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  • Question 1 - A 32 year old with a documented peanut allergy is currently receiving treatment...

    Correct

    • A 32 year old with a documented peanut allergy is currently receiving treatment for an anaphylactic reaction. What are the most likely cardiovascular manifestations that you would observe in a patient experiencing an episode of anaphylaxis?

      Your Answer: Hypotension and tachycardia

      Explanation:

      Anaphylaxis, also known as anaphylactic shock, is characterized by certain symptoms similar to other types of shock. These symptoms include low blood pressure (hypotension), rapid heart rate (tachycardia), irregular heart rhythm (arrhythmia), changes in the electrocardiogram (ECG) indicating reduced blood flow to the heart (myocardial ischemia), such as ST elevation, and in severe cases, cardiac arrest.

      Further Reading:

      Anaphylaxis is a severe and life-threatening hypersensitivity reaction that can have sudden onset and progression. It is characterized by skin or mucosal changes and can lead to life-threatening airway, breathing, or circulatory problems. Anaphylaxis can be allergic or non-allergic in nature.

      In allergic anaphylaxis, there is an immediate hypersensitivity reaction where an antigen stimulates the production of IgE antibodies. These antibodies bind to mast cells and basophils. Upon re-exposure to the antigen, the IgE-covered cells release histamine and other inflammatory mediators, causing smooth muscle contraction and vasodilation.

      Non-allergic anaphylaxis occurs when mast cells degrade due to a non-immune mediator. The clinical outcome is the same as in allergic anaphylaxis.

      The management of anaphylaxis is the same regardless of the cause. Adrenaline is the most important drug and should be administered as soon as possible. The recommended doses for adrenaline vary based on age. Other treatments include high flow oxygen and an IV fluid challenge. Corticosteroids and chlorpheniramine are no longer recommended, while non-sedating antihistamines may be considered as third-line treatment after initial stabilization of airway, breathing, and circulation.

      Common causes of anaphylaxis include food (such as nuts, which is the most common cause in children), drugs, and venom (such as wasp stings). Sometimes it can be challenging to determine if a patient had a true episode of anaphylaxis. In such cases, serum tryptase levels may be measured, as they remain elevated for up to 12 hours following an acute episode of anaphylaxis.

      The Resuscitation Council (UK) provides guidelines for the management of anaphylaxis, including a visual algorithm that outlines the recommended steps for treatment.
      https://www.resus.org.uk/sites/default/files/2021-05/Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf

    • This question is part of the following fields:

      • Cardiology
      5.9
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  • Question 2 - A 58-year-old woman presents with abrupt intense chest discomfort that extends to her...

    Correct

    • A 58-year-old woman presents with abrupt intense chest discomfort that extends to her back. She is perspiring and experiencing nausea. During the examination, her blood pressure measures 176/96 in her right arm and 143/78 in her left arm. An early diastolic murmur is audible upon auscultation.

      What is the SINGLE most probable diagnosis?

      Your Answer: Aortic dissection

      Explanation:

      Acute aortic dissection is characterized by the rapid formation of a false, blood-filled channel within the middle layer of the aorta. It is estimated to occur in 3 out of every 100,000 individuals per year.

      Patients with aortic dissection typically experience intense chest pain that spreads to the area between the shoulder blades. The pain is often described as tearing or ripping and may also extend to the neck. Sweating, paleness, and rapid heartbeat are commonly observed at the time of presentation. Other possible symptoms include focal neurological deficits, weak pulses, fainting, and reduced blood flow to organs.

      A significant difference in blood pressure between the arms, greater than 20 mmHg, is a highly sensitive indicator. If the dissection extends backward, it can involve the aortic valve, leading to the early diastolic murmur of aortic regurgitation.

      Risk factors for aortic dissection include hypertension, atherosclerosis, aortic coarctation, the use of sympathomimetic drugs like cocaine, Marfan syndrome, Ehlers-Danlos syndrome, Turner’s syndrome, tertiary syphilis, and pre-existing aortic aneurysm.

      Aortic dissection can be classified according to the Stanford classification system:
      – Type A affects the ascending aorta and the arch, accounting for 60% of cases. These cases are typically managed surgically and may result in the blockage of coronary arteries and aortic regurgitation.
      – Type B begins distal to the left subclavian artery and accounts for approximately 40% of cases. These cases are usually managed with medication to control blood pressure.

    • This question is part of the following fields:

      • Cardiology
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  • Question 3 - A 45-year-old male smoker comes in with a severe episode of chest pain...

    Correct

    • A 45-year-old male smoker comes in with a severe episode of chest pain that spreads to his left arm and jaw. The pain lasted for about half an hour before being relieved by GTN spray and aspirin. A troponin test is done 12 hours later, which comes back positive. His ECG at the time of presentation reveals widespread ST depression.

      What is the MOST LIKELY diagnosis in this case?

      Your Answer: Non-ST-elevation myocardial infarction

      Explanation:

      This patient has developed a non-ST elevation myocardial infarction (NSTEMI). The electrocardiogram (ECG) reveals widespread ST depression, indicating widespread subendocardial ischemia. Additionally, the troponin test results are positive, indicating myocyte necrosis.

      The acute coronary syndromes consist of unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI).

      Unstable angina is characterized by one or more of the following: angina of effort occurring over a few days with increasing frequency, angina episodes occurring recurrently and predictably without specific provocation, or an unprovoked and prolonged episode of cardiac chest pain. The ECG may show T-wave/ST-segment changes, similar to this case. Cardiac enzymes are typically normal, and the troponin test is negative in unstable angina.

      Non-ST elevation myocardial infarction (NSTEMI) typically presents with sustained cardiac chest pain lasting more than 20 minutes. The ECG often shows abnormalities in T-waves or ST-segments. Cardiac enzymes are elevated, and the troponin test is positive.

      ST-elevation myocardial infarction (STEMI) usually presents with typical cardiac chest pain suggestive of an acute myocardial infarction. The ECG reveals ST-segment elevation and the development of Q waves. Cardiac enzymes are elevated, and the troponin test is positive.

    • This question is part of the following fields:

      • Cardiology
      3.2
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  • Question 4 - A 72 year old male comes to the emergency department complaining of central...

    Incorrect

    • A 72 year old male comes to the emergency department complaining of central chest pain. An ECG is performed to check for signs of ischemic changes. Which of the following results is most indicative of a non ST elevation myocardial infarction (NSTEMI)?

      Your Answer: T wave inversion in lead V1

      Correct Answer: Q wave in lead V2

      Explanation:

      Q waves in V2 and V3 are typically abnormal and indicate a pathological condition. Q waves are negative deflections that occur before an R wave. They can be either normal or abnormal. Small normal Q waves, which are less than 1mm deep, may be present in most leads. Deeper normal Q waves are commonly seen in lead III, as long as they are not present in the adjacent leads II and AVF. On the other hand, pathological Q waves are usually deeper and wider. In particular, Q waves should not be observed in V2 and V3. The specific criteria for identifying pathological Q waves are as follows: any Q wave in leads V2-V3 that is greater than 0.02s in duration or a QS complex in leads V2-V3; a Q wave that is greater than 0.03s in duration and deeper than 1mm, or a QS complex, in leads I, II, aVL, aVF, or V4-V6 in any two leads of a contiguous lead grouping; an R wave that is greater than 0.04s in duration in V1-V2 and has an R/S ratio greater than 1, along with a concordant positive T wave, in the absence of a conduction defect. In healthy individuals, the T-wave is normally inverted in aVR and inverted or flat in V1. T-wave inversion in III is also considered a normal variation. If there is ST elevation in lead V1, it would suggest a ST-elevation myocardial infarction (STEMI) rather than a non-ST-elevation myocardial infarction (NSTEMI).

      Further Reading:

      Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).

      The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.

      There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.

      The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.

      The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.

      The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.

    • This question is part of the following fields:

      • Cardiology
      31.1
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  • Question 5 - You are called to a cardiac arrest in a child in the Emergency...

    Incorrect

    • You are called to a cardiac arrest in a child in the Emergency Department. Which SINGLE statement regarding resuscitation in children is true?

      Your Answer:

      Correct Answer: The ratio of chest compressions to ventilations is 15:2

      Explanation:

      The ratio of chest compressions to ventilations is 15:2. This ratio has not been proven through experiments, but it has been validated through mathematical studies. When performing chest compressions on a child, it is recommended to make them at least 1/3 of the depth of the child’s chest. Additionally, the optimal compression rate is between 100 and 120 compressions per minute.
      To protect the airway of an unconscious child, the oropharyngeal (Guedel) airway is the best option. However, it should not be used on awake patients as there is a risk of vomiting and aspiration.
      In children, asystole is the most common arrest rhythm. This occurs when the young heart responds to prolonged hypoxia and acidosis by progressively slowing down, eventually resulting in asystole.

    • This question is part of the following fields:

      • Cardiology
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  • Question 6 - A 40-year-old woman with Marfan syndrome presents with a severe tearing chest pain...

    Incorrect

    • A 40-year-old woman with Marfan syndrome presents with a severe tearing chest pain that spreads to her back. A diagnosis of aortic dissection is suspected.
      Which SINGLE statement regarding aortic dissection is FALSE?

      Your Answer:

      Correct Answer: An inter-arm blood pressure differential of greater than 10 mmHg is a highly sensitive predictor

      Explanation:

      Acute aortic dissection is characterized by the rapid formation of a false, blood-filled channel within the middle layer of the aorta. It is estimated to occur in 3 out of every 100,000 individuals per year.

      Patients with aortic dissection typically experience intense chest pain that spreads to the area between the shoulder blades. The pain is often described as tearing or ripping and may also extend to the neck. Sweating, paleness, and rapid heartbeat are commonly observed at the time of presentation. Other possible symptoms include focal neurological deficits, weak pulses, fainting, and reduced blood flow to organs.

      A significant difference in blood pressure between the arms, greater than 20 mmHg, is a highly sensitive indicator. If the dissection extends backward, it can involve the aortic valve, leading to the early diastolic murmur of aortic regurgitation.

      Risk factors for aortic dissection include hypertension, atherosclerosis, aortic coarctation, the use of sympathomimetic drugs like cocaine, Marfan syndrome, Ehlers-Danlos syndrome, Turner’s syndrome, tertiary syphilis, and pre-existing aortic aneurysm.

      Aortic dissection can be classified according to the Stanford classification system:
      – Type A affects the ascending aorta and the arch, accounting for 60% of cases. These cases are typically managed surgically and may result in the blockage of coronary arteries and aortic regurgitation.
      – Type B begins distal to the left subclavian artery and accounts for approximately 40% of cases. These cases are usually managed with medication to control blood pressure.

    • This question is part of the following fields:

      • Cardiology
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  • Question 7 - A 42-year-old man presents with central chest pain that has been present for...

    Incorrect

    • A 42-year-old man presents with central chest pain that has been present for the past three days. The pain is worsened by deep inspiration and lying flat and relieved by sitting forwards. He recently returned from a vacation in Spain, which involved a short flight. He has no significant medical history but smokes 15 cigarettes per day. His father died from a heart attack at the age of 58. His vital signs are as follows: HR 102, BP 128/72, temperature 37.1oC, SaO2 96% on room air. His ECG shows widespread concave ST elevation and PR depression.
      What is the SINGLE most likely diagnosis?

      Your Answer:

      Correct Answer: Pericarditis

      Explanation:

      Pericarditis refers to the inflammation of the pericardium, which can be caused by various factors such as infections (typically viral, like coxsackie virus), drug-induced reactions (e.g. isoniazid, cyclosporine), trauma, autoimmune conditions (e.g. SLE), paraneoplastic syndromes, uremia, post myocardial infarction (known as Dressler’s syndrome), post radiotherapy, and post cardiac surgery.

      The clinical presentation of pericarditis often includes retrosternal chest pain that worsens with lying flat and improves when sitting forwards, along with shortness of breath, rapid heartbeat, and the presence of a pericardial friction rub.

      Characteristic electrocardiogram (ECG) changes associated with pericarditis typically show widespread concave or ‘saddle-shaped’ ST elevation, widespread PR depression, reciprocal ST depression and PR elevation in aVR (and sometimes V1), and sinus tachycardia is commonly observed.

    • This question is part of the following fields:

      • Cardiology
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  • Question 8 - A 68 year old is brought to the emergency department by his son....

    Incorrect

    • A 68 year old is brought to the emergency department by his son. The patient complained of feeling sick. On checking the patient's medication the son believes he may have taken an excessive amount of digoxin tablets over the past few days. You are worried about digoxin toxicity. What ECG characteristics are linked to digoxin toxicity?

      Your Answer:

      Correct Answer: Downsloping ST depression

      Explanation:

      One way to assess for digoxin toxicity is by examining the patient’s electrocardiogram (ECG) for specific characteristics. In the case of digoxin toxicity, ECG findings may include downsloping ST depression, prolonged QT interval, tall tented T-waves, and possibly delta waves. However, a short PR interval (< 120ms) is not typically associated with digoxin toxicity. Further Reading: Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, digoxin toxicity can occur, and plasma concentration alone does not determine if a patient has developed toxicity. Symptoms of digoxin toxicity include feeling generally unwell, lethargy, nausea and vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia. ECG changes seen in digoxin toxicity include downsloping ST depression with a characteristic Salvador Dali sagging appearance, flattened, inverted, or biphasic T waves, shortened QT interval, mild PR interval prolongation, and prominent U waves. There are several precipitating factors for digoxin toxicity, including hypokalaemia, increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, verapamil, and diltiazem. Management of digoxin toxicity involves the use of digoxin specific antibody fragments, also known as Digibind or digifab. Arrhythmias should be treated, and electrolyte disturbances should be corrected with close monitoring of potassium levels. It is important to note that digoxin toxicity can be precipitated by hypokalaemia, and toxicity can then lead to hyperkalaemia.

    • This question is part of the following fields:

      • Cardiology
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  • Question 9 - A 35-year-old man presents with recurring episodes of intense chest pain. These attacks...

    Incorrect

    • A 35-year-old man presents with recurring episodes of intense chest pain. These attacks have been happening in clusters during the past few weeks and consistently occur at night. An exercise tolerance test has been scheduled, and the results came back completely normal.
      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Prinzmetal angina

      Explanation:

      Prinzmetal angina is a rare form of angina that typically occurs during periods of rest, specifically between midnight and early morning. The attacks can be severe and happen in clusters. This condition is caused by spasms in the coronary arteries, even though patients may have normal arteries. The main treatment options for controlling these spasms are calcium-channel blockers and nitrates. The spasms often follow a cyclical pattern and may disappear after a few months, only to reappear later on.

      Unstable angina may present similarly to Prinzmetal angina, but it does not exclusively occur at night and the exercise tolerance test results are typically abnormal.

      Decubitus angina, on the other hand, is angina that occurs when lying down. It is often a result of cardiac failure caused by increased intravascular volume, which puts extra strain on the heart.

      Takotsubo cardiomyopathy, also known as acute stress cardiomyopathy, can present in a manner similar to an acute myocardial infarction. The cause of this condition is unknown, but it tends to occur in individuals who have recently experienced significant emotional or physical stress. The term Takotsubo refers to the shape the left ventricle takes on, resembling an octopus pot with a narrow neck and round bottom. ECGs often show characteristic changes, such as ST-elevation, but subsequent angiograms reveal normal coronary arteries. The diagnosis is confirmed when the angiogram shows the distinctive octopus pot shape of the left ventricle.

      There is no indication of a psychogenic cause in this particular case.

    • This question is part of the following fields:

      • Cardiology
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  • Question 10 - A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations....

    Incorrect

    • A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations. She informs you that she was recently diagnosed with Wolff-Parkinson-White syndrome. You proceed to perform an ECG.

      Which ONE statement about the ECG findings in Wolff-Parkinson-White (WPW) syndrome is accurate?

      Your Answer:

      Correct Answer: Type A WPW can resemble right bundle branch block

      Explanation:

      Wolff-Parkinson-White (WPW) syndrome is a condition that affects the electrical system of the heart. It occurs when there is an abnormal pathway, known as the bundle of Kent, between the atria and the ventricles. This pathway can cause premature contractions of the ventricles, leading to a type of rapid heartbeat called atrioventricular re-entrant tachycardia (AVRT).

      In a normal heart rhythm, the electrical signals travel through the bundle of Kent and stimulate the ventricles. However, in WPW syndrome, these signals can cause the ventricles to contract prematurely. This can be seen on an electrocardiogram (ECG) as a shortened PR interval, a slurring of the initial rise in the QRS complex (known as a delta wave), and a widening of the QRS complex.

      There are two distinct types of WPW syndrome that can be identified on an ECG. Type A is characterized by predominantly positive delta waves and QRS complexes in the praecordial leads, with a dominant R wave in V1. This can sometimes be mistaken for right bundle branch block (RBBB). Type B, on the other hand, shows predominantly negative delta waves and QRS complexes in leads V1 and V2, and positive in the other praecordial leads, resembling left bundle branch block (LBBB).

      Overall, WPW syndrome is a condition that affects the electrical conduction system of the heart, leading to abnormal heart rhythms. It can be identified on an ECG by specific features such as shortened PR interval, delta waves, and widened QRS complex.

    • This question is part of the following fields:

      • Cardiology
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  • Question 11 - A 67 year old female attends the emergency department complaining of palpitations. The...

    Incorrect

    • A 67 year old female attends the emergency department complaining of palpitations. The patient reports experiencing brief episodes of palpitations over the past few weeks, but they usually resolve themselves after 5-10 minutes. However, today's episode has been ongoing for 30 minutes. The patient denies any chest pain or shortness of breath. She is currently taking aspirin 75mg once daily as her only medication. Blood tests are conducted, and the results are as follows:

      Hemoglobin (Hb): 115 g/l
      Platelets: 155 * 109/l
      White blood cells (WBC): 6.4 * 109/l
      Sodium: 138 mmol/l
      Potassium: 3.8 mmol/l
      Urea: 4.1 mmol/l
      Creatinine: 74 µmol/l
      Glomerular filtration rate (GFR): 68 mL/min/1.73m2

      An electrocardiogram (ECG) is performed, revealing atrial fibrillation. You decide to assess the patient's bleeding risk using the ORBIT tool. What is this patient's ORBIT score?

      Your Answer:

      Correct Answer: 3

      Explanation:

      Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting around 5% of patients over the age of 70-75 years and 10% of patients aged 80-85 years. While AF can cause palpitations and inefficient cardiac function, the most important aspect of managing patients with AF is reducing the increased risk of stroke.

      AF can be classified as first detected episode, paroxysmal, persistent, or permanent. First detected episode refers to the initial occurrence of AF, regardless of symptoms or duration. Paroxysmal AF occurs when a patient has 2 or more self-terminating episodes lasting less than 7 days. Persistent AF refers to episodes lasting more than 7 days that do not self-terminate. Permanent AF is continuous atrial fibrillation that cannot be cardioverted or if attempts to do so are deemed inappropriate. The treatment goals for permanent AF are rate control and anticoagulation if appropriate.

      Symptoms of AF include palpitations, dyspnea, and chest pain. The most common sign is an irregularly irregular pulse. An electrocardiogram (ECG) is essential for diagnosing AF, as other conditions can also cause an irregular pulse.

      Managing patients with AF involves two key parts: rate/rhythm control and reducing stroke risk. Rate control involves slowing down the irregular pulse to avoid negative effects on cardiac function. This is typically achieved using beta-blockers or rate-limiting calcium channel blockers. If one drug is not effective, combination therapy may be used. Rhythm control aims to restore and maintain normal sinus rhythm through pharmacological or electrical cardioversion. However, the majority of patients are managed with a rate control strategy.

      Reducing stroke risk in patients with AF is crucial. Risk stratifying tools, such as the CHA2DS2-VASc score, are used to determine the most appropriate anticoagulation strategy. Anticoagulation is recommended for patients with a score of 2 or more. Clinicians can choose between warfarin and novel oral anticoagulants (NOACs) for anticoagulation.

      Before starting anticoagulation, the patient’s bleeding risk should be assessed using tools like the HAS-BLED score or the ORBIT tool. These tools evaluate factors such as hypertension, abnormal renal or liver function, history of bleeding, age, and use of drugs that predispose to bleeding.

    • This question is part of the following fields:

      • Cardiology
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  • Question 12 - A 25-year-old woman arrives at the emergency department with complaints of palpitations and...

    Incorrect

    • A 25-year-old woman arrives at the emergency department with complaints of palpitations and difficulty breathing. During triage, the patient reveals that she was previously diagnosed with narrow complex tachycardia a couple of years ago after experiencing palpitations during a night out. You order an ECG. What are the specific criteria used to define narrow complex tachycardia?

      Your Answer:

      Correct Answer: Pulse rate greater than 100 beats per minute and QRS duration less than 0.12 seconds

      Explanation:

      Narrow QRS complex tachycardia is a term used to describe a fast heart rhythm with a pulse rate over 100 bpm and a QRS duration shorter than 120 ms.

      Further Reading:

      Supraventricular tachycardia (SVT) is a type of tachyarrhythmia that originates from the atria or above the bundle of His in the heart. It includes all atrial and junctional tachycardias, although atrial fibrillation is often considered separately. SVT typically produces a narrow QRS complex tachycardia on an electrocardiogram (ECG), unless there is an underlying conduction abnormality below the atrioventricular (AV) node. Narrow complex tachycardias are considered SVTs, while some broad complex tachycardias can also be SVTs with co-existent conduction delays.

      SVT can be classified into three main subtypes based on where it arises: re-entrant accessory circuits (the most common type), atrial tachycardias, and junctional tachycardias. The most common SVTs are AVNRT (AV nodal re-entry tachycardia) and AVRT (AV re-entry tachycardia), which arise from accessory circuits within the heart. AVNRT involves an accessory circuit within the AV node itself, while AVRT involves an accessory pathway between the atria and ventricles that allows additional electrical signals to trigger the AV node.

      Atrial tachycardias originate from abnormal foci within the atria, except for the SA node, AV node, or accessory pathway. Junctional tachycardias arise in the AV junction. The ECG features of SVTs vary depending on the type. Atrial tachycardias may have abnormal P wave morphology, an isoelectric baseline between P waves (in atrial flutter), and inverted P waves in certain leads. AVNRT may show pseudo R waves in V1 or pseudo S waves in certain leads, with an RP interval shorter than the PR interval. AVRT (WPW) may exhibit a delta wave on a resting ECG and retrograde P waves in the ST segment, with an RP interval shorter than the PR interval. Junctional tachycardias may have retrograde P waves before, during, or after the QRS complex, with inverted P waves in certain leads and upright P waves in others.

      Treatment of SVT follows the 2021 resuscitation council algorithm for tachycardia with a pulse. The algorithm provides guidelines for managing stable patients with SVT.

    • This question is part of the following fields:

      • Cardiology
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  • Question 13 - A 70 year old male visits the emergency department with a complaint of...

    Incorrect

    • A 70 year old male visits the emergency department with a complaint of increasing shortness of breath. You observe that the patient had moderate aortic regurgitation on an echocardiogram conducted 12 months ago.

      What is a characteristic symptom of aortic regurgitation (AR)?

      Your Answer:

      Correct Answer: Water hammer pulse

      Explanation:

      A collapsing pulse, also known as a water hammer pulse, is a common clinical feature associated with aortic regurgitation (AR). In AR, the pulse rises rapidly and forcefully before quickly collapsing. This pulsation pattern may also be referred to as Watson’s water hammer pulse or Corrigan’s pulse. Heart sounds in AR are typically quiet, and the second heart sound (S2) may even be absent if the valve fails to fully close. A characteristic early to mid diastolic murmur is often present. Other typical features of AR include a wide pulse pressure, a mid-diastolic Austin-Flint murmur in severe cases, a soft S1 and S2 (with S2 potentially being absent), a hyperdynamic apical pulse, and signs of heart failure such as lung creases, raised jugular venous pressure (JVP), and tachypnea.

      Further Reading:

      Valvular heart disease refers to conditions that affect the valves of the heart. In the case of aortic valve disease, there are two main conditions: aortic regurgitation and aortic stenosis.

      Aortic regurgitation is characterized by an early diastolic murmur, a collapsing pulse (also known as a water hammer pulse), and a wide pulse pressure. In severe cases, there may be a mid-diastolic Austin-Flint murmur due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams. The first and second heart sounds (S1 and S2) may be soft, and S2 may even be absent. Additionally, there may be a hyperdynamic apical pulse. Causes of aortic regurgitation include rheumatic fever, infective endocarditis, connective tissue diseases like rheumatoid arthritis and systemic lupus erythematosus, and a bicuspid aortic valve. Aortic root diseases such as aortic dissection, spondyloarthropathies like ankylosing spondylitis, hypertension, syphilis, and genetic conditions like Marfan’s syndrome and Ehler-Danlos syndrome can also lead to aortic regurgitation.

      Aortic stenosis, on the other hand, is characterized by a narrow pulse pressure, a slow rising pulse, and a delayed ESM (ejection systolic murmur). The second heart sound (S2) may be soft or absent, and there may be an S4 (atrial gallop) that occurs just before S1. A thrill may also be felt. The duration of the murmur is an important factor in determining the severity of aortic stenosis. Causes of aortic stenosis include degenerative calcification (most common in older patients), a bicuspid aortic valve (most common in younger patients), William’s syndrome (supravalvular aortic stenosis), post-rheumatic disease, and subvalvular conditions like hypertrophic obstructive cardiomyopathy (HOCM).

      Management of aortic valve disease depends on the severity of symptoms. Asymptomatic patients are generally observed, while symptomatic patients may require valve replacement. Surgery may also be considered for asymptomatic patients with a valvular gradient greater than 40 mmHg and features such as left ventricular systolic dysfunction. Balloon valvuloplasty is limited to patients with critical aortic stenosis who are not fit for valve replacement.

    • This question is part of the following fields:

      • Cardiology
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  • Question 14 - A 68 year old male presents to the emergency department with central heavy...

    Incorrect

    • A 68 year old male presents to the emergency department with central heavy chest pain that began 10 hours ago while the patient was sitting down watching television. The patient has previously refused treatment for high cholesterol and stage 1 hypertension. Physical examination reveals a mildly elevated blood pressure of 156/94 mmHg, but is otherwise unremarkable. The ECG shows ST depression and T wave inversion in leads V1-V3. Initial troponin results are negative, and a second high sensitivity troponin assay performed 3 hours later also returns negative. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Unstable angina

      Explanation:

      Distinguishing between unstable angina and other acute coronary syndromes can be done by looking at normal troponin results. If serial troponin tests come back negative, it can rule out a diagnosis of myocardial infarction. Unstable angina is characterized by myocardial ischemia occurring at rest or with minimal exertion, without any acute damage or death of heart muscle cells. The patient in question shows ECG and biochemical features that align with this definition. Vincent’s angina, on the other hand, refers to an infection in the throat accompanied by ulcerative gingivitis.

      Further Reading:

      Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).

      The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.

      There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.

      The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.

      The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.

      The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.

    • This question is part of the following fields:

      • Cardiology
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  • Question 15 - A 72 year old male is brought to the emergency department by his...

    Incorrect

    • A 72 year old male is brought to the emergency department by his daughter due to sudden confusion, severe headache, and problems with coordination. Upon initial assessment at triage, the patient's blood pressure is found to be significantly elevated at 224/126 mmHg. You suspect the presence of hypertensive encephalopathy. What is the primary treatment option for this condition?

      Your Answer:

      Correct Answer: Labetalol

      Explanation:

      The primary treatment option for hypertensive encephalopathy, a condition characterized by sudden confusion, severe headache, and coordination problems due to significantly elevated blood pressure, is labetalol.

      Further Reading:

      A hypertensive emergency is characterized by a significant increase in blood pressure accompanied by acute or progressive damage to organs. While there is no specific blood pressure value that defines a hypertensive emergency, systolic blood pressure is typically above 180 mmHg and/or diastolic blood pressure is above 120 mmHg. The most common presentations of hypertensive emergencies include cerebral infarction, pulmonary edema, encephalopathy, and congestive cardiac failure. Less common presentations include intracranial hemorrhage, aortic dissection, and pre-eclampsia/eclampsia.

      The signs and symptoms of hypertensive emergencies can vary widely due to the potential dysfunction of every physiological system. Some common signs and symptoms include headache, nausea and/or vomiting, chest pain, arrhythmia, proteinuria, signs of acute kidney failure, epistaxis, dyspnea, dizziness, anxiety, confusion, paraesthesia or anesthesia, and blurred vision. Clinical assessment focuses on detecting acute or progressive damage to the cardiovascular, renal, and central nervous systems.

      Investigations that are essential in evaluating hypertensive emergencies include U&Es (electrolyte levels), urinalysis, ECG, and CXR. Additional investigations may be considered depending on the suspected underlying cause, such as a CT head for encephalopathy or new onset confusion, CT thorax for suspected aortic dissection, and CT abdomen for suspected phaeochromocytoma. Plasma free metanephrines, urine total catecholamines, vanillylmandelic acid (VMA), and metanephrine may be tested if phaeochromocytoma is suspected. Urine screening for cocaine and/or amphetamines may be appropriate in certain cases, as well as an endocrine screen for Cushing’s syndrome.

      The management of hypertensive emergencies involves cautious reduction of blood pressure to avoid precipitating renal, cerebral, or coronary ischemia. Staged blood pressure reduction is typically the goal, with an initial reduction in mean arterial pressure (MAP) by no more than 25% in the first hour. Further gradual reduction to a systolic blood pressure of 160 mmHg and diastolic blood pressure of 100 mmHg over the next 2 to 6 hours is recommended. Initial management involves treatment with intravenous antihypertensive agents in an intensive care setting with appropriate monitoring.

    • This question is part of the following fields:

      • Cardiology
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  • Question 16 - A 45-year-old man presents with palpitations and is found to have atrial fibrillation....

    Incorrect

    • A 45-year-old man presents with palpitations and is found to have atrial fibrillation. You are requested to evaluate his ECG.
      Which of the following statements is NOT true regarding the ECG in atrial fibrillation?

      Your Answer:

      Correct Answer: Ashman beats have a poor prognosis

      Explanation:

      The classic ECG features of atrial fibrillation include an irregularly irregular rhythm, the absence of p-waves, an irregular ventricular rate, and the presence of fibrillation waves. This irregular rhythm occurs because the atrial impulses are filtered out by the AV node.

      In addition, Ashman beats may be observed in atrial fibrillation. These beats are characterized by wide complex QRS complexes, often with a morphology resembling right bundle branch block. They occur after a short R-R interval that is preceded by a prolonged R-R interval. Fortunately, Ashman beats are generally considered harmless.

      The disorganized electrical activity in atrial fibrillation typically originates at the root of the pulmonary veins.

    • This question is part of the following fields:

      • Cardiology
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  • Question 17 - A 52-year-old woman comes in with a history of two episodes of atrial...

    Incorrect

    • A 52-year-old woman comes in with a history of two episodes of atrial fibrillation (AF). The most recent episode lasted for six days before resolving on its own. How would you classify the type of AF she has experienced?

      Your Answer:

      Correct Answer: Paroxysmal

      Explanation:

      In order to gain a comprehensive understanding of AF management, it is crucial to familiarize oneself with the terminology used to describe its various subtypes. These terms help categorize different episodes of AF based on their characteristics and outcomes.

      Acute AF refers to any episode that occurs within the previous 48 hours. It can manifest with or without symptoms and may or may not recur. On the other hand, paroxysmal AF describes episodes that spontaneously end within 7 days, typically within 48 hours. While these episodes are often recurrent, they can progress into a sustained form of AF.

      Recurrent AF is defined as experiencing two or more episodes of AF. If the episodes self-terminate, they are classified as paroxysmal AF. However, if the episodes do not self-terminate, they are categorized as persistent AF. Persistent AF lasts longer than 7 days or has occurred after a previous cardioversion. To terminate persistent AF, electrical or pharmacological intervention is required. In some cases, persistent AF can progress into permanent AF.

      Permanent AF, also known as Accepted AF, refers to episodes that cannot be successfully terminated, have relapsed after termination, or where cardioversion is not pursued. This subtype signifies a more chronic and ongoing form of AF.

      By understanding and utilizing these terms, healthcare professionals can effectively communicate and manage the different subtypes of AF.

    • This question is part of the following fields:

      • Cardiology
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  • Question 18 - You are summoned to the resuscitation bay to provide assistance with a 72-year-old...

    Incorrect

    • You are summoned to the resuscitation bay to provide assistance with a 72-year-old patient who is undergoing treatment for cardiac arrest. After three shocks, the patient experiences a return of spontaneous circulation.

      What are the recommended blood pressure goals following a return of spontaneous circulation (ROSC) after cardiac arrest?

      Your Answer:

      Correct Answer: Mean arterial pressure 65-100 mmHg

      Explanation:

      After the return of spontaneous circulation (ROSC), there are two specific blood pressure targets that need to be achieved. The first target is to maintain a systolic blood pressure above 100 mmHg. The second target is to maintain the mean arterial pressure (MAP) within the range of 65 to 100 mmHg.

      Further Reading:

      Cardiopulmonary arrest is a serious event with low survival rates. In non-traumatic cardiac arrest, only about 20% of patients who arrest as an in-patient survive to hospital discharge, while the survival rate for out-of-hospital cardiac arrest is approximately 8%. The Resus Council BLS/AED Algorithm for 2015 recommends chest compressions at a rate of 100-120 per minute with a compression depth of 5-6 cm. The ratio of chest compressions to rescue breaths is 30:2.

      After a cardiac arrest, the goal of patient care is to minimize the impact of post cardiac arrest syndrome, which includes brain injury, myocardial dysfunction, the ischaemic/reperfusion response, and the underlying pathology that caused the arrest. The ABCDE approach is used for clinical assessment and general management. Intubation may be necessary if the airway cannot be maintained by simple measures or if it is immediately threatened. Controlled ventilation is aimed at maintaining oxygen saturation levels between 94-98% and normocarbia. Fluid status may be difficult to judge, but a target mean arterial pressure (MAP) between 65 and 100 mmHg is recommended. Inotropes may be administered to maintain blood pressure. Sedation should be adequate to gain control of ventilation, and short-acting sedating agents like propofol are preferred. Blood glucose levels should be maintained below 8 mmol/l. Pyrexia should be avoided, and there is some evidence for controlled mild hypothermia but no consensus on this.

      Post ROSC investigations may include a chest X-ray, ECG monitoring, serial potassium and lactate measurements, and other imaging modalities like ultrasonography, echocardiography, CTPA, and CT head, depending on availability and skills in the local department. Treatment should be directed towards the underlying cause, and PCI or thrombolysis may be considered for acute coronary syndrome or suspected pulmonary embolism, respectively.

      Patients who are comatose after ROSC without significant pre-arrest comorbidities should be transferred to the ICU for supportive care. Neurological outcome at 72 hours is the best prognostic indicator of outcome.

    • This question is part of the following fields:

      • Cardiology
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  • Question 19 - A 72-year-old woman is evaluated in the cardiac care unit 2 days after...

    Incorrect

    • A 72-year-old woman is evaluated in the cardiac care unit 2 days after experiencing a heart attack. She complains of significant shortness of breath. During the physical examination, a pansystolic murmur is audible and is most prominent at the lower left sternal border.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Ventricular septal defect

      Explanation:

      Post myocardial infarction ventricular septal defect (VSD) is a rare but serious complication that occurs when the cardiac wall ruptures. It typically develops 2-3 days after a heart attack, and if left untreated, 85% of patients will die within two months. The murmur associated with VSD is a continuous sound throughout systole, and it is loudest at the lower left sternal edge. A palpable vibration, known as a thrill, is often felt along with the murmur.

      Dressler’s syndrome, on the other hand, is a type of pericarditis that occurs 2-10 weeks after a heart attack or cardiac surgery. It is characterized by sharp chest pain that is relieved by sitting forwards. Other signs of Dressler’s syndrome include a rubbing sound heard when listening to the heart, pulsus paradoxus (an abnormal drop in blood pressure during inspiration), and signs of right ventricular failure.

      Mitral regurgitation also causes a continuous murmur throughout systole, but it is best heard at the apex of the heart and may radiate to the axilla (armpit).

      Tricuspid stenosis, on the other hand, causes an early diastolic murmur that is best heard at the lower left sternal edge during inspiration.

      Lastly, mitral stenosis causes a rumbling mid-diastolic murmur that is best heard at the apex of the heart. To listen for this murmur, the patient should be in the left lateral position, and the stethoscope bell should be used during expiration.

    • This question is part of the following fields:

      • Cardiology
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  • Question 20 - A 37 year old female presents to the emergency department complaining of shortness...

    Incorrect

    • A 37 year old female presents to the emergency department complaining of shortness of breath and chest pain in the center of her chest. Upon further questioning, the patient reveals that she experienced muscle pain, gastrointestinal issues, a mild fever, and fatigue for approximately three days about a week ago. She informs you that she is typically in good health and regularly runs 5-10km two to three times per week. The patient has no significant medical history, does not take any medications on a regular basis, has never smoked, and does not consume alcohol. Given the patient's symptoms, you suspect the possibility of myocarditis. Which of the following sets of blood test results would be expected in a patient with myocarditis?

      Your Answer:

      Correct Answer: creatine kinase: elevated, troponin I: elevated, BNP: elevated

      Explanation:

      In cases of myocarditis, levels of cardiac muscle enzymes (CK-MB, Troponin I, and Troponin T) and B-type natriuretic peptide (BNP) are usually elevated. It is important to note that CK-MB is a subtype of CK, so an increase in CK-MB will also result in an increase in total CK levels. This poses a challenge in differentiating myocarditis from coronary artery disease in the emergency department. Typically, a definitive diagnosis is not made until the patient undergoes additional tests such as angiography and possibly endomyocardial biopsy (EMB).

      Further Reading:

      Myocarditis is inflammation of the myocardium, the middle layer of the heart wall, that is not caused by a blockage in the coronary arteries. It can be caused by various factors, including infections (such as viruses, bacteria, parasites, and fungi), immune reactions, toxins, physical injury, and certain medications or vaccines. Coxsackie virus is the most common cause of myocarditis in Europe and the USA, while globally, Trypanosoma cruzi, which causes Chagas disease, is the most common cause.

      The symptoms of myocarditis can vary widely and often resemble those of heart failure or coronary heart disease. Common symptoms include chest pain, palpitations, breathlessness, fatigue, and swelling. The clinical presentation can also be influenced by the underlying cause of the inflammation. Diagnosis of myocarditis is challenging as there is no specific clinical presentation, and the gold standard test, endomyocardial biopsy, is not readily available in emergency departments.

      Various tests can be performed to aid in the diagnosis of myocarditis, including electrocardiogram (ECG), chest X-ray, cardiac enzymes (such as troponin or CK-MB), brain natriuretic peptide (BNP) levels, and echocardiogram. These tests may show non-specific abnormalities, such as ST-segment and T-wave abnormalities on ECG, bilateral pulmonary infiltrates on chest X-ray, elevated cardiac enzymes and BNP levels, and left ventricular motion abnormalities on echocardiogram.

      Management of myocarditis is primarily supportive, focusing on treating cardiac failure and addressing the underlying cause. Supportive care and conventional heart failure therapy, such as ACE inhibitors or angiotensin II receptor blockers, vasodilators, beta-blockers, and diuretics, may be used to improve cardiac function and reduce symptoms. Treatment of the underlying cause, such as antiparasitic agents for Chagas disease or antibiotics for bacterial infections, may also be necessary. In severe cases leading to cardiogenic shock, more aggressive treatment with invasive monitoring, inotropes, vasopressors, and potentially heart transplantation may be required.

      In summary, myocarditis is inflammation of the myocardium that can be caused by various factors. It presents with a wide range of symptoms and can be challenging to diagnose. Management involves supportive care, treatment of cardiac failure, and addressing the underlying cause. Severe cases may require more aggressive treatment and potentially heart transplantation.

    • This question is part of the following fields:

      • Cardiology
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  • Question 21 - A 55-year-old male with a past medical history of high blood pressure arrives...

    Incorrect

    • A 55-year-old male with a past medical history of high blood pressure arrives at the emergency department complaining of sudden chest and interscapular pain that feels like tearing. You suspect aortic dissection. Which of the following signs and symptoms aligns with the diagnosis of aortic dissection?

      Your Answer:

      Correct Answer: Blood pressure differential of more than 10 mmHg between left and right arms

      Explanation:

      A significant proportion of the population experiences a difference of 10 mmHg or more in blood pressure between their upper limbs. Pericarditis can be identified by the presence of saddle-shaped ST elevation and pain in the trapezius ridge. Aortic dissection is characterized by a diastolic murmur with a decrescendo pattern, which indicates aortic incompetence.

      Further Reading:

      Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.

      The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.

      Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.

      Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.

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      • Cardiology
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  • Question 22 - A 67 year old male presents to the emergency department with complaints of...

    Incorrect

    • A 67 year old male presents to the emergency department with complaints of dizziness, difficulty breathing, and heart palpitations. The patient reports that these symptoms began six hours ago. Upon examination, the patient's vital signs are as follows:

      - Blood pressure: 118/76 mmHg
      - Pulse rate: 86 bpm
      - Respiration rate: 15 bpm
      - Oxygen saturation: 97% on room air

      An electrocardiogram (ECG) is performed, confirming the presence of atrial fibrillation. As part of the treatment plan, you need to calculate the patient's CHA2DS2-VASc score.

      According to NICE guidelines, what is the usual threshold score for initiating anticoagulation in this case?

      Your Answer:

      Correct Answer: 2

      Explanation:

      According to NICE guidelines, the usual threshold score for initiating anticoagulation in this case is 2.

      Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting around 5% of patients over the age of 70-75 years and 10% of patients aged 80-85 years. While AF can cause palpitations and inefficient cardiac function, the most important aspect of managing patients with AF is reducing the increased risk of stroke.

      AF can be classified as first detected episode, paroxysmal, persistent, or permanent. First detected episode refers to the initial occurrence of AF, regardless of symptoms or duration. Paroxysmal AF occurs when a patient has 2 or more self-terminating episodes lasting less than 7 days. Persistent AF refers to episodes lasting more than 7 days that do not self-terminate. Permanent AF is continuous atrial fibrillation that cannot be cardioverted or if attempts to do so are deemed inappropriate. The treatment goals for permanent AF are rate control and anticoagulation if appropriate.

      Symptoms of AF include palpitations, dyspnea, and chest pain. The most common sign is an irregularly irregular pulse. An electrocardiogram (ECG) is essential for diagnosing AF, as other conditions can also cause an irregular pulse.

      Managing patients with AF involves two key parts: rate/rhythm control and reducing stroke risk. Rate control involves slowing down the irregular pulse to avoid negative effects on cardiac function. This is typically achieved using beta-blockers or rate-limiting calcium channel blockers. If one drug is not effective, combination therapy may be used. Rhythm control aims to restore and maintain normal sinus rhythm through pharmacological or electrical cardioversion. However, the majority of patients are managed with a rate control strategy.

      Reducing stroke risk in patients with AF is crucial. Risk stratifying tools, such as the CHA2DS2-VASc score, are used to determine the most appropriate anticoagulation strategy. Anticoagulation is recommended for patients with a score of 2 or more. Clinicians can choose between warfarin and novel oral anticoagulants (NOACs) for anticoagulation.

      Before starting anticoagulation, the patient’s bleeding risk should be assessed using tools like the HAS-BLED score or the ORBIT tool. These tools evaluate factors such as hypertension, abnormal renal or liver function, history of bleeding, age, and use of drugs that predispose to bleeding.

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      • Cardiology
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  • Question 23 - You are asked to assess an older patient who has fainted. They have...

    Incorrect

    • You are asked to assess an older patient who has fainted. They have a bradyarrhythmia evident on their ECG, and you determine to administer a dose of atropine.
      Which ONE statement about the use of atropine is accurate?

      Your Answer:

      Correct Answer: It blocks the effects of the vagus nerve on both the SA and AV nodes

      Explanation:

      Atropine acts as an antagonist to the parasympathetic neurotransmitter acetylcholine at muscarinic receptors. This means that it blocks the effects of the vagus nerve on both the SA node and the AV node, resulting in increased sinus automaticity and improved AV node conduction.

      The side effects of atropine are dependent on the dosage and may include dry mouth, nausea and vomiting, blurred vision, urinary retention, and tachyarrhythmias. Elderly patients may also experience acute confusion and hallucinations.

      Atropine is recommended for use in cases of sinus, atrial, or nodal bradycardia or AV block when the patient’s hemodynamic condition is unstable due to the bradycardia. According to the ALS bradycardia algorithm, an initial dose of 500 mcg IV is suggested if any adverse features such as shock, syncope, myocardial ischemia, or heart failure are present. If this initial dose is unsuccessful, additional 500 mcg doses can be administered at 3-5 minute intervals, with a maximum dose of 3 mg. It is important to avoid doses exceeding 3 mg as they can paradoxically slow the heart rate.

      Asystole during cardiac arrest is typically caused by primary myocardial pathology rather than excessive vagal tone. Therefore, there is no evidence supporting the routine use of atropine in the treatment of asystole or PEA. Consequently, atropine is no longer included in the non-shockable part of the ALS algorithm.

      Aside from its use in cardiac conditions, atropine also has other applications. It can be used topically in the eyes as a cycloplegic and mydriatic, to reduce secretions during anesthesia, and in the treatment of organophosphate poisoning.

