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Question 1
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: Digoxin
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 2
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: Mitral valve prolapse
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 3
Incorrect
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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:
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.
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This question is part of the following fields:
- Cardiology
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Question 4
Incorrect
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A 12-year-old girl is diagnosed with rheumatic fever after presenting with a 3-day history of fever and polyarthralgia. The patient’s mother is concerned about any potential lasting damage to the heart.
What is the most common cardiac sequelae of rheumatic fever?Your Answer:
Correct Answer: Mitral stenosis
Explanation:Rheumatic Fever and its Effects on Cardiac Valves
Rheumatic fever is a condition caused by group A β-haemolytic streptococcal infection. To diagnose it, the revised Duckett-Jones criteria are used, which require evidence of streptococcal infection and the presence of certain criteria. While all four cardiac valves may be damaged as a result of rheumatic fever, the mitral valve is the most commonly affected, with major criteria including carditis, subcutaneous nodule, migratory polyarthritis, erythema marginatum, and Sydenham’s chorea. Minor criteria include arthralgia, fever, raised CRP or ESR, raised WCC, heart block, and previous rheumatic fever. Mitral stenosis is the most common result of rheumatic fever, but it is becoming less frequently seen in clinical practice. Pulmonary regurgitation, aortic sclerosis, and tricuspid regurgitation are also possible effects, but they are less common than mitral valve damage. Ventricular septal defect is not commonly associated with rheumatic fever.
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This question is part of the following fields:
- Cardiology
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Question 5
Incorrect
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A patient presents to the Emergency Department following a fracture dislocation of his ankle after a night out drinking vodka red-bulls. His blood pressure is low at 90/50 mmHg. He insists that it is never normally that low.
Which one of these is a possible cause for this reading?Your Answer:
Correct Answer: Incorrect cuff size (cuff too large)
Explanation:Common Factors Affecting Blood Pressure Readings
Blood pressure readings can be affected by various factors, including cuff size, alcohol and caffeine consumption, white coat hypertension, pain, and more. It is important to be aware of these factors to ensure accurate readings.
Incorrect Cuff Size:
Using a cuff that is too large can result in an underestimation of blood pressure, while a cuff that is too small can cause a falsely elevated reading.Alcohol and Caffeine:
Both alcohol and caffeine can cause a temporary increase in blood pressure.White Coat Hypertension:
Many patients experience elevated blood pressure in medical settings due to anxiety. To obtain an accurate reading, blood pressure should be measured repeatedly on separate occasions.Pain:
Pain is a common cause of blood pressure increase and should be taken into consideration during medical procedures. A significant rise in blood pressure during a procedure may indicate inadequate anesthesia.Factors Affecting Blood Pressure Readings
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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 49-year-old man presents to the Emergency Department with complaints of chest pain and pain in his left shoulder. He had spent the previous 2 h shoveling snow, but had to stop because of the pain. He admits to several prior episodes of chest pain under similar circumstances. No ST segment changes are seen on the electrocardiogram (ECG). The patient is given sublingual nitroglycerin, which relieves his pain, and is admitted for an overnight stay. The following morning, serum cardiac enzymes are within normal limits and no ECG changes are seen.
Which one of the following is the most likely diagnosis?Your Answer:
Correct Answer: Stable (typical) angina
Explanation:Differentiating Types of Angina
When a patient presents with chest pain, it is important to differentiate between the different types of angina. In the case of a patient who has experienced chest pain triggered by heavy physical labor without characteristic ECG changes, and without rise in serum cardiac enzymes, it is likely that they are experiencing stable (typical) angina. This is not the patient’s first episode, and the pain is not becoming progressively worse with less severe triggers, ruling out unstable (crescendo) angina. Additionally, the fact that the pain was triggered by physical activity rather than occurring at rest rules out Prinzmetal variant angina. Subendocardial infarction and transmural infarction can also be ruled out as both would result in elevated cardiac enzyme levels and characteristic ECG changes, such as ST depression or ST elevation and Q waves, respectively. Therefore, based on the patient’s presentation, stable (typical) angina is the most likely diagnosis.
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This question is part of the following fields:
- Cardiology
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Question 7
Incorrect
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A 68-year-old woman presents to the hospital with complaints of shortness of breath, extreme weakness, and epigastric pain that started 30 minutes ago while she was using the restroom. She is still experiencing these symptoms and is sweating profusely. Her heart rate is 150 bpm, and her blood pressure is 180/110 mmHg. An ECG is ordered, which shows elevated ST segments in consecutive leads and Q waves. What is the most probable cause of this woman's condition?
Your Answer:
Correct Answer: Completely occlusive thrombus
Explanation:Causes of Chest Pain: Understanding Myocardial Infarction and Other Conditions
Chest pain can be a symptom of various conditions, including myocardial infarction, coronary artery stenosis, coronary vasospasm, partially occlusive thrombus, and pulmonary embolism. Understanding the differences between these conditions is crucial for accurate diagnosis and treatment.
Myocardial Infarction
Myocardial infarction, or heart attack, is a serious condition that occurs when a completely occlusive thrombus blocks blood flow to the heart. Women are more likely to experience atypical symptoms such as shortness of breath, weakness, and fatigue, rather than the typical substernal chest pain. However, heart rate, blood pressure, and ECG changes indicate a myocardial infarction.
Coronary Artery Stenosis
Coronary artery stenosis causes stable angina, which subsides with rest. It is characterized by a narrowing of the coronary arteries that supply blood to the heart.
Coronary Vasospasm
Coronary vasospasm is the cause of Prinzmetal’s angina, which presents as intermittent chest pain at rest. It is caused by the sudden constriction of the coronary arteries.
Partially Occlusive Thrombus
A partially occlusive thrombus may present similarly to a completely occlusive thrombus, but it does not usually cause an elevation in the ST segment.
Pulmonary Embolism
A pulmonary embolism is an occlusion of circulation in the lungs and presents as severe shortness of breath. However, it does not typically cause the specific ECG changes seen in myocardial infarction.
Understanding the differences between these conditions can help healthcare professionals accurately diagnose and treat chest pain.
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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 38-year-old man presents to the Emergency Department with a 2-day history of flu-like symptoms. He reports experiencing sharp central chest pain that worsens with coughing and improves when he sits forwards. Upon examination, he is found to be tachycardic and has a temperature of 39 °C. A third heart sound is heard upon auscultation. What is the most probable cause of this patient's chest pain?
Your Answer:
Correct Answer: Pericarditis
Explanation:Differential Diagnosis of Chest Pain: Pericarditis, Aortic Dissection, Myocardial Ischaemia, Oesophageal Reflux, and Pneumonia
Chest pain is a common presenting symptom in clinical practice. It can be caused by a variety of conditions, including pericarditis, aortic dissection, myocardial ischaemia, oesophageal reflux, and pneumonia.
Pericarditis is an acute inflammation of the pericardial sac, which contains the heart. It typically presents with central or left-sided chest pain that is relieved by sitting forwards and worsened by coughing and lying flat. Other signs include tachycardia, raised temperature, and pericardial friction rub. Investigations include blood tests, electrocardiography, chest X-ray, and echocardiography. Treatment aims to address the underlying cause and manage symptoms, such as analgesia and bed rest.
Aortic dissection is characterized by central chest or epigastric pain radiating to the back. It is associated with Marfan syndrome, and symptoms of this condition should be sought when assessing patients.
Myocardial ischaemia is unlikely in a 35-year-old patient without risk factors such as illegal drug use or family history. Ischaemic pain is typically central and heavy/’crushing’ in character, with radiation to the jaw or arm.
Oesophageal reflux disease (GORD) typically presents with chest pain associated with reflux after eating. Patients do not typically have a fever or history of recent illness.
Pneumonia is a possible cause of chest pain, but it is unlikely in the absence of a productive cough. Pleuritic chest pain associated with pneumonia is also unlikely to be relieved by sitting forward, which is a classical sign of pericarditis.
In conclusion, a thorough history and examination, along with appropriate investigations, are necessary to differentiate between the various causes of chest pain and provide appropriate management.
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This question is part of the following fields:
- Cardiology
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Question 9
Incorrect
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A 33-year-old known intravenous drug user presents to your GP clinic with complaints of fatigue, night sweats and joint pain. During the examination, you observe a new early-diastolic murmur. What is the probable causative organism for this patient's condition?
Your Answer:
Correct Answer: Staphylococcus aureus
Explanation:Common Causes of Infective Endocarditis and their Characteristics
Infective endocarditis is a serious condition that can lead to severe complications if left untreated. The most common causative organism of acute infective endocarditis is Staphylococcus aureus, especially in patients with risk factors such as prosthetic valves or intravenous drug use. Symptoms and signs consistent with infective endocarditis include fever, heart murmur, and arthritis, as well as pathognomonic signs like splinter hemorrhages, Osler’s nodes, Roth spots, Janeway lesions, and petechiae.
Group B streptococci is less common than Staphylococcus aureus but has a high mortality rate of 70%. Streptococcus viridans is not the most common cause of infective endocarditis, but it does cause 50-60% of subacute cases. Group D streptococci is the third most common cause of infective endocarditis. Pseudomonas aeruginosa is not the most common cause of infective endocarditis and usually requires surgery for cure.
In summary, knowing the characteristics of the different causative organisms of infective endocarditis can help in the diagnosis and treatment of this serious condition.
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This question is part of the following fields:
- Cardiology
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Question 10
Incorrect
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A 23-year-old woman with a history of two episodes of pneumothorax over the last 12 months was found to have ectopia lentis, during a recent examination by an ophthalmologist. It is noted that she has pectus excavatum, pes planus, a high arched palate and a positive wrist and thumb sign.
What is the likely finding from her echocardiogram?Your Answer:
Correct Answer: Dilated aortic root
Explanation:Cardiovascular Conditions and Marfan Syndrome
Marfan syndrome is a genetic disorder that affects the connective tissue and can lead to various cardiovascular conditions. One of the most common complications is aortic aneurysm, which occurs when the ascending aorta becomes dilated and can result in acute aortic dissection. Additionally, the stretching of the aortic valve annulus can cause aortic regurgitation. Marfan syndrome is caused by a mutation in the FBN1 gene and can be differentiated from other connective tissue disorders such as Ehlers-Danlos syndrome, pseudoxanthoma elasticum, and homocystinuria.
Aortic valve stenosis, on the other hand, is not associated with Marfan syndrome and is caused by either senile calcific degeneration or a congenital bicuspid aortic valve. Coarctation of the aorta is associated with Turner syndrome and presents with hypertension in the upper extremities and hypotension in the lower extremities. Ventricular septal defects and Ebstein’s anomaly are also not associated with Marfan syndrome.
In summary, Marfan syndrome can lead to various cardiovascular complications, and it is important to differentiate it from other connective tissue disorders and understand the associated conditions.
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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 56-year-old Caucasian man presents to his General Practitioner (GP) for routine health screening. He has a background history of obesity (BMI 31 kg/m2), impaired glucose tolerance and he used to smoke. His blood pressure is 162/100 mmHg. It is the same in both arms. There is no renal bruit and he does not appear cushingoid. He does not take regular exercise. At his previous appointment his blood pressure was 168/98 mm/Hg and he has been testing his BP at home. Average readings are 155/95 mmHg. He does not drink alcohol. His father had a heart attack at age 58. Blood results are listed below:
Investigation Result Normal value
HbA1C 46 mmol/l < 53 mmol/mol (<7.0%)
Potassium 4.1 mmol/l 3.5–5 mmol/l
Urea 7 mmol/l 2.5–6.5 mmol/l
Creatinine 84 µmol/l 50–120 µmol/l
Total cholesterol 5.2 mmol/l < 5.2 mmol/l
High-density lipoprotein (HDL) 1.1 mmol/l > 1.0 mmol/l
Low density-lipoprotein (LDL) 3 mmol/l < 3.5 mmol/l
Triglycerides 1.1 mmol/l 0–1.5 mmol/l
Thyroid Stimulating Hormone (TSH) 2 µU/l 0.17–3.2 µU/l
Free T4 16 pmol/l 11–22 pmol/l
What is the most appropriate next step in management of this patient?Your Answer:
Correct Answer: Commence ACE inhibitor
Explanation:Treatment for Stage 2 Hypertension: Commencing ACE Inhibitor
Stage 2 hypertension is a serious condition that requires prompt treatment to reduce the risk of a cardiac event. According to NICE guidelines, ACE inhibitors or ARBs are the first-line treatment for hypertension. This man, who has multiple risk factors for hypertension, including age, obesity, and physical inactivity, should commence pharmacological treatment. Lifestyle advice alone is not sufficient in this case.
It is important to note that beta blockers are not considered first-line treatment due to their side-effect profile. Spironolactone is used as fourth-line treatment in resistant hypertension or in the setting of hyperaldosteronism. If cholesterol-lowering treatment were commenced, a statin would be first line. However, in this case, the patient’s cholesterol is normal, so a fibrate is not indicated.
In summary, commencing an ACE inhibitor is the appropriate course of action for this patient with stage 2 hypertension.
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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 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:
Correct Answer: Left atrial myxoma
Explanation:Cardiac Conditions: Differentiating Left Atrial Myxoma from Other Pathologies
Left atrial myxoma is a cardiac condition characterized by heart sounds, systemic embolization, and intracardiac calcification seen on X-ray. Echocardiography is used to confirm the diagnosis, and surgery is usually curative. However, other cardiac pathologies can present with similar symptoms, including rheumatic heart disease, mitral stenosis, mitral regurgitation, and infective endocarditis. It is important to differentiate between these conditions to provide appropriate treatment. This article discusses the key features of each pathology to aid in diagnosis.
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This question is part of the following fields:
- Cardiology
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Question 13
Incorrect
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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:
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.
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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 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:
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 15
Incorrect
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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:
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.
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This question is part of the following fields:
- Cardiology
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Question 16
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 17
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 18
Incorrect
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A 48-year-old man presents to the Emergency Department with chest tightness. His blood pressure is 200/105 mmHg and heart rate is 70 bpm. His femoral pulses cannot be felt. Echocardiography reveals cardiomegaly and a left-ventricular ejection fraction of 34%. The patient also has a N-terminal pro-brain natriuretic peptide (NT-proBNP) of 25,000 pg/mL. As a result of the patient’s hypertension and high levels of NT-proBNP, he undergoes coronary angiography to exclude cardiac ischaemia. There is no evidence of myocardial ischaemia, but there are significant arterial findings.
Which of the following is most likely to be seen on coronary angiography of this patient?Your Answer:
Correct Answer: Stenotic arteries
Explanation:Differentiating Arterial Conditions: Understanding the Symptoms and Causes
When it comes to arterial conditions, it is important to understand the symptoms and causes in order to make an accurate diagnosis. Here, we will explore several potential conditions and how they may present in a patient.
Stenotic Arteries:
Coarctation of the aorta is a potential condition to consider in younger adults with poorly controlled hypertension. Symptoms may include weak or absent femoral pulses, heart failure, and left-ventricular hypertrophy. Angiography may reveal stenosis in the middle and proximal segments of the left anterior descending artery, as well as in the left circumflex artery.Thickened Arteries:
Atherosclerosis, or the build-up of plaque in the arteries, is a risk factor for heart attacks and stroke. However, it is unlikely to explain persistently high blood pressure or an absent femoral pulse.Aortic Aneurysm:
While chronic high blood pressure can increase the risk of an aortic aneurysm, sudden, intense chest or back pain is a more common symptom. Additionally, a patient with an aneurysm would likely have low blood pressure and an elevated heart rate, which is inconsistent with the vitals seen in this presentation.Calcified Arteries:
Calcification of arteries is caused by elevated lipid content and increases with age. While it can increase the risk of heart attack and stroke, it would not explain the absence of a femoral pulse or extremely high blood pressure.Patent Foramen Ovale:
This condition, which predisposes patients to paradoxical emboli, is typically diagnosed on an echocardiogram and is unlikely to cause hypertension. It should be considered in patients who have had a stroke before the age of 50.In summary, understanding the symptoms and causes of arterial conditions is crucial for accurate diagnosis and treatment.
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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 7-year-old girl comes to the clinic complaining of headaches, particularly during times of stress or physical activity. She has no significant medical history. During her neurological exam, no abnormalities are found. However, a systolic murmur is heard along the length of her left sternal edge and spine. Her chest is clear and her blood pressure is 156/88 mmHg in her left arm and 104/68 mmHg in her left leg. An ECG reveals sinus rhythm with evidence of left ventricular hypertrophy. What is the most likely diagnosis?
