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  • Question 1 - A 30-year-old man presents with syncope, which was preceded by palpitations. He has...

    Incorrect

    • A 30-year-old man presents with syncope, which was preceded by palpitations. He has no past medical history and is generally fit and well. The electrocardiogram (ECG) shows a positive delta wave in V1.
      Which of the following is the most likely diagnosis?

      Your Answer: Maladie de Roger

      Correct Answer: Wolff–Parkinson–White (WPW) syndrome

      Explanation:

      Differentiating ECG Features of Various Heart Conditions

      Wolff-Parkinson-White (WPW) syndrome is a congenital heart condition characterized by an accessory conduction pathway connecting the atria and ventricles. Type A WPW syndrome, identified by a delta wave in V1, can cause supraventricular tachycardia due to the absence of rate-lowering properties in the accessory pathway. Type B WPW syndrome, on the other hand, causes a negative R wave in V1. Radiofrequency ablation is the definitive treatment for WPW syndrome.

      Maladie de Roger is a type of ventricular septal defect that does not significantly affect blood flow. Atrioventricular septal defect, another congenital heart disease, can cause ECG features related to blood shunting.

      Brugada syndrome, which has three distinct types, does not typically present with a positive delta wave in V1 on ECG. Tetralogy of Fallot, a congenital heart defect, presents earlier with symptoms such as cyanosis and exertional dyspnea.

    • This question is part of the following fields:

      • Cardiology
      32
      Seconds
  • Question 2 - A 57-year-old male with a known history of rheumatic fever and frequent episodes...

    Incorrect

    • A 57-year-old male with a known history of rheumatic fever and frequent episodes of pulmonary oedema is diagnosed with pulmonary hypertension. During examination, an irregularly irregular pulse was noted and auscultation revealed a loud first heart sound and a rumbling mid-diastolic murmur. What is the most probable cause of this patient's pulmonary hypertension?

      Your Answer: Mitral regurgitation

      Correct Answer: Mitral stenosis

      Explanation:

      Cardiac Valve Disorders: Mitral Stenosis, Mitral Regurgitation, Aortic Regurgitation, Pulmonary Stenosis, and Primary Pulmonary Hypertension

      Cardiac valve disorders are conditions that affect the proper functioning of the heart valves. Among these disorders are mitral stenosis, mitral regurgitation, aortic regurgitation, pulmonary stenosis, and primary pulmonary hypertension.

      Mitral stenosis is a narrowing of the mitral valve, usually caused by rheumatic fever. Symptoms include palpitations, dyspnea, and hemoptysis. Diagnosis is aided by electrocardiogram, chest X-ray, and echocardiography. Management may be medical or surgical.

      Mitral regurgitation is a systolic murmur that presents with a sustained apex beat displaced to the left and a left parasternal heave. On auscultation, there will be a soft S1, a loud S2, and a pansystolic murmur heard at the apex radiating to the left axilla.

      Aortic regurgitation presents with a collapsing pulse with a wide pulse pressure. On palpation of the precordium, there will be a sustained and displaced apex beat with a soft S2 and an early diastolic murmur at the left sternal edge.

      Pulmonary stenosis is associated with a normal pulse, with an ejection systolic murmur radiating to the lung fields. There may be a palpable thrill over the pulmonary area.

      Primary pulmonary hypertension most commonly presents with progressive weakness and shortness of breath. There is evidence of an underlying cardiac disease, meaning the underlying pulmonary hypertension is more likely to be secondary to another disease process.

    • This question is part of the following fields:

      • Cardiology
      56
      Seconds
  • Question 3 - A 29-year-old woman presents with sudden-onset palpitation and chest pain that began 1...

    Incorrect

    • A 29-year-old woman presents with sudden-onset palpitation and chest pain that began 1 hour ago. The palpitation is constant and is not alleviated or aggravated by anything. She is worried that something serious is happening to her. She recently experienced conflict at home with her husband and left home the previous day to stay with her sister. She denies any medication or recreational drug use. Past medical history is unremarkable. Vital signs are within normal limits, except for a heart rate of 180 bpm. Electrocardiography shows narrow QRS complexes that are regularly spaced. There are no visible P waves preceding the QRS complexes. Carotid sinus massage results in recovery of normal sinus rhythm.
      What is the most likely diagnosis?

      Your Answer: Atrial flutter

      Correct Answer: Atrioventricular nodal re-entrant tachycardia

      Explanation:

      Differentiating Types of Tachycardia

      Paroxysmal supraventricular tachycardia (PSVT) is a sudden-onset tachycardia with a heart rate of 180 bpm, regularly spaced narrow QRS complexes, and no visible P waves preceding the QRS complexes. Carotid sinus massage or adenosine administration can diagnose PSVT, which is commonly caused by atrioventricular nodal re-entrant tachycardia.

      Sinus tachycardia is characterized by normal P waves preceding each QRS complex. Atrial flutter is less common than atrioventricular nodal re-entrant tachycardia and generally does not respond to carotid massage. Atrial fibrillation is characterized by irregularly spaced QRS complexes and does not respond to carotid massage. Paroxysmal ventricular tachycardia is associated with wide QRS complexes.

    • This question is part of the following fields:

      • Cardiology
      83.2
      Seconds
  • Question 4 - A 61-year-old man comes to his General Practitioner complaining of increasing exertional dyspnoea...

    Correct

    • A 61-year-old man comes to his General Practitioner complaining of increasing exertional dyspnoea accompanied by bilateral peripheral oedema. He reports feeling extremely fatigued lately. During the physical examination, his lungs are clear, but he has ascites. On auscultation of his heart sounds, you detect a holosystolic murmur with a high pitch at the left sternal edge, extending to the right sternal edge. What is the probable reason for this patient's symptoms?

      Your Answer: Tricuspid regurgitation

      Explanation:

      Differentiating Heart Murmurs and Symptoms

      Tricuspid regurgitation is characterized by signs of right heart failure, such as dyspnea and peripheral edema, and a classical murmur. The backflow of blood to the right atrium leads to right heart dilation, weakness, and eventually failure, resulting in ascites and poor ejection fraction causing edema.

      Mitral regurgitation has a similar murmur to tricuspid regurgitation but is heard best at the apex.

      Aortic regurgitation is identified by an early diastolic decrescendo murmur at the left sternal edge.

      Aortic stenosis does not typically result in ascites, and its murmur is ejection systolic.

      Pulmonary stenosis is characterized by a mid-systolic crescendo-decrescendo murmur best heard over the pulmonary post and not a holosystolic murmur at the left sternal edge.

      Understanding Heart Murmurs and Symptoms

    • This question is part of the following fields:

      • Cardiology
      66.6
      Seconds
  • Question 5 - A 56-year-old, 80 kg woman arrives at the Emergency Department complaining of chest...

    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: Aspirin 300 mg, clopidogrel 75 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
      43.5
      Seconds
  • Question 6 - A 66-year-old patient visits her General Practitioner (GP) with complaints of chest pain...

    Correct

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

      Your Answer: Ejection systolic murmur (ESM)

      Explanation:

      Common Heart Murmurs and Their Associations

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

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

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

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

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

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

    • This question is part of the following fields:

      • Cardiology
      73
      Seconds
  • Question 7 - You are assisting in the anaesthesia of an 80-year-old man for a plastics...

    Incorrect

    • 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: 100% O2, Intralipid® as per guideline for local anaesthetic toxicity

      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.

    • This question is part of the following fields:

      • Cardiology
      61
      Seconds
  • Question 8 - A 60-year-old man is seen at cardiology outpatients 6 weeks after an anterior...

    Incorrect

    • A 60-year-old man is seen at cardiology outpatients 6 weeks after an anterior myocardial infarction. His wife complains that she cannot sleep at night due to his constant coughing and throat clearing.
      Which medication is likely causing these symptoms?

      Your Answer:

      Correct Answer: Perindopril

      Explanation:

      Common Side-Effects of Cardiovascular Medications

      Cardiovascular medications are commonly prescribed to manage various heart conditions. However, they can also cause side-effects that can affect a patient’s quality of life. Here are some common side-effects of popular cardiovascular medications:

      Perindopril: This medication can cause a dry, persistent cough, as well as hyperkalaemia, fatigue, dizziness, and hypotension.

