had been hospitalized four weeks ago for acute coronary syndrome and was discharged on bisoprolol, simvastatin, aspirin, and ramipril. During the examination, a narrow complex tachycardia is observed. What is the absolute contraindication in this scenario?
Your Answer:
Correct Answer: Verapamil
Explanation:Verapamil and Beta Blockers: A Dangerous Combination
Verapamil is a type of medication that blocks calcium channels in the heart, leading to a decrease in cardiac output and a slower heart rate. However, it also has negative effects on the heart’s ability to contract, making it a highly negatively inotropic drug. Additionally, it may impair the conduction of electrical signals between the atria and ventricles of the heart.
According to the British National Formulary (BNF), verapamil should not be given to patients who are already taking beta blockers. This is because the combination of these two drugs can lead to dangerously low blood pressure and even asystole, a condition where the heart stops beating altogether.
Therefore, it is important for healthcare professionals to carefully consider a patient’s medication history before prescribing verapamil. If a patient is already taking beta blockers, alternative treatments should be considered to avoid the potentially life-threatening consequences of combining these two drugs.
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This question is part of the following fields:
- Cardiology
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Question 25
Incorrect
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A 60-year-old man comes to the hospital with sudden central chest pain. An ECG is done and shows ST elevation, indicating an infarct on the inferior surface of the heart. The patient undergoes primary PCI, during which a blockage is discovered in a vessel located within the coronary sulcus.
What is the most probable location of the occlusion?Your Answer:
Correct Answer: Right coronary artery
Explanation:Identifying the Affected Artery in a Myocardial Infarction
Based on the ECG findings of ST elevation in the inferior leads and the primary PCI result of an occlusion within the coronary sulcus, it is likely that the right coronary artery has been affected. The anterior interventricular artery does not supply the inferior surface of the heart and does not lie within the coronary sulcus. The coronary sinus is a venous structure and is unlikely to be the site of occlusion. The right (acute) marginal artery supplies a portion of the inferior surface of the heart but does not run within the coronary sulcus. Although the left coronary artery lies within the coronary sulcus, the ECG findings suggest an infarction of the inferior surface of the heart, which is evidence for a right coronary artery event.
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This question is part of the following fields:
- Cardiology
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Question 26
Incorrect
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A 56-year-old man presents to the Emergency Department with crushing substernal chest pain that radiates to the jaw. He has a history of poorly controlled hypertension and uncontrolled type II diabetes mellitus for the past 12 years. An electrocardiogram (ECG) reveals ST elevation, and he is diagnosed with acute myocardial infarction. The patient undergoes percutaneous coronary intervention (PCI) and stenting and is discharged from the hospital. Eight weeks later, he experiences fever, leukocytosis, and chest pain that is relieved by leaning forwards. There is diffuse ST elevation in multiple ECG leads, and a pericardial friction rub is heard on auscultation. What is the most likely cause of the patient's current symptoms?
Your Answer:
Correct Answer: Dressler’s syndrome
Explanation:Complications of Transmural Myocardial Infarction
Transmural myocardial infarction can lead to various complications, including Dressler’s syndrome and ventricular aneurysm. Dressler’s syndrome typically occurs weeks to months after an infarction and is characterized by acute fibrinous pericarditis, fever, pleuritic chest pain, and leukocytosis. On the other hand, ventricular aneurysm is characterized by a systolic bulge in the precordial area and predisposes to stasis and thrombus formation. Acute fibrinous pericarditis, which manifests a few days after an infarction, is not due to an autoimmune reaction. Reinfarction is unlikely in a patient who has undergone successful treatment for STEMI. Infectious myocarditis, caused by viruses such as Coxsackie B, Epstein-Barr, adenovirus, and echovirus, is not the most likely cause of the patient’s symptoms, given his medical history.
Complications of Transmural Myocardial Infarction
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This question is part of the following fields:
- Cardiology
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Question 27
Incorrect
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A 50-year-old man who is a known alcoholic is brought to the Emergency Department after being found unconscious. Over several hours, he regains consciousness. His blood alcohol level is high and a head computerised tomography (CT) scan is negative, so you diagnose acute intoxication. A routine chest X-ray demonstrated an enlarged globular heart. An echocardiogram revealed a left ventricular ejection fraction of 45%.
What is the most likely cause of his cardiac pathology, and what might gross examination of his heart reveal?Your Answer:
Correct Answer: Alcohol and dilation of all four chambers of the heart
Explanation:Alcohol and its Effects on Cardiomyopathy: Understanding the Relationship
Alcohol consumption has been linked to various forms of cardiomyopathy, a condition that affects the heart muscle. One of the most common types of cardiomyopathy is dilated cardiomyopathy, which is characterized by the dilation of all four chambers of the heart. This condition results in increased end-diastolic volume, decreased contractility, and depressed ejection fraction. Chronic alcohol use is a significant cause of dilated cardiomyopathy, along with viral infections, toxins, genetic mutations, and trypanosome infections.
Chagas’ disease, caused by trypanosomes, can lead to cardiomyopathy, resulting in the dilation of all four chambers of the heart. On the other hand, alcoholic cardiomyopathy leads to the dilation of all four chambers of the heart, including the atria. Alcohol consumption can also cause concentric hypertrophy of the left ventricle, which is commonly seen in long-term hypertension. Asymmetric hypertrophy of the interventricular septum is another form of cardiomyopathy that can result from alcohol consumption. This condition is known as hypertrophic cardiomyopathy, a genetic disease that can lead to sudden cardiac death in young athletes.
In conclusion, understanding the relationship between alcohol consumption and cardiomyopathy is crucial in preventing and managing this condition. It is essential to limit alcohol intake and seek medical attention if any symptoms of cardiomyopathy are present.
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This question is part of the following fields:
- Cardiology
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Question 28
Incorrect
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A 57-year-old man arrives at the Emergency Department with sudden onset central crushing chest pain. The patient reports feeling pain in his neck and jaw as well. He has no significant medical history, but he does smoke occasionally and consumes up to 60 units of alcohol per week. An ECG is performed, revealing widespread ST elevation indicative of an acute coronary syndrome. At what point do the microscopic changes of acute MI become visible?
Your Answer:
Correct Answer: 12-24 hours after the infarct
Explanation:The Pathological Progression of Myocardial Infarction: A Timeline of Changes
Myocardial infarction, commonly known as a heart attack, is a serious medical condition that occurs when blood flow to the heart is blocked, leading to tissue damage and potentially life-threatening complications. The pathological progression of myocardial infarction follows a predictable sequence of events, with macroscopic and microscopic changes occurring over time.
Immediately after the infarct occurs, there are usually no visible changes to the myocardium. However, within 3-6 hours, maximal inflammatory changes occur, with the most prominent changes occurring between 24-72 hours. During this time, coagulative necrosis and acute inflammatory responses are visible, with marked infiltration by neutrophils.
Between 3-10 days, the infarcted area begins to develop a hyperaemic border, and the process of organisation and repair begins. Granulation tissue replaces dead muscle, and dying neutrophils are replaced by macrophages. Disintegration and phagocytosis of dead myofibres occur during this time.
If a patient survives an acute infarction, the infarct heals through the formation of scar tissue. However, scar tissue does not possess the usual contractile properties of normal cardiac muscle, leading to contractile dysfunction or congestive cardiac failure. The entire process from coagulative necrosis to the formation of well-formed scar tissue takes 6-8 weeks.
In summary, understanding the timeline of changes that occur during myocardial infarction is crucial for early diagnosis and effective treatment. By recognising the macroscopic and microscopic changes that occur over time, healthcare professionals can provide appropriate interventions to improve patient outcomes.
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This question is part of the following fields:
- Cardiology
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Question 29
Incorrect
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Various cardiac diseases necessitate the use of pacemakers to maintain regular heartbeats and sustain the patient's life. The following are three types of pacemakers, labeled 1-3: AAI, VVI, and DDD. Can you correctly match each pacemaker to the condition it is typically used to treat?
Your Answer:
Correct Answer: AAI – sinus node dysfunction; VVI – AF; DDD – second-degree heart block
Explanation:Understanding Pacemaker Coding and Indications
Pacemakers are electronic devices that are implanted in the chest to regulate the heartbeat. They are used to treat a variety of heart conditions, including sinus node dysfunction, atrial fibrillation (AF), and heart block. Pacemakers are coded based on the chambers they pace, sense, and respond to, as well as their ability to modulate heart rate and provide multisite pacing.
AAI pacemakers are used to pace the atria in patients with sinus node dysfunction and intact AV conduction. VVI pacemakers are used in patients with chronic atrial impairment, such as AF. DDD pacemakers are used to pace both the atria and ventricles in patients with second-degree heart block.
It is important to note that AAI pacemakers would not be effective in treating ventricular systolic dysfunction, and DDD pacemakers cannot be used in the treatment of long QT syndrome. However, pacemakers can be used in long QT syndrome if clinically necessary, and DDD pacing may be appropriate for some patients with first-degree heart block.
In summary, understanding pacemaker coding and indications is crucial for selecting the appropriate device for each patient’s unique heart condition.
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This question is part of the following fields:
- Cardiology
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Question 30
Incorrect
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A 32-year-old woman with shortness of breath on exercise comes to the clinic some 6 months after the birth of her second child. The recent pregnancy and post-partum period were uneventful. Her general practitioner has diagnosed her with asthma and prescribed a salbutamol inhaler. On examination, she looks unwell and is slightly short of breath at rest. Her blood pressure is 150/80 mmHg and her body mass index (BMI) is 24. There is mild bilateral pitting ankle oedema. Auscultation of the chest reveals no wheeze.
Investigations
Investigation Result Normal value
Haemoglobin 129 g/l 115–155 g/l
White cell count (WCC) 5.8 × 109/l 4–11 × 109/l
Platelets 190 × 109/l 150–400 × 109/l
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 4.8 mmol/l 3.5–5.0 mmol/l
Creatinine 110 µmol/l 50–120 µmol/l
Electrocardiogram (ECG) Right axis deviation,
incomplete right bundle branch block
Pulmonary artery systolic pressure 33 mmHg
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Primary pulmonary hypertension
Explanation:Differential Diagnosis for Postpartum Dyspnea: A Review
Postpartum dyspnea can be a concerning symptom for new mothers. In this case, the patient presents with dyspnea and fatigue several weeks after giving birth. The following differentials should be considered:
1. Primary Pulmonary Hypertension: This condition can present with right ventricular strain on ECG and elevated pulmonary artery systolic pressure. It is not uncommon for symptoms to develop after childbirth.
2. Dilated Cardiomyopathy: Patients with dilated cardiomyopathy may present with left bundle branch block and right axis deviation. Symptoms can develop weeks to months after giving birth.
3. Multiple Pulmonary Emboli: While a possible differential, the absence of pleuritic pain and risk factors such as a raised BMI make this less likely.
4. Hypertrophic Obstructive Cardiomyopathy (HOCM): HOCM typically presents with exertional syncope or pre-syncope and ECG changes such as left ventricular hypertrophy or asymmetrical septal hypertrophy.
5. Hypertensive Heart Disease: This condition is characterized by elevated blood pressure during pregnancy, which is not reported in this case. The patient’s symptoms are also not typical of hypertensive heart disease.
In conclusion, a thorough evaluation and consideration of these differentials can aid in the diagnosis and management of postpartum dyspnea.
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This question is part of the following fields:
- Cardiology
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