Your Answer:
Correct Answer: Coarctation of the aorta
Explanation:Coarctation of the Aorta and its Interventions
Coarctation of the aorta is a condition where the aorta narrows, usually distal to the left subclavian artery. This can cause an asymptomatic difference in upper and lower body blood pressures and can lead to left ventricular hypertrophy. The severity of the restriction varies, with severe cases presenting early with cardiac failure, while less severe cases can go undiagnosed into later childhood.
Interventions for coarctation of the aorta include stenting, excision and graft placement, and using the left subclavian artery to bypass the coarctation. An atrial septal defect and hypertrophic occlusive cardiomyopathy would not cause a blood pressure difference between the upper and lower body. Stress headaches and a flow murmur are not appropriate diagnoses for a child with hypertension, which should be thoroughly investigated for an underlying cause.
In contrast, transposition of the great arteries is a major cyanotic cardiac abnormality that presents in infancy. It is important to diagnose and treat coarctation of the aorta to prevent complications such as left ventricular hypertrophy and cardiac 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 45-year-old man visits his GP for a routine check-up. He reports feeling well today but has a history of chronic respiratory tract infections and lung issues. He is immunocompetent.
During the examination, his temperature and blood pressure are normal. His heart rate is regular and his breathing is effortless. The GP detects a diastolic murmur with a snap that is most audible at the right fifth intercostal space in the mid-clavicular line.
What is the most probable diagnosis?Your Answer:
Correct Answer: Primary ciliary dyskinesia
Explanation:Possible Diagnosis for a Patient with Chronic Respiratory Infections and a Heart Murmur
Primary Ciliary Dyskinesia: A Congenital Syndrome of Ciliary Dysfunction
The patient described in the case likely has primary ciliary dyskinesia, also known as Kartagener’s syndrome, which is a congenital syndrome of ciliary dysfunction. This disorder affects the proper beating of Ciliary, leading to the accumulation of infectious material within the respiratory tree and abnormal cell migration during development, resulting in situs inversus. Additionally, abnormal Ciliary can lead to non-motile sperm and infertility.
Other Possible Diagnoses
Although the GP noticed a diastolic murmur suggestive of mitral stenosis, the patient does not have symptoms of congestive heart failure. Asthma could be associated with chronic lung and respiratory tract infections, but it would not explain the heart murmur. Squamous cell lung cancer is less likely in a man who is 40 years old with a normal respiratory examination and would not explain the heart murmur. Idiopathic pulmonary hypertension usually causes progressive breathlessness, a dry cough, and fine inspiratory crepitations on examination, rather than the picture here.
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This question is part of the following fields:
- Cardiology
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Question 21
Incorrect
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A patient in their 60s with idiopathic pericarditis becomes increasingly unwell, with hypotension, jugular venous distention and muffled heart sounds on auscultation. Echocardiogram confirms a pericardial effusion.
At which of the following sites does this effusion occur?Your Answer:
Correct Answer: Between the visceral pericardium and the parietal pericardium
Explanation:Understanding the Site of Pericardial Effusion
Pericardial effusion is a condition where excess fluid accumulates in the pericardial cavity, causing compression of the heart. To understand the site of pericardial effusion, it is important to know the layers of the pericardium.
The pericardium has three layers: the fibrous pericardium, the parietal pericardium, and the visceral pericardium. The pericardial fluid is located in between the visceral and parietal pericardium, which is the site where a pericardial effusion occurs.
It is important to note that pericardial effusion does not occur between the parietal pericardium and the fibrous pericardium, the visceral pericardium and the myocardium, the fibrous pericardium and the mediastinal pleura, or the fibrous pericardium and the central tendon of the diaphragm.
In summary, pericardial effusion occurs at the site where pericardial fluid is normally produced – between the parietal and visceral layers of the serous pericardium. Understanding the site of pericardial effusion is crucial in diagnosing and treating this condition.
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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 38-year-old man comes for his 6-week post-myocardial infarction (MI) follow-up. He was discharged without medication. His total cholesterol is 9 mmol/l, with triglycerides of 1.2 mmol/l. He is a non-smoker with a blood pressure of 145/75. His father passed away from an MI at the age of 43.