      Amiodarone: Side-effects of this medication include dizziness, visual disturbance, unco-ordination, tremors, paraesthesia, deranged liver function tests (LFTs), deranged thyroid function tests (TFTs), and lung fibrosis.

      Atenolol: β-blockers like atenolol can cause fatigue, Raynaud’s phenomenon, bronchospasm, change in bowel habit, and sexual dysfunction.

      Atorvastatin: Statins like atorvastatin can cause myopathy/myositis, derangement of glucose control, and deranged LFTs.

      Candesartan: Angiotensin receptor blockers like candesartan can cause dizziness, headache, hyperkalaemia, and first-dose orthostatic hypotension. They are often prescribed to patients who are intolerant of ACE inhibitors due to dry cough.

      In conclusion, patients taking cardiovascular medications should be aware of these potential side-effects and report any concerns to their healthcare provider.

    • This question is part of the following fields:

      • Cardiology
      0
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  • Question 9 - A 50-year-old man with a long-standing history of hypertension visits his primary care...

    Incorrect

    • A 50-year-old man with a long-standing history of hypertension visits his primary care physician for a routine check-up. He mentions experiencing a painful, burning sensation in his legs when he walks long distances and feeling cold in his lower extremities. He has no history of dyslipidaemia. During the examination, his temperature is recorded as 37.1 °C, and his blood pressure in the left arm is 174/96 mmHg, with a heart rate of 78 bpm, respiratory rate of 16 breaths per minute, and oxygen saturation of 98% on room air. Bilateral 1+ dorsalis pedis pulses are noted, and his lower extremities feel cool to the touch. Cardiac auscultation does not reveal any murmurs, rubs, or gallops. His abdominal examination is unremarkable, and no bruits are heard on auscultation. His renal function tests show a creatinine level of 71 μmol/l (50–120 μmol/l), which is his baseline. What is the most likely defect present in this patient?

      Your Answer:

      Correct Answer: Coarctation of the aorta

      Explanation:

      The patient’s symptoms suggest coarctation of the aorta, a condition where the aortic lumen narrows just after the branches of the aortic arch. This causes hypertension in the upper extremities and hypotension in the lower extremities, leading to lower extremity claudication. Chest X-rays may show notching of the ribs. Treatment involves surgical resection of the narrowed lumen. Bilateral lower extremity deep vein thrombosis, patent ductus arteriosus, renal artery stenosis, and atrial septal defects are other conditions that can cause different symptoms and require different treatments.

    • This question is part of the following fields:

      • Cardiology
      0
      Seconds
  • Question 10 - A 68-year-old man comes in with bilateral ankle swelling. During the examination, an...

    Incorrect

    • A 68-year-old man comes in with bilateral ankle swelling. During the examination, an elevated jugular venous pressure (JVP) of 7 cm above the sternal angle and large V waves are observed. Upon listening to the heart, a soft pansystolic murmur is heard at the left sternal edge. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Tricuspid regurgitation

      Explanation:

      Common Heart Murmurs and Their Characteristics

      Tricuspid Regurgitation: This condition leads to an elevated jugular venous pressure (JVP) with large V waves and a pan-systolic murmur at the left sternal edge. Other features include pulsatile hepatomegaly and left parasternal heave.

      Tricuspid Stenosis: Tricuspid stenosis causes a mid-diastolic murmur.

      Pulmonary Stenosis: This condition produces an ejection systolic murmur.

      Mitral Regurgitation: Mitral regurgitation causes a pan-systolic murmur at the apex, which radiates to the axilla.

      Aortic Stenosis: Aortic stenosis causes an ejection systolic murmur that radiates to the neck.

      Mitral Stenosis: Mitral stenosis causes a mid-diastolic murmur at the apex, and severe cases may have secondary pulmonary hypertension (a cause of tricuspid regurgitation).

      These common heart murmurs have distinct characteristics that can aid in their diagnosis.

    • This question is part of the following fields:

      • Cardiology
      0
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  • Question 11 - A 25-year-old man visits his general practitioner (GP), as he is concerned that...

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Cardiology
      0
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  • Question 12 - A 25-year-old with cystic fibrosis was evaluated for cor pulmonale to determine eligibility...

    Incorrect

    • A 25-year-old with cystic fibrosis was evaluated for cor pulmonale to determine eligibility for a deceased donor double-lung transplant.
      What is the surface landmark used to identify right ventricular hypertrophy?

      Your Answer:

      Correct Answer: Fourth intercostal space, left parasternal area

      Explanation:

      Anatomical Landmarks for Cardiac Examination

      When examining the heart, it is important to know the anatomical landmarks for locating specific valves and ventricles. Here are some key locations to keep in mind:

      1. Fourth intercostal space, left parasternal area: This is the correct location for examining the tricuspid valve and the right ventricle, particularly when detecting a right ventricular heave.

      2. Second intercostal space, left parasternal area: The pulmonary valve can be found at this location.

      3. Second intercostal space, right parasternal area: The aortic valve is located here.

      4. Fourth intercostal space, right parasternal area: In cases of true dextrocardia, the tricuspid valve and a right ventricular heave can be found at this location.

      5. Fifth intercostal space, mid-clavicular line: This is the location of the apex beat, which can be examined for a left ventricular heave and the mitral valve.

      Knowing these landmarks can help healthcare professionals accurately assess and diagnose cardiac conditions.

    • This question is part of the following fields:

      • Cardiology
      0
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  • Question 13 - A 30-year-old woman visits her GP to discuss contraception options, specifically the combined...

    Incorrect

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

      Your Answer:

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

      Explanation:

      Diagnostic Tests for Secondary Hypertension: Assessing the Causes

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

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

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

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

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

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

      Diagnostic Tests for Secondary Hypertension: Assessing the Causes

    • This question is part of the following fields:

      • Cardiology
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  • Question 14 - A 59-year-old man is admitted to the Intensive Care Unit from the Coronary...

    Incorrect

    • A 59-year-old man is admitted to the Intensive Care Unit from the Coronary Care Ward. He has suffered from an acute myocardial infarction two days earlier. On examination, he is profoundly unwell with a blood pressure of 85/60 mmHg and a pulse rate of 110 bpm. He has crackles throughout his lung fields, with markedly decreased oxygen saturations; he has no audible cardiac murmurs. He is intubated and ventilated, and catheterised.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 121 g/l 135–175 g/l
      White cell count (WCC) 5.8 × 109/l 4–11 × 109/l
      Platelets 285 × 109/l 150–400 × 109/l
      Sodium (Na+) 128 mmol/l 135–145 mmol/l
      Potassium (K+) 6.2 mmol/l 3.5–5.0 mmol/l
      Creatinine 195 μmol/l 50–120 µmol/l
      Troponin T 5.8 ng/ml <0.1 ng/ml
      Urine output 30 ml in the past 3 h
      ECG – consistent with a myocardial infarction 48 h earlier
      Chest X-ray – gross pulmonary oedema
      Which of the following fits best with the clinical picture?

      Your Answer:

      Correct Answer:

      Explanation:

      Treatment Options for Cardiogenic Shock Following Acute Myocardial Infarction

      Cardiogenic shock following an acute myocardial infarction is a serious condition that requires prompt and appropriate treatment. One potential treatment option is the use of an intra-aortic balloon pump, which can provide ventricular support without compromising blood pressure. High-dose dopamine may also be used to preserve renal function, but intermediate and high doses can have negative effects on renal blood flow. The chance of death in this situation is high, but with appropriate treatment, it can be reduced to less than 10%. Nesiritide, a synthetic natriuretic peptide, is not recommended as it can worsen renal function and increase mortality. Nitrate therapy should also be avoided as it can further reduce renal perfusion and worsen the patient’s condition. Overall, careful consideration of treatment options is necessary to improve outcomes for patients with cardiogenic shock following an acute myocardial infarction.

    • This question is part of the following fields:

      • Cardiology
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  • Question 15 - A 65-year-old man presents with a 1-hour history of chest pain and is...

    Incorrect

    • A 65-year-old man presents with a 1-hour history of chest pain and is found to have an acute ST elevation inferior myocardial infarct. His blood pressure is 126/78 mmHg and has a pulse of 58 bpm. He is loaded with anti-platelets, and the cardiac monitor shows second-degree heart block (Wenckebach’s phenomenon).
      What would you consider next for this patient?

      Your Answer:

      Correct Answer: Temporary pacing and primary PCI

      Explanation:

      Management of Heart Block in Acute Myocardial Infarction

      Wenckebach’s phenomenon is usually not a cause for concern in patients with normal haemodynamics. However, if it occurs alongside acute myocardial infarction, complete heart block, or symptomatic Mobitz type II block, temporary pacing is necessary. Even with complete heart block, revascularisation can improve conduction if the patient is haemodynamically stable. Beta blockers should be avoided in second- and third-degree heart block as they can worsen the situation. Temporary pacing is required before proceeding to primary percutaneous intervention (PCI). A permanent pacemaker may be necessary for patients with irreversible heart block, but revascularisation should be prioritised as it may improve conduction. The block may be complete or second- or third-degree. If the heart block is reversible, temporary pacing should be followed by an assessment for permanent pacing.

    • This question is part of the following fields:

      • Cardiology
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  • Question 16 - A 56-year-old patient presents for an annual review. He has no significant past...

    Incorrect

    • A 56-year-old patient presents for an annual review. He has no significant past medical history. He is a smoker and has a family history of ischaemic heart disease: body mass index (BMI) 27.4, blood pressure (BP) 178/62 mmHg, fasting serum cholesterol 7.9 mmol/l (normal value < 5.17 mmol/l), triglycerides 2.2 mmol/l (normal value < 1.7 mmol/l), fasting glucose 5.8 mmol/l (normal value 3.9–5.6 mmol/l).
      Which of the following would be the most appropriate treatment for his cholesterol?

      Your Answer:

      Correct Answer: Start atorvastatin

      Explanation:

      Treatment Options for Primary Prevention of Cardiovascular Disease

      The primary prevention of cardiovascular disease (CVD) involves identifying and managing risk factors such as high cholesterol, smoking, hypertension, and family history of heart disease. The National Institute for Health and Care Excellence (NICE) provides guidelines for the treatment of these risk factors.

      Start Atorvastatin: NICE recommends offering atorvastatin 20 mg to people with a 10% or greater 10-year risk of developing CVD. Atorvastatin is preferred over simvastatin due to its superior efficacy and side-effect profile.

      Reassure and Repeat in One Year: NICE advises using the QRISK2 risk assessment tool to assess CVD risk and starting treatment if the risk is >10%.

      Dietary Advice and Repeat in Six Months: Dietary advice should be offered to all patients, including reducing saturated fat intake, increasing mono-unsaturated fat intake, choosing wholegrain varieties of starchy food, reducing sugar intake, eating fruits and vegetables, fish, nuts, seeds, and legumes.

      Start Bezafibrate: NICE advises against routinely offering fibrates for the prevention of CVD to people being treated for primary prevention.

      Start Ezetimibe: Ezetimibe is not a first-line treatment for hyperlipidaemia, but people with primary hypercholesterolaemia should be considered for ezetimibe treatment.

      Overall, a combination of lifestyle changes and medication can effectively manage cardiovascular risk factors and prevent the development of CVD.

    • This question is part of the following fields:

      • Cardiology
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  • Question 17 - An 85-year-old woman attends her general practice for a medication review. She is...

    Incorrect

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

      Your Answer:

      Correct Answer: Alcohol

      Explanation:

      Understanding Risk Factors for Atrial Fibrillation

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

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

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

    • This question is part of the following fields:

      • Cardiology
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  • Question 18 - A 50-year-old man who is a known alcoholic is brought to the Emergency...

    Incorrect

    • 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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      • Cardiology
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  • Question 19 - A 28-year-old female presents with palpitations, chest pain, and shortness of breath that...

    Incorrect

    • A 28-year-old female presents with palpitations, chest pain, and shortness of breath that radiates to her left arm. These symptoms began six weeks ago after she witnessed her father's death from a heart attack. Over the past decade, she has undergone various investigations for abdominal pain, headaches, joint pains, and dyspareunia, but no significant cause has been identified for these symptoms. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Somatisation disorder

      Explanation:

      Somatisation Disorder as the Most Likely Diagnosis

      Somatisation disorder is the most probable diagnosis for the given scenario, although it lacks sufficient criteria for a complete diagnosis. This disorder is characterised by recurring pains, gastrointestinal, sexual, and pseudo-neurologic symptoms that persist for years. To meet the diagnostic criteria, the patient’s physical complaints must not be intentionally induced and must result in medical attention or significant impairment in social, occupational, or other important areas of functioning. Typically, the first symptoms appear during adolescence, and the full criteria are met by the age of 30.

      Among the other disorders, factitious disorder is the least likely explanation. The other three disorders are possible explanations, but they are not as likely as somatisation disorder.

    • This question is part of the following fields:

      • Cardiology
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  • Question 20 - What condition would make exercise testing completely unsafe? ...

    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.

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      • Cardiology
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  • Question 21 - A 55-year-old man presents to the clinic with complaints of chest pain and...

    Incorrect

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

      Your Answer:

      Correct Answer: Verapamil

      Explanation:

      Verapamil and Beta Blockers: A Dangerous Combination

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

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

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

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      • Cardiology
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  • Question 22 - A 59-year-old man, a bus driver, with a history of angina, is admitted...

    Incorrect

    • A 59-year-old man, a bus driver, with a history of angina, is admitted to hospital with chest pain. He is diagnosed and successfully treated for a STEMI, and discharged one week later.
      Which of the following activities is permitted during the first month of his recovery?

      Your Answer:

      Correct Answer: Drinking alcohol (up to 14 units)

      Explanation:

      Post-Myocardial Infarction (MI) Precautions: Guidelines for Alcohol, Machinery, Driving, Sex, and Exercise

      After experiencing a myocardial infarction (MI), also known as a heart attack, it is crucial to take precautions to prevent further complications. Here are some guidelines to follow:

      Alcohol Consumption: Patients should be advised to keep their alcohol consumption within recommended limits, which is now 14 units per week for both men and women.

      Operating Heavy Machinery: Patients should avoid operating heavy machinery for four weeks post MI.

      Bus Driving: Patients should refrain from driving a bus or lorry for six weeks post MI. If the patient had angioplasty, driving is not allowed for one week if successful and four weeks if unsuccessful or not performed.

      Sexual Intercourse: Patients should avoid sexual intercourse for four weeks post MI.

      Vigorous Exercise: Patients should refrain from vigorous exercise for four weeks post MI.

      Following these guidelines can help prevent further complications and aid in the recovery process after a myocardial infarction.

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      • Cardiology
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  • Question 23 - A 75-year-old man presents to his General Practitioner with chest pain. The man...

    Incorrect

    • 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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      • Cardiology
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  • Question 24 - A 72-year-old man is brought by ambulance to Accident and Emergency. He presents...

    Incorrect

    • A 72-year-old man is brought by ambulance to Accident and Emergency. He presents with central crushing chest pain and has ST-segment elevation present on an electrocardiogram (ECG). You are at a District General Hospital without access to percutaneous coronary intervention (PCI), and you will not be able to transfer the patient across for PCI in time.
      Which of the following is an absolute contraindication to thrombolysis?

      Your Answer:

      Correct Answer: Brain neoplasm

      Explanation:

      Relative and Absolute Contraindications to Thrombolysis

      Thrombolysis is a treatment option for patients with ongoing cardiac ischemia and presentation within 12 hours of onset of pain. However, it is important to consider both relative and absolute contraindications before administering thrombolysis.

      Cerebral neoplasm is the only absolute contraindication, while advanced liver disease, severe hypertension (not meeting absolute contraindication values), active peptic ulceration, and pregnancy or recent delivery are all relative contraindications.

      Primary PCI is the preferred treatment option if available, but thrombolysis can be used as an alternative if necessary. The benefit of thrombolysis decreases over time, and a target time of less than 30 minutes from admission is recommended. Thrombolysis should not be given if the onset of pain is more than 24 hours after presentation.

      It is important to carefully consider contraindications before administering thrombolysis to ensure patient safety and optimal treatment outcomes.

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      • Cardiology
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  • Question 25 - A 48-year-old woman comes to you for a follow-up appointment after a recent...