    • This question is part of the following fields:

      • Cardiology
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  • Question 24 - A 75 year old female is brought to the hospital by paramedics after...

    Incorrect

    • A 75 year old female is brought to the hospital by paramedics after experiencing a cardiac arrest at home during a family gathering. The patient is pronounced deceased shortly after being admitted to the hospital. The family informs you that the patient had been feeling unwell for the past few days but chose not to seek medical attention due to concerns about the Coronavirus. The family inquires about the likelihood of the patient surviving if the cardiac arrest had occurred within the hospital?

      Your Answer:

      Correct Answer: 20%

      Explanation:

      For the exam, it is important to be familiar with the statistics regarding the outcomes of outpatient and inpatient cardiac arrest in the UK.

      Further Reading:

      Cardiopulmonary arrest is a serious event with low survival rates. In non-traumatic cardiac arrest, only about 20% of patients who arrest as an in-patient survive to hospital discharge, while the survival rate for out-of-hospital cardiac arrest is approximately 8%. The Resus Council BLS/AED Algorithm for 2015 recommends chest compressions at a rate of 100-120 per minute with a compression depth of 5-6 cm. The ratio of chest compressions to rescue breaths is 30:2.

      After a cardiac arrest, the goal of patient care is to minimize the impact of post cardiac arrest syndrome, which includes brain injury, myocardial dysfunction, the ischaemic/reperfusion response, and the underlying pathology that caused the arrest. The ABCDE approach is used for clinical assessment and general management. Intubation may be necessary if the airway cannot be maintained by simple measures or if it is immediately threatened. Controlled ventilation is aimed at maintaining oxygen saturation levels between 94-98% and normocarbia. Fluid status may be difficult to judge, but a target mean arterial pressure (MAP) between 65 and 100 mmHg is recommended. Inotropes may be administered to maintain blood pressure. Sedation should be adequate to gain control of ventilation, and short-acting sedating agents like propofol are preferred. Blood glucose levels should be maintained below 8 mmol/l. Pyrexia should be avoided, and there is some evidence for controlled mild hypothermia but no consensus on this.

      Post ROSC investigations may include a chest X-ray, ECG monitoring, serial potassium and lactate measurements, and other imaging modalities like ultrasonography, echocardiography, CTPA, and CT head, depending on availability and skills in the local department. Treatment should be directed towards the underlying cause, and PCI or thrombolysis may be considered for acute coronary syndrome or suspected pulmonary embolism, respectively.

      Patients who are comatose after ROSC without significant pre-arrest comorbidities should be transferred to the ICU for supportive care. Neurological outcome at 72 hours is the best prognostic indicator of outcome.

    • This question is part of the following fields:

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  • Question 25 - A 68 year old man is brought to the emergency department due to...

    Incorrect

    • A 68 year old man is brought to the emergency department due to sudden difficulty in breathing. You observe that the patient was diagnosed with mitral regurgitation a year ago. Which arrhythmia is commonly seen in individuals with chronic mitral regurgitation?

      Your Answer:

      Correct Answer: Atrial fibrillation

      Explanation:

      People with chronic mitral regurgitation often experience atrial fibrillation.

      Mitral Stenosis:
      – Causes: Rheumatic fever, Mucopolysaccharidoses, Carcinoid, Endocardial fibroelastosis
      – Features: Mid-late diastolic murmur, loud S1, opening snap, low volume pulse, malar flush, atrial fibrillation, signs of pulmonary edema, tapping apex beat
      – Features of severe mitral stenosis: Length of murmur increases, opening snap becomes closer to S2
      – Investigation findings: CXR may show left atrial enlargement, echocardiography may show reduced cross-sectional area of the mitral valve

      Mitral Regurgitation:
      – Causes: Mitral valve prolapse, Myxomatous degeneration, Ischemic heart disease, Rheumatic fever, Connective tissue disorders, Endocarditis, Dilated cardiomyopathy
      – Features: pansystolic murmur radiating to left axilla, soft S1, S3, laterally displaced apex beat with heave
      – Signs of acute MR: Decompensated congestive heart failure symptoms
      – Signs of chronic MR: Leg edema, fatigue, arrhythmia (atrial fibrillation)
      – Investigation findings: Doppler echocardiography to detect regurgitant flow and pulmonary hypertension, ECG may show signs of LA enlargement and LV hypertrophy, CXR may show LA and LV enlargement in chronic MR and pulmonary edema in acute MR.

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  • Question 26 - You are requested to evaluate a 60-year-old male in the emergency department who...

    Incorrect

    • You are requested to evaluate a 60-year-old male in the emergency department who has arrived with complaints of dizziness and difficulty breathing. Following an ECG examination, the patient is diagnosed with Torsades de pointes. What are the two electrolyte imbalances most frequently linked to this cardiac rhythm disorder?

      Your Answer:

      Correct Answer: Hypokalaemia and hypomagnesaemia

      Explanation:

      Torsades de pointes is a condition that is linked to low levels of potassium (hypokalaemia) and magnesium (hypomagnesaemia). When potassium and magnesium levels are low, it can cause the QT interval to become prolonged, which increases the risk of developing Torsades de pointes.

      Further Reading:

      Torsades de pointes is an irregular broad-complex tachycardia that can be life-threatening. It is a polymorphic ventricular tachycardia that can lead to sudden cardiac death. It is characterized by distinct features on the electrocardiogram (ECG).

      The causes of irregular broad-complex tachycardia include atrial fibrillation with bundle branch block, atrial fibrillation with ventricular pre-excitation (in patients with Wolff-Parkinson-White syndrome), and polymorphic ventricular tachycardia such as torsades de pointes. However, sustained polymorphic ventricular tachycardia is unlikely to be present without adverse features, so it is important to seek expert help for the assessment and treatment of this condition.

      Torsades de pointes can be caused by drug-induced QT prolongation, diarrhea, hypomagnesemia, hypokalemia, and congenital long QT syndrome. It may also be seen in malnourished individuals due to low potassium and/or low magnesium levels. Additionally, it can occur in individuals taking drugs that prolong the QT interval or inhibit their metabolism.

      The management of torsades de pointes involves immediate action. All drugs known to prolong the QT interval should be stopped. Amiodarone should not be given for definite torsades de pointes. Electrolyte abnormalities, especially hypokalemia, should be corrected. Magnesium sulfate should be administered intravenously. If adverse features are present, immediate synchronized cardioversion should be arranged. sought, as other treatments such as overdrive pacing may be necessary to prevent relapse once the arrhythmia has been corrected. If the patient becomes pulseless, defibrillation should be attempted immediately.

      In summary, torsades de pointes is a dangerous arrhythmia that requires prompt management. It is important to identify and address the underlying causes, correct electrolyte abnormalities, and seek expert help for appropriate treatment.

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      • Cardiology
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  • Question 27 - Your hospital’s pediatrics department is currently evaluating the utility of a triple marker...

    Incorrect

    • Your hospital’s pediatrics department is currently evaluating the utility of a triple marker test for use in risk stratification of patients with a suspected heart condition. The test will use troponin I, myoglobin, and heart-type fatty acid-binding protein (HFABP).
      How long after a heart event do troponin I levels reach their highest point?

      Your Answer:

      Correct Answer: 24 hours

      Explanation:

      The timing of the initial rise, peak, and return to normality of various cardiac enzymes can serve as a helpful guide. Creatine kinase, the main cardiac isoenzyme, typically experiences an initial rise within 4-8 hours, reaches its peak at 18 hours, and returns to normal within 2-3 days. Myoglobin, which lacks specificity due to its association with skeletal muscle damage, shows an initial rise within 1-4 hours, peaks at 6-7 hours, and returns to normal within 24 hours. Troponin I, known for its sensitivity and specificity, exhibits an initial rise within 3-12 hours, reaches its peak at 24 hours, and returns to normal within 3-10 days. HFABP, or heart fatty acid binding protein, experiences an initial rise within 1.5 hours, peaks at 5-10 hours, and returns to normal within 24 hours. Lastly, LDH, predominantly found in cardiac muscle, shows an initial rise at 10 hours, peaks at 24-48 hours, and returns to normal within 14 days.

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      • Cardiology
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  • Question 28 - A 68 year old male presents to the emergency department complaining of dizziness...

    Incorrect

    • A 68 year old male presents to the emergency department complaining of dizziness and palpitations that have been occurring for the past 2 hours. An ECG confirms the presence of atrial fibrillation. The patient has no previous history of atrial fibrillation but was diagnosed with mild aortic valve stenosis 8 months ago during an echocardiogram ordered by his primary care physician. The patient reports that the echocardiogram was done because he was experiencing shortness of breath, which resolved after 2-3 months and was attributed to a recent bout of pneumonia. The decision is made to attempt pharmacological cardioversion. What is the most appropriate medication to use for this purpose in this patient?

      Your Answer:

      Correct Answer: Amiodarone

      Explanation:

      According to NICE guidelines, amiodarone is recommended as the initial choice for pharmacological cardioversion of atrial fibrillation (AF) in individuals who have evidence of structural heart disease.

      Further Reading:

      Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting around 5% of patients over the age of 70-75 years and 10% of patients aged 80-85 years. While AF can cause palpitations and inefficient cardiac function, the most important aspect of managing patients with AF is reducing the increased risk of stroke.

      AF can be classified as first detected episode, paroxysmal, persistent, or permanent. First detected episode refers to the initial occurrence of AF, regardless of symptoms or duration. Paroxysmal AF occurs when a patient has 2 or more self-terminating episodes lasting less than 7 days. Persistent AF refers to episodes lasting more than 7 days that do not self-terminate. Permanent AF is continuous atrial fibrillation that cannot be cardioverted or if attempts to do so are deemed inappropriate. The treatment goals for permanent AF are rate control and anticoagulation if appropriate.

      Symptoms of AF include palpitations, dyspnea, and chest pain. The most common sign is an irregularly irregular pulse. An electrocardiogram (ECG) is essential for diagnosing AF, as other conditions can also cause an irregular pulse.

      Managing patients with AF involves two key parts: rate/rhythm control and reducing stroke risk. Rate control involves slowing down the irregular pulse to avoid negative effects on cardiac function. This is typically achieved using beta-blockers or rate-limiting calcium channel blockers. If one drug is not effective, combination therapy may be used. Rhythm control aims to restore and maintain normal sinus rhythm through pharmacological or electrical cardioversion. However, the majority of patients are managed with a rate control strategy.

      Reducing stroke risk in patients with AF is crucial. Risk stratifying tools, such as the CHA2DS2-VASc score, are used to determine the most appropriate anticoagulation strategy. Anticoagulation is recommended for patients with a score of 2 or more. Clinicians can choose between warfarin and novel oral anticoagulants (NOACs) for anticoagulation.

      Before starting anticoagulation, the patient’s bleeding risk should be assessed using tools like the HAS-BLED score or the ORBIT tool. These tools evaluate factors such as hypertension, abnormal renal or liver function, history of bleeding, age, and use of drugs that predispose to bleeding.

    • This question is part of the following fields:

      • Cardiology
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  • Question 29 - A 35-year-old woman with a history of paroxysmal supraventricular tachycardia is found to...

    Incorrect

    • A 35-year-old woman with a history of paroxysmal supraventricular tachycardia is found to have a diagnosis of Lown-Ganong-Levine (LGL) syndrome.
      Which of the following statements about LGL syndrome is NOT true?

      Your Answer:

      Correct Answer: It is caused by an accessory pathway for conduction

      Explanation:

      Lown-Ganong-Levine (LGL) syndrome is a condition that affects the electrical conducting system of the heart. It is classified as a pre-excitation syndrome, similar to the more well-known Wolff-Parkinson-White (WPW) syndrome. However, unlike WPW syndrome, LGL syndrome does not involve an accessory pathway for conduction. Instead, it is believed that there may be accessory fibers present that bypass all or part of the atrioventricular node.

      When looking at an electrocardiogram (ECG) of a patient with LGL syndrome in sinus rhythm, there are several characteristic features to observe. The PR interval, which represents the time it takes for the electrical signal to travel from the atria to the ventricles, is typically shortened and measures less than 120 milliseconds. The QRS duration, which represents the time it takes for the ventricles to contract, is normal. The P wave, which represents the electrical activity of the atria, may be normal or inverted. However, what distinguishes LGL syndrome from other pre-excitation syndromes is the absence of a delta wave, which is a slurring of the initial rise in the QRS complex.

      It is important to note that LGL syndrome predisposes individuals to paroxysmal supraventricular tachycardia (SVT), a rapid heart rhythm that originates above the ventricles. However, it does not increase the risk of developing atrial fibrillation or flutter, which are other types of abnormal heart rhythms.

    • This question is part of the following fields:

      • Cardiology
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  • Question 30 - You evaluate a 45-year-old Asian man with a heart murmur. During auscultation, you...

    Incorrect

    • You evaluate a 45-year-old Asian man with a heart murmur. During auscultation, you observe a loud first heart sound and a mid-diastolic murmur at the apex. Upon examination, you observe that he has plum-red discoloration of his cheeks.
      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Mitral stenosis

      Explanation:

      The clinical symptoms of mitral stenosis include shortness of breath, which tends to worsen during exercise and when lying flat. Tiredness, palpitations, ankle swelling, cough, and haemoptysis are also common symptoms. Chest discomfort is rarely reported.

      The clinical signs of mitral stenosis can include a malar flush, an irregular pulse if atrial fibrillation is present, a tapping apex beat that can be felt as the first heart sound, and a left parasternal heave if there is pulmonary hypertension. The first heart sound is often loud, and a mid-diastolic murmur can be heard.

      The mid-diastolic murmur of mitral stenosis is a rumbling sound that is best heard at the apex, in the left lateral position during expiration, using the bell of the stethoscope.

      Mitral stenosis is typically caused by rheumatic heart disease, and it is more common in females, with about two-thirds of patients being female.

    • This question is part of the following fields:

      • Cardiology
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  • Question 31 - A 28-year-old woman presents after experiencing a syncopal episode earlier in the day....

    Incorrect

    • A 28-year-old woman presents after experiencing a syncopal episode earlier in the day. She fainted while jogging on the treadmill at her local gym. She regained consciousness quickly and currently feels completely fine. Upon examination, she has a slim physique, normal heart sounds without any additional sounds or murmurs, clear lungs, and a soft abdomen. She is originally from Thailand and mentions that her mother passed away suddenly in her 30s.

      Her ECG reveals:
      - Right bundle branch block pattern
      - Downward-sloping 'coved' ST elevation in leads V1-V3
      - Widespread upward-sloping ST depression in other leads

      What is the SINGLE most likely diagnosis?

      Your Answer:

      Correct Answer: Brugada syndrome

      Explanation:

      Brugada syndrome is a genetic disorder that is passed down from one generation to another in an autosomal dominant manner. It is characterized by abnormal findings on an electrocardiogram (ECG) and can lead to sudden cardiac death. The cause of death in individuals with Brugada syndrome is typically ventricular fibrillation, which occurs as a result of specific defects in ion channels that are determined by our genes. Interestingly, this syndrome is more commonly observed in South East Asia and is actually the leading cause of sudden unexplained cardiac death in Thailand.

      One of the key features seen on an ECG that is consistent with Type 1 Brugada syndrome is a pattern known as right bundle branch block. Additionally, there is a distinct downward sloping coved ST elevation observed in leads V1-V3. These specific ECG findings help to identify individuals who may be at risk for developing Brugada syndrome and experiencing its potentially fatal consequences.

    • This question is part of the following fields:

      • Cardiology
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  • Question 32 - A 32-year-old man is brought to the Emergency Department by ambulance due to...

    Incorrect

    • A 32-year-old man is brought to the Emergency Department by ambulance due to 'severe palpitations.' His heart rate is 180 bpm, and his rhythm strip is suggestive of supraventricular tachycardia. You plan to administer adenosine.
      Which of the following is a contraindication to the use of adenosine?

      Your Answer:

      Correct Answer: Recent severe asthma exacerbation

      Explanation:

      Adenosine is a type of purine nucleoside that is primarily utilized in the diagnosis and treatment of paroxysmal supraventricular tachycardia. Its main mechanism of action involves stimulating A1-adenosine receptors and opening acetylcholine-sensitive potassium channels. This leads to hyperpolarization of the cell membrane in the atrioventricular (AV) node and slows down conduction in the AV node by inhibiting calcium channels.

      When administering adenosine, it is given rapidly through an intravenous bolus, followed by a saline flush. The initial dose for adults is 6 mg, and if necessary, additional doses of 12 mg or 18 mg can be given at 1-2 minute intervals until the desired effect is observed. It is important to note that the latest ALS guidelines recommend 18 mg for the third dose, while the BNF/NICE guidelines suggest 12 mg.

      One of the advantages of adenosine is its very short half-life, which is less than 10 seconds. This means that its effects are rapid, typically occurring within 10 seconds. However, the duration of action is also short, lasting only 10-20 seconds. Due to its short half-life, any side effects experienced are usually brief. These side effects may include a sense of impending doom, facial flushing, dyspnea, chest discomfort, and a metallic taste.

      There are certain contraindications to the use of adenosine. These include 2nd or 3rd degree AV block, sick sinus syndrome, long QT syndrome, severe hypotension, decompensated heart failure, chronic obstructive lung disease, and asthma. It is important to exercise caution when administering adenosine to patients with a heart transplant, as they are particularly sensitive to its effects. In these cases, a reduced initial dose of 3 mg is recommended, followed by 6 mg and then 12 mg.

      It is worth noting that the effects of adenosine can be potentiated by dipyridamole, a medication commonly used in combination with adenosine. Therefore, the dose of adenosine should be adjusted and reduced in patients who are also taking dipyridamole.

    • This question is part of the following fields:

      • Cardiology
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  • Question 33 - You evaluate a 70 year old male who complains of chest tightness during...

    Incorrect

    • You evaluate a 70 year old male who complains of chest tightness during physical activity. The patient reports a gradual increase in shortness of breath during exertion over the past half year. During the examination, you observe a murmur and suspect aortic stenosis. Which of the following characteristics is commonly seen in symptomatic individuals with aortic stenosis?

      Your Answer:

      Correct Answer: Slow rising pulse

      Explanation:

      Severe aortic stenosis is characterized by several distinct features. These include a narrow pulse pressure, which refers to the difference between the systolic and diastolic blood pressure readings. Additionally, individuals with severe aortic stenosis may exhibit a slow rising pulse, meaning that the pulse wave takes longer to reach its peak. Another common feature is a delayed ejection systolic murmur, which is a heart sound that occurs during the ejection phase of the cardiac cycle. The second heart sound (S2) may also be soft or absent in individuals with severe aortic stenosis. Another potential finding is the presence of an S4 heart sound, which occurs during the filling phase of the cardiac cycle. A thrill, which is a palpable vibration, may also be felt in severe cases. The duration of the murmur, as well as the presence of left ventricular hypertrophy or failure, are additional features that may be observed in individuals with severe aortic stenosis.

      Further Reading:

      Valvular heart disease refers to conditions that affect the valves of the heart. In the case of aortic valve disease, there are two main conditions: aortic regurgitation and aortic stenosis.

      Aortic regurgitation is characterized by an early diastolic murmur, a collapsing pulse (also known as a water hammer pulse), and a wide pulse pressure. In severe cases, there may be a mid-diastolic Austin-Flint murmur due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams. The first and second heart sounds (S1 and S2) may be soft, and S2 may even be absent. Additionally, there may be a hyperdynamic apical pulse. Causes of aortic regurgitation include rheumatic fever, infective endocarditis, connective tissue diseases like rheumatoid arthritis and systemic lupus erythematosus, and a bicuspid aortic valve. Aortic root diseases such as aortic dissection, spondyloarthropathies like ankylosing spondylitis, hypertension, syphilis, and genetic conditions like Marfan’s syndrome and Ehler-Danlos syndrome can also lead to aortic regurgitation.

      Aortic stenosis, on the other hand, is characterized by a narrow pulse pressure, a slow rising pulse, and a delayed ESM (ejection systolic murmur). The second heart sound (S2) may be soft or absent, and there may be an S4 (atrial gallop) that occurs just before S1. A thrill may also be felt. The duration of the murmur is an important factor in determining the severity of aortic stenosis. Causes of aortic stenosis include degenerative calcification (most common in older patients), a bicuspid aortic valve (most common in younger patients), William’s syndrome (supravalvular aortic stenosis), post-rheumatic disease, and subvalvular conditions like hypertrophic obstructive cardiomyopathy (HOCM).

      Management of aortic valve disease depends on the severity of symptoms. Asymptomatic patients are generally observed, while symptomatic patients may require valve replacement. Surgery may also be considered for asymptomatic patients with a valvular gradient greater than 40 mmHg and features such as left ventricular systolic dysfunction. Balloon valvuloplasty is limited to patients with critical aortic stenosis who are not fit for valve replacement.

    • This question is part of the following fields:

      • Cardiology
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  • Question 34 - You are summoned to a cardiac arrest in the resuscitation area of your...

    Incorrect

    • You are summoned to a cardiac arrest in the resuscitation area of your Emergency Department.
      Which ONE statement about the utilization of amiodarone in cardiac arrest is accurate?

      Your Answer:

      Correct Answer: It increases the duration of the action potential

      Explanation:

      Amiodarone is a medication that is recommended to be administered after the third shock in a shockable cardiac arrest (Vf/pVT) while chest compressions are being performed. The prescribed dose is 300 mg, given as an intravenous bolus that is diluted in 5% dextrose to a volume of 20 mL. It is important to note that amiodarone is not suitable for treating PEA or asystole.

      In cases where VF/pVT persists after five defibrillation attempts, an additional dose of 150 mg of amiodarone should be given. However, if amiodarone is not available, lidocaine can be used as an alternative. The recommended dose of lidocaine is 1 mg/kg. It is crucial to avoid administering lidocaine if amiodarone has already been given.

      Amiodarone is classified as a membrane-stabilizing antiarrhythmic drug. It works by prolonging the duration of the action potential and the refractory period in both the atrial and ventricular myocardium. This medication also slows down atrioventricular conduction and has a similar effect on accessory pathways.

      Additionally, amiodarone has a mild negative inotropic action, meaning it weakens the force of heart contractions. It also causes peripheral vasodilation through non-competitive alpha-blocking effects.

      It is important to note that while there is no evidence of long-term benefits from using amiodarone, it may improve short-term survival rates, which justifies its continued use.

    • This question is part of the following fields:

      • Cardiology
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  • Question 35 - A 45 year old female patient presents to the emergency department after calling...

    Incorrect

    • A 45 year old female patient presents to the emergency department after calling 111 for guidance regarding recent chest discomfort. The patient is worried that she might be experiencing a heart attack. During the assessment, you inquire about the nature of the pain, accompanying symptoms, and factors that worsen or alleviate the discomfort, prior to conducting a physical examination. Which history would be most suggestive of a acute myocardial infarct (AMI)?