What is the most suitable initial treatment for this patient?Your Answer:
Correct Answer: High-dose atorvastatin
Explanation:Treatment Options for a Patient with Hypercholesterolemia and Recent MI
When treating a patient with hypercholesterolemia and a recent myocardial infarction (MI), it is important to choose the most appropriate treatment option. In this case, high-dose atorvastatin is the best choice due to the patient’s high cholesterol levels and family history. It is crucial to note that medication should have been prescribed before the patient’s discharge.
While dietary advice can be helpful, it is not the most urgent treatment option. Ezetimibe would only be prescribed if a statin were contraindicated. In this high-risk patient, low-dose atorvastatin is not sufficient, and high-dose atorvastatin is required, provided it is tolerated. If cholesterol control does not improve with high-dose atorvastatin, ezetimibe can be added at a later check-up. Overall, the priority is to control the patient’s high cholesterol levels with medication.
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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 27-year-old Asian woman complains of palpitations, shortness of breath on moderate exertion and a painful and tender knee. During auscultation, a mid-diastolic murmur with a loud S1 is heard. Echocardiography reveals valvular heart disease with a normal left ventricular ejection fraction.
What is the most probable valvular disease?Your Answer:
Correct Answer: Mitral stenosis
Explanation:Differentiating Heart Murmurs: Causes and Characteristics
Heart murmurs are abnormal sounds heard during a heartbeat and can indicate underlying heart conditions. Here are some common causes and characteristics of heart murmurs:
Mitral Stenosis: This condition is most commonly caused by rheumatic fever in childhood and is rare in developed countries. Patients with mitral stenosis will have a loud S1 with an associated opening snap. However, if the mitral valve is calcified or there is severe stenosis, the opening snap may be absent and S1 soft.
Mitral Regurgitation and Ventricular Septal Defect: These conditions cause a pan-systolic murmur, which is not the correct option for differentiating heart murmurs.
Aortic Regurgitation: This condition leads to an early diastolic murmur.
Aortic Stenosis: Aortic stenosis causes an ejection systolic murmur.
Ventricular Septal Defect: As discussed, a ventricular septal defect will cause a pan-systolic murmur.
By understanding the causes and characteristics of different heart murmurs, healthcare professionals can better diagnose and treat underlying heart conditions.
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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 70-year-old patient comes to her doctor for a routine check-up. During the examination, her blood pressure is measured in both arms, and the readings are as follows:
Right arm 152/100
Left arm 138/92
What should be the next step in managing this patient's condition?Your Answer:
Correct Answer: Ask the patient to start ambulatory blood pressure monitoring
Explanation:Proper Management of High Blood Pressure Readings
In order to properly manage high blood pressure readings, it is important to follow established guidelines. If a patient displays a blood pressure of over 140/90 in one arm, the patient should have ambulatory blood pressure monitoring (ABPM) in order to confirm the presence or lack of hypertension, in accordance with NICE guidelines.
It is important to note that a diagnosis of hypertension cannot be made from one blood pressure recording. However, if hypertension is confirmed, based upon the patients’ age, amlodipine would be the antihypertensive of choice.
When measuring blood pressure in both arms (as it should clinically be done), the higher of the two readings should be taken. Asking the patient to come back in one week to re-record blood pressure sounds reasonable, but it is not in accordance with the NICE guidelines.
Lastly, it is important to note that considering the patients’ age, ramipril is second line and should not be the first choice for treatment. Proper management of high blood pressure readings is crucial for the overall health and well-being of the patient.
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This question is part of the following fields:
- Cardiology
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Question 25
Incorrect
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A 60-year-old woman received a blood transfusion of 2 units of crossmatched blood 1 hour ago, following acute blood loss. She reports noticing a funny feeling in her chest, like her heart keeps missing a beat. You perform an electrocardiogram (ECG) which shows tall, tented T-waves and flattened P-waves in multiple leads.
An arterial blood gas (ABG) test shows:
Investigation Result Normal value
Sodium (Na+) 136 mmol/l 135–145 mmol/l
Potassium (K+) 7.1 mmol/l 5–5.0 mmol/l
Chloride (Cl–) 96 mmol/l 95–105 mmol/l
Given the findings, what treatment should be given immediately?Your Answer:
Correct Answer: Calcium gluconate
Explanation:Treatment Options for Hyperkalaemia: Understanding the Role of Calcium Gluconate, Insulin and Dextrose, Calcium Resonium, Nebulised Salbutamol, and Dexamethasone
Hyperkalaemia is a condition characterized by high levels of potassium in the blood, which can lead to serious complications such as arrhythmias. When a patient presents with hyperkalaemia and ECG changes, the initial treatment is calcium gluconate. This medication stabilizes the myocardial membranes by reducing the excitability of cardiomyocytes. However, it does not reduce potassium levels, so insulin and dextrose are needed to correct the underlying hyperkalaemia. Insulin shifts potassium intracellularly, reducing serum potassium levels by 0.6-1.0 mmol/l every 15 minutes. Nebulised salbutamol can also drive potassium intracellularly, but insulin and dextrose are preferred due to their increased effectiveness and decreased side-effects. Calcium Resonium is a slow-acting treatment that removes potassium from the body by binding it and preventing its absorption in the gastrointestinal tract. While it can help reduce potassium levels in the long term, it is not effective in protecting the patient from arrhythmias acutely. Dexamethasone, a steroid, is not useful in the treatment of hyperkalaemia. Understanding the role of these treatment options is crucial in managing hyperkalaemia and preventing serious complications.
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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 30-year-old woman patient presents with a subacute history of lethargy and low-grade fever. Among other findings, full clinical examination reveals retinal haemorrhages with pale centres, painful red raised lesions on the hands and feet and subcentimetre, non-tender, raised papules on the palms and soles of the feet.
What is the underlying condition?Your Answer:
Correct Answer: Endocarditis
Explanation:Clinical Signs and Diagnosis of Subacute Bacterial Endocarditis
Subacute bacterial endocarditis (SBE) is a condition caused by Streptococcus viridans, an oral commensal, and presents with malaise, weakness, and low-grade fever. Diagnosis is often delayed due to non-specific presentation, but it should be suspected in any febrile or unwell patient with a new or changing murmur. The three classic clinical signs of SBE are finger clubbing, Roth spots, and Osler’s nodes, along with Janeway lesions, which are subcentimeter, non-tender, raised papules on the palms and soles of the feet. Confirmation of SBE usually requires three separate sets of blood cultures taken in a 24-hour period, ideally during times the patient is febrile.
While Janeway lesions may be found in systemic lupus erythaematosus (SLE), the combination of the three described findings is unique to SBE. Tuberculosis does not present with the above constellation of findings but would be expected to present with chronic cough, haemoptysis, fever, and night sweats. Subacute meningococcal septicaemia typically gives a non-blanching petechial rash in the context of fulminating sepsis and does not present subacutely as described here. Rheumatoid arthritis (RA) patients may have subcutaneous rheumatoid nodules on the extensor surfaces of the limbs, but RA does not give the findings described.
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This question is part of the following fields:
- Cardiology
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Question 27
Incorrect
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You are urgently requested to assess a 23-year-old male who has presented to the Emergency department after confessing to consuming 14 units of alcohol and taking 2 ecstasy tablets tonight. He is alert and oriented but is experiencing palpitations. He denies any chest pain or difficulty breathing.
The patient's vital signs are as follows: heart rate of 180 beats per minute, regular rhythm, blood pressure of 115/80 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 99% on room air. An electrocardiogram (ECG) is performed and reveals an atrioventricular nodal re-entry tachycardia (SVT).
What would be your first course of action in terms of treatment?Your Answer:
Correct Answer: Vagal manoeuvres
Explanation:SVT is a type of arrhythmia that occurs above the ventricles and is commonly seen in patients in their 20s with alcohol and drug use as precipitating factors. Early evaluation of ABC is important, and vagal manoeuvres are recommended as the first line of treatment. Adenosine is the drug of choice if vagal manoeuvres fail, and DC cardioversion is required if signs of decompensation are present. Amiodarone is not a first-line treatment for regular narrow complex SVT.
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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 32-year-old woman presents with dyspnoea on exertion and palpitations. She has an irregularly irregular and tachycardic pulse, and a systolic murmur is heard on auscultation. An ECG reveals atrial fibrillation and right axis deviation, while an echocardiogram shows an atrial septal defect.
What is the process of atrial septum formation?Your Answer:
Correct Answer: The septum secundum grows down to the right of the septum primum
Explanation:During embryonic development, the septum primum grows down from the roof of the primitive atrium and fuses with the endocardial cushions. It initially has a hole called the ostium primum, which closes as the septum grows downwards. However, a second hole called the ostium secundum develops in the septum primum before fusion can occur. The septum secundum then grows downwards and to the right of the septum primum and ostium secundum. The foramen ovale is a passage through the septum secundum that allows blood to shunt from the right to the left atrium in the fetus, bypassing the pulmonary circulation. This defect closes at birth due to a drop in pressure within the pulmonary circulation after the infant takes a breath. If there is overlap between the foramen ovale and ostium secundum or if the ostium primum fails to close, an atrial septal defect results. This defect does not cause cyanosis because oxygenated blood flows from left to right through the defect.
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This question is part of the following fields:
- Cardiology
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Question 29
Incorrect
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A woman with known angina currently managed on glyceryl trinitrate (GTN) spray presents to Accident and Emergency with crushing central chest pain. A 12-lead electrocardiogram (ECG) reveals ST depression and flat T waves. She is managed as acute coronary syndrome without ST elevation.
Which one of the following options is most likely to be used in her immediate management?Your Answer:
Correct Answer: Fondaparinux
Explanation:Medications for Acute Coronary Syndrome: Indications and Uses
Acute coronary syndrome (ACS) is a medical emergency that requires prompt and appropriate treatment to prevent further damage to the heart muscle. The management of ACS involves a combination of medications and interventions, depending on the type and severity of the condition. Here are some commonly used medications for ACS and their indications:
1. Fondaparinux: This medication is a factor Xa inhibitor that is used for anticoagulation in ACS without ST-segment elevation. It is usually given along with other drugs such as aspirin, clopidogrel, and nitrates to prevent blood clots and reduce the risk of future cardiovascular events.
2. Warfarin: This medication is used for the treatment and prevention of venous thrombosis and thromboembolism. It is not indicated for the immediate management of ACS.
3. Furosemide: This medication is a diuretic that is used to treat pulmonary edema in patients with heart failure. It is not indicated for ACS as it may cause dehydration.
4. Paracetamol: This medication is not effective as an analgesic option for ACS. Morphine is commonly used for pain relief in ACS.
5. Simvastatin: This medication is a statin that is used for the long-term management of high cholesterol levels. It is not indicated for the initial management of ACS.
In summary, the management of ACS involves a combination of medications and interventions that are tailored to the individual patient’s needs. Prompt and appropriate treatment can help improve outcomes and reduce the risk of future cardiovascular events.
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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 man in his early 40s comes to you with a rash. Upon examination, you notice that he has eruptive xanthoma. What is the most probable diagnosis?
Your Answer:
Correct Answer: Familial hypertriglyceridaemia
Explanation:Eruptive Xanthoma and its Association with Hypertriglyceridaemia and Diabetes Mellitus
Eruptive xanthoma is a skin condition that can occur in individuals with hypertriglyceridaemia and uncontrolled diabetes mellitus. Hypertriglyceridaemia is a condition characterized by high levels of triglycerides in the blood, which can be caused by a number of factors including genetics, diet, and lifestyle. Eruptive xanthoma is a type of xanthoma that appears as small, yellowish bumps on the skin, often in clusters.
Of the conditions listed, familial hypertriglyceridaemia is the most likely to be associated with eruptive xanthoma. This is a genetic condition that causes high levels of triglycerides in the blood, and can lead to a range of health problems including cardiovascular disease. Uncontrolled diabetes mellitus, which is characterized by high blood sugar levels, can also be a risk factor for eruptive xanthoma.
It is important for individuals with hypertriglyceridaemia or diabetes mellitus to manage their condition through lifestyle changes and medication, in order to reduce the risk of complications such as eruptive xanthoma. Regular monitoring and treatment can help to prevent the development of this skin condition and other related health problems.
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This question is part of the following fields:
- Cardiology
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