    Incorrect

    • A 48-year-old woman comes to you for a follow-up appointment after a recent 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 118 kg. During her last visit, her ECG showed atrial fibrillation (AF) with a heart rate of 180 bpm, and she was started on bisoprolol. She underwent a 48-hour ECG monitoring, which revealed non-paroxysmal AF. What is the most appropriate course of action for her management?

      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 for medication, 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 either a novel oral anticoagulant or warfarin is also necessary. Electrical cardioversion is not appropriate for this patient. Increasing the dose of bisoprolol may be reasonable, but considering the patient’s clinical presentation and past medical history, it may not be the best option. Amlodipine will not have an effect on rate control in AF, and calcium-channel blockers should not be used in heart failure. Amiodarone should not be first-line treatment in this patient due to her heart failure. Overall, the best treatment option for AF in a patient with heart failure should be carefully considered based on the individual’s medical history and current condition.

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      • Cardiology
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  • Question 26 - A 70-year-old man with a history of chronic cardiac failure with reduced ventricular...

    Incorrect

    • A 70-year-old man with a history of chronic cardiac failure with reduced ventricular systolic function presents with recent onset of increasing breathlessness, and worsening peripheral oedema and lethargy. He is currently taking ramipril and bisoprolol alongside occasional paracetamol.
      What is the most appropriate long-term management?

      Your Answer:

      Correct Answer: Addition of spironolactone

      Explanation:

      For the management of heart failure, first line options include ACE inhibitors, beta-blockers, and aldosterone antagonists. In this case, the patient was already on a beta-blocker and an ACE inhibitor which had been effective. The addition of an aldosterone antagonist such as spironolactone would be the best option as it prevents fluid retention and reduces pressure on the heart. Ivabradine is a specialist intervention that should only be considered after trying all other recommended options. Addition of furosemide would only provide symptomatic relief. Insertion of an implantable cardiac defibrillator device is a late-stage intervention. Encouraging regular exercise and a healthy diet is important but does not directly address the patient’s clinical deterioration.

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      • Cardiology
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  • Question 27 - A 50-year-old man with type II diabetes, is having his annual diabetes review....

    Incorrect

    • A 50-year-old man with type II diabetes, is having his annual diabetes review. During this review it is noticed that the man has a heart rate between 38–48 beats/min. On questioning, he mentions that he has noticed occasional palpitations, but otherwise has been asymptomatic.
      An ECG is performed, which shows that on every fourth beat there is a non-conducted P-wave (a P-wave without QRS complex). Otherwise there are no other abnormalities and the PR interval is constant.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Second degree heart block – Mobitz type II

      Explanation:

      Understanding Different Types of Heart Blocks on an ECG

      An electrocardiogram (ECG) is a diagnostic tool used to monitor the electrical activity of the heart. It can help identify different types of heart blocks, which occur when the electrical signals that control the heartbeat are disrupted. Here are some common types of heart blocks and how they appear on an ECG:

      Second Degree Heart Block – Mobitz Type II
      This type of heart block is characterized by a regular non-conducted P-wave on the ECG. It may also show a widened QRS, indicating that the block is in the bundle branches of Purkinje fibers. If a patient is symptomatic with Mobitz type II heart block, permanent pacing is required to prevent progression to third degree heart block.

      Third Degree Heart Block
      An ECG of a third degree heart block would show dissociated P-waves and QRS-waves. This means that the atria and ventricles are not communicating properly, and the heart may beat very slowly or irregularly.

      Atrial Flutter
      Atrial flutter on an ECG would typically show a saw-toothed baseline. This occurs when the atria are beating too quickly and not in sync with the ventricles.

      Ectopic Beats
      Ectopic beats are premature heartbeats that occur outside of the normal rhythm. They would not result in regular non-conducted P-waves on an ECG.

      Second Degree Heart Block – Mobitz Type I
      Mobitz type I heart block would typically show progressive lengthening of the PR interval over several complexes, before a non-conducted P-wave would occur. This type of heart block is usually not as serious as Mobitz type II, but may still require monitoring and treatment.

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      • Cardiology
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  • Question 28 - You are in pre-assessment clinic and request an electrocardiogram (ECG) on a 58-year-old...

    Incorrect

    • You are in pre-assessment clinic and request an electrocardiogram (ECG) on a 58-year-old man attending for a radical prostatectomy.
      What are the limits of the normal cardiac axis?

      Your Answer:

      Correct Answer: -30 to 90 degrees

      Explanation:

      Understanding ECG Analysis: The Normal Cardiac Axis

      ECG analysis is a fundamental concept that is essential to understand early on. One of the key components of ECG analysis is the normal cardiac axis, which ranges from −30 to 90 degrees. If the axis is greater than 90 degrees, it implies right axis deviation, while an axis less than −30 degrees indicates left axis deviation.

      To determine the axis, leads I, II, and III of the ECG are typically examined. A normal axis is characterized by upgoing waves in all three leads. In contrast, right axis deviation is indicated by a downgoing wave in lead I and an upgoing wave in leads II and III. Left axis deviation is indicated by an upgoing wave in lead I and a downgoing wave in leads II and III.

      While −30 to −90 degrees is considered left axis deviation and not a normal axis, −30 to 60 degrees is a normal axis, but it does not cover the full spectrum of a normal axis. Therefore, the correct answer is -30 to 90 degrees. Understanding the normal cardiac axis is crucial for accurate ECG interpretation and diagnosis.

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      • Cardiology
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  • Question 29 - A radiologist examining a routine chest X-ray in a 50-year-old man is taken...

    Incorrect

    • A radiologist examining a routine chest X-ray in a 50-year-old man is taken aback by the presence of calcification of a valve orifice located at the upper left sternum at the level of the third costal cartilage.
      Which valve is most likely affected?

      Your Answer:

      Correct Answer: The pulmonary valve

      Explanation:

      Location and Auscultation of Heart Valves

      The heart has four valves that regulate blood flow through its chambers. Each valve has a specific location and can be auscultated to assess its function.

      The Pulmonary Valve: Located at the junction of the sternum and left third costal cartilage, the pulmonary valve is best auscultated at the level of the second left intercostal space parasternally.

      The Aortic Valve: Positioned posterior to the left side of the sternum at the level of the third intercostal space, the aortic valve is best auscultated in the second right intercostal space parasternally.

      The Mitral Valve: Found posteriorly to the left side of the sternum at the level of left fourth costal cartilage, in the fifth intercostal space in mid-clavicular line, the mitral valve can be auscultated to assess its function.

      The Valve of the Coronary Sinus: The Thebesian valve of the coronary sinus is an endocardial flap that plays a role in regulating blood flow through the heart.

      The Tricuspid Valve: Located behind the lower mid-sternum at the level of the fourth and fifth intercostal spaces, the tricuspid valve is best auscultated over the lower sternum.

      Understanding the location and auscultation of heart valves is essential for diagnosing and treating heart conditions.

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      • Cardiology
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  • Question 30 - A 58-year-old Caucasian man with type II diabetes is seen for annual review....

    Incorrect

    • A 58-year-old Caucasian man with type II diabetes is seen for annual review. His blood pressure is 174/99 mmHg, and his 24-hour urine collection reveals moderately increased albuminuria (microalbuminuria). Blood results show Na+ 140 mmol/l, K+ 4.0 mmol/l, urea 4.2 mmol/l and creatinine 75 μmol/l.
      Which of the following medications would be the most appropriate to use first line to treat the hypertension?

      Your Answer:

      Correct Answer: Ramipril

      Explanation:

      First-line treatment for hypertension in diabetic patients: Ramipril

      Ramipril is the first-line treatment for hypertension in diabetic patients due to its ability to reduce proteinuria in diabetic nephropathy, in addition to its antihypertensive effect. Calcium channel blockers, such as amlodipine, may be preferred for pregnant women or patients with hypertension but no significant proteinuria. Bendroflumethiazide may be introduced if first-line therapy is ineffective, while atenolol can be used in difficult-to-treat hypertension where dual therapy is ineffective. Furosemide is usually avoided in type II diabetes due to its potential to interfere with blood glucose levels.

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      • Cardiology
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SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiology (2/7) 29%
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