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Question 1
Correct
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A 68-year-old man presents to the Emergency Department (ED) with chest tightness. The tightness started about a day ago, however today it is worse and associated with shortness of breath and dizziness.
Upon examination, there is a slow rising carotid pulse and systolic murmur which radiates to carotids 3/6. Examination is otherwise unremarkable without calf tenderness. The patient does not have any significant past medical history apart from type II diabetes mellitus and hypertension which are both well controlled.
What is the best diagnostic investigation?Your Answer: Echocardiogram
Explanation:Diagnostic Investigations for Cardiac Conditions
When a patient presents with signs and symptoms of a cardiac condition, various diagnostic investigations may be performed to determine the underlying cause. In the case of a patient with chest tightness, the first-line investigation is usually an electrocardiogram (ECG) to rule out acute coronary syndrome. However, if the patient is suspected of having aortic stenosis (AS), the best diagnostic investigation is an echocardiogram and Doppler to measure the size of the aortic valve. A normal aortic valve area is more than 2 cm2, while severe AS is defined as less than 1 cm2.
Other diagnostic investigations for cardiac conditions include a coronary angiogram to assess the patency of the coronary arteries and potentially perform an angioplasty to insert a stent if any narrowing is found. Exercise tolerance tests can also be useful in monitoring patients with a cardiac history and heart failure classification. However, a D-dimer test, which is used to diagnose pulmonary embolism, would not be indicated in a patient with suspected AS unless there were additional features suggestive of a pulmonary embolism, such as calf tenderness.
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This question is part of the following fields:
- Cardiology
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Question 2
Incorrect
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A 56-year-old man presents to the Emergency Department with chest pain. He has a medical history of angina, hypertension, high cholesterol, and is a current smoker. Upon arrival, a 12-lead electrocardiogram (ECG) is conducted, revealing ST elevation in leads II, III, and aVF. Which coronary artery is most likely responsible for this presentation?
Your Answer: Left circumflex
Correct Answer: Right coronary artery
Explanation:ECG Changes and Localisation of Infarct in Coronary Artery Disease
Patients with chest pain and multiple risk factors for cardiac disease require prompt evaluation to determine the underlying cause. Electrocardiogram (ECG) changes can help localise the infarct to a particular territory, which can aid in diagnosis and treatment.
Inferior infarcts are often due to lesions in the right coronary artery, as evidenced by ST elevation in leads II, III, and aVF. However, in 20% of cases, this can also be caused by an occlusion of a dominant left circumflex artery.
Lateral infarcts involve branches of the left anterior descending (LAD) and left circumflex arteries, and are characterised by ST elevation in leads I, aVL, and V5-6. It is unusual for a lateral STEMI to occur in isolation, and it usually occurs as part of a larger territory infarction.
Anterior infarcts are caused by blockage of the LAD artery, and are characterised by ST elevation in leads V1-V6.
Blockage of the right marginal artery does not have a specific pattern of ECG changes associated with it, and it is not one of the major coronary vessels.
In summary, understanding the ECG changes associated with different coronary arteries can aid in localising the infarct and guiding appropriate treatment.
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This question is part of the following fields:
- Cardiology
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Question 3
Correct
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A 27-year-old woman is brought to the Emergency Department by ambulance from a music festival. It is a hot day and she had been standing in the crowd when she suddenly collapsed and lost consciousness. She is now fully alert and gives a history of feeling dizzy and nauseated before the collapse. She tells you that she is healthy, plays tennis for her local club and is a keen runner. She has had no previous episodes of losing consciousness. Her father has recently had a heart attack aged 60 years. Her resting electrocardiogram (ECG) shows a corrected QT interval of 400 ms and a slightly prolonged PR interval but is otherwise normal.
What is the most likely diagnosis?Your Answer: Vasovagal syncope
Explanation:Differential Diagnosis for a Patient with Vasovagal Syncope
Vasovagal syncope is a common cause of transient loss of consciousness. The hallmark of this condition is the three Ps – pallor, palpitations, and sweating. In patients with a history of vasovagal syncope, the ECG is typically normal. A prolonged PR interval may be seen in young athletes, but first-degree heart block rarely causes cardiac syncope. Ischemic heart disease is not a significant factor in this condition, and a family history of myocardial infarction is not relevant.
If there are no features suggesting a more serious cause of transient loss of consciousness or a significant personal or family cardiac history, the patient can be discharged from the Emergency Department. However, they should be advised to seek medical attention if they experience any further episodes.
Other conditions that may cause transient loss of consciousness include complete heart block, hypertrophic cardiomyopathy, substance misuse, and long QT syndrome. However, in this case, the patient’s history and ECG are not suggestive of these conditions.
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This question is part of the following fields:
- Cardiology
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Question 4
Incorrect
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A 55-year-old woman from India visits the general practice clinic, reporting fatigue and tiredness after completing household tasks. During the examination, the physician observes periodic involuntary contractions of her left arm and multiple lumps beneath the skin. The doctor inquires about the patient's medical history and asks if she had any childhood illnesses. The patient discloses that she had a severe throat infection in India as a child but did not receive any treatment.
What is the most frequent abnormality that can be detected by listening to the heart during auscultation?Your Answer: A late systolic crescendo murmur with a mid-systolic click
Correct Answer: An opening snap after S2, followed by a rumbling mid-diastolic murmur
Explanation:Common Heart Murmurs and their Association with Rheumatic Heart Disease
Rheumatic heart disease (RHD) is a condition resulting from untreated pharyngitis caused by group A beta-haemolytic streptococcal infection. RHD can lead to heart valve dysfunction, most commonly the mitral valve, resulting in mitral stenosis. The characteristic murmur of mitral stenosis is a mid-diastolic rumbling murmur that follows an opening snap after S2. Aortic stenosis can also be present in RHD but is less prevalent. Other heart murmurs associated with RHD include a high-pitched blowing diastolic decrescendo murmur, which is associated with aortic regurgitation, and a continuous machine-like murmur that is loudest at S2, consistent with patent ductus arteriosus. A late systolic crescendo murmur with a mid-systolic click is seen in mitral valve prolapse. A crescendo-decrescendo systolic ejection murmur following an ejection click describes the murmur heard in aortic stenosis. It is important to recognize these murmurs and their association with RHD for proper diagnosis and management.
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This question is part of the following fields:
- Cardiology
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Question 5
Incorrect
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You are called to see a 62-year-old man who has suddenly deteriorated after pacemaker insertion. He has sudden-onset shortness of breath and is cold and clammy. On examination, his blood pressure is 90/50 mmHg, pulse 100 bpm and regular. His jugular venous pressure (JVP) is markedly elevated and his heart sounds are muffled. You give him oxygen and plasma volume expanders intravenously (iv).
Which of the following is the next most appropriate intervention?Your Answer: Arrange an urgent chest X-ray
Correct Answer: Prepare for pericardiocentesis
Explanation:Management of Cardiac Tamponade
Cardiac tamponade is a medical emergency that requires urgent intervention. The condition is characterized by a large amount of fluid in the pericardial sac, which can lead to compression of the heart and subsequent haemodynamic instability.
The first step in managing cardiac tamponade is to perform pericardiocentesis, which involves draining the fluid from the pericardial sac. Delaying this procedure can result in cardiac arrest and death.
While echocardiography can aid in diagnosis, it should not delay the initiation of pericardiocentesis. Similarly, a chest X-ray is not necessary for management. Swann-Ganz catheter insertion and inotropic support are also not recommended as they do not address the underlying cause of the condition.
In summary, prompt recognition and treatment of cardiac tamponade is crucial for patient survival.
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This question is part of the following fields:
- Cardiology
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Question 6
Incorrect
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A 57-year-old male with a known history of rheumatic fever and frequent episodes of pulmonary oedema is diagnosed with pulmonary hypertension. During examination, an irregularly irregular pulse was noted and auscultation revealed a loud first heart sound and a rumbling mid-diastolic murmur. What is the most probable cause of this patient's pulmonary hypertension?
Your Answer: Aortic regurgitation
Correct Answer: Mitral stenosis
Explanation:Cardiac Valve Disorders: Mitral Stenosis, Mitral Regurgitation, Aortic Regurgitation, Pulmonary Stenosis, and Primary Pulmonary Hypertension
Cardiac valve disorders are conditions that affect the proper functioning of the heart valves. Among these disorders are mitral stenosis, mitral regurgitation, aortic regurgitation, pulmonary stenosis, and primary pulmonary hypertension.
Mitral stenosis is a narrowing of the mitral valve, usually caused by rheumatic fever. Symptoms include palpitations, dyspnea, and hemoptysis. Diagnosis is aided by electrocardiogram, chest X-ray, and echocardiography. Management may be medical or surgical.
Mitral regurgitation is a systolic murmur that presents with a sustained apex beat displaced to the left and a left parasternal heave. On auscultation, there will be a soft S1, a loud S2, and a pansystolic murmur heard at the apex radiating to the left axilla.
Aortic regurgitation presents with a collapsing pulse with a wide pulse pressure. On palpation of the precordium, there will be a sustained and displaced apex beat with a soft S2 and an early diastolic murmur at the left sternal edge.
Pulmonary stenosis is associated with a normal pulse, with an ejection systolic murmur radiating to the lung fields. There may be a palpable thrill over the pulmonary area.
Primary pulmonary hypertension most commonly presents with progressive weakness and shortness of breath. There is evidence of an underlying cardiac disease, meaning the underlying pulmonary hypertension is more likely to be secondary to another disease process.
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This question is part of the following fields:
- Cardiology
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Question 7
Correct
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A 57-year-old man comes to the Emergency Department with severe crushing pain in his chest and left shoulder that has been ongoing for 2 hours. Despite taking sublingual nitroglycerin, the pain persists, and his electrocardiogram shows ST elevation in multiple leads. Due to preexisting renal impairment, primary percutaneous intervention (PCI) is not an option, and he is started on medical management in the Coronary Care Unit. The following day, his serum cardiac enzymes are found to be four times higher than the upper limit of normal, and his electrocardiographic changes remain.
What is the most probable diagnosis?Your Answer: Transmural infarction
Explanation:Differentiating Types of Myocardial Infarction and Angina
When a patient presents with elevated serum cardiac enzymes and typical myocardial pain, it is likely that a myocardial infarction has occurred. If the ST elevation is limited to a few leads, it is indicative of a transmural infarction caused by the occlusion of a coronary artery. On the other hand, severely hypotensive patients who are hospitalized typically experience a more generalized subendocardial infarction.
Unstable angina, which is characterized by chest pain at rest or with minimal exertion, does not cause a rise in cardiac enzymes or ST elevation. Similarly, Prinzmetal angina, which is caused by coronary artery spasm, would not result in a marked increase in serum enzymes.
Stable angina, which is chest pain that occurs with exertion and is relieved by rest or medication, is not associated with ST elevation or a rise in cardiac enzymes.
Subendocardial infarction, which affects most ECG leads, usually occurs in the setting of shock. It is important to differentiate between the different types of myocardial infarction and angina in order to provide appropriate treatment and management.
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This question is part of the following fields:
- Cardiology
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Question 8
Correct
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A 30-year-old man presents with syncope, which was preceded by palpitations. He has no past medical history and is generally fit and well. The electrocardiogram (ECG) shows a positive delta wave in V1.
Which of the following is the most likely diagnosis?Your Answer: Wolff–Parkinson–White (WPW) syndrome
Explanation:Differentiating ECG Features of Various Heart Conditions
Wolff-Parkinson-White (WPW) syndrome is a congenital heart condition characterized by an accessory conduction pathway connecting the atria and ventricles. Type A WPW syndrome, identified by a delta wave in V1, can cause supraventricular tachycardia due to the absence of rate-lowering properties in the accessory pathway. Type B WPW syndrome, on the other hand, causes a negative R wave in V1. Radiofrequency ablation is the definitive treatment for WPW syndrome.
Maladie de Roger is a type of ventricular septal defect that does not significantly affect blood flow. Atrioventricular septal defect, another congenital heart disease, can cause ECG features related to blood shunting.
Brugada syndrome, which has three distinct types, does not typically present with a positive delta wave in V1 on ECG. Tetralogy of Fallot, a congenital heart defect, presents earlier with symptoms such as cyanosis and exertional dyspnea.
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This question is part of the following fields:
- Cardiology
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Question 9
Correct
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A 32-year-old woman presents with dyspnoea on exertion and palpitations. She has an irregularly irregular and tachycardic pulse, and a systolic murmur is heard on auscultation. An ECG reveals atrial fibrillation and right axis deviation, while an echocardiogram shows an atrial septal defect.
What is the process of atrial septum formation?Your Answer: The septum secundum grows down to the right of the septum primum
Explanation:During embryonic development, the septum primum grows down from the roof of the primitive atrium and fuses with the endocardial cushions. It initially has a hole called the ostium primum, which closes as the septum grows downwards. However, a second hole called the ostium secundum develops in the septum primum before fusion can occur. The septum secundum then grows downwards and to the right of the septum primum and ostium secundum. The foramen ovale is a passage through the septum secundum that allows blood to shunt from the right to the left atrium in the fetus, bypassing the pulmonary circulation. This defect closes at birth due to a drop in pressure within the pulmonary circulation after the infant takes a breath. If there is overlap between the foramen ovale and ostium secundum or if the ostium primum fails to close, an atrial septal defect results. This defect does not cause cyanosis because oxygenated blood flows from left to right through the defect.
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This question is part of the following fields:
- Cardiology
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Question 10
Correct
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A 60-year-old man with hypertension and hypercholesterolaemia experienced severe central chest pain lasting one hour. His electrocardiogram (ECG) in the ambulance reveals anterolateral ST segment elevation. Although his symptoms stabilized with medical treatment in the ambulance, he suddenly passed away while en route to the hospital.
What is the probable reason for his deterioration and death?Your Answer: Ventricular arrhythmia
Explanation:Complications of Myocardial Infarction
Myocardial infarction (MI) is a serious medical condition that can lead to various complications. Among these complications, ventricular arrhythmia is the most common cause of death. Malignant ventricular arrhythmias require immediate direct current (DC) electrical therapy to terminate the arrhythmias. Mural thrombosis, although it may cause systemic emboli, is not a common cause of death. Myocardial wall rupture and muscular rupture typically occur 4-7 days post-infarction, while papillary muscle rupture is also a possibility. Pulmonary edema, which can be life-threatening, is accompanied by symptoms of breathlessness and orthopnea. However, it can be treated effectively with oxygen, positive pressure therapy, and vasodilators.
Understanding the Complications of Myocardial Infarction
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This question is part of the following fields:
- Cardiology
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Question 11
Correct
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A 29-year-old man with valvular heart disease is urgently admitted with fever, worsening shortness of breath and a letter from his GP confirming the presence of a new murmur. During examination, a harsh pansystolic murmur and early diastolic murmur are detected, along with a temperature of 38.3 °C and bilateral fine basal crepitations. Initial blood cultures have been collected.
What is the most pressing concern that needs to be addressed immediately?Your Answer: Administration of intravenous antibiotics
Explanation:Prioritizing Interventions in Suspected Infective Endocarditis
When dealing with suspected infective endocarditis, time is of the essence. The following interventions should be prioritized in order to limit valve destruction and improve patient outcomes.
Administration of Intravenous Antibiotics
Prompt initiation of intravenous antibiotics is crucial. An empirical regime of gentamicin and benzylpenicillin may be used until microbiological advice suggests any alternative.Electrocardiogram (ECG)
An ECG provides important diagnostic information and should be performed as part of the initial work-up. However, it does not take priority over antibiotic administration.Echocardiogram (ECHO)
An ECHO should be performed in all patients with suspected infective endocarditis, but it does not take priority over administration of antibiotics. A transoesophageal ECHO is more sensitive and should be considered if necessary.Throat Swab
While a throat swab may be useful in identifying the causative organism of infective endocarditis, it should not take precedence over commencing antibiotics. Careful examination of a patient’s dentition is also crucial to evaluate for a possible infectious source.Administration of Paracetamol
Symptomatic relief is important, but administration of paracetamol should not take priority over antibiotic delivery. Both interventions should be given as soon as possible to improve patient outcomes. -
This question is part of the following fields:
- Cardiology
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Question 12
Incorrect
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Which statement about congenital heart disease is accurate?
Your Answer: Atrial septal defects (ASDs), in contrast with ventricular septal defects, never close spontaneously
Correct Answer: In Down's syndrome with an endocardial cushion defect, irreversible pulmonary hypertension occurs earlier than in children with normal chromosomes
Explanation:Common Congenital Heart Defects and their Characteristics
An endocardial cushion defect, also known as an AVSD, is the most prevalent cardiac malformation in individuals with Down Syndrome. This defect can lead to irreversible pulmonary hypertension, which is known as Eisenmenger’s syndrome. It is unclear why children with Down Syndrome tend to have more severe cardiac disease than unaffected children with the same abnormality.
ASDs, or atrial septal defects, may close on their own, and the likelihood of spontaneous closure is related to the size of the defect. If the defect is between 5-8 mm, there is an 80% chance of closure, but if it is larger than 8 mm, the chance of closure is minimal.
Tetralogy of Fallot, a cyanotic congenital heart disease, typically presents after three months of age. The murmur of VSD, or ventricular septal defect, becomes more pronounced after one month of life. Overall, the characteristics of these common congenital heart defects is crucial for proper diagnosis and treatment.
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This question is part of the following fields:
- Cardiology
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Question 13
Correct
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A previously healthy 58-year-old man collapsed while playing with his grandchildren. Although he quickly regained consciousness and became fully alert, his family called an ambulance. The emergency medical team found no abnormalities on the electrocardiogram. Physical examination was unremarkable. However, the patient was admitted to the Coronary Care Unit of the local hospital. During the evening, the patient was noted to have a fast rhythm with a wide complex on his monitor, followed by hypotension and loss of consciousness.
After electrical cardioversion with 200 watt-seconds of direct current, which one of the following may possible therapy include?Your Answer: Amiodarone
Explanation:The patient in the scenario is experiencing a fast rhythm with wide complexes, which is likely ventricular tachycardia (VT). As the patient is unstable, electrical cardioversion was attempted first, as recommended by the Resuscitation Council Guideline. If cardioversion fails and the patient remains unstable, intravenous amiodarone can be used as a loading dose of 300 mg over 10-20 minutes, followed by an infusion of 900 mg/24 hours. Amiodarone is a class III anti-arrhythmic agent that prolongs the repolarization phase of the cardiac action potential by blocking potassium efflux. Side-effects associated with amiodarone include deranged thyroid and liver function tests, nausea, vomiting, bradycardia, interstitial lung disease, jaundice, and sleep disorders.
Epinephrine is used in the treatment of acute anaphylaxis and cardiopulmonary resuscitation. It acts on adrenergic receptors, causing bronchodilation and vasoconstriction. Side-effects associated with epinephrine include palpitations, arrhythmias, headache, tremor, and hypertension.
Intravenous propranolol is a non-selective β-adrenergic receptor blocker that has limited use in treating arrhythmias and thyrotoxic crisis. It is contraindicated in patients with severe hypotension, asthma, COPD, bradycardia, sick sinus rhythm, atrioventricular block, and cardiogenic shock. Side-effects associated with propranolol include insomnia, nightmares, nausea, diarrhea, bronchospasm, exacerbation of Raynaud’s, bradycardia, hypotension, and heart block.
Digoxin, a cardiac glycoside extracted from the plant genus Digitalis, can be used in the treatment of supraventricular arrhythmias and heart failure. However, it is of no use in this scenario as the patient is experiencing a broad complex tachycardia. Digoxin has a narrow therapeutic window, and even small changes in dosing can lead to toxicity. Side-effects associated with digoxin include nausea, vomiting, diarrhea, bradycardia, dizziness, yellow vision, and eosinophilia.
Diltiazem, a non-dihydropyridine calcium channel blocker, is normally used for hypertension and prophylaxis and treatment of ang
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This question is part of the following fields:
- Cardiology
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Question 14
Incorrect
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A 60-year-old woman undergoes cardiac catheterisation. A catheter is inserted in her right femoral vein in the femoral triangle and advanced through the iliac veins and inferior vena cava to the right side of the heart so that right chamber pressures can be recorded.
What two other structures pass within the femoral triangle?Your Answer: Saphenous vein, femoral nerve
Correct Answer: Femoral artery, femoral nerve
Explanation:Anatomy of the Femoral Triangle
The femoral triangle is a triangular area on the anterior aspect of the thigh, formed by the crossing of various muscles. Within this area, the femoral vein, femoral artery, and femoral nerve lie medial to lateral (VAN). It is important to note that the inguinal lymph nodes and saphenous vein are not part of the femoral triangle. Understanding the anatomy of the femoral triangle is crucial for medical professionals when performing procedures in this area.
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This question is part of the following fields:
- Cardiology
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Question 15
Incorrect
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A 59-year-old woman was recently diagnosed with essential hypertension and prescribed medication to lower her blood pressure. However, she stopped taking the medication due to reported dizziness. Her blood pressure readings usually run at 150/100 mmHg. She denies any chest pain, shortness of breath, leg swelling, or visual problems. She has a history of occasional migraines but no other medical conditions. She has no known drug allergies. Her vital signs are within normal limits, other than high blood pressure. The S1 and S2 sounds are normal. There is no S3 or S4 sound, murmur, rub, or gallop. The peripheral pulses are normal and symmetric. The serum electrolytes (sodium, potassium, calcium, and chloride), creatinine, and urea nitrogen are within normal range. What is the most appropriate antihypertensive medication for this patient?
Your Answer: Amlodipine
Correct Answer: Indapamide
Explanation:The best medication for the patient in the scenario would be indapamide, a thiazide diuretic that blocks the Na+/Cl− cotransporter in the distal convoluted tubules, increasing calcium reabsorption and reducing the risk of osteoporotic fractures. Common side-effects include hyponatraemia, hypokalaemia, hypercalcaemia, hyperglycaemia, hyperuricaemia, gout, postural hypotension and hypochloraemic alkalosis.
Prazosin is used for benign prostatic hyperplasia.
Enalapril is not preferred for patients over 55 years old and can increase osteoporosis risk.
Propranolol is not a preferred initial treatment for hypertension, and amlodipine can cause ankle swelling and should be avoided in patients with myocardial infarction and symptomatic heart failure.
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This question is part of the following fields:
- Cardiology
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Question 16
Incorrect
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A 25-year-old man with a known harsh ejection systolic murmur on cardiac examination collapses and passes away during a sporting event. His father and uncle also died suddenly in their forties. The reason for death is identified as an obstruction of the ventricular outflow tract caused by an abnormality in the ventricular septum.
What is the accurate diagnosis for this condition?Your Answer: Dilated cardiomyopathy
Correct Answer: Hypertrophic cardiomyopathy
Explanation:Types of Cardiomyopathy and Congenital Heart Defects
Cardiomyopathy is a group of heart diseases that affect the structure and function of the heart muscle. There are different types of cardiomyopathy, each with its own causes and symptoms. Additionally, there are congenital heart defects that can affect the heart’s structure and function from birth. Here are some of the most common types:
1. Hypertrophic cardiomyopathy: This is an inherited condition that causes the heart muscle to thicken, making it harder for the heart to pump blood. It can lead to sudden death in young athletes.
2. Restrictive cardