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Question 1
Correct
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A 28 yr. old male was admitted with palpitations and chest discomfort for the past 1 hour. On examination his pulse rate was 200 bpm and blood pressure was 80/50 mmHg. His ECG revealed narrow complex tachycardia with a heart rate of 200 bpm. Which of the following is the most appropriate management of this patient?
Your Answer: Synchronised DC synchronised cardioversion
Explanation:Narrow complex tachycardia with hypotension is a medical emergency. Immediate synchronized cardioversion is the ideal management.
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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 60 yr. old man with previous history of myocardial infarction and hypertension presented with severe retrosternal chest pain for the past 2 hours. During initial management he collapsed and pulseless ventricular tachycardia was detected. The external defibrillator arrived in 3 minutes. From the following answers, what is the most appropriate immediate management of this patient?
Your Answer: He should be given a precordial thump
Explanation:A precordial thumb is not routinely recommended because of its very low success rate for cardioversion of a shockable rhythm. It’s only recommended when there is a delay in getting the defibrillator.
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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 42 yr. old female presented with pain in her calves during walking which settled after resting. On examination there were orange colour deposits in the her palmar creases. Her fasting lipid profile showed a total cholesterol of 9.2 mmol/l (<5) and triglycerides of 7.0 mmol/l (<2). Which of the following is the most likely diagnosis?
Your Answer: Familial hypercholesterolaemia
Correct Answer: Type III hyperlipidaemia
Explanation:Palmar xanthomas are found in type III hyperlipoproteinemia. Her total cholesterol level and triglyceride level support the diagnosis.
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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 55 yr. old man presented with retrosternal chest pain associated with excessive sweating and vomiting. On examination his BP was 100/60 mmHg and pulse rate was 72 bpm. Bibasal crepitations were auscultated. His ECG showed ST elevation in V1 to V4 and ST depression in leads II, III and aVF. Which of the following would be the finding during angioplasty?
Your Answer: Complete occlusion of the left anterior descending artery
Explanation:The ECG findings are suggestive of anterior myocardial infarction and the most likely artery affected is the left anterior descending artery. Occlusion of the right coronary artery will be shown by ST elevation in lead II, III, aVF and occlusion of the circumflex artery will show changes in leads I, aVL, V5 and V6. To have ST elevation, there should be complete occlusion of the artery.
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This question is part of the following fields:
- Cardiology
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Question 5
Correct
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A 65 yr. old male patient admitted with myocardial infarction received thrombolysis, which lead to full resolution of the ST elevations on his ECG. He was on aspirin, clopidogrel, atorvastatin and enalapril. The next day he complained of pain in his legs and there was a diffuse petechial rash over his lower legs, especially in the feet. All his peripheral pulses were palpable. His FBC revealed neutrophilia with eosinophilia. His IgE antibodies were 3 kU/L (<2). What is the most likely reason for this presentation?
Your Answer: Cholesterol emboli
Explanation:He has a consequence of atherosclerotic disease (MI). The most probable diagnosis is cutaneous cholesterol emboli as it is more common after anticoagulation or thrombolytics, the skin involvement, eosinophilia and raised IgE. It is more common above 60 yrs. of age.
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This question is part of the following fields:
- Cardiology
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Question 6
Incorrect
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A 60 yr. old female presented with difficulty in breathing. What is the clinical sign that will indicate the presence of established pulmonary hypertension?
Your Answer: Single loud second heart sound
Correct Answer: Raised jugular venous pressure
Explanation:A prominent A wave is observed in the jugular venous pulse and this indicates the presence of established pulmonary hypertension. In addition the pulmonic component of the second heart sound (P2) may be increased and the P2 may demonstrate fixed or paradoxical splitting. The signs of right ventricular failure include a high-pitched systolic murmur of tricuspid regurgitation, hepatomegaly, a pulsatile liver, ascites, and peripheral oedema.
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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 60 yr. old man presented with difficulty in breathing. On examination he was severely dyspnoeic and tachycardic. What is the clinical sign that would favour the diagnosis of cardiac tamponade over constrictive pericarditis?
Your Answer: Muffled heart sounds
Correct Answer: Pulsus paradoxus
Explanation:Pulsus paradoxus is defined as the exaggerated fall in systolic blood pressure during inspiration by greater than 10 mmHg. Cardiac tamponade is the classic cause of pulsus paradoxus. Kussmaul’s sign (a rise in the jugular venous pressure on inspiration) is mostly seen in constrictive pericarditis. Hypotension, muffled heart sounds and raised JVP can be seen in both conditions.
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This question is part of the following fields:
- Cardiology
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Question 8
Correct
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A 60 yr. old man presented with severe central chest pain for the last 2 hours. He was on insulin for diabetes mellitus and he was dependent on haemodialysis because of end stage renal failure. He had undergone haemodialysis 48 hours prior to this presentation. His ECG showed an acute inferior myocardial infarction. Despite thrombolysis and other appropriate treatment, he continued to have chest pain after 6 hours from the initial presentation. His blood pressure was 88/54 mmHg and he had bibasal crepitations. His investigation results are given below. Serum sodium 140 mmol/l (137-144), Serum potassium 6.6 mmol/l (3.5-4.9), Serum urea 50 mmol/l (2.5-7.5), Serum creatinine 940 μmol/l (60-110), Haemoglobin 10.2g/dl (13.0-18.0), Troponin T >24 g/l (<0.04), Left ventricular ejection fraction was 20%. What is the most appropriate management for this patient?
Your Answer: Coronary angiography and rescue PCI
Explanation:According to the history the patient has cardiogenic shock and pulmonary oedema. On-going ischaemia is indicated by persisting symptoms. So the most appropriate management is coronary angiography and rescue PCI. There are no indications for blood transfusion at this moment and it will aggravate the pulmonary oedema. Haemodialysis, beta blockers and furosemide cannot be given due to low blood pressure.
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This question is part of the following fields:
- Cardiology
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Question 9
Correct
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A 32 yr. old previously well primigravida in her 16th week of pregnancy came to the antenatal clinic for a routine review. Her blood pressure was 152/90 mmHg. On her last clinic visit 4 weeks ago her blood pressure was 148/86 mmHg. She was put on ambulatory blood pressure monitoring and her mean blood pressure was 148/88 mmHg. Her urine examination was negative for protein. Which of the following is the most likely diagnosis?
Your Answer: Pre-existing hypertension
Explanation:Pre-eclampsia is excluded from negative proteinuria. White coat hypertension is excluded with ambulatory blood pressure monitoring. Pregnancy induced hypertension develops after 20 weeks of gestation. So the most likely answer is pre-existing hypertension. She should be investigated for a secondary cause for hypertension.
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This question is part of the following fields:
- Cardiology
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Question 10
Correct
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A 60 yr. old male smoker and a known hypertensive presented with central chest pain radiating to the back. On examination he was tachycardic and hypotensive. His ECG showed inferior ST elevation and his transoesophageal echocardiogram showed a double lumen in the ascending aorta. Which of the following is the most probable diagnosis?
Your Answer: Dissecting aortic aneurysm
Explanation:The classic history in this high risk patient is suggestive of a dissecting aortic aneurysm. His transoesophageal echocardiogram confirms the diagnosis. ST elevation in ECG is probably due to the extension of the dissection of the aorta which results in compromised coronary blood supply.
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This question is part of the following fields:
- Cardiology
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Question 11
Correct
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A previously well 33 yr. old female is admitted with a history of recurrent episodes of palpitations. She has not experience chest pain but rather a feeling of a rapidly beating heart. She frequently drinks coffee and alcohol. Her blood pressure is 120/80 mmHg and pulse rate 200 bpm which is regular. There is no sign of heart failure. Her ECG reveals a narrow complex tachycardia. She is given 3mg of IV adenosine but there is no response. Which of the following is the most appropriate management if she doesn't respond to 6mg of IV adenosine?
Your Answer: 12mg IV adenosine
Explanation:If 3mg of adenosine has no effect, then adenosine 6 mg can be given by rapid IV push. If patient does not convert to a normal rhythm, give another dose of adenosine 12 mg via rapid IV push. This can be repeated if there is no response. If no response, diltiazem or beta-blockers can be given as alternatives.
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This question is part of the following fields:
- Cardiology
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Question 12
Correct
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A 30 yr. old male patient presented with palpitations that occur randomly at rest. There have however been episodes of fast palpitations and dizziness on exertion. On examination there was a systolic murmur at the apex as well as a prominent apex beat and the chest was clear. Which of the following is LEAST likely to suggest a diagnosis of hypertrophic cardiomyopathy?
Your Answer: A history of hypertension for 10 years
Explanation:Hypertrophic cardiomyopathy is an autosomal dominant condition. Patients present with sudden cardiac death, dyspnoea, syncope and presyncope, angina, palpitations, orthopnoea and paroxysmal nocturnal dyspnoea, Congestive heart failure and dizziness. Physical findings include double or triple apical impulse, prominent a wave in the JVP, an ejection systolic crescendo-decrescendo murmur and a holosystolic murmur at the apex and axilla of mitral regurgitation.
ECG shows ST-T wave abnormalities and LVH, axis deviation (right or left), conduction abnormalities (P-R prolongation, bundle-branch block), sinus bradycardia with ectopic atrial rhythm, atrial enlargement, abnormal and prominent Q wave in the anterior precordial and lateral limb leads.
2D echocardiography shows abnormal systolic anterior leaflet motion of the mitral valve, LVH, left atrial enlargement, small ventricular chamber size, septal hypertrophy with septal-to-free wall ratio greater than 1.4:1, mitral valve prolapse and mitral regurgitation, decreased midaortic flow, partial systolic closure of the aortic valve in midsystole -
This question is part of the following fields:
- Cardiology
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Question 13
Correct
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A 70 yr. old man underwent temporary transvenous pacing. While in the coronary care unit he developed pre-syncope. His pulse rate was 30 bpm. His ECG showed pacing spikes which were not related to QRS complexes. What is the most appropriate action that can be taken?
Your Answer: Increase the pacing voltage to a maximum
Explanation:Pacemaker spikes on the ECG indicate that pacemaker is functioning. The most probable cause for this presentation is the change of the position of the tip of the pacing wire. Increasing the voltage will solve the problem. If it works, repositioning of the pacing wire should be done.
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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 60 yr. old male patient with hypertension presented with acute onset retrosternal chest pain for 3 hours. On examination his pulse rate was 68 bpm, BP was 100/60 mmHg and JVP was seen 3mm from the sternal notch. Respiratory examination was normal. His ECG showed narrow QRS complexes, ST segment elevation of 2mm in leads II, III and aVF and a complete heart block. What is the most immediate treatment from the following answers?
Your Answer: Atenolol 50 mg oral
Correct Answer: Chewable aspirin 300 mg
Explanation:The diagnosis is inferior ST elevation myocardial infarction. As the right coronary artery supplies the SA and AV nodes and bundle of His, conduction abnormalities are more common with inferior MIs. The most immediate drug management is high dose Aspirin. Definite treatment is urgent cardiac revascularization.
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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 25 yr. old female presented with a history of sudden collapse. She had been playing netball and had suddenly collapsed. This collapse had been accompanied by a brief period of loss of consciousness. She experienced palpitations for a brief period prior to losing consciousness. On examination her BP was 120/70 mmHg and pulse rate was 72 bpm, which was regular. The rest of the examination was also normal. She had similar experience of collapse, about two years ago. She was well except for these two incidents and she has not been on any medication. All the investigations done at the first presentation (2 years ago), including FBC, ECG and echocardiography were normal. Her ECG done at this presentation revealed QT prolongation of 0.50 s. FBC, CXR and other investigations were normal. Which of the following is the best way of managing this patient?
Your Answer: Insert a pacemaker
Correct Answer: Start on a beta-blocker
Explanation:Beta-blockers are drugs of choice for patients with LQTS. The protective effect of beta-blockers is related to their adrenergic blockade, which diminishes the risk of cardiac arrhythmias. They may also reduce the QT interval in some patients.
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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 30 yr. old male presented with exercise related syncope and dyspnoea for 2 weeks. His father passed away at the age of 40, due to sudden cardiac death. His ECG showed left ventricular hypertrophy with widespread T wave inversions. Which of the following is the most appropriate next investigation to confirm the diagnosis?
Your Answer: Transoesophageal echo
Correct Answer: Transthoracic echo
Explanation:The most likely diagnosis is hypertrophic obstructive cardiomyopathy which is suggestive by the history, positive family history and ECG findings. Two-dimensional echocardiography is diagnostic for hypertrophic cardiomyopathy. In general, a summary of echocardiography findings includes abnormal systolic anterior leaflet motion of the mitral valve, LV hypertrophy, left atrial enlargement, small ventricular chamber size, septal hypertrophy with septal-to-free wall ratio greater than 1.4:1, mitral valve prolapse and mitral regurgitation, decreased midaortic flow, and partial systolic closure of the aortic valve in midsystole.
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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 60 yr. old patient with hypertension attended his regular clinic. His compliance was poor. His blood pressure was 180/100 mmHg. His pulse rate was 85 bpm which was irregularly irregular. On examination there was bibasal crepitation. No murmurs were heard. What is the most likely cause for these findings?
Your Answer: Cor pulmonale
Correct Answer: Left ventricular hypertrophy
Explanation:Left ventricular hypertrophy due to long standing hypertension is the most probable cause. The irregularly irregular pulse was suggestive of atrial fibrillation, which is due to diastolic dysfunction. Poor ventricular filling causes pulmonary congestion which manifests as bibasal crepitations.
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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 30 yr. old male was brought in with a history of a stab injury to left chest. He was complaining of chest pain. On examination he was tachycardic, hypotensive and had an elevated JVP, pulsus paradoxus and muffled heart sounds. Respiratory examination was unremarkable. Which of the following is most probable diagnosis?
Your Answer: Cardiogenic shock
Correct Answer: Cardiac tamponade
Explanation:Becks triad (hypotension, elevated systemic venous pressure, often with jugular venous distention and muffled heart sounds) is a characteristic collection of clinical findings found in cardiac tamponade. Pulsus paradoxus is also associated with it. The history and clinical findings in this scenario are compatible with the diagnosis of cardica tamponade. The normal respiratory examination excludes tension pneumothorax.
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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 70 yr. old male patient presented with chronic congestive heart failure. Which of the following is the most important factor to consider when prescribing drugs for this patient?
Your Answer: Loop diuretic administration would result in a decrease in mortality
Correct Answer: Administration of a B-blocker reduces the time spent in hospital
Explanation:It is proven that spironolactone has survival benefits and loop diuretics only give symptomatic relief. Beta blockers are however, known to improve exercise tolerance, left ventricular function and reduce symptoms. They also reduce the mortality associated with heart failure. So administration of beta blockers will reduce the time spent in hospital by improving symptoms.
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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 65 yr. old male presented with acute ST elevation myocardial infarction and thrombolysis was planned. Which of the following is an absolute contraindication for thrombolysis?
Your Answer: Family history of haemophilia
Correct Answer: Intracerebral Haemorrhage
Explanation:Absolute contraindications for fibrinolytic use in STEMI
Prior intracranial haemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 months -
This question is part of the following fields:
- Cardiology
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Question 21
Incorrect
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Which of the following is not associated with right axis deviation?
Your Answer: Pulmonary embolism
Correct Answer: Wolf-Parkinson-White syndrome with right-sided accessory pathway
Explanation:Causes for right axis deviation:
-Right ventricular hypertrophy and Left posterior fascicular block
-Lateral myocardial infarction.
-Acute or chronic lung diseases: Pulmonary embolism, pulmonary hypertension, chronic obstructive pulmonary disease (COPD), cor pulmonale.
-Congenital heart disease (e.g., dextrocardia, secundum atrial septal defect).
-Wolff-Parkinson-White syndrome.
-Ventricular ectopic rhythms (e.g., ventricular tachycardia). -
This question is part of the following fields:
- Cardiology
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Question 22
Incorrect
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A 60 yr. old male with no past medical history presented to Casualty with acute chest pain. ST elevation myocardial infarction (STEMI) is diagnosed following an ECG on arrival. He was subsequently successfully thrombolysed. Which of the following combinations of drugs is the most suitable combination for him to be taking 4 weeks after his STEMI?
Your Answer: Beta-blocker + statin + aspirin + clopidogrel
Correct Answer: ACE inhibitor + beta-blocker + statin + aspirin + clopidogrel
Explanation:According to NICE guidelines (2013) all people who have had an acute MI, treatment should be offered with ACE inhibitor, dual antiplatelet therapy (aspirin plus a second antiplatelet agent), beta-blocker and a statin.
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This question is part of the following fields:
- Cardiology
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Question 23
Incorrect
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A 60 yr. old male presented with ventricular tachycardia which was successfully cardioverted. To check whether he had prolonged QT interval, which of the following is the most appropriate method to measure the QT interval in ECG?
Your Answer: Time between the end of the Q wave and the start of the T wave
Correct Answer: Time between the start of the Q wave and the end of the T wave
Explanation:The QT interval is the time from the start of the Q wave to the end of the T wave. It represents the time taken for ventricular depolarisation and repolarisation. The QT interval should be measured in either lead II or V5-6.
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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 25 yr. old previously well male presented with chest discomfort and difficulty in breathing while running to the bus. Symptoms disappeared after resting. But the symptoms reappeared whilst he was climbing the stairs. On examination he was not dyspnoeic at rest. BP was 110/70 mmHg and pulse rate was 72 bpm. His heart sounds were normal. There was an additional clicking noise in the fourth left intercostal space which is heard with each heart beat. Which of the following is the most probable cause for his presentation?
Your Answer: Acute pericarditis
Correct Answer: Spontaneous pneumothorax
Explanation:The given history is more compatible with spontaneous pneumothorax. Left-sided pneumothoraxes may be associated with a clicking noise, which is heard with each heart-beat and can sometimes be heard by the patient.
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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 55 yr. old male with a history of myocardial infarction 4 years ago, was admitted with a history of fever for the past 2 weeks. On investigation, his echocardiography revealed a small vegetation around the mitral valve. His blood culture was positive for Streptococcus viridans. Which of the following is the most appropriate antibiotic therapy?
Your Answer: IV benzylpenicillin + ceftriaxone
Correct Answer: IV benzylpenicillin
Explanation:According to the American Heart Association (AHA) penicillin-susceptible S viridans, S bovis, and other streptococci (MIC of penicillin of ≤0.1 mcg/mL) should be treated with penicillin G or ceftriaxone or penicillin G + a gentamicin combination or vancomycin (if allergy to penicillin).
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This question is part of the following fields:
- Cardiology
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Question 26
Correct
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A 50 yr. old male with a history of type II diabetes mellitus and hypertension presented with exertional dyspnoea and chest pain for 2 weeks. On examination his blood pressure was 145/80 mmHg. On auscultation reversed splitting of the second heart sound and bibasal crepitations were detected. What would be the most likely finding on his ECG?
Your Answer: Left bundle branch block
Explanation:When closure of the pulmonary valve occurs before the aortic valve, reversed splitting occurs. The causes of reversed splitting are aortic stenosis, hypertrophic cardiomyopathy, left bundle branch block (LBBB), and a ventricular pacemaker.
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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 28 yr. old primigravida in her 24th week of pregnancy presented with a history of palpitations, which are fast and regular. She doesn't complain of any episodes of collapse. On examination she was well, pulse rate was 102 bpm, which was regular and her blood pressure was 110/70 mmHg. Her JVP was not elevated. Heart sounds were normal. ECH showed sinus tachycardia. Which of the following can be expected because of the physiological changes which occur in the boy during pregnancy?
Your Answer: Elevated JVP
Correct Answer: Tachycardia
Explanation:The cardiovascular alterations which occur during pregnancy are for the optimal growth and development of the foetus and help to protect the mother from the risks of delivery, such as haemorrhage. The changes are characterized by an increased vascular volume, cardiac output, and heart rate, with a marked fall in vascular resistance and reduction in blood pressure.
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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 80 yr. old male was found on the floor. His blood pressure was 100/60 mmHg. His core temperature was 31ºC. His FBC and serum electrolytes were within normal limits. Which of the following would be found in his ECG?
Your Answer: U waves
Correct Answer: Long QT interval
Explanation:Hypothermia is defined as a core body temperature of < 35 °C.
Hypothermia may produce the following ECG changes:
-Bradyarrhythmia
-Osborne Waves (= J waves)
-Prolonged PR, QRS and QT intervals
-Shivering artefact
-Ventricular ectopics
-Cardiac arrest due to VT, VF or asystole -
This question is part of the following fields:
- Cardiology
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Question 29
Incorrect
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A 48 yr. old male presented with exertional angina for 2 weeks. He has no significant past medical history or cardiac risk factors except a total cholesterol of 5.8 mmol/L. He has been already started on aspirin. Which of the following is the most suitable drug combination for him?
Your Answer: Isosorbide dinitrate and statin
Correct Answer: B-blocker and statin
Explanation:Beta blockers and calcium channel blockers have proven prognostic benefits. Nitrates don’t have any proven prognostic benefits. A statin is indicated for a patient with angina and cholesterol level of 5.5 to 8.5 to prevent risk of myocardial infarction. So the preferred combination from the given answers is beta blocker + statin.
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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 30 yr. old primigravida in her 23rd week of pregnancy presented with palpitations. Her ECG showed supraventricular tachycardia (SVT). 15 minutes after admission the SVT spontaneously reverted to sinus rhythm. She had two episodes of SVT later which were associated with palpitations. Which of the following is the most appropriate treatment for this presentation?
Your Answer:
Correct Answer: Verapamil
Explanation:Both long-acting calcium channel blockers and beta blockers improve symptoms of patients with SVT. Verapamil does not have adverse maternal or fetal side effects which would suggest that the use of verapamil in the treatment of supraventricular arrhythmias in pregnancy is safe and effective. Beta blockers are associated with intrauterine fetal growth restriction.
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This question is part of the following fields:
- Cardiology
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SESSION STATS - PERFORMANCE PER SPECIALTY
