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  • Question 1 - A typically healthy and fit 35-year-old man presents to Accident and Emergency with...

    Incorrect

    • A typically healthy and fit 35-year-old man presents to Accident and Emergency with palpitations that have been ongoing for 4 hours. He reports no chest pain and has a National Early Warning Score (NEWS) of 0. Upon examination, the only notable finding is an irregularly irregular pulse. An electrocardiogram (ECG) confirms that the patient is experiencing atrial fibrillation (AF). The patient has no significant medical history and is not taking any regular medications. Blood tests (thyroid function tests (TFTs), full blood count (FBC), urea and electrolytes (U&Es), liver function tests (LFTs), and coagulation screen) are normal, and a chest X-ray (CXR) is unremarkable.

      What is the most appropriate course of action for this patient?

      Your Answer: Trial of b-blocker (sotalol), give anticoagulation and review in 1 week

      Correct Answer: IV flecainide

      Explanation:

      Treatment options for acute atrial fibrillation

      Atrial fibrillation (AF) is a common arrhythmia that can lead to serious complications such as stroke and heart failure. When a patient presents with acute AF, it is important to determine the underlying cause and choose the appropriate treatment. Here are some treatment options for acute AF:

      Treatment options for acute atrial fibrillation

      Initial investigation

      The patient should be investigated for any reversible causes of AF such as hyperthyroidism and alcohol. Blood tests and a chest X-ray should be performed to rule out any underlying conditions.

      Medical cardioversion

      If no reversible causes are found, medical cardioversion is the most appropriate treatment for haemodynamically stable patients who have presented within 48 hours of the onset of AF.

      Anticoagulation therapy

      If the patient remains in persistent AF for more than 48 hours, their CHA2DS2 VASc score should be calculated to determine the risk of emboli. If the score is high, anticoagulation therapy should be started.

      Trial of b-blocker

      Sotalol is often used in paroxysmal AF as a ‘pill in the pocket’ regimen. However, in acute first-time presentations without significant cardiac risk factors, cardioversion should be attempted first.

      Intravenous adenosine

      This treatment may transiently block the atrioventricular (AV) node and is commonly used in atrial flutter. However, it is not recommended for use in acute AF presentation in an otherwise well patient.

      In conclusion, the appropriate treatment for acute AF depends on the underlying cause and the patient’s risk factors. It is important to choose the right treatment to prevent serious complications.

    • This question is part of the following fields:

      • Cardiology
      24.2
      Seconds
  • Question 2 - A 68-year-old man is being evaluated in the Cardiac Unit. He has developed...

    Incorrect

    • A 68-year-old man is being evaluated in the Cardiac Unit. He has developed a ventricular tachycardia of 160 bpm, appears ill, and has a blood pressure of 70/52 mmHg. What would be the most immediate treatment option?

      Your Answer: Intravenous adenosine

      Correct Answer: DC cardioversion

      Explanation:

      Treatment Options for Ventricular Arrhythmia: Evaluating the Choices

      When faced with a patient experiencing ventricular arrhythmia, it is important to consider the appropriate treatment options. In the scenario of a broad complex tachycardia with low blood pressure, immediate DC cardioversion is the clear choice. Carotid sinus massage and IV adenosine are not appropriate options as they are used in the diagnosis and termination of SVT. Immediate heparinisation is not the immediate treatment for ventricular arrhythmia. Intravenous lidocaine may be considered if the VT is haemodynamically stable, but in this scenario, it cannot be the correct answer choice. It is important to carefully evaluate the available options and choose the most appropriate treatment for the patient’s specific condition.

    • This question is part of the following fields:

      • Cardiology
      10.8
      Seconds
  • Question 3 - A 40-year-old male patient complains of shortness of breath, weight loss, and night...

    Correct

    • A 40-year-old male patient complains of shortness of breath, weight loss, and night sweats for the past six weeks. Despite being generally healthy, he is experiencing these symptoms. During the examination, the patient's fingers show clubbing, and his temperature is 37.8°C. His pulse is 88 beats per minute, and his blood pressure is 128/80 mmHg. Upon listening to his heart, a pansystolic murmur is audible. What signs are likely to be found in this patient?