      Your Answer:

      Correct Answer: Radiation of the pain to the right arm

      Explanation:

      The characteristic with the highest likelihood ratio for AMI is the radiation of chest pain to the right arm or both arms. Additionally, the history characteristics of cardiac pain also have a high likelihood ratio for AMI.

      Further Reading:

      Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).

      The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.

      There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.

      The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.

      The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.

      The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.

    • This question is part of the following fields:

      • Cardiology
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  • Question 36 - You are called to a VF cardiac arrest in the resus area of...

    Incorrect

    • You are called to a VF cardiac arrest in the resus area of your Pediatric Emergency Department.
      Epinephrine should be administered at which of the following points during a pediatric VF arrest?

      Your Answer:

      Correct Answer: After the 3rd shock once chest compressions have been resumed

      Explanation:

      Adrenaline is recommended to be administered after the third shock in a shockable cardiac arrest (Vf/pVT) once chest compressions have been resumed. The recommended dose is 1 mg, which can be administered as either 10 mL of a 1:10,000 solution or 1 mL of a 1:1000 solution.

      Subsequently, adrenaline should be given every 3-5 minutes, alternating with chest compressions. It is important to administer adrenaline without interrupting chest compressions to ensure continuous circulation and maximize the chances of successful resuscitation.

    • This question is part of the following fields:

      • Cardiology
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  • Question 37 - A 65 year old male is brought to the emergency department following a...

    Incorrect

    • A 65 year old male is brought to the emergency department following a fall which occurred while the patient was getting out of bed. The patient complains of feeling dizzy as he got out of bed before experiencing tunnel vision and briefly losing consciousness. The patient is certain he only blacked out for a few seconds as the time on the bedside clock had not changed. The patient informs you that he has had several similar episodes over the past few months when getting out of bed, but most of the time he only feels dizzy and doesn't faint. He denies any loss of bladder or bowel control or biting his tongue. An ECG is performed which shows normal sinus rhythm. You note the patient takes the following medication:
      Lisinopril 10 mg OD
      Fluoxetine 20 mg OD

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Orthostatic hypotension

      Explanation:

      Orthostatic hypotension is a condition where patients feel lightheaded and may experience tunnel vision when they stand up from a lying down position. These symptoms are often worse in the morning. The patient’s history of recurrent episodes after being in a supine position for a long time strongly suggests orthostatic hypotension. There are no signs of epilepsy, such as deja-vu or jambs vu prodrome, tongue biting, loss of bladder or bowel control, or postictal confusion. The normal ECG and consistent timing of symptoms make postural orthostatic tachycardia syndrome (PAF) less likely. There are no neurological deficits to suggest a transient ischemic attack (TIA). The prodromal symptoms, such as tunnel vision and lightheadedness, align more with orthostatic hypotension rather than vasovagal syncope, which typically occurs after long periods of standing and is characterized by feeling hot and sweaty. Although carotid sinus syndrome could be considered as a differential diagnosis, as the patient’s head turning on getting out of bed may trigger symptoms, it is not one of the options.

      Further Reading:

      Blackouts, also known as syncope, are defined as a spontaneous transient loss of consciousness with complete recovery. They are most commonly caused by transient inadequate cerebral blood flow, although epileptic seizures can also result in blackouts. There are several different causes of blackouts, including neurally-mediated reflex syncope (such as vasovagal syncope or fainting), orthostatic hypotension (a drop in blood pressure upon standing), cardiovascular abnormalities, and epilepsy.

      When evaluating a patient with blackouts, several key investigations should be performed. These include an electrocardiogram (ECG), heart auscultation, neurological examination, vital signs assessment, lying and standing blood pressure measurements, and blood tests such as a full blood count and glucose level. Additional investigations may be necessary depending on the suspected cause, such as ultrasound or CT scans for aortic dissection or other abdominal and thoracic pathology, chest X-ray for heart failure or pneumothorax, and CT pulmonary angiography for pulmonary embolism.

      During the assessment, it is important to screen for red flags and signs of any underlying serious life-threatening condition. Red flags for blackouts include ECG abnormalities, clinical signs of heart failure, a heart murmur, blackouts occurring during exertion, a family history of sudden cardiac death at a young age, an inherited cardiac condition, new or unexplained breathlessness, and blackouts in individuals over the age of 65 without a prodrome. These red flags indicate the need for urgent assessment by an appropriate specialist.

      There are several serious conditions that may be suggested by certain features. For example, myocardial infarction or ischemia may be indicated by a history of coronary artery disease, preceding chest pain, and ECG signs such as ST elevation or arrhythmia. Pulmonary embolism may be suggested by dizziness, acute shortness of breath, pleuritic chest pain, and risk factors for venous thromboembolism. Aortic dissection may be indicated by chest and back pain, abnormal ECG findings, and signs of cardiac tamponade include low systolic blood pressure, elevated jugular venous pressure, and muffled heart sounds. Other conditions that may cause blackouts include severe hypoglycemia, Addisonian crisis, and electrolyte abnormalities.

    • This question is part of the following fields:

      • Cardiology
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  • Question 38 - A 25 year old female is brought to the emergency department with a...

    Incorrect

    • A 25 year old female is brought to the emergency department with a gunshot wound to the abdomen. You observe that the patient is breathing rapidly and her neck veins are distended. The trachea is centrally located. Her vital signs are as follows:

      Blood pressure: 88/56 mmHg
      Heart rate: 127 bpm
      Respiration rate: 28 rpm
      SpO2: 99% on 15L oxygen

      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Cardiac tamponade

      Explanation:

      Cardiac tamponade is characterized by several classical signs, including distended neck veins, muffled heart sounds, and hypotension. When neck veins are distended, it suggests that the right ventricle is not filling properly. In cases of trauma, this is often caused by the compression of air (tension pneumothorax) or fluid (blood in the pericardial space). One important distinguishing feature is the deviation of the trachea.

      Further Reading:

      Cardiac tamponade, also known as pericardial tamponade, occurs when fluid accumulates in the pericardial sac and compresses the heart, leading to compromised blood flow. Classic clinical signs of cardiac tamponade include distended neck veins, hypotension, muffled heart sounds, and pulseless electrical activity (PEA). Diagnosis is typically done through a FAST scan or an echocardiogram.

      Management of cardiac tamponade involves assessing for other injuries, administering IV fluids to reduce preload, performing pericardiocentesis (inserting a needle into the pericardial cavity to drain fluid), and potentially performing a thoracotomy. It is important to note that untreated expanding cardiac tamponade can progress to PEA cardiac arrest.

      Pericardiocentesis can be done using the subxiphoid approach or by inserting a needle between the 5th and 6th intercostal spaces at the left sternal border. Echo guidance is the gold standard for pericardiocentesis, but it may not be available in a resuscitation situation. Complications of pericardiocentesis include ST elevation or ventricular ectopics, myocardial perforation, bleeding, pneumothorax, arrhythmia, acute pulmonary edema, and acute ventricular dilatation.

      It is important to note that pericardiocentesis is typically used as a temporary measure until a thoracotomy can be performed. Recent articles published on the RCEM learning platform suggest that pericardiocentesis has a low success rate and may delay thoracotomy, so it is advised against unless there are no other options available.

    • This question is part of the following fields:

      • Cardiology
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  • Question 39 - A 60-year-old woman presents with worsening symptoms of shortness of breath. Upon examination...

    Incorrect

    • A 60-year-old woman presents with worsening symptoms of shortness of breath. Upon examination of her cardiovascular system, you find a collapsing pulse. Her apex beat is hyperkinetic and displaced to the side. During auscultation, you detect an early diastolic murmur that is most pronounced when the patient is sitting forward and exhaling.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Aortic regurgitation

      Explanation:

      Aortic regurgitation is a condition where the aortic valve fails to close tightly, resulting in the backflow of blood from the aorta into the left ventricle during ventricular diastole. This valvular lesion presents with various clinical symptoms and signs.

      The clinical symptoms of aortic regurgitation include exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. These symptoms are experienced by patients during physical activity, while lying flat, and during episodes of sudden nighttime breathlessness, respectively.

      On the other hand, the clinical signs of aortic regurgitation can be observed during physical examination. These signs include a collapsing pulse, widened pulse pressure, hyperkinetic laterally displaced apex beat, and a thrill in the aortic area. Additionally, an early diastolic murmur can be heard, which is loudest at the lower left sternal edge when the patient is sitting forward and exhaling.

      Aortic regurgitation is also associated with several eponymous signs, which are named after the physicians who first described them. These signs include Corrigan’s sign, which is characterized by visible and forceful neck pulsation. De Musset’s sign refers to head nodding in time with the heartbeat. Quincke’s sign is the observation of visible nail bed capillary pulsation. Duroziez’s sign is the presence of a diastolic murmur heard proximal to femoral artery compression. Traube’s sign is the perception of a pistol shot sound over the femoral arteries. The Lighthouse sign is the blanching and flushing of the forehead. Becker’s sign is the pulsation seen in retinal vessels. Rosenbach’s sign is the presence of a pulsatile liver. Lastly, Muller’s sign refers to pulsations of the uvula.

      In summary, aortic regurgitation is a valvular lesion that leads to the incomplete closure of the aortic valve. It manifests with various clinical symptoms, signs, and eponymous findings, which can be identified through careful examination and observation.

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      • Cardiology
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  • Question 40 - You conduct a cardiovascular examination on a 72-year-old man who complains of difficulty...

    Incorrect

    • You conduct a cardiovascular examination on a 72-year-old man who complains of difficulty breathing. He informs you that he has a known heart valve issue. During the examination, you observe a pronounced first heart sound (S1).
      What is the most probable cause of this finding?

      Your Answer:

      Correct Answer: Mitral stenosis

      Explanation:

      The first heart sound (S1) is created by vibrations produced when the mitral and tricuspid valves close. It occurs at the end of diastole and the start of ventricular systole, coming before the upstroke of the carotid pulsation.

      A sample of the normal heart sounds can be listened to here (courtesy of Littman stethoscopes).

      A loud S1 can be associated with the following conditions:
      – Increased transvalvular gradient (e.g. mitral stenosis, tricuspid stenosis)
      – Increased force of ventricular contraction (e.g. tachycardia, hyperdynamic states like fever and thyrotoxicosis)
      – Shortened PR interval (e.g. Wolff-Parkinson-White syndrome)
      – Mitral valve prolapse
      – Thin individuals

      A soft S1 can be associated with the following conditions:
      – Inappropriate apposition of the AV valves (e.g. mitral regurgitation, tricuspid regurgitation)
      – Prolonged PR interval (e.g. heart block, digoxin toxicity)
      – Decreased force of ventricular contraction (e.g. myocarditis, myocardial infarction)
      – Increased distance from the heart (e.g. obesity, emphysema, pericardial effusion)

      A split S1 can be associated with the following conditions:
      – Right bundle branch block
      – LV pacing
      – Ebstein anomaly

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      • Cardiology
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  • Question 41 - A 42-year-old woman presents with central chest pain that has been intermittent for...

    Incorrect

    • A 42-year-old woman presents with central chest pain that has been intermittent for the past few weeks. She reports that it tends to occur when she is climbing stairs or walking uphill but subsides quickly when she rests. Her medical history includes type 2 diabetes mellitus, which is managed with metformin, and gastroesophageal reflux disease (GERD), for which she takes lansoprazole. On examination, her heart sounds are normal, and her chest is clear.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Stable angina

      Explanation:

      Stable angina is characterized by chest pain in the center of the chest that is triggered by activities such as exercise and emotional stress. The pain may spread to the jaw or left arm and can be relieved by resting for a few minutes. Typically, the pain is brought on by a predictable amount of exertion.

      On the other hand, unstable angina is defined by the presence of one or more of the following: angina of effort occurring over a few days with increasing frequency, episodes of angina occurring recurrently and predictably without specific provocation, or an unprovoked and prolonged episode of cardiac chest pain. In unstable angina, the ECG may appear normal or show T wave / ST segment changes, and cardiac enzymes are usually normal.

      Prinzmetal angina is a rare form of angina that typically occurs at rest between midnight and early morning. These attacks can be severe and happen in clusters. It is caused by spasms in the coronary arteries, and patients with this condition often have normal coronary arteries.

      It is important to note that gastro-esophageal reflux (GORD) is not relevant to this question and is included in the patient’s history to distract the candidate. Typical symptoms of GORD include heartburn and acid regurgitation, and it can also present with non-cardiac chest pain, dyspepsia, and difficulty swallowing.

      Lastly, Ludwig’s angina is a serious and potentially life-threatening infection in the submandibular area. It most commonly occurs due to an infection in the floor of the mouth that spreads into the submandibular space.

    • This question is part of the following fields:

      • Cardiology
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  • Question 42 - A 68 year old male presents to the emergency department by ambulance due...

    Incorrect

    • A 68 year old male presents to the emergency department by ambulance due to worsening shortness of breath over the past 6 hours. The patient's wife informs you that he had complained of chest discomfort earlier in the day but attributed it to 'indigestion'. The patient is visibly breathing rapidly from the end of the bed and examination reveals crackling sounds throughout both lungs with no breath sounds and dullness when tapping the lower parts of the lungs. The following observations are noted:

      Blood pressure 100/60 mmHg
      Pulse rate 110 bpm
      Respiration rate 26 bpm
      Oxygen saturation 95% on 15L O2
      Temperature 37.2ºC

      You diagnose pulmonary edema as a result of acute heart failure secondary to cardiogenic shock. What is the mortality rate associated with this condition during hospitalization?

      Your Answer:

      Correct Answer: 50%

      Explanation:

      The mortality rate associated with pulmonary edema as a result of acute heart failure secondary to cardiogenic shock during hospitalization is 50%.

      Further Reading:

      Cardiac failure, also known as heart failure, is a clinical syndrome characterized by symptoms and signs resulting from abnormalities in the structure or function of the heart. This can lead to reduced cardiac output or high filling pressures at rest or with stress. Heart failure can be caused by various problems such as myocardial, valvular, pericardial, endocardial, or arrhythmic issues.

      The most common causes of heart failure in the UK are coronary heart disease and hypertension. However, there are many other possible causes, including valvular heart disease, structural heart disease, cardiomyopathies, certain drugs or toxins, endocrine disorders, nutritional deficiencies, infiltrative diseases, infections, and arrhythmias. Conditions that increase peripheral demand on the heart, such as anemia, pregnancy, sepsis, hyperthyroidism, Paget’s disease of bone, arteriovenous malformations, and beriberi, can also lead to high-output cardiac failure.

      Signs and symptoms of heart failure include edema, lung crepitations, tachycardia, tachypnea, hypotension, displaced apex beat, right ventricular heave, elevated jugular venous pressure, cyanosis, hepatomegaly, ascites, pleural effusions, breathlessness, fatigue, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough or wheeze, and Presyncope.

      To diagnose heart failure, NICE recommends three key tests: N-terminal pro-B-type natriuretic peptide (NT‑proBNP), transthoracic echocardiography, and ECG. Additional tests may include chest X-ray, blood tests (U&Es, thyroid function, LFT’s, lipid profile, HbA1C, FBC), urinalysis, and peak flow or spirometry.

      Management of cardiogenic pulmonary edema, a complication of heart failure, involves ensuring a patent airway, optimizing breathing with supplemental oxygen and non-invasive ventilation if necessary, and addressing circulation with loop diuretics to reduce preload, vasodilators to reduce preload and afterload, and inotropes if hypotension or signs of end organ hypoperfusion persist.

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  • Question 43 - A 72-year-old woman with a history of type II diabetes and hypertension presents...

    Incorrect

    • A 72-year-old woman with a history of type II diabetes and hypertension presents with a history of central chest pain that lasted approximately 45 minutes. Her ECG showed T wave inversion in the lateral leads, but her pain settled, and ECG normalized following the administration of GTN spray and IV morphine. She was also given 325 mg of aspirin on arrival. A troponin test has been organized and admission arranged.
      Which of the following medications should you also consider administering to this patient?

      Your Answer:

      Correct Answer: Fondaparinux

      Explanation:

      This patient is likely experiencing an acute coronary syndrome, possibly a non-ST-elevation myocardial infarction (NSTEMI) or unstable angina. The troponin test will help confirm the diagnosis. The patient’s ECG showed ST depression in the inferior leads, but this normalized after treatment with GTN and morphine, ruling out a ST-elevation myocardial infarction (STEMI).

      Immediate pain relief should be provided. GTN (sublingual or buccal) can be used, but intravenous opioids like morphine should be considered, especially if a heart attack is suspected.

      Aspirin should be given to all patients with unstable angina or NSTEMI as soon as possible and continued indefinitely, unless there are contraindications like bleeding risk or aspirin hypersensitivity. A loading dose of 300 mg should be administered right after presentation.

      Fondaparinux should be given to patients without a high bleeding risk, unless coronary angiography is planned within 24 hours of admission. Unfractionated heparin can be an alternative to fondaparinux for patients who will undergo coronary angiography within 24 hours. For patients with significant renal impairment, unfractionated heparin can also be considered, with dose adjustment based on clotting function monitoring.

      Routine administration of oxygen is no longer recommended, but oxygen saturation should be monitored using pulse oximetry as soon as possible, preferably before hospital admission. Supplemental oxygen should only be offered to individuals with oxygen saturation (SpO2) below 94% who are not at risk of hypercapnic respiratory failure, aiming for a SpO2 of 94-98%. For individuals with chronic obstructive pulmonary disease at risk of hypercapnic respiratory failure, a target SpO2 of 88-92% should be achieved until blood gas analysis is available.

      Bivalirudin, a specific and reversible direct thrombin inhibitor (DTI), is recommended by NICE as a possible treatment for adults with STEMI undergoing percutaneous coronary intervention.

      For more information, refer to the NICE guidelines on the assessment and diagnosis of chest pain of recent onset.

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      • Cardiology
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  • Question 44 - Your hospital’s cardiology department is currently evaluating the utility of a triple marker...

    Incorrect

    • Your hospital’s cardiology department is currently evaluating the utility of a triple marker test for use risk stratification of patients with a suspected acute coronary syndrome. The test will use troponin I, myoglobin and heart-type fatty acid-binding protein (HFABP).

      How long after heart attack do troponin I levels return to normal?

      Your Answer:

      Correct Answer: 3-10 days

      Explanation:

      The timing of the initial rise, peak, and return to normality of various cardiac enzymes can serve as a helpful guide. Creatine kinase, the main cardiac isoenzyme, typically experiences an initial rise within 4-8 hours, reaches its peak at 18 hours, and returns to normal within 2-3 days. Myoglobin, which lacks specificity due to its association with skeletal muscle damage, shows an initial rise within 1-4 hours, peaks at 6-7 hours, and returns to normal within 24 hours. Troponin I, known for its sensitivity and specificity, exhibits an initial rise within 3-12 hours, reaches its peak at 24 hours, and returns to normal within 3-10 days. HFABP, or heart fatty acid binding protein, experiences an initial rise within 1.5 hours, peaks at 5-10 hours, and returns to normal within 24 hours. Lastly, LDH, predominantly found in cardiac muscle, shows an initial rise at 10 hours, peaks at 24-48 hours, and returns to normal within 14 days.

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  • Question 45 - A 72-year-old woman with a history of type II diabetes and hypertension presents...

    Incorrect

    • A 72-year-old woman with a history of type II diabetes and hypertension presents with central chest discomfort. Her ECG showed ST depression in the inferior leads, but her discomfort subsides, and ECG returns to normal after receiving GTN spray and IV morphine. She was also given 300 mg of aspirin in the ambulance en route to the hospital. Her vital signs are as follows: SaO2 99% on room air, HR 89 bpm, and BP 139/82 mmHg. A troponin test has been scheduled and she is scheduled for an urgent coronary angiography.
      Which of the following medications should you also consider administering to this patient?

      Your Answer:

      Correct Answer: Unfractionated heparin

      Explanation:

      This patient is likely experiencing an acute coronary syndrome, possibly a non-ST-elevation myocardial infarction (NSTEMI) or unstable angina. The troponin test will help confirm the diagnosis. The patient’s ECG showed ST depression in the inferior leads, but this normalized after treatment with GTN and morphine, ruling out a ST-elevation myocardial infarction (STEMI).

      Immediate pain relief should be provided. GTN (sublingual or buccal) can be used, but intravenous opioids like morphine should be considered, especially if a heart attack is suspected.

      Aspirin should be given to all patients with unstable angina or NSTEMI as soon as possible and continued indefinitely, unless there are contraindications like bleeding risk or aspirin hypersensitivity. A loading dose of 300 mg should be administered right after presentation.

      Fondaparinux should be given to patients without a high bleeding risk, unless coronary angiography is planned within 24 hours of admission. Unfractionated heparin can be an alternative to fondaparinux for patients who will undergo coronary angiography within 24 hours. For patients with significant renal impairment, unfractionated heparin can also be considered, with dose adjustment based on clotting function monitoring.

      Routine administration of oxygen is no longer recommended, but oxygen saturation should be monitored using pulse oximetry as soon as possible, preferably before hospital admission. Supplemental oxygen should only be offered to individuals with oxygen saturation (SpO2) below 94% who are not at risk of hypercapnic respiratory failure, aiming for a SpO2 of 94-98%. For individuals with chronic obstructive pulmonary disease at risk of hypercapnic respiratory failure, a target SpO2 of 88-92% should be achieved until blood gas analysis is available.

      Bivalirudin, a specific and reversible direct thrombin inhibitor (DTI), is recommended by NICE as a possible treatment for adults with STEMI undergoing percutaneous coronary intervention.

      For more information, refer to the NICE guidelines on the assessment and diagnosis of chest pain of recent onset.

    • This question is part of the following fields:

      • Cardiology
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  • Question 46 - You conduct a cardiovascular examination on a 72-year-old man who complains of difficulty...

    Incorrect

    • You conduct a cardiovascular examination on a 72-year-old man who complains of difficulty breathing. He informs you that he has a known heart valve issue. During the examination, you observe a faint first heart sound (S1).
      What is the most probable cause of this finding?

      Your Answer:

      Correct Answer: Tricuspid regurgitation

      Explanation:

      The first heart sound (S1) is created by vibrations produced when the mitral and tricuspid valves close. It occurs at the end of diastole and the start of ventricular systole, coming before the upstroke of the carotid pulsation.

      A sample of the normal heart sounds can be listened to here (courtesy of Littman stethoscopes).

      A loud S1 can be associated with the following conditions:
      – Increased transvalvular gradient (e.g. mitral stenosis, tricuspid stenosis)
      – Increased force of ventricular contraction (e.g. tachycardia, hyperdynamic states like fever and thyrotoxicosis)
      – Shortened PR interval (e.g. Wolff-Parkinson-White syndrome)
      – Mitral valve prolapse
      – Thin individuals

      A soft S1 can be associated with the following conditions:
      – Inappropriate apposition of the AV valves (e.g. mitral regurgitation, tricuspid regurgitation)
      – Prolonged PR interval (e.g. heart block, digoxin toxicity)
      – Decreased force of ventricular contraction (e.g. myocarditis, myocardial infarction)
      – Increased distance from the heart (e.g. obesity, emphysema, pericardial effusion)

      A split S1 can be associated with the following conditions:
      – Right bundle branch block
      – LV pacing
      – Ebstein anomaly

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  • Question 47 - You are summoned to a cardiac arrest in the resuscitation area of your...

    Incorrect

    • You are summoned to a cardiac arrest in the resuscitation area of your Emergency Department. The patient is experiencing ventricular fibrillation, and adrenaline is being administered as part of the cardiac arrest protocol.
      Which ONE statement is accurate regarding the utilization of adrenaline in this arrest?

      Your Answer:

      Correct Answer: There is no evidence of long-term benefit from its use

      Explanation:

      Adrenaline is recommended to be administered after the third shock in a shockable cardiac arrest (Vf/pVT) once chest compressions have been resumed. The recommended dose is 1 mg, which can be administered as either 10 mL of 1:10,000 or 1 mL of 1:1000 concentration. Subsequently, adrenaline should be given every 3-5 minutes, alternating with chest compressions, and it should be administered without interrupting the compressions. While there is no evidence of long-term benefit from the use of adrenaline in cardiac arrest, some studies have shown improved short-term survival, which justifies its continued use.

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  • Question 48 - A 35-year-old female smoker presents with an episode of acute right-sided chest pain....

    Incorrect

    • A 35-year-old female smoker presents with an episode of acute right-sided chest pain. She describes the pain as being ‘extremely severe’, and it is aggravated by movement and coughing. The pain radiates to her neck and shoulder on the affected side. Her vital signs are within normal limits, and her oxygen saturation is 98% on room air. On examination, she exhibits localized tenderness around the 4th rib on the right-hand side. Her lung fields are clear, and her heart sounds are normal.
      What is the SINGLE most likely diagnosis?

      Your Answer:

      Correct Answer: Tietze’s syndrome

      Explanation:

      Tietze’s syndrome is an uncommon condition that leads to localized pain and tenderness in one or more of the upper four ribs, with the second and third ribs being the most commonly affected. The exact cause of this syndrome is still unknown, although it has been suggested that it may be linked to repeated small injuries to the chest wall.

      The pain experienced in Tietze’s syndrome is typically aggravated by movement, sneezing, and coughing, and it can also extend to the neck or shoulder on the affected side. In some cases, a firm swelling can be felt over the cartilage of the affected rib. While the pain usually diminishes after a few weeks or months, the swelling may persist.

      Treatment for Tietze’s syndrome involves the use of pain-relieving medications, such as NSAIDs. In more severe or persistent cases, local steroid injections may be beneficial.

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      • Cardiology
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  • Question 49 - You conduct a cardiovascular examination on a 62-year-old man who complains of palpitations....

    Incorrect

    • You conduct a cardiovascular examination on a 62-year-old man who complains of palpitations. He informs you that he has a known heart valve issue. During auscultation, you observe a faint second heart sound (S2).
      What is the most probable cause of this finding?

      Your Answer:

      Correct Answer: Pulmonary stenosis

      Explanation:

      The second heart sound (S2) is created by vibrations produced when the aortic and pulmonary valves close. It marks the end of systole. It is normal to hear a split in the sound during inspiration.

      A loud S2 can be associated with certain conditions such as systemic hypertension (resulting in a loud A2), pulmonary hypertension (resulting in a loud P2), hyperdynamic states (like tachycardia, fever, or thyrotoxicosis), and atrial septal defect (which causes a loud P2).

      On the other hand, a soft S2 can be linked to decreased aortic diastolic pressure (as seen in aortic regurgitation), poorly mobile cusps (such as calcification of the aortic valve), aortic root dilatation, and pulmonary stenosis (which causes a soft P2).

      A widely split S2 can occur during deep inspiration, right bundle branch block, prolonged right ventricular systole (seen in conditions like pulmonary stenosis or pulmonary embolism), and severe mitral regurgitation. However, in the case of atrial septal defect, the splitting is fixed and does not vary with respiration.

      Reversed splitting of S2, where P2 occurs before A2 (paradoxical splitting), can occur during deep expiration, left bundle branch block, prolonged left ventricular systole (as seen in hypertrophic cardiomyopathy), severe aortic stenosis, and right ventricular pacing.

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  • Question 50 - A 60-year-old woman comes in with severe, crushing chest pain that spreads to...

    Incorrect

    • A 60-year-old woman comes in with severe, crushing chest pain that spreads to her left shoulder and jaw. The pain has improved after receiving GTN spray under the tongue and intravenous morphine.
      What other medication should be recommended at this point?

      Your Answer:

      Correct Answer: Aspirin

      Explanation:

      This particular patient has a high risk of experiencing an acute coronary syndrome. Therefore, it is recommended to administer aspirin at a dosage of 300 mg and clopidogrel at a dosage ranging from 300-600 mg.

      Further Reading:

      Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).

      The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.

      There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.

      The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.

      The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.

      The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.

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  • Question 51 - You assess a 60-year-old individual who has arrived at the emergency department with...

    Incorrect

    • You assess a 60-year-old individual who has arrived at the emergency department with a progressive increase in difficulty breathing. Upon reviewing the patient's medical history, you discover that they underwent an echocardiogram a year ago, which revealed moderate tricuspid regurgitation. Which of the following physical indications is linked to tricuspid regurgitation?

      Your Answer:

      Correct Answer: Positive Carvallo's sign

      Explanation:

      Carvallo’s sign is a term used to describe the phenomenon where the systolic murmur of tricuspid regurgitation becomes louder when taking a deep breath in. Tricuspid regurgitation is characterized by a continuous murmur that starts in systole and continues throughout the entire cardiac cycle. This murmur is best heard at the lower left sternal edge and has a low frequency. In addition to Carvallo’s sign, other features of tricuspid regurgitation include the presence of an S3 heart sound, the possibility of atrial arrhythmias such as flutter or fibrillation, the presence of giant C-V waves in the jugular pulse, hepatomegaly (often with a pulsatile nature), and the development of edema, which may be accompanied by lung crepitations or pleural effusions.

      Further Reading:

      Tricuspid regurgitation (TR) is a condition where blood flows backwards through the tricuspid valve in the heart. It is classified as either primary or secondary, with primary TR being caused by abnormalities in the tricuspid valve itself and secondary TR being the result of other conditions outside of the valve. Mild TR is common, especially in young adults, and often does not cause symptoms. However, severe TR can lead to right-sided heart failure and the development of symptoms such as ascites, peripheral edema, and hepatomegaly.

      The causes of TR can vary. Primary TR can be caused by conditions such as rheumatic heart disease, myxomatous valve disease, or Ebstein anomaly. Secondary TR is often the result of right ventricular dilatation due to left heart failure or pulmonary hypertension. Other causes include endocarditis, traumatic chest injury, left ventricular systolic dysfunction, chronic lung disease, pulmonary thromboembolism, myocardial disease, left to right shunts, and carcinoid heart disease. In some cases, TR can occur as a result of infective endocarditis in IV drug abusers.

      Clinical features of TR can include a pansystolic murmur that is best heard at the lower left sternal edge, Carvallo’s sign (murmur increases with inspiration and decreases with expiration), an S3 heart sound, and the presence of atrial arrhythmias such as flutter or fibrillation. Other signs can include giant C-V waves in the jugular pulse, hepatomegaly (often pulsatile), and edema with lung crepitations or pleural effusions.

      The management of TR depends on the underlying cause and the severity of the condition. In severe cases, valve repair or replacement surgery may be necessary. Treatment may also involve addressing the underlying conditions contributing to TR, such as managing left heart failure or pulmonary hypertension.

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  • Question 52 - A 42-year-old woman comes in with retrosternal central chest discomfort that has been...

    Incorrect

    • A 42-year-old woman comes in with retrosternal central chest discomfort that has been ongoing for the past 48 hours. The discomfort intensifies with deep breaths and when lying flat, but eases when she sits upright. Additionally, the discomfort radiates to both of her shoulders. Her ECG reveals widespread concave ST elevation and PR depression. You strongly suspect a diagnosis of pericarditis.
      Which nerve is accountable for the pattern of her discomfort?

      Your Answer:

      Correct Answer: Phrenic nerve

      Explanation:

      Pericarditis refers to the inflammation of the pericardium, which can be caused by various factors such as infections (typically viral, like coxsackie virus), drug-induced reactions (e.g. isoniazid, cyclosporine), trauma, autoimmune conditions (e.g. SLE), paraneoplastic syndromes, uraemia, post myocardial infarction (known as Dressler’s syndrome), post radiotherapy, and post cardiac surgery.

      The clinical presentation of pericarditis often includes retrosternal chest pain that is pleuritic in nature. This pain is typically relieved by sitting forwards and worsened when lying flat. It may also radiate to the shoulders. Other symptoms may include shortness of breath, tachycardia, and the presence of a pericardial friction rub.

      The pericardium receives sensory supply from the phrenic nerve, which also provides sensory innervation to the diaphragm, various mediastinal structures, and certain abdominal structures such as the superior peritoneum, liver, and gallbladder. Since the phrenic nerve originates from the 4th cervical nerve, which also provides cutaneous innervation to the front of the shoulder girdle, pain from pericarditis can also radiate to the shoulders.

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  • Question 53 - A 72 year old male comes to the emergency department complaining of sudden...

    Incorrect

    • A 72 year old male comes to the emergency department complaining of sudden difficulty breathing, heart palpitations, and a cough that produces pink frothy sputum. During the examination, you observe an irregular heart rhythm, crackling sounds in the lower parts of the lungs, a loud first heart sound, and a mid-late diastolic murmur. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Mitral stenosis

      Explanation:

      Mitral stenosis is a condition characterized by a narrowing of the mitral valve, which can lead to various symptoms. One common symptom is a mid-late diastolic murmur, which can be heard during a physical examination. This murmur may also be described as mid-diastolic, late-diastolic, or mid-late diastolic. Additionally, patients with chronic mitral stenosis may not experience any symptoms, and the murmur may only be detected incidentally.

      A significant risk associated with mitral stenosis is the development of atrial fibrillation (AF). When AF occurs in patients with mitral stenosis, it can trigger acute pulmonary edema. This happens because the left atrium, which is responsible for pumping blood across the narrowed mitral valve into the left ventricle, needs to generate higher pressure. However, when AF occurs, the atrial contraction becomes inefficient, leading to impaired emptying of the left atrium. This, in turn, causes increased back pressure in the pulmonary circulation.

      The elevated pressure in the left atrium and pulmonary circulation can result in the rupture of bronchial veins, leading to the production of pink frothy sputum. This symptom is often observed in patients with mitral stenosis who develop acute pulmonary edema.

      Further Reading:

      Mitral Stenosis:
      – Causes: Rheumatic fever, Mucopolysaccharidoses, Carcinoid, Endocardial fibroelastosis
      – Features: Mid-late diastolic murmur, loud S1, opening snap, low volume pulse, malar flush, atrial fibrillation, signs of pulmonary edema, tapping apex beat
      – Features of severe mitral stenosis: Length of murmur increases, opening snap becomes closer to S2
      – Investigation findings: CXR may show left atrial enlargement, echocardiography may show reduced cross-sectional area of the mitral valve

      Mitral Regurgitation:
      – Causes: Mitral valve prolapse, Myxomatous degeneration, Ischemic heart disease, Rheumatic fever, Connective tissue disorders, Endocarditis, Dilated cardiomyopathy
      – Features: pansystolic murmur radiating to left axilla, soft S1, S3, laterally displaced apex beat with heave
      – Signs of acute MR: Decompensated congestive heart failure symptoms
      – Signs of chronic MR: Leg edema, fatigue, arrhythmia (atrial fibrillation)
      – Investigation findings: Doppler echocardiography to detect regurgitant flow and pulmonary hypertension, ECG may show signs of LA enlargement and LV hypertrophy, CXR may show LA and LV enlargement in chronic MR and pulmonary edema in acute MR.

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  • Question 54 - A 48 year old woman comes to the emergency department complaining of episodes...

    Incorrect

    • A 48 year old woman comes to the emergency department complaining of episodes of lightheadedness. She mentions that she is an avid jogger and noticed on her fitness tracker that her heart rate had dropped to 48 beats per minute. Which of the following characteristics would warrant drug intervention or transcutaneous pacing in a patient with bradycardia?

      Your Answer:

      Correct Answer: Myocardial ischaemia

      Explanation:

      Indications for drug treatment or pacing in patients with bradycardia include shock, syncope, myocardial ischemia, heart failure, and the presence of risk factors for asystole. If any of these adverse features are present, it is important to consider drug treatment or pacing. However, even if none of these adverse features are present, patients may still require drug treatment or pacing if they have risk factors for developing asystole, such as recent asystole, Mobitz II AV block, complete heart block with broad QRS, or a ventricular pause longer than 3 seconds.

      Further Reading:

      Causes of Bradycardia:
      – Physiological: Athletes, sleeping
      – Cardiac conduction dysfunction: Atrioventricular block, sinus node disease
      – Vasovagal & autonomic mediated: Vasovagal episodes, carotid sinus hypersensitivity
      – Hypothermia
      – Metabolic & electrolyte disturbances: Hypothyroidism, hyperkalaemia, hypermagnesemia
      – Drugs: Beta-blockers, calcium channel blockers, digoxin, amiodarone
      – Head injury: Cushing’s response
      – Infections: Endocarditis
      – Other: Sarcoidosis, amyloidosis

      Presenting symptoms of Bradycardia:
      – Presyncope (dizziness, lightheadedness)
      – Syncope
      – Breathlessness
      – Weakness
      – Chest pain
      – Nausea

      Management of Bradycardia:
      – Assess and monitor for adverse features (shock, syncope, myocardial ischaemia, heart failure)
      – Treat reversible causes of bradycardia
      – Pharmacological treatment: Atropine is first-line, adrenaline and isoprenaline are second-line
      – Transcutaneous pacing if atropine is ineffective
      – Other drugs that may be used: Aminophylline, dopamine, glucagon, glycopyrrolate

      Bradycardia Algorithm:
      – Follow the algorithm for management of bradycardia, which includes assessing and monitoring for adverse features, treating reversible causes, and using appropriate medications or pacing as needed.
      https://acls-algorithms.com/wp-content/uploads/2020/12/Website-Bradycardia-Algorithm-Diagram.pdf

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  • Question 55 - A 32-year-old woman is brought to the Emergency Department by ambulance due to...

    Incorrect

    • A 32-year-old woman is brought to the Emergency Department by ambulance due to 'severe palpitations.' Her heart rate is 180 bpm, and her rhythm strip is suggestive of supraventricular tachycardia. You plan to administer adenosine.
      Which of the following is NOT a contraindication to the use of adenosine?

      Your Answer:

      Correct Answer: History of heart transplant

      Explanation:

      Adenosine is a type of purine nucleoside that is primarily utilized in the diagnosis and treatment of paroxysmal supraventricular tachycardia. Its main mechanism of action involves stimulating A1-adenosine receptors and opening acetylcholine-sensitive potassium channels. This leads to hyperpolarization of the cell membrane in the atrioventricular (AV) node and slows down conduction in the AV node by inhibiting calcium channels.

      When administering adenosine, it is given rapidly through an intravenous bolus, followed by a saline flush. The initial dose for adults is 6 mg, and if necessary, additional doses of 12 mg or 18 mg can be given at 1-2 minute intervals until the desired effect is observed. It is important to note that the latest ALS guidelines recommend 18 mg for the third dose, while the BNF/NICE guidelines suggest 12 mg.

      One of the advantages of adenosine is its very short half-life, which is less than 10 seconds. This means that its effects are rapid, typically occurring within 10 seconds. However, the duration of action is also short, lasting only 10-20 seconds. Due to its short half-life, any side effects experienced are usually brief. These side effects may include a sense of impending doom, facial flushing, dyspnea, chest discomfort, and a metallic taste.

      There are certain contraindications to the use of adenosine. These include 2nd or 3rd degree AV block, sick sinus syndrome, long QT syndrome, severe hypotension, decompensated heart failure, chronic obstructive lung disease, and asthma. It is important to exercise caution when administering adenosine to patients with a heart transplant, as they are particularly sensitive to its effects. In these cases, a reduced initial dose of 3 mg is recommended, followed by 6 mg and then 12 mg.

      It is worth noting that the effects of adenosine can be potentiated by dipyridamole, a medication commonly used in combination with adenosine. Therefore, the dose of adenosine should be adjusted and reduced in patients who are also taking dipyridamole.

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  • Question 56 - A 72-year-old woman comes to the Emergency Department complaining of severe chest pain,...

    Incorrect

    • A 72-year-old woman comes to the Emergency Department complaining of severe chest pain, difficulty breathing, and feeling nauseous for the past hour. The ECG reveals ST-segment elevation in the anterolateral leads. After starting treatment, her condition improves, and the ECG changes indicate signs of resolution.
      Which medication is responsible for the rapid restoration of blood flow in this patient?

      Your Answer:

      Correct Answer: Tenecteplase

      Explanation:

      Tenecteplase is a medication known as a tissue plasminogen activator (tPA). Its main mechanism of action involves binding specifically to fibrin and converting plasminogen into plasmin. This process leads to the breakdown of the fibrin matrix and promotes reperfusion at the affected site. Among the options provided, Tenecteplase is the sole drug that primarily acts by facilitating reperfusion.

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  • Question 57 - A 35-year-old woman with a previous diagnosis of paroxysmal supraventricular tachycardia is found...

    Incorrect

    • A 35-year-old woman with a previous diagnosis of paroxysmal supraventricular tachycardia is found to have Lown-Ganong-Levine (LGL) syndrome.
      Which of the following statements about LGL syndrome is correct?

      Your Answer:

      Correct Answer: The QRS duration is typically normal

      Explanation:

      Lown-Ganong-Levine (LGL) syndrome is a condition that affects the electrical conducting system of the heart. It is classified as a pre-excitation syndrome, similar to the more well-known Wolff-Parkinson-White (WPW) syndrome. However, unlike WPW syndrome, LGL syndrome does not involve an accessory pathway for conduction. Instead, it is believed that there may be accessory fibers present that bypass all or part of the atrioventricular node.

      When looking at an electrocardiogram (ECG) of a patient with LGL syndrome in sinus rhythm, there are several characteristic features to observe. The PR interval, which represents the time it takes for the electrical signal to travel from the atria to the ventricles, is typically shortened and measures less than 120 milliseconds. The QRS duration, which represents the time it takes for the ventricles to contract, is normal. The P wave, which represents the electrical activity of the atria, may be normal or inverted. However, what distinguishes LGL syndrome from other pre-excitation syndromes is the absence of a delta wave, which is a slurring of the initial rise in the QRS complex.

      It is important to note that LGL syndrome predisposes individuals to paroxysmal supraventricular tachycardia (SVT), a rapid heart rhythm that originates above the ventricles. However, it does not increase the risk of developing atrial fibrillation or flutter, which are other types of abnormal heart rhythms.

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  • Question 58 - A 70-year-old male smoker presents with intense chest discomfort. His electrocardiogram (ECG) indicates...

    Incorrect

    • A 70-year-old male smoker presents with intense chest discomfort. His electrocardiogram (ECG) indicates an acute myocardial infarction, and he is immediately taken to the catheterization laboratory. Angiography reveals a blockage in the left anterior descending artery.
      Which area of the heart is most likely affected in this scenario?

      Your Answer:

      Correct Answer: Anteroseptal

      Explanation:

      A summary of the vessels involved in different types of myocardial infarction, along with the corresponding ECG leads and the location of the infarction.

      For instance, an anteroseptal infarction involving the left anterior descending artery is indicated by ECG leads V1-V3. Similarly, an anterior infarction involving the left anterior descending artery is indicated by leads V3-V4.

      In cases of anterolateral infarctions, both the left anterior descending artery and the left circumflex artery are involved, and this is reflected in ECG leads V5-V6. An extensive anterior infarction involving the left anterior descending artery is indicated by leads V1-V6.

      Lateral infarcts involving the left circumflex artery are indicated by leads I, II, aVL, and V6. Inferior infarctions, on the other hand, involve either the right coronary artery (in 80% of cases) or the left circumflex artery (in 20% of cases), and this is shown by leads II, III, and aVF.

      In the case of a right ventricular infarction, the right coronary artery is involved, and this is indicated by leads V1 and V4R. Lastly, a posterior infarction involving the right coronary artery is shown by leads V7-V9.

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  • Question 59 - A 70-year-old female smoker presents with intense chest discomfort. Her ECG indicates an...

    Incorrect

    • A 70-year-old female smoker presents with intense chest discomfort. Her ECG indicates an acute myocardial infarction and she is immediately taken to the cath lab. Angiography reveals a blockage in the left anterior descending artery.
      Which area of the heart is most likely affected in this scenario?

      Your Answer:

      Correct Answer: Right ventricle

      Explanation:

      A summary of the vessels involved in different types of myocardial infarction, along with the corresponding ECG leads and the location of the infarction.

      For instance, an anteroseptal infarction involving the left anterior descending artery is indicated by ECG leads V1-V3. Similarly, an anterior infarction involving the left anterior descending artery is indicated by leads V3-V4.

      In cases of anterolateral infarctions, both the left anterior descending artery and the left circumflex artery are involved, and this is reflected in ECG leads V5-V6. An extensive anterior infarction involving the left anterior descending artery is indicated by leads V1-V6.

      Lateral infarcts involving the left circumflex artery are indicated by leads I, II, aVL, and V6. Inferior infarctions, on the other hand, involve either the right coronary artery (in 80% of cases) or the left circumflex artery (in 20% of cases), and this is shown by leads II, III, and aVF.

      In the case of a right ventricular infarction, the right coronary artery is involved, and this is indicated by leads V1 and V4R. Lastly, a posterior infarction involving the right coronary artery is shown by leads V7-V9.

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  • Question 60 - You are summoned to a cardiac arrest in the resuscitation area of your...

    Incorrect

    • You are summoned to a cardiac arrest in the resuscitation area of your Emergency Department. The patient is experiencing asystole, and adrenaline is given as part of the cardiac arrest protocol.
      Which ONE statement is NOT TRUE regarding the utilization of adrenaline in cardiac arrest?

      Your Answer:

      Correct Answer: In VF arrest it should be given before the 3rd shock

      Explanation:

      Adrenaline should be administered promptly once access to the circulatory system has been established in cases of non-shockable cardiac arrests such as PEA or asystole. The recommended dose is 1 mg, which can be given either as 10 mL of a 1:10,000 solution or as 1 mL of a 1:1000 solution through the intravenous (IV) or intraosseous (IO) routes.

      In cases of shockable cardiac arrests like ventricular fibrillation (Vf) or pulseless ventricular tachycardia (pVT), adrenaline should be administered after the third shock has been delivered and chest compressions have been resumed. The same dose of 1 mg can be given using the same concentration options as mentioned earlier.

      Subsequently, adrenaline should be administered every 3-5 minutes, alternating with chest compressions, without interrupting the compressions. The alpha-adrenergic effects of adrenaline cause constriction of blood vessels throughout the body, leading to increased pressures in the coronary and cerebral circulation.

      The beta-adrenergic effects of adrenaline have positive effects on the heart, increasing its contractility (inotropic) and heart rate (chronotropic), which may also enhance blood flow to the coronary and cerebral arteries. However, it is important to note that these benefits may be counteracted by increased oxygen consumption by the heart, the potential for abnormal heart rhythms, temporary decrease in oxygen levels due to abnormal blood flow in the lungs, impaired microcirculation, and increased dysfunction of the heart after the cardiac arrest.

      While there is no evidence supporting the long-term benefits of adrenaline use in cardiac arrest cases, some studies have shown improved short-term survival rates, which justifies its continued use.

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  • Question 61 - You are managing a 72 year old female who has presented to the...

    Incorrect

    • You are managing a 72 year old female who has presented to the emergency department with sudden onset of dizziness and difficulty breathing. The patient's pulse rate is recorded as 44 beats per minute. Your assessment focuses on identifying reversible causes of bradycardia. Which of the following metabolic conditions is commonly associated with reversible bradycardia?

      Your Answer:

      Correct Answer: Hypermagnesemia

      Explanation:

      Some reversible metabolic causes of bradycardia include hypothyroidism, hyperkalaemia, hypermagnesemia, and hypothermia. These conditions can lead to a slow heart rate and can be treated or reversed.

      Further Reading:

      Causes of Bradycardia:
      – Physiological: Athletes, sleeping
      – Cardiac conduction dysfunction: Atrioventricular block, sinus node disease
      – Vasovagal & autonomic mediated: Vasovagal episodes, carotid sinus hypersensitivity
      – Hypothermia
      – Metabolic & electrolyte disturbances: Hypothyroidism, hyperkalaemia, hypermagnesemia
      – Drugs: Beta-blockers, calcium channel blockers, digoxin, amiodarone
      – Head injury: Cushing’s response
      – Infections: Endocarditis
      – Other: Sarcoidosis, amyloidosis

      Presenting symptoms of Bradycardia:
      – Presyncope (dizziness, lightheadedness)
      – Syncope
      – Breathlessness
      – Weakness
      – Chest pain
      – Nausea

      Management of Bradycardia:
      – Assess and monitor for adverse features (shock, syncope, myocardial ischaemia, heart failure)
      – Treat reversible causes of bradycardia
      – Pharmacological treatment: Atropine is first-line, adrenaline and isoprenaline are second-line
      – Transcutaneous pacing if atropine is ineffective
      – Other drugs that may be used: Aminophylline, dopamine, glucagon, glycopyrrolate

      Bradycardia Algorithm:
      – Follow the algorithm for management of bradycardia, which includes assessing and monitoring for adverse features, treating reversible causes, and using appropriate medications or pacing as needed.
      https://acls-algorithms.com/wp-content/uploads/2020/12/Website-Bradycardia-Algorithm-Diagram.pdf

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  • Question 62 - A 45-year-old woman comes in with central chest pain that is spreading to...

    Incorrect

    • A 45-year-old woman comes in with central chest pain that is spreading to her left arm for the past 30 minutes. Her vital signs are as follows: heart rate of 80 beats per minute, blood pressure of 118/72, and oxygen saturation of 98% on room air. The ECG shows the following findings:
      ST depression in leads V1-V4 and aVR
      ST elevation in V5-V6, II, III, and aVF
      Positive R wave in V1 and V2
      What is the most likely diagnosis in this case?

      Your Answer:

      Correct Answer: Acute inferoposterior myocardial infarction

      Explanation:

      The ECG shows the following findings:
      – There is ST depression in leads V1-V4 and aVR.
      – There is ST elevation in leads V5-V6, II, III, and aVF.
      – There is a positive R wave in leads V1 and V2, which indicates a reverse Q wave.
      These ECG changes indicate that there is an acute inferoposterior myocardial infarction.

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  • Question 63 - A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations....

    Incorrect

    • A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations. She informs you that she was recently diagnosed with type A Wolff-Parkinson-White syndrome. You proceed to perform an ECG.
      Which of the following ECG characteristics is NOT observed in type A Wolff-Parkinson-White (WPW) syndrome?

      Your Answer:

      Correct Answer: Predominantly negative QRS complexes in leads V1 and V2

      Explanation:

      Wolff-Parkinson-White (WPW) syndrome is a condition that affects the electrical system of the heart. It occurs when there is an abnormal pathway, known as the bundle of Kent, between the atria and the ventricles. This pathway can cause premature contractions of the ventricles, leading to a type of rapid heartbeat called atrioventricular re-entrant tachycardia (AVRT).

      In a normal heart rhythm, the electrical signals travel through the bundle of Kent and stimulate the ventricles. However, in WPW syndrome, these signals can cause the ventricles to contract prematurely. This can be seen on an electrocardiogram (ECG) as a shortened PR interval, a slurring of the initial rise in the QRS complex (known as a delta wave), and a widening of the QRS complex.

      There are two distinct types of WPW syndrome that can be identified on an ECG. Type A is characterized by predominantly positive delta waves and QRS complexes in the praecordial leads, with a dominant R wave in V1. This can sometimes be mistaken for right bundle branch block (RBBB). Type B, on the other hand, shows predominantly negative delta waves and QRS complexes in leads V1 and V2, and positive in the other praecordial leads, resembling left bundle branch block (LBBB).

      Overall, WPW syndrome is a condition that affects the electrical conduction system of the heart, leading to abnormal heart rhythms. It can be identified on an ECG by specific features such as shortened PR interval, delta waves, and widened QRS complex.

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  • Question 64 - A 55 year old female presents to the emergency department 3 hours after...

    Incorrect

    • A 55 year old female presents to the emergency department 3 hours after experiencing severe central chest pain that radiates to the back while gardening. The patient describes the pain as tearing and states it is the worst pain she has ever felt. You note a past medical history of poorly controlled hypertension. The patient's vital signs are as follows:

      Blood pressure 182/98 mmHg
      Pulse rate 94 bpm
      Respiration rate 22 rpm
      Oxygen saturation 97% on room air
      Temperature 37.3ºC

      An ECG is performed which shows normal sinus rhythm. Chest X-ray reveals a widened mediastinum and an abnormal aortic contour.

      What is the most appropriate initial treatment for this patient?

      Your Answer:

      Correct Answer: Intravenous labetalol

      Explanation:

      The most appropriate initial treatment for this patient would be intravenous labetalol. Labetalol is a non-selective beta blocker with alpha-blocking properties. It is the preferred initial treatment for aortic dissection because it helps to reduce blood pressure and heart rate, which can help to decrease the shear forces acting on the aortic wall and prevent further dissection. Intravenous administration of labetalol allows for rapid and effective control of blood pressure.

      Other treatment options, such as intravenous magnesium sulphate, intravenous verapamil, GTN sublingual spray, and oral nifedipine, are not appropriate for the management of aortic dissection. Magnesium sulphate is used for the treatment of certain arrhythmias and pre-eclampsia, but it does not address the underlying issue of aortic dissection. Verapamil and nifedipine are calcium channel blockers that can lower blood pressure, but they can also cause reflex tachycardia, which can worsen the condition. GTN sublingual spray is used for the treatment of angina, but it does not address the underlying issue of aortic dissection.

      Further Reading:

      Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.

      The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.

      Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.

      Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.

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  • Question 65 - A 32 year old male attends the emergency department due to sharp chest...

    Incorrect

    • A 32 year old male attends the emergency department due to sharp chest pain that has come on gradually over the past 48 hours. The patient reports he has general muscle aches and feels more fatigued than usual. The patient indicates the pain is retrosternal and worsens with deep inspiration and lying supine. On auscultation of the chest, a rub is audible that resembles the sound of squeaky leather. The rhythm is regular and quiet heart sounds are noted. Observations are shown below:

      Blood pressure: 112/68 mmHg
      Pulse rate: 92 bpm
      Respiratory rate: 18 rpm
      Temperature: 37.4ºC
      Oxygen saturations: 98% on air

      What is the likely diagnosis?

      Your Answer:

      Correct Answer: Pericarditis

      Explanation:

      Pericardial friction rub is a common finding in pericarditis and is often described as a sound similar to squeaking leather. This patient exhibits symptoms that are consistent with acute pericarditis, including flu-like illness with muscle pain and fatigue, chest pain that worsens when lying down and improves when sitting up or leaning forward, and the presence of a pleural rub. The gradual onset of symptoms rules out conditions like pulmonary embolism or acute myocardial ischemia. It is important to note that while the pericardial rub is often considered part of the classic triad of clinical features, it is only present in about one-third of patients. Additionally, the rub may come and go, so repeated examinations may increase the chances of detecting this sign.

      Further Reading:

      Pericarditis is an inflammation of the pericardium, which is the protective sac around the heart. It can be acute, lasting less than 6 weeks, and may present with chest pain, cough, dyspnea, flu-like symptoms, and a pericardial rub. The most common causes of pericarditis include viral infections, tuberculosis, bacterial infections, uremia, trauma, and autoimmune diseases. However, in many cases, the cause remains unknown. Diagnosis is based on clinical features, such as chest pain, pericardial friction rub, and electrocardiographic changes. Treatment involves symptom relief with nonsteroidal anti-inflammatory drugs (NSAIDs), and patients should avoid strenuous activity until symptoms improve. Complicated cases may require treatment for the underlying cause, and large pericardial effusions may need urgent drainage. In cases of purulent effusions, antibiotic therapy is necessary, and steroid therapy may be considered for pericarditis related to autoimmune disorders or if NSAIDs alone are ineffective.

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  • Question 66 - Your hospital’s oncology department is currently evaluating the utility of a triple marker...

    Incorrect

    • Your hospital’s oncology department is currently evaluating the utility of a triple marker test for use in risk stratification of patients with suspected breast cancer. The test will use estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2).
      How long after tumor formation do ER levels start to increase?

      Your Answer:

      Correct Answer: 1.5 hours

      Explanation:

      The timing of the initial rise, peak, and return to normality of various cardiac enzymes can serve as a helpful guide. Creatine kinase, the main cardiac isoenzyme, typically experiences an initial rise within 4-8 hours, reaches its peak at 18 hours, and returns to normal within 2-3 days. Myoglobin, which lacks specificity due to its association with skeletal muscle damage, shows an initial rise within 1-4 hours, peaks at 6-7 hours, and returns to normal within 24 hours. Troponin I, known for its sensitivity and specificity, exhibits an initial rise within 3-12 hours, reaches its peak at 24 hours, and returns to normal within 3-10 days. HFABP, or heart fatty acid binding protein, experiences an initial rise within 1.5 hours, peaks at 5-10 hours, and returns to normal within 24 hours. Lastly, LDH, predominantly found in cardiac muscle, shows an initial rise at 10 hours, peaks at 24-48 hours, and returns to normal within 14 days.

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      • Cardiology
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  • Question 67 - A 28-year-old woman comes in with a one-week history of occasional dizzy spells...

    Incorrect

    • A 28-year-old woman comes in with a one-week history of occasional dizzy spells and feeling generally under the weather. She experienced one brief episode where she fainted. She was diagnosed with systemic lupus erythematosus four months ago and has been prescribed high-dose ibuprofen. During the examination, she has swelling in her hands and feet but no other notable findings. Her EKG shows broad QRS complexes and tall peaked T waves.
      Which ONE blood test will confirm the diagnosis?

      Your Answer:

      Correct Answer: Urea and electrolytes

      Explanation:

      This patient’s ECG shows signs consistent with hyperkalemia, including broad QRS complexes, tall-peaked T waves, and bizarre p waves. It is estimated that around 10% of patients with SLE have hyperkalemia, which is believed to be caused by hyporeninemic hypoaldosteronism. Additionally, the patient has been taking a high dose of ibuprofen, which can also contribute to the development of hyperkalemia. NSAIDs are thought to induce hyperkalemia by reducing renin secretion, leading to decreased potassium excretion.

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      • Cardiology
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  • Question 68 - A 32-year-old man presents with an episode of atrial fibrillation (AF) that began...

    Incorrect

    • A 32-year-old man presents with an episode of atrial fibrillation (AF) that began a few hours ago. This is his first-ever episode, and he has no significant medical history.
      Which of the following accurately characterizes the type of AF he has experienced?

      Your Answer:

      Correct Answer: Acute

      Explanation:

      In order to gain a comprehensive understanding of AF management, it is crucial to familiarize oneself with the terminology used to describe its various subtypes. These terms help categorize different episodes of AF based on their characteristics and outcomes.

      Acute AF refers to any episode that occurs within the previous 48 hours. It can manifest with or without symptoms and may or may not recur. On the other hand, paroxysmal AF describes episodes that spontaneously end within 7 days, typically within 48 hours. While these episodes are often recurrent, they can progress into a sustained form of AF.

      Recurrent AF is defined as experiencing two or more episodes of AF. If the episodes self-terminate, they are classified as paroxysmal AF. However, if the episodes do not self-terminate, they are categorized as persistent AF. Persistent AF lasts longer than 7 days or has occurred after a previous cardioversion. To terminate persistent AF, electrical or pharmacological intervention is required. In some cases, persistent AF can progress into permanent AF.

      Permanent AF, also known as Accepted AF, refers to episodes that cannot be successfully terminated, have relapsed after termination, or where cardioversion is not pursued. This subtype signifies a more chronic and ongoing form of AF.

      By understanding and utilizing these terms, healthcare professionals can effectively communicate and manage the different subtypes of AF.

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  • Question 69 - You are requested to evaluate a teenager who is in resus with a...

    Incorrect

    • You are requested to evaluate a teenager who is in resus with a supraventricular tachycardia. The patient is stable hemodynamically but has already received 3 doses of IV adenosine and vagal maneuvers. However, there has been no improvement in their condition.
      Based on the current APLS guidelines, what would be the most suitable next course of action in managing this patient?

      Your Answer:

      Correct Answer: Give IV amiodarone 5-10 mg/kg

      Explanation:

      Supraventricular tachycardia (SVT) is the most common arrhythmia that occurs in children and infants, causing cardiovascular instability. According to the current APLS guidelines, if a patient with SVT shows no signs of shock and remains stable, initial attempts should be made to use vagal maneuvers. If these maneuvers are unsuccessful, the following steps are recommended:

      – Administer an initial dose of 100 mcg/kg of adenosine.
      – After two minutes, if the child is still in stable SVT, administer another dose of 200 mcg/kg of adenosine.
      – After an additional two minutes, if the child remains in stable SVT, administer another dose of 300 mcg/kg of adenosine.

      If these measures do not resolve the SVT, the guidelines suggest considering the following options:

      – Administer adenosine at a dose of 400-500 mcg/kg.
      – Perform a synchronous DC shock.
      – Administer amiodarone.

      When using amiodarone, the initial dose should be 5-10 mg/kg given over a period of 20 minutes to 2 hours. This should be followed by a continuous infusion of 300 mcg/kg/hour, with adjustments made based on the response, increasing by 1.5 mg/kg/hour. The total infusion rate should not exceed 1.2 g in a 24-hour period.

      If defibrillation is necessary for the treatment of SVT in children, it should be performed as a DC synchronous shock at a dosage of 1-2 J/kg.

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  • Question 70 - A 35 year old male presents to the emergency department with complaints of...

    Incorrect

    • A 35 year old male presents to the emergency department with complaints of palpitations. An ECG is conducted, revealing a regular narrow complex supraventricular tachycardia with a rate of around 160 bpm. There are no signs of ST elevation or depression. The patient's vital signs are as follows:

      Blood pressure: 128/76 mmHg
      Pulse rate: 166
      Respiration rate: 19
      Oxygen saturations: 97% on room air

      What would be the most appropriate initial treatment for this patient?

      Your Answer:

      Correct Answer: Vagal manoeuvres

      Explanation:

      In stable patients with SVT, it is recommended to first try vagal manoeuvres before resorting to drug treatment. This approach is particularly applicable to patients who do not exhibit any adverse features, as mentioned in the case above.

      Further Reading:

      Supraventricular tachycardia (SVT) is a type of tachyarrhythmia that originates from the atria or above the bundle of His in the heart. It includes all atrial and junctional tachycardias, although atrial fibrillation is often considered separately. SVT typically produces a narrow QRS complex tachycardia on an electrocardiogram (ECG), unless there is an underlying conduction abnormality below the atrioventricular (AV) node. Narrow complex tachycardias are considered SVTs, while some broad complex tachycardias can also be SVTs with co-existent conduction delays.

      SVT can be classified into three main subtypes based on where it arises: re-entrant accessory circuits (the most common type), atrial tachycardias, and junctional tachycardias. The most common SVTs are AVNRT (AV nodal re-entry tachycardia) and AVRT (AV re-entry tachycardia), which arise from accessory circuits within the heart. AVNRT involves an accessory circuit within the AV node itself, while AVRT involves an accessory pathway between the atria and ventricles that allows additional electrical signals to trigger the AV node.

      Atrial tachycardias originate from abnormal foci within the atria, except for the SA node, AV node, or accessory pathway. Junctional tachycardias arise in the AV junction. The ECG features of SVTs vary depending on the type. Atrial tachycardias may have abnormal P wave morphology, an isoelectric baseline between P waves (in atrial flutter), and inverted P waves in certain leads. AVNRT may show pseudo R waves in V1 or pseudo S waves in certain leads, with an RP interval shorter than the PR interval. AVRT (WPW) may exhibit a delta wave on a resting ECG and retrograde P waves in the ST segment, with an RP interval shorter than the PR interval. Junctional tachycardias may have retrograde P waves before, during, or after the QRS complex, with inverted P waves in certain leads and upright P waves in others.

      Treatment of SVT follows the 2021 resuscitation council algorithm for tachycardia with a pulse. The algorithm provides guidelines for managing stable patients with SVT.

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  • Question 71 - A 30-year-old woman presents with a severe 'tearing' abdominal pain that radiates to...

    Incorrect

    • A 30-year-old woman presents with a severe 'tearing' abdominal pain that radiates to her lower back. A diagnosis of aortic dissection is suspected.
      Which of the following would be the LEAST likely risk factor for aortic dissection?

      Your Answer:

      Correct Answer: Cannabis usage

      Explanation:

      There is no known connection between the use of cannabis and aortic dissection. Some factors that are recognized as increasing the risk of aortic dissection include hypertension, atherosclerosis, aortic coarctation, the use of sympathomimetic drugs like cocaine, Marfan syndrome, Ehlers-Danlos syndrome, Turner’s syndrome, tertiary syphilis, and pre-existing aortic aneurysm.

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  • Question 72 - A 72-year-old woman presents with worsening abdominal distension and discomfort. During the examination,...

    Incorrect

    • A 72-year-old woman presents with worsening abdominal distension and discomfort. During the examination, she exhibits significant dependent edema and an elevated JVP. Cardiac auscultation reveals a pansystolic murmur. The abdomen is distended and tender, with the presence of shifting dullness.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Tricuspid regurgitation

      Explanation:

      Tricuspid regurgitation is commonly caused by right ventricular dilatation, often as a result of heart failure. Other factors that can contribute to this condition include right ventricular infarction and cor pulmonale. The clinical signs of right-sided heart failure are frequently observed, such as an elevated jugular venous pressure, peripheral edema, hepatomegaly, and ascites.

      The murmur associated with tricuspid regurgitation is a pansystolic murmur that is most audible at the tricuspid area during inspiration. A thrill may also be felt at the left sternal edge. Reverse splitting of the second heart sound can occur due to the early closure of the pulmonary valve. Additionally, a third heart sound may be present due to rapid filling of the right ventricle.

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  • Question 73 - You are summoned to a cardiac arrest in the resuscitation area of your...

    Incorrect

    • You are summoned to a cardiac arrest in the resuscitation area of your Emergency Department.
      Which ONE statement about the utilization of amiodarone in cardiac arrest is NOT true?

      Your Answer:

      Correct Answer: It should be administered as an infusion of 300 mg over 20-60 minutes

      Explanation:

      Amiodarone is a medication that is recommended to be administered after the third shock in a shockable cardiac arrest (Vf/pVT) while chest compressions are being performed. The prescribed dose is 300 mg, given as an intravenous bolus that is diluted in 5% dextrose to a volume of 20 mL. It is important to note that amiodarone is not suitable for treating PEA or asystole.

      In cases where VF/pVT persists after five defibrillation attempts, an additional dose of 150 mg of amiodarone should be given. However, if amiodarone is not available, lidocaine can be used as an alternative. The recommended dose of lidocaine is 1 mg/kg. It is crucial to avoid administering lidocaine if amiodarone has already been given.

      Amiodarone is classified as a membrane-stabilizing antiarrhythmic drug. It works by prolonging the duration of the action potential and the refractory period in both the atrial and ventricular myocardium. This medication also slows down atrioventricular conduction and has a similar effect on accessory pathways.

      Additionally, amiodarone has a mild negative inotropic action, meaning it weakens the force of heart contractions. It also causes peripheral vasodilation through non-competitive alpha-blocking effects.

      It is important to note that while there is no evidence of long-term benefits from using amiodarone, it may improve short-term survival rates, which justifies its continued use.

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  • Question 74 - A 65 year old male presents to the emergency department with a 3...

    Incorrect

    • A 65 year old male presents to the emergency department with a 3 hour history of severe chest pain that radiates to his left arm and neck. On examination, his chest is clear and his heart sounds are normal with a regular rhythm. No carotid bruits are heard. The following observations are noted:

      Blood pressure: 150/90 mmHg
      Pulse rate: 88 bpm
      Respiration rate: 18 rpm
      Oxygen saturation: 97% on room air
      Temperature: 37.2ºC

      An ECG reveals normal sinus rhythm and a chest X-ray shows no abnormalities. The patient's pain subsides after receiving buccal GTN (glyceryl trinitrate). Cardiac enzyme tests are pending. What is the most appropriate course of action for this patient?

      Your Answer:

      Correct Answer: Administer 300 mg oral aspirin

      Explanation:

      For patients suspected of having acute coronary syndromes (ACS), it is recommended that they receive 300 mg of aspirin and pain relief in the form of glyceryl trinitrate (GTN) with the option of intravenous opioids such as morphine. However, if the patient is pain-free after taking GTN, there is no need to administer morphine. The next steps in medical management or intervention will be determined once the diagnosis is confirmed.

      Further Reading:

      Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).

      The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.

      There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.

      The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.

      The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.

      The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.

    • This question is part of the following fields:

      • Cardiology
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  • Question 75 - A 45 year old female comes to the emergency department with abrupt onset...

    Incorrect

    • A 45 year old female comes to the emergency department with abrupt onset tearing chest pain that spreads to the throat and back. You contemplate the likelihood of aortic dissection. What is the predominant risk factor observed in individuals with aortic dissection?

      Your Answer:

      Correct Answer: Hypertension

      Explanation:

      Aortic dissection is a condition that occurs when the middle layer of the aorta, known as the tunica media, becomes weakened. This weakening leads to the development of cases of aortic dissection.

      Further Reading:

      Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.

      The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.

      Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.

      Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.

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      • Cardiology
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  • Question 76 - A 68 year old man is brought to the emergency department due to...

    Incorrect

    • A 68 year old man is brought to the emergency department due to sudden difficulty breathing. During auscultation, you detect a murmur. The patient then undergoes a bedside echocardiogram which reveals mitral regurgitation. What murmur is commonly associated with mitral regurgitation?

      Your Answer:

      Correct Answer: pansystolic murmur

      Explanation:

      Mitral regurgitation is characterized by a continuous murmur throughout systole that is often heard loudest at the apex and can be heard radiating to the left axilla.

      Further Reading:

      Mitral Stenosis:
      – Causes: Rheumatic fever, Mucopolysaccharidoses, Carcinoid, Endocardial fibroelastosis
      – Features: Mid-late diastolic murmur, loud S1, opening snap, low volume pulse, malar flush, atrial fibrillation, signs of pulmonary edema, tapping apex beat
      – Features of severe mitral stenosis: Length of murmur increases, opening snap becomes closer to S2
      – Investigation findings: CXR may show left atrial enlargement, echocardiography may show reduced cross-sectional area of the mitral valve

      Mitral Regurgitation:
      – Causes: Mitral valve prolapse, Myxomatous degeneration, Ischemic heart disease, Rheumatic fever, Connective tissue disorders, Endocarditis, Dilated cardiomyopathy
      – Features: pansystolic murmur radiating to left axilla, soft S1, S3, laterally displaced apex beat with heave
      – Signs of acute MR: Decompensated congestive heart failure symptoms
      – Signs of chronic MR: Leg edema, fatigue, arrhythmia (atrial fibrillation)
      – Investigation findings: Doppler echocardiography to detect regurgitant flow and pulmonary hypertension, ECG may show signs of LA enlargement and LV hypertrophy, CXR may show LA and LV enlargement in chronic MR and pulmonary edema in acute MR.

    • This question is part of the following fields:

      • Cardiology
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  • Question 77 - You evaluate a 75-year-old woman with chronic heart failure.
    Which specific beta-blocker is approved...

    Incorrect

    • You evaluate a 75-year-old woman with chronic heart failure.
      Which specific beta-blocker is approved for the treatment of chronic heart failure?

      Your Answer:

      Correct Answer: Nebivolol

      Explanation:

      Currently, there are three beta-blockers that have been approved for the treatment of chronic heart failure. These medications include bisoprolol, carvedilol, and nebivolol.

      Chronic HF is a common clinical syndrome resulting from coronary artery disease (CAD), HTN, valvular heart disease, and/or primary cardiomyopathy. There is now conclusive evidence that β-blockers, when added to ACE inhibitors, substantially reduce mortality, decrease sudden death, and improve symptoms in patients with HF. Despite the overwhelming evidence and guidelines that mandate the use of β-blockers in all HF patients without contraindications, many patients do not receive this treatment.

    • This question is part of the following fields:

      • Cardiology
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  • Question 78 - Whilst assessing a patient in the Emergency Department, you observe a pansystolic murmur.
    Which...

    Incorrect

    • Whilst assessing a patient in the Emergency Department, you observe a pansystolic murmur.
      Which of the following is NOT a potential cause of a pansystolic murmur?

      Your Answer:

      Correct Answer: Aortic stenosis

      Explanation:

      Aortic stenosis leads to the presence of a murmur during the ejection phase of the cardiac cycle. This murmur is most audible at the right second intercostal space and can be heard extending into the right neck.

      Mitral regurgitation, on the other hand, produces a high-pitched murmur that occurs throughout the entire systolic phase of the cardiac cycle. This murmur is best heard at the apex of the heart and can be heard radiating into the axilla.

      Tricuspid regurgitation is characterized by a blowing murmur that occurs throughout the entire systolic phase of the cardiac cycle. This murmur is most clearly heard at the lower left sternal edge.

      Ventricular septal defect results in a harsh murmur that occurs throughout the entire systolic phase of the cardiac cycle. This murmur is best heard at the third or fourth left intercostal space and can be heard radiating throughout the praecordium.

      Aortopulmonary shunts are an extremely rare cause of a murmur that occurs throughout the entire systolic phase of the cardiac cycle.

    • This question is part of the following fields:

      • Cardiology
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  • Question 79 - You evaluate a 55-year-old woman with chest discomfort and suspect a diagnosis of...

    Incorrect

    • You evaluate a 55-year-old woman with chest discomfort and suspect a diagnosis of an acute coronary syndrome (ACS).
      Which ONE statement about ACS is NOT TRUE?

      Your Answer:

      Correct Answer: Cardiac enzymes are usually elevated in unstable angina

      Explanation:

      Cardiac enzymes do not increase in unstable angina. However, if cardiac markers do rise, it is classified as a non-ST elevation myocardial infarction (NSTEMI). Both unstable angina and NSTEMI can have a normal ECG. An extended ventricular activation time indicates damage to the heart muscle. This occurs because infarcting myocardium conducts electrical impulses at a slower pace, resulting in a prolonged interval between the start of the QRS complex and the apex of the R wave. A positive troponin test indicates the presence of necrosis in cardiac myocytes.

      Summary:
      Marker | Initial Rise | Peak | Normal at
      Creatine kinase | 4-8 hours | 18 hours 2-3 days | CK-MB = main cardiac isoenzyme
      Myoglobin | 1-4 hours | 6-7 hours | 24 hours | Low specificity due to skeletal muscle damage
      Troponin I | 3-12 hours | 24 hours | 3-10 days | Appears to be the most sensitive and specific
      HFABP | 1-2 hours | 5-10 hours | 24 hours | HFABP = heart fatty acid binding protein
      LDH | 10 hours | 24-48 hours | 14 days | Cardiac muscle mainly contains LDH

    • This question is part of the following fields:

      • Cardiology
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  • Question 80 - You are requested to evaluate a 62-year-old individual who has arrived with complaints...

    Incorrect

    • You are requested to evaluate a 62-year-old individual who has arrived with complaints of chest discomfort. The nurse has handed you the ECG report, as the ECG machine has indicated 'anterior infarction' in its comments.

      Which leads would you anticipate observing ST elevation in an acute anterior STEMI?

      Your Answer:

      Correct Answer: V3-V4

      Explanation:

      The leads V3 and V4 represent the anterior myocardial area.

      Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).

      The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.

      There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.

      The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.

      The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.

      The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.

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      • Cardiology
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  • Question 81 - A 72 year old male presents with central chest pain radiating to the...

    Incorrect

    • A 72 year old male presents with central chest pain radiating to the jaw and left arm. The patient is sweating profusely and appears pale. The pain began 4 hours ago. ECG reveals 2-3 mm ST elevation in leads II, III and aVF. 300 mg aspirin has been administered. Transporting the patient to the nearest coronary catheter lab for primary PCI will take 2 hours 45 minutes. What is the most suitable course of action for managing this patient?

      Your Answer:

      Correct Answer: Administer fibrinolysis

      Explanation:

      Fibrinolysis is a treatment option for patients with ST-elevation myocardial infarction (STEMI) if they are unable to receive primary percutaneous coronary intervention (PCI) within 120 minutes, but fibrinolysis can be administered within that time frame. Primary PCI is the preferred treatment for STEMI patients who present within 12 hours of symptom onset. However, if primary PCI cannot be performed within 120 minutes of the time when fibrinolysis could have been given, fibrinolysis should be considered. Along with fibrinolysis, an antithrombin medication such as unfractionated heparin (UFH), low molecular weight heparin (LMWH), fondaparinux, or bivalirudin is typically administered.

      Further Reading:

      Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).

      The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.

      There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.

      The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.

      The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.

      The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.

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      • Cardiology
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  • Question 82 - A 60 year old female presents to the emergency department complaining of increasing...

    Incorrect

    • A 60 year old female presents to the emergency department complaining of increasing shortness of breath. The patient reports feeling more fatigued and breathless with minimal exertion over the past few months, but in the past few days, she has been experiencing breathlessness even at rest. She informs you that she has been taking aspirin, ramipril, bisoprolol, and rosuvastatin for the past 5 years since she had a minor heart attack. Upon examination, you observe prominent neck veins, bilateral lung crepitations that are worse at the bases, faint heart sounds, and pitting edema below the knee. The patient's vital signs are as follows:

      Blood pressure: 130/84 mmHg
      Pulse rate: 90 bpm
      Respiration rate: 23 bpm
      Temperature: 37.0ºC
      Oxygen saturation: 93% on room air

      What would be the most appropriate initial treatment for this patient?

      Your Answer:

      Correct Answer: Furosemide 40 mg IV

      Explanation:

      Given the patient’s symptoms and physical findings, the most appropriate initial treatment would be to administer Furosemide 40 mg intravenously. Furosemide is a loop diuretic that helps remove excess fluid from the body, which can alleviate symptoms of fluid overload such as shortness of breath and edema. By reducing fluid volume, Furosemide can help improve the patient’s breathing and relieve the strain on the heart.

      Further Reading:

      Cardiac failure, also known as heart failure, is a clinical syndrome characterized by symptoms and signs resulting from abnormalities in the structure or function of the heart. This can lead to reduced cardiac output or high filling pressures at rest or with stress. Heart failure can be caused by various problems such as myocardial, valvular, pericardial, endocardial, or arrhythmic issues.

      The most common causes of heart failure in the UK are coronary heart disease and hypertension. However, there are many other possible causes, including valvular heart disease, structural heart disease, cardiomyopathies, certain drugs or toxins, endocrine disorders, nutritional deficiencies, infiltrative diseases, infections, and arrhythmias. Conditions that increase peripheral demand on the heart, such as anemia, pregnancy, sepsis, hyperthyroidism, Paget’s disease of bone, arteriovenous malformations, and beriberi, can also lead to high-output cardiac failure.

      Signs and symptoms of heart failure include edema, lung crepitations, tachycardia, tachypnea, hypotension, displaced apex beat, right ventricular heave, elevated jugular venous pressure, cyanosis, hepatomegaly, ascites, pleural effusions, breathlessness, fatigue, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough or wheeze, and Presyncope.

      To diagnose heart failure, NICE recommends three key tests: N-terminal pro-B-type natriuretic peptide (NT‑proBNP), transthoracic echocardiography, and ECG. Additional tests may include chest X-ray, blood tests (U&Es, thyroid function, LFT’s, lipid profile, HbA1C, FBC), urinalysis, and peak flow or spirometry.

      Management of cardiogenic pulmonary edema, a complication of heart failure, involves ensuring a patent airway, optimizing breathing with supplemental oxygen and non-invasive ventilation if necessary, and addressing circulation with loop diuretics to reduce preload, vasodilators to reduce preload and afterload, and inotropes if hypotension or signs of end organ hypoperfusion persist.

      In summary, cardiac failure is a clinical syndrome resulting from abnormalities in cardiac function. It can have various causes and is characterized by specific signs and symptoms. Diagnosis involves specific tests, and management focuses on addressing

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      • Cardiology
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  • Question 83 - A 72 year old male attends the emergency department complaining of feeling lightheaded,...

    Incorrect

    • A 72 year old male attends the emergency department complaining of feeling lightheaded, experiencing shortness of breath, and having irregular heartbeats. He states that these symptoms started six hours ago. Upon listening to his chest, clear lung fields are detected but an irregularly irregular pulse is observed. The patient has type 2 diabetes, which is currently controlled through diet. The only medications he takes are:
      - Lisinopril 2.5 mg once daily
      - Simvastatin 20 mg once daily
      There is no history of heart disease, vascular disease, or stroke. The recorded observations are as follows:
      - Blood pressure: 148/92 mmHg
      - Pulse rate: 86 bpm
      - Respiration rate: 15 bpm
      - Oxygen saturation: 97% on room air
      An ECG is performed, confirming atrial fibrillation. As part of the management, you need to calculate the patient's CHA2DS2-VASc score.

      What is this patient's score?

      Your Answer:

      Correct Answer: 4

      Explanation:

      The patient is currently taking 20 mg of Atorvastatin once daily. They do not have a history of heart disease, vascular disease, or stroke. Their blood pressure is 148/92 mmHg, pulse rate is 86 bpm, and respiration rate is 1.

      Further Reading:

      Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting around 5% of patients over the age of 70-75 years and 10% of patients aged 80-85 years. While AF can cause palpitations and inefficient cardiac function, the most important aspect of managing patients with AF is reducing the increased risk of stroke.

      AF can be classified as first detected episode, paroxysmal, persistent, or permanent. First detected episode refers to the initial occurrence of AF, regardless of symptoms or duration. Paroxysmal AF occurs when a patient has 2 or more self-terminating episodes lasting less than 7 days. Persistent AF refers to episodes lasting more than 7 days that do not self-terminate. Permanent AF is continuous atrial fibrillation that cannot be cardioverted or if attempts to do so are deemed inappropriate. The treatment goals for permanent AF are rate control and anticoagulation if appropriate.

      Symptoms of AF include palpitations, dyspnea, and chest pain. The most common sign is an irregularly irregular pulse. An electrocardiogram (ECG) is essential for diagnosing AF, as other conditions can also cause an irregular pulse.

      Managing patients with AF involves two key parts: rate/rhythm control and reducing stroke risk. Rate control involves slowing down the irregular pulse to avoid negative effects on cardiac function. This is typically achieved using beta-blockers or rate-limiting calcium channel blockers. If one drug is not effective, combination therapy may be used. Rhythm control aims to restore and maintain normal sinus rhythm through pharmacological or electrical cardioversion. However, the majority of patients are managed with a rate control strategy.

      Reducing stroke risk in patients with AF is crucial. Risk stratifying tools, such as the CHA2DS2-VASc score, are used to determine the most appropriate anticoagulation strategy. Anticoagulation is recommended for patients with a score of 2 or more. Clinicians can choose between warfarin and novel oral anticoagulants (NOACs) for anticoagulation.

      Before starting anticoagulation, the patient’s bleeding risk should be assessed using tools like the HAS-BLED score or the ORBIT tool. These tools evaluate factors such as hypertension, abnormal renal or liver function, history of bleeding, age, and use of drugs that predispose to bleeding.

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  • Question 84 - A 45-year-old woman presents with recurrent episodes of central chest pain that radiate...

    Incorrect

    • A 45-year-old woman presents with recurrent episodes of central chest pain that radiate to her left arm. She has a history of angina and uses a GTN spray for relief. She reports that the pains have been occurring more frequently in the past few days and have been triggered by less exertion. Currently, she is not experiencing any pain, and her ECG shows normal sinus rhythm with no abnormalities in T wave or ST-segment.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Unstable angina

      Explanation:

      Unstable angina is characterized by the presence of one or more of the following symptoms: angina of effort occurring over a few days with increasing frequency, episodes of angina occurring recurrently and predictably without specific provocation, or an unprovoked and prolonged episode of cardiac chest pain. The electrocardiogram (ECG) may appear normal or show T-wave/ST-segment changes, and cardiac enzymes are typically within normal range.

      On the other hand, stable angina is defined by central chest pain that is triggered by activities such as exercise and emotional stress. This pain may radiate to the jaw or left arm and is relieved by resting for a few minutes. It is usually brought on by a predictable amount of exertion.

      Prinzmetal angina, although rare, is a variant of angina that primarily occurs at rest between midnight and early morning. The attacks can be severe and tend to happen in clusters. This type of angina is caused by coronary artery spasm, and patients may have normal coronary arteries.

      Decubitus angina, on the other hand, is angina that occurs when lying down. It often develops as a result of cardiac failure due to an increased volume of blood within the blood vessels, which places additional strain on the heart.

      Lastly, Ludwig’s angina is an extremely serious and potentially life-threatening cellulitis that affects the submandibular area. It most commonly arises from an infection in the floor of the mouth, which then spreads to the submandibular space.

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      • Cardiology
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  • Question 85 - A 25-year-old is brought into the emergency department after being discovered unresponsive in...

    Incorrect

    • A 25-year-old is brought into the emergency department after being discovered unresponsive in a neighbor's backyard. It is suspected that the patient had consumed alcohol at a nearby bar and opted to walk home in the snowy conditions. The patient's temperature is documented as 27.8ºC. The nurse connects leads to conduct a 12-lead ECG. Which of the subsequent ECG alterations is most closely linked to hypothermia?

      Your Answer:

      Correct Answer: Osborne Waves (J waves)

      Explanation:

      Hypothermia can cause various changes in an electrocardiogram (ECG). These changes include a slower heart rate (bradycardia), the presence of Osborn waves (also known as J waves), a prolonged PR interval, a widened QRS complex, and a prolonged QT interval. Additionally, shivering artifact, ventricular ectopics (abnormal heartbeats originating from the ventricles), and even cardiac arrest (ventricular tachycardia, ventricular fibrillation, or asystole) may occur.

      Further Reading:

      Hypothermic cardiac arrest is a rare situation that requires a tailored approach. Resuscitation is typically prolonged, but the prognosis for young, previously healthy individuals can be good. Hypothermic cardiac arrest may be associated with drowning. Hypothermia is defined as a core temperature below 35ºC and can be graded as mild, moderate, severe, or profound based on the core temperature. When the core temperature drops, basal metabolic rate falls and cell signaling between neurons decreases, leading to reduced tissue perfusion. Signs and symptoms of hypothermia progress as the core temperature drops, initially presenting as compensatory increases in heart rate and shivering, but eventually ceasing as the temperature drops into moderate hypothermia territory.

      ECG changes associated with hypothermia include bradyarrhythmias, Osborn waves, prolonged PR, QRS, and QT intervals, shivering artifact, ventricular ectopics, and cardiac arrest. When managing hypothermic cardiac arrest, ALS should be initiated as per the standard ALS algorithm, but with modifications. It is important to check for signs of life, re-warm the patient, consider mechanical ventilation due to chest wall stiffness, adjust dosing or withhold drugs due to slowed drug metabolism, and correct electrolyte disturbances. The resuscitation of hypothermic patients is often prolonged and may continue for a number of hours.

      Pulse checks during CPR may be difficult due to low blood pressure, and the pulse check is prolonged to 1 minute for this reason. Drug metabolism is slowed in hypothermic patients, leading to a build-up of potentially toxic plasma concentrations of administered drugs. Current guidance advises withholding drugs if the core temperature is below 30ºC and doubling the drug interval at core temperatures between 30 and 35ºC. Electrolyte disturbances are common in hypothermic patients, and it is important to interpret results keeping the setting in mind. Hypoglycemia should be treated, hypokalemia will often correct as the patient re-warms, ABG analyzers may not reflect the reality of the hypothermic patient, and severe hyperkalemia is a poor prognostic indicator.

      Different warming measures can be used to increase the core body temperature, including external passive measures such as removal of wet clothes and insulation with blankets, external active measures such as forced heated air or hot-water immersion, and internal active measures such as inhalation of warm air, warmed intravenous fluids, gastric, bladder, peritoneal and/or pleural lavage and high volume renal haemofilter.

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  • Question 86 - A 35-year-old male presents to the emergency department complaining of gradual onset sharp...

    Incorrect

    • A 35-year-old male presents to the emergency department complaining of gradual onset sharp chest pain over the past 24 hours. The patient reports that the pain worsens with deep inspiration and feels more comfortable when sitting leaning forward. When asked about pain radiation, the patient confirms that the pain extends to the left side of the neck and points to the ridge of the trapezius. Physical examination reveals clear lung fields, regular rhythm with quiet heart sounds, and no murmurs. The patient's vital signs are as follows:

      Blood pressure: 108/66 mmHg
      Pulse rate: 94 bpm
      Respiratory rate: 18 rpm
      Temperature: 37.3ºC
      Oxygen saturations: 97% on room air

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Acute pericarditis

      Explanation:

      Radiation to the trapezius ridge is a distinct symptom of acute pericarditis. The patient in question exhibits characteristics that align with a diagnosis of pericarditis. Pericarditis is a common condition affecting the pericardium, and it is often considered as a potential cause for chest pain. It is worth noting that the specific radiation of pain to the trapezius ridge is highly indicative of pericarditis, as it occurs when the phrenic nerve, which also innervates the trapezius muscle, becomes irritated while passing through the pericardium.

      Further Reading:

      Pericarditis is an inflammation of the pericardium, which is the protective sac around the heart. It can be acute, lasting less than 6 weeks, and may present with chest pain, cough, dyspnea, flu-like symptoms, and a pericardial rub. The most common causes of pericarditis include viral infections, tuberculosis, bacterial infections, uremia, trauma, and autoimmune diseases. However, in many cases, the cause remains unknown. Diagnosis is based on clinical features, such as chest pain, pericardial friction rub, and electrocardiographic changes. Treatment involves symptom relief with nonsteroidal anti-inflammatory drugs (NSAIDs), and patients should avoid strenuous activity until symptoms improve. Complicated cases may require treatment for the underlying cause, and large pericardial effusions may need urgent drainage. In cases of purulent effusions, antibiotic therapy is necessary, and steroid therapy may be considered for pericarditis related to autoimmune disorders or if NSAIDs alone are ineffective.

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  • Question 87 - A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations....

    Incorrect

    • A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations. She informs you that she was recently diagnosed with type B Wolff-Parkinson-White syndrome. You conduct an ECG.
      Which of the following ECG characteristics is NOT observed in type B Wolff-Parkinson-White (WPW) syndrome?

      Your Answer:

      Correct Answer: Dominant R wave in V1

      Explanation:

      Wolff-Parkinson-White (WPW) syndrome is a condition that affects the electrical system of the heart. It occurs when there is an abnormal pathway, known as the bundle of Kent, between the atria and the ventricles. This pathway can cause premature contractions of the ventricles, leading to a type of rapid heartbeat called atrioventricular re-entrant tachycardia (AVRT).

      In a normal heart rhythm, the electrical signals travel through the bundle of Kent and stimulate the ventricles. However, in WPW syndrome, these signals can cause the ventricles to contract prematurely. This can be seen on an electrocardiogram (ECG) as a shortened PR interval, a slurring of the initial rise in the QRS complex (known as a delta wave), and a widening of the QRS complex.

      There are two distinct types of WPW syndrome that can be identified on an ECG. Type A is characterized by predominantly positive delta waves and QRS complexes in the praecordial leads, with a dominant R wave in V1. This can sometimes be mistaken for right bundle branch block (RBBB). Type B, on the other hand, shows predominantly negative delta waves and QRS complexes in leads V1 and V2, and positive in the other praecordial leads, resembling left bundle branch block (LBBB).

      Overall, WPW syndrome is a condition that affects the electrical conduction system of the heart, leading to abnormal heart rhythms. It can be identified on an ECG by specific features such as shortened PR interval, delta waves, and widened QRS complex.

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  • Question 88 - A 62 year old male arrives at the emergency department complaining of abrupt...

    Incorrect

    • A 62 year old male arrives at the emergency department complaining of abrupt tearing chest pain that extends to the throat and back. The possibility of aortic dissection is being considered. What is the primary location for dissection?

      Your Answer:

      Correct Answer: Ascending aorta

      Explanation:

      The primary location for aortic dissection, which is being considered in this case, is the ascending aorta.

      Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.

      The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.

      Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.

      Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.

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  • Question 89 - A 62 year old female presents to the emergency department 1 hour after...

    Incorrect

    • A 62 year old female presents to the emergency department 1 hour after experiencing intense tearing chest pain that radiates to the back. The patient reports the pain as being extremely severe, rating it as 10/10. It is noted that the patient is prescribed medication for high blood pressure but admits to rarely taking the tablets. The patient's vital signs are as follows:

      Blood pressure: 188/92 mmHg
      Pulse rate: 96 bpm
      Respiration rate: 23 rpm
      Oxygen saturation: 98% on room air
      Temperature: 37.1ºC

      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Aortic dissection

      Explanation:

      The majority of dissections happen in individuals between the ages of 40 and 70, with the highest occurrence observed in the age group of 50 to 65.

      Further Reading:

      Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.

      The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.

      Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.

      Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.

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  • Question 90 - A 48 year old female presents to the emergency department complaining of palpitations....

    Incorrect

    • A 48 year old female presents to the emergency department complaining of palpitations. She reports experiencing brief episodes of palpitations over the past week, which typically resolve on their own after 5-10 minutes. However, today's episode has been ongoing for 30 minutes. The patient denies any chest pain or shortness of breath. The patient's vital signs are as follows:

      Blood pressure: 110/70 mmHg
      Pulse: 120 bpm
      Respiration rate: 17 bpm
      Temperature: 36.5ºC
      Oxygen saturations: 97% on room air

      An electrocardiogram (ECG) is performed and reveals atrial fibrillation. What is the most appropriate initial management for this patient?

      Your Answer:

      Correct Answer: Administer 50 mg atenolol

      Explanation:

      When managing newly diagnosed atrial fibrillation, a rate control strategy is often used. In this approach, beta blockers are typically the first line of treatment. However, sotalol is not recommended, and instead, other beta blockers like atenolol, acebutolol, metoprolol, nadolol, oxprenolol, and propranolol are preferred. Among these options, atenolol is commonly chosen in NHS trusts due to its cost-effectiveness.

      For patients with signs of hemodynamic instability or adverse features, rhythm control (cardioversion) may be considered if they present within 48 hours of likely onset. However, in the case of this patient, their symptoms started a week ago, and there are no indications of hemodynamic instability or adverse features.

      Digoxin monotherapy is typically reserved for individuals who have limited physical activity or are unable to take other first-line rate control medications due to other health conditions or contraindications.

      Further Reading:

      Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting around 5% of patients over the age of 70-75 years and 10% of patients aged 80-85 years. While AF can cause palpitations and inefficient cardiac function, the most important aspect of managing patients with AF is reducing the increased risk of stroke.

      AF can be classified as first detected episode, paroxysmal, persistent, or permanent. First detected episode refers to the initial occurrence of AF, regardless of symptoms or duration. Paroxysmal AF occurs when a patient has 2 or more self-terminating episodes lasting less than 7 days. Persistent AF refers to episodes lasting more than 7 days that do not self-terminate. Permanent AF is continuous atrial fibrillation that cannot be cardioverted or if attempts to do so are deemed inappropriate. The treatment goals for permanent AF are rate control and anticoagulation if appropriate.

      Symptoms of AF include palpitations, dyspnea, and chest pain. The most common sign is an irregularly irregular pulse. An electrocardiogram (ECG) is essential for diagnosing AF, as other conditions can also cause an irregular pulse.

      Managing patients with AF involves two key parts: rate/rhythm control and reducing stroke risk. Rate control involves slowing down the irregular pulse to avoid negative effects on cardiac function. This is typically achieved using beta-blockers or rate-limiting calcium channel blockers. If one drug is not effective, combination therapy may be used. Rhythm control aims to restore and maintain normal sinus rhythm through pharmacological or electrical cardioversion. However, the majority of patients are managed with a rate control strategy.

      Reducing stroke risk in patients with AF is crucial. Risk stratifying tools, such as the CHA2DS2-VASc score, are used to determine the most appropriate anticoagulation strategy. Anticoagulation is recommended for patients with a score of 2 or more. Clinicians can choose between warfarin and novel oral anticoagulants (NOACs) for anticoagulation.

      Before starting anticoagulation, the patient’s bleeding risk should be assessed using tools like the HAS-BLED score or the ORBIT tool. These tools evaluate factors such as hypertension, abnormal renal or liver function, history of bleeding, age, and use of drugs that predispose to bleeding.

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  • Question 91 - A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations....

    Incorrect

    • A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations. She informs you that she was recently diagnosed with Wolff-Parkinson-White syndrome. She is connected to an ECG monitor, and you observe the presence of an arrhythmia.
      What is the most frequently encountered type of arrhythmia in Wolff-Parkinson-White syndrome?

      Your Answer:

      Correct Answer: Atrioventricular re-entrant tachycardia

      Explanation:

      Wolff-Parkinson-White (WPW) syndrome is a condition that affects the electrical system of the heart. It occurs when there is an abnormal pathway, known as the bundle of Kent, between the atria and the ventricles. This pathway can cause premature contractions of the ventricles, leading to a type of rapid heartbeat called atrioventricular re-entrant tachycardia (AVRT).

      In a normal heart rhythm, the electrical signals travel through the bundle of Kent and stimulate the ventricles. However, in WPW syndrome, these signals can cause the ventricles to contract prematurely. This can be seen on an electrocardiogram (ECG) as a shortened PR interval, a slurring of the initial rise in the QRS complex (known as a delta wave), and a widening of the QRS complex.

      There are two distinct types of WPW syndrome that can be identified on an ECG. Type A is characterized by predominantly positive delta waves and QRS complexes in the praecordial leads, with a dominant R wave in V1. This can sometimes be mistaken for right bundle branch block (RBBB). Type B, on the other hand, shows predominantly negative delta waves and QRS complexes in leads V1 and V2, and positive in the other praecordial leads, resembling left bundle branch block (LBBB).

      Overall, WPW syndrome is a condition that affects the electrical conduction system of the heart, leading to abnormal heart rhythms. It can be identified on an ECG by specific features such as shortened PR interval, delta waves, and widened QRS complex.

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  • Question 92 - A 55-year-old woman comes in with severe chest pain in the center of...

    Incorrect

    • A 55-year-old woman comes in with severe chest pain in the center of her chest. Her ECG reveals the following findings:
      ST elevation in leads I, II, aVF, and V6
      Reciprocal ST depression in leads V1-V4 and aVR
      Prominent tall R waves in leads V2-V3
      Upright T waves in leads V2-V3
      Based on these findings, which blood vessel is most likely affected in this case?

      Your Answer:

      Correct Answer: Right coronary artery

      Explanation:

      This ECG indicates changes that are consistent with an acute inferoposterior myocardial infarction (MI). There is ST elevation in leads I, II, aVF, and V6, along with reciprocal ST depression in leads V1-V4 and aVR. Additionally, there are tall dominant R waves in leads V2-V3 and upright T waves in leads V2-V3. Based on these findings, the most likely vessel involved in this case is the right coronary artery.

      To summarize the vessels involved in different types of myocardial infarction see below:
      ECG Leads – Location of MI | Vessel involved
      V1-V3 – Anteroseptal | Left anterior descending
      V3-V4 – Anterior | Left anterior descending
      V5-V6 – Anterolateral | Left anterior descending / left circumflex artery
      V1-V6 – Extensive anterior | Left anterior descending
      I, II, aVL, V6 – Lateral | Left circumflex artery
      II, III, aVF – Inferior | Right coronary artery (80%), Left circumflex artery (20%)
      V1, V4R – Right ventricle | Right coronary artery
      V7-V9 – Posterior | Right coronary artery

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  • Question 93 - You assess a 60-year-old woman who has a confirmed diagnosis of aortic stenosis.
    Which...

    Incorrect

    • You assess a 60-year-old woman who has a confirmed diagnosis of aortic stenosis.
      Which ONE statement accurately describes aortic stenosis?

      Your Answer:

      Correct Answer: A 4th heart sound may be present

      Explanation:

      Aortic stenosis can be identified through various clinical signs. These signs include a slow rising and low-volume pulse, as well as a narrow pulse pressure. The ejection systolic murmur, which is loudest in the aortic area (2nd intercostal space, close to the sternum), is another indicator. Additionally, a sustained apex beat and a thrill in the aortic area can be felt when the patient is sitting forward at the end of expiration. In some cases, a 4th heart sound may also be present. It is important to note that in severe cases of aortic stenosis, there may be reverse splitting of the second heart sound. However, fixed splitting of the 2nd heart sound is typically associated with ASD and VSD. Lastly, the presence of an ejection click can help exclude supra- or subaortic stenosis, especially if the valve is pliable.

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  • Question 94 - You conduct a cardiovascular examination on a 62-year-old man who complains of shortness...

    Incorrect

    • You conduct a cardiovascular examination on a 62-year-old man who complains of shortness of breath. He informs you that he has a known heart valve issue. During auscultation, you observe reversed splitting of the second heart sound (S2).
      What is the most probable cause of this finding?

      Your Answer:

      Correct Answer: Aortic stenosis

      Explanation:

      The second heart sound (S2) is created by vibrations produced when the aortic and pulmonary valves close. It marks the end of systole. It is normal to hear a split in the sound during inspiration.

      A loud S2 can be associated with certain conditions such as systemic hypertension (resulting in a loud A2), pulmonary hypertension (resulting in a loud P2), hyperdynamic states (like tachycardia, fever, or thyrotoxicosis), and atrial septal defect (which causes a loud P2).

      On the other hand, a soft S2 can be linked to decreased aortic diastolic pressure (as seen in aortic regurgitation), poorly mobile cusps (such as calcification of the aortic valve), aortic root dilatation, and pulmonary stenosis (which causes a soft P2).

      A widely split S2 can occur during deep inspiration, right bundle branch block, prolonged right ventricular systole (seen in conditions like pulmonary stenosis or pulmonary embolism), and severe mitral regurgitation. However, in the case of atrial septal defect, the splitting is fixed and does not vary with respiration.

      Reversed splitting of S2, where P2 occurs before A2 (paradoxical splitting), can occur during deep expiration, left bundle branch block, prolonged left ventricular systole (as seen in hypertrophic cardiomyopathy), severe aortic stenosis, and right ventricular pacing.

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  • Question 95 - You are managing a 62-year-old male patient presenting with symptomatic bradycardia. Despite multiple...

    Incorrect

    • You are managing a 62-year-old male patient presenting with symptomatic bradycardia. Despite multiple administrations of atropine, there has been no improvement in the patient's condition. Which two medications would be the most suitable options to consider next for treating this rhythm?

      Your Answer:

      Correct Answer: Adrenaline/Isoprenaline

      Explanation:

      Adrenaline and isoprenaline are considered as second-line medications for the treatment of bradycardia. If atropine fails to improve the condition, transcutaneous pacing is recommended. However, if pacing is not available, the administration of second-line drugs becomes necessary. Adrenaline is typically given intravenously at a dosage of 2-10 mcg/minute, while isoprenaline is given at a dosage of 5 mcg/minute. It is important to note that glucagon is not mentioned as a treatment option for this patient’s bradycardia, as the cause of the condition is not specified as a beta-blocker overdose.

      Further Reading:

      Causes of Bradycardia:
      – Physiological: Athletes, sleeping
      – Cardiac conduction dysfunction: Atrioventricular block, sinus node disease
      – Vasovagal & autonomic mediated: Vasovagal episodes, carotid sinus hypersensitivity
      – Hypothermia
      – Metabolic & electrolyte disturbances: Hypothyroidism, hyperkalaemia, hypermagnesemia
      – Drugs: Beta-blockers, calcium channel blockers, digoxin, amiodarone
      – Head injury: Cushing’s response
      – Infections: Endocarditis
      – Other: Sarcoidosis, amyloidosis

      Presenting symptoms of Bradycardia:
      – Presyncope (dizziness, lightheadedness)
      – Syncope
      – Breathlessness
      – Weakness
      – Chest pain
      – Nausea

      Management of Bradycardia:
      – Assess and monitor for adverse features (shock, syncope, myocardial ischaemia, heart failure)
      – Treat reversible causes of bradycardia
      – Pharmacological treatment: Atropine is first-line, adrenaline and isoprenaline are second-line
      – Transcutaneous pacing if atropine is ineffective
      – Other drugs that may be used: Aminophylline, dopamine, glucagon, glycopyrrolate

      Bradycardia Algorithm:
      – Follow the algorithm for management of bradycardia, which includes assessing and monitoring for adverse features, treating reversible causes, and using appropriate medications or pacing as needed.
      https://acls-algorithms.com/wp-content/uploads/2020/12/Website-Bradycardia-Algorithm-Diagram.pdf

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  • Question 96 - A 70-year-old male smoker comes in with intense chest pain. His ECG indicates...

    Incorrect

    • A 70-year-old male smoker comes in with intense chest pain. His ECG indicates an acute myocardial infarction and he is immediately taken to the cath lab. Angiography reveals a blockage in the left circumflex artery.
      Which area of the heart is most likely affected in this scenario?

      Your Answer:

      Correct Answer: Lateral

      Explanation:

      A summary of the vessels involved in different types of myocardial infarction, along with the corresponding ECG leads and the location of the infarction.

      For instance, an anteroseptal infarction involving the left anterior descending artery is indicated by ECG leads V1-V3. Similarly, an anterior infarction involving the left anterior descending artery is indicated by leads V3-V4.

      In cases of anterolateral infarctions, both the left anterior descending artery and the left circumflex artery are involved, and this is reflected in ECG leads V5-V6. An extensive anterior infarction involving the left anterior descending artery is indicated by leads V1-V6.

      Lateral infarcts involving the left circumflex artery are indicated by leads I, II, aVL, and V6. Inferior infarctions, on the other hand, involve either the right coronary artery (in 80% of cases) or the left circumflex artery (in 20% of cases), and this is shown by leads II, III, and aVF.

      In the case of a right ventricular infarction, the right coronary artery is involved, and this is indicated by leads V1 and V4R. Lastly, a posterior infarction involving the right coronary artery is shown by leads V7-V9.

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  • Question 97 - You evaluate a 56-year-old individual who arrives at the ER complaining of chest...

    Incorrect

    • You evaluate a 56-year-old individual who arrives at the ER complaining of chest discomfort and increasing swelling. Upon reviewing the patient's medical history, you discover that they underwent an echocardiogram a year ago, which revealed moderate-severe tricuspid regurgitation. Which of the following heart murmurs is commonly associated with tricuspid regurgitation?

      Your Answer:

      Correct Answer: Low-frequency pansystolic murmur

      Explanation:

      Tricuspid regurgitation is characterized by a continuous murmur that spans the entire systolic phase of the cardiac cycle. This murmur is best audible at the lower left sternal edge and has a low frequency. Interestingly, the intensity of the murmur increases during inspiration and decreases during expiration, a phenomenon referred to as Carvallo’s sign.

      Further Reading:

      Tricuspid regurgitation (TR) is a condition where blood flows backwards through the tricuspid valve in the heart. It is classified as either primary or secondary, with primary TR being caused by abnormalities in the tricuspid valve itself and secondary TR being the result of other conditions outside of the valve. Mild TR is common, especially in young adults, and often does not cause symptoms. However, severe TR can lead to right-sided heart failure and the development of symptoms such as ascites, peripheral edema, and hepatomegaly.

      The causes of TR can vary. Primary TR can be caused by conditions such as rheumatic heart disease, myxomatous valve disease, or Ebstein anomaly. Secondary TR is often the result of right ventricular dilatation due to left heart failure or pulmonary hypertension. Other causes include endocarditis, traumatic chest injury, left ventricular systolic dysfunction, chronic lung disease, pulmonary thromboembolism, myocardial disease, left to right shunts, and carcinoid heart disease. In some cases, TR can occur as a result of infective endocarditis in IV drug abusers.

      Clinical features of TR can include a pansystolic murmur that is best heard at the lower left sternal edge, Carvallo’s sign (murmur increases with inspiration and decreases with expiration), an S3 heart sound, and the presence of atrial arrhythmias such as flutter or fibrillation. Other signs can include giant C-V waves in the jugular pulse, hepatomegaly (often pulsatile), and edema with lung crepitations or pleural effusions.

      The management of TR depends on the underlying cause and the severity of the condition. In severe cases, valve repair or replacement surgery may be necessary. Treatment may also involve addressing the underlying conditions contributing to TR, such as managing left heart failure or pulmonary hypertension.

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  • Question 98 - A 70-year-old diabetic smoker presents with central chest pain that radiates to his...

    Incorrect

    • A 70-year-old diabetic smoker presents with central chest pain that radiates to his left shoulder and jaw. He is given 300 mg aspirin and morphine, and his pain subsides. The pain lasted approximately 90 minutes in total. His ECG shows normal sinus rhythm. He is referred to the on-call medical team for admission, and a troponin test is scheduled at the appropriate time. His blood tests today reveal a creatinine level of 298 micromoles per litre.
      Which of the following medications should you also consider administering to this patient?

      Your Answer:

      Correct Answer: Unfractionated heparin

      Explanation:

      This patient’s medical history suggests a diagnosis of acute coronary syndrome. It is important to provide pain relief as soon as possible. This can be achieved by administering GTN (sublingual or buccal), but if there is suspicion of an acute myocardial infarction (MI), intravenous opioids such as morphine should be offered.

      Aspirin should be given to all patients with unstable angina or NSTEMI as soon as possible and should be continued indefinitely, unless there are contraindications such as a high risk of bleeding or aspirin hypersensitivity. A single loading dose of 300 mg should be given immediately after presentation.

      For patients without a high risk of bleeding and no planned coronary angiography within 24 hours of admission, fondaparinux should be administered. However, if coronary angiography is planned within 24 hours, unfractionated heparin can be offered as an alternative to fondaparinux. For patients with significant renal impairment (creatinine above 265 micromoles per litre), unfractionated heparin should be considered, with dose adjustment based on clotting function monitoring.

      Routine administration of oxygen is no longer recommended, but oxygen saturation should be monitored using pulse oximetry as soon as possible, preferably before hospital admission. Supplemental oxygen should only be given to individuals with an oxygen saturation (SpO2) below 94% who are not at risk of hypercapnic respiratory failure, aiming for an SpO2 of 94-98%. For individuals with chronic obstructive pulmonary disease at risk of hypercapnic respiratory failure, a target SpO2 of 88-92% should be achieved until blood gas analysis is available.

      Bivalirudin, a specific and reversible direct thrombin inhibitor (DTI), is recommended by NICE as a potential treatment for adults with STEMI undergoing percutaneous coronary intervention.

      For more information, refer to the NICE guidelines on the assessment and diagnosis of chest pain of recent onset.

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  • Question 99 - A 72 year old male patient has arrived at the emergency department after...

    Incorrect

    • A 72 year old male patient has arrived at the emergency department after injuring himself in a fall. Upon reviewing the patient's medical history, you discover that he was diagnosed with mitral stenosis last year. You advise the medical students to assess the patient for indications of this condition.

      What is a typical symptom observed in individuals with mitral stenosis?

      Your Answer:

      Correct Answer: Malar flush

      Explanation:

      One of the clinical features of mitral stenosis is malar flush, which refers to a reddening or flushing of the cheeks. Other clinical features include a mid-late diastolic murmur that is best heard during expiration, a loud S1 heart sound with an opening snap, a low volume pulse, atrial fibrillation, and signs of pulmonary edema such as crepitations or the presence of white or pink frothy sputum.

      Further Reading:

      Mitral Stenosis:
      – Causes: Rheumatic fever, Mucopolysaccharidoses, Carcinoid, Endocardial fibroelastosis
      – Features: Mid-late diastolic murmur, loud S1, opening snap, low volume pulse, malar flush, atrial fibrillation, signs of pulmonary edema, tapping apex beat
      – Features of severe mitral stenosis: Length of murmur increases, opening snap becomes closer to S2
      – Investigation findings: CXR may show left atrial enlargement, echocardiography may show reduced cross-sectional area of the mitral valve

      Mitral Regurgitation:
      – Causes: Mitral valve prolapse, Myxomatous degeneration, Ischemic heart disease, Rheumatic fever, Connective tissue disorders, Endocarditis, Dilated cardiomyopathy
      – Features: pansystolic murmur radiating to left axilla, soft S1, S3, laterally displaced apex beat with heave
      – Signs of acute MR: Decompensated congestive heart failure symptoms
      – Signs of chronic MR: Leg edema, fatigue, arrhythmia (atrial fibrillation)
      – Investigation findings: Doppler echocardiography to detect regurgitant flow and pulmonary hypertension, ECG may show signs of LA enlargement and LV hypertrophy, CXR may show LA and LV enlargement in chronic MR and pulmonary edema in acute MR.

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  • Question 100 - A 42 year old male comes to the emergency department with a sudden...

    Incorrect

    • A 42 year old male comes to the emergency department with a sudden onset of 'tearing' pain in the middle of his chest that extends to the center of his back. The patient is tall and has a slender physique. Additionally, you observe that the patient has elongated arms and fingers. During the chest examination, you notice a prominent protrusion of the sternum (pectus carinatum). What is the probable underlying cause of this patient's chest pain?

      Your Answer:

      Correct Answer: Aortic dissection

      Explanation:

      Marfan’s syndrome is a condition that greatly increases the risk of aortic dissection. This patient exhibits several characteristics commonly seen in individuals with Marfan syndrome, such as tall stature, low BMI, and pectoral abnormalities like pectus carinatum and excavatum. Additionally, their long limbs and fingers are also indicative of Marfan’s syndrome. It is important to note that aortic dissection tends to occur at a much younger age in individuals with Marfan syndrome compared to those without connective tissue diseases. The median age for type A dissection in Marfan’s patients is 36.7 years, while for type B dissection it is 40 years. In contrast, individuals without Marfan’s syndrome typically experience dissection at the ages of 63 and 62 years for type A and type B dissections, respectively.

      Further Reading:

      Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.

      The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.

      Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.

      Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.

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