      Your Answer: Splinter haemorrhages

      Explanation:

      Symptoms and Diagnosis of Infective Endocarditis

      This individual has a lengthy medical history of experiencing night sweats and has developed clubbing of the fingers, along with a murmur. These symptoms are indicative of infective endocarditis. In addition to splinter hemorrhages in the nails, other symptoms that may be present include Roth spots in the eyes, Osler’s nodes and Janeway lesions in the palms and fingers of the hands, and splenomegaly instead of cervical lymphadenopathy. Cyanosis is not typically associated with clubbing and may suggest idiopathic pulmonary fibrosis or cystic fibrosis in younger individuals. However, this individual has no prior history of cystic fibrosis and has only been experiencing symptoms for six weeks.

    • This question is part of the following fields:

      • Cardiology
      15.5
      Seconds
  • Question 4 - A 57-year-old male with a history of hypertension for six years presents to...

    Correct

    • A 57-year-old male with a history of hypertension for six years presents to the Emergency department with complaints of severe chest pain that radiates to his back, which he describes as tearing in nature. He is currently experiencing tachycardia and hypertension, with a blood pressure reading of 185/95 mmHg. A soft early diastolic murmur is also noted. The ECG shows ST elevation of 2 mm in the inferior leads, and a small left-sided pleural effusion is visible on chest x-ray. Based on the patient's clinical history, what is the initial diagnosis that needs to be ruled out?

      Your Answer: Aortic dissection

      Explanation:

      Aortic Dissection in a Hypertensive Patient

      This patient is experiencing an aortic dissection, which is a serious medical condition. The patient’s hypertension is a contributing factor, and the pain they are experiencing is typical for this condition. One of the key features of aortic dissection is radiation of pain to the back. Upon examination, the patient also exhibits hypertension, aortic regurgitation, and pleural effusion, which are all consistent with this diagnosis. The ECG changes in the inferior lead are likely due to the aortic dissection compromising the right coronary artery. To properly diagnose and treat this patient, it is crucial to thoroughly evaluate their peripheral pulses and urgently perform imaging of the aorta. Proper and timely medical intervention is necessary to prevent further complications and ensure the best possible outcome for the patient.

    • This question is part of the following fields:

      • Cardiology
      10.8
      Seconds
  • Question 5 - A final-year medical student is taking a history from a 63-year-old patient as...

    Correct

    • A final-year medical student is taking a history from a 63-year-old patient as a part of their general practice attachment. The patient informs her that she has a longstanding heart condition, the name of which she cannot remember. The student decides to review an old electrocardiogram (ECG) in her notes, and from it she is able to see that the patient has atrial fibrillation (AF).
      Which of the following ECG findings is typically found in AF?

      Your Answer: Absent P waves

      Explanation:

      Common ECG Findings and Their Significance

      Electrocardiogram (ECG) is a diagnostic tool used to evaluate the electrical activity of the heart. It records the heart’s rhythm and detects any abnormalities. Here are some common ECG findings and their significance:

      1. Absent P waves: Atrial fibrillation causes an irregular pulse and palpitations. ECG findings include absent P waves and irregular QRS complexes.

      2. Long PR interval: A long PR interval indicates heart block. First-degree heart block is a fixed prolonged PR interval.

      3. T wave inversion: T wave inversion can occur in fast atrial fibrillation, indicating cardiac ischaemia.

      4. Bifid P wave (p mitrale): Bifid P waves are caused by left atrial hypertrophy.

      5. ST segment elevation: ST segment elevation typically occurs in myocardial infarction. However, it may also occur in pericarditis and subarachnoid haemorrhage.

      Understanding these ECG findings can help healthcare professionals diagnose and treat various cardiac conditions.

    • This question is part of the following fields:

      • Cardiology
      5
      Seconds
  • Question 6 - A 55-year-old man was brought to the Emergency Department following a car accident....

    Correct

    • A 55-year-old man was brought to the Emergency Department following a car accident. Upon examination, there are no visible signs of external bleeding, but his blood pressure is 90/40 mmHg and his heart rate is 120 bpm. He presents with distended neck veins and muffled heart sounds.

      What is the most probable echocardiogram finding in this case?

      Your Answer: Pericardial effusion

      Explanation:

      Differential Diagnosis for a Trauma Patient with Beck’s Triad

      When a trauma patient presents with hypotension, tachycardia, distended neck veins, and muffled heart sounds, the clinician should suspect pericardial effusion, also known as cardiac tamponade. This condition occurs when fluid accumulates in the pericardial space, compressing the heart and impairing its function. In the context of chest trauma, pericardial effusion is a life-threatening emergency that requires prompt diagnosis and treatment.

      Other conditions that may cause similar symptoms but have different underlying mechanisms include mitral regurgitation, pneumothorax, haemothorax, and pleural effusion. Mitral regurgitation refers to the backflow of blood from the left ventricle to the left atrium due to a faulty mitral valve. While it can be detected on an echocardiogram, it is unlikely to cause Beck’s triad as it does not involve fluid accumulation outside the heart.

      Pneumothorax is the presence of air in the pleural space, which can cause lung collapse and respiratory distress. A tension pneumothorax, in which air accumulates under pressure and shifts the mediastinum, can also compress the heart and impair its function. However, it would not be visible on an echocardiogram, which focuses on the heart and pericardium.

      Haemothorax is the accumulation of blood in the pleural space, usually due to chest trauma or surgery. Like pneumothorax, it can cause respiratory compromise and hypovolemia, but it does not affect the heart directly and would not cause Beck’s triad.

      Pleural effusion is a generic term for any fluid accumulation in the pleural space, which can be caused by various conditions such as infection, cancer, or heart failure. While it may cause respiratory symptoms and chest pain, it does not affect the heart’s function and would not cause Beck’s triad or be visible on an echocardiogram.

      In summary, a trauma patient with Beck’s triad should be evaluated for pericardial effusion as the most likely cause, but other conditions such as tension pneumothorax or haemothorax should also be considered depending on the clinical context. An echocardiogram can help confirm or rule out pericardial effusion and guide further management.

    • This question is part of the following fields:

      • Cardiology
      20
      Seconds
  • Question 7 - In a 25-year-old woman undergoing a routine physical examination for a new job,...

    Incorrect

    • In a 25-year-old woman undergoing a routine physical examination for a new job, a mid-systolic ejection murmur is discovered in the left upper sternal border. The cardiac examination reveals a significant right ventricular cardiac impulse and wide and fixed splitting of the second heart sound. An electrocardiogram (ECG) shows a right axis deviation, and a chest X-ray shows enlargement of the right ventricle and atrium. What is the most probable diagnosis?

      Your Answer: Pulmonary valve stenosis

      Correct Answer: Atrial septal defect

      Explanation:

      Cardiac Abnormalities and their Clinical Findings

      Atrial Septal Defect:
      Atrial septal defect is characterized by a prominent right ventricular cardiac impulse, a systolic ejection murmur heard best in the pulmonic area and along the left sternal border, and fixed splitting of the second heart sound. These findings are due to an abnormal left-to-right shunt through the defect, which creates a volume overload on the right side. Small atrial septal defects are usually asymptomatic.

      Pulmonary Valve Stenosis:
      Pulmonary valve stenosis causes an increased right ventricular pressure which results in right ventricular hypertrophy and pulmonary artery dilation. A crescendo–decrescendo murmur may be heard if there is a severe stenosis. Right atrial enlargement would not be present.

      Mitral Regurgitation:
      Mitral regurgitation would also present with a systolic murmur; however, left atrial enlargement would be seen before right ventricular enlargement.

      Mitral Stenosis:
      Mitral stenosis would present with an ‘opening snap’ and a diastolic murmur.

      Aortic Stenosis:
      Aortic stenosis is also associated with a systolic ejection murmur. However, the murmur is usually loudest at the right sternal border and radiates upwards to the jugular notch. Aortic stenosis is associated with left ventricular hypertrophy.

      Clinical Findings of Common Cardiac Abnormalities

    • This question is part of the following fields:

      • Cardiology
      40.6
      Seconds
  • Question 8 - A 56-year-old, 80 kg woman arrives at the Emergency Department complaining of chest...

    Correct

    • A 56-year-old, 80 kg woman arrives at the Emergency Department complaining of chest pain that began 5 hours ago. She has no known allergies and is not taking any regular medications. Her electrocardiogram shows T-wave inversion in lateral leads but no ST changes, and her serum troponin level is significantly elevated. What is the appropriate combination of drugs to administer immediately?

      Your Answer: Aspirin 300 mg, prasugrel 60 mg, fondaparinux 2.5 mg

      Explanation:

      For patients with different combinations of medications, the appropriate treatment plan may vary. In general, aspirin should be given as soon as possible and other medications may be added depending on the patient’s condition and the likelihood of undergoing certain procedures. For example, if angiography is not planned within 24 hours of admission, a loading dose of aspirin and prasugrel with fondaparinux may be given. If PCI is planned, unfractionated heparin may be considered. The specific dosages and medications may differ based on the patient’s individual needs and risk factors.

    • This question is part of the following fields:

      • Cardiology
      13.7
      Seconds
  • Question 9 - A 70-year-old patient comes to her doctor for a routine check-up. During the...

    Correct

    • A 70-year-old patient comes to her doctor for a routine check-up. During the examination, her blood pressure is measured in both arms, and the readings are as follows:
      Right arm 152/100
      Left arm 138/92
      What should be the next step in managing this patient's condition?

      Your Answer: Ask the patient to start ambulatory blood pressure monitoring

      Explanation:

      Proper Management of High Blood Pressure Readings

      In order to properly manage high blood pressure readings, it is important to follow established guidelines. If a patient displays a blood pressure of over 140/90 in one arm, the patient should have ambulatory blood pressure monitoring (ABPM) in order to confirm the presence or lack of hypertension, in accordance with NICE guidelines.

      It is important to note that a diagnosis of hypertension cannot be made from one blood pressure recording. However, if hypertension is confirmed, based upon the patients’ age, amlodipine would be the antihypertensive of choice.

      When measuring blood pressure in both arms (as it should clinically be done), the higher of the two readings should be taken. Asking the patient to come back in one week to re-record blood pressure sounds reasonable, but it is not in accordance with the NICE guidelines.

      Lastly, it is important to note that considering the patients’ age, ramipril is second line and should not be the first choice for treatment. Proper management of high blood pressure readings is crucial for the overall health and well-being of the patient.

    • This question is part of the following fields:

      • Cardiology
      17.5
      Seconds
  • Question 10 - A 42-year-old man presents to the Emergency Department with severe central chest pain...

    Correct

    • A 42-year-old man presents to the Emergency Department with severe central chest pain that worsens when lying down, but improves when sitting forward. The pain radiates to his left shoulder. He has a history of prostate cancer and has recently completed two cycles of radiotherapy. On examination, his blood pressure is 96/52 mmHg (normal <120/80 mmHg), his JVP is elevated, and his pulse is 98 bpm, which appears to fade on inspiration. Heart sounds are faint. The ECG shows low-voltage QRS complexes. What is the most appropriate initial management for this patient?

      Your Answer: Urgent pericardiocentesis

      Explanation:

      The patient is experiencing cardiac tamponade, which is caused by fluid in the pericardial sac compressing the heart and reducing ventricular filling. This is likely due to pericarditis caused by recent radiotherapy. Beck’s triad of low blood pressure, raised JVP, and muffled heart sounds are indicative of tamponade. Urgent pericardiocentesis is necessary to aspirate the pericardial fluid, and echocardiographic guidance is the safest method. Ibuprofen is the initial treatment for acute pericarditis without haemodynamic compromise, but in severe cases like this, it will not help. A fluid challenge with 1 litre of sodium chloride is not recommended as it may worsen the pericardial fluid. GTN spray, morphine, clopidogrel, and aspirin are useful in managing an MI, but not tamponade. LMWH is important in managing a PE, but not tamponade, and may even worsen the condition if caused by haemopericardium.

    • This question is part of the following fields:

      • Cardiology
      20.4
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiology (7/10) 70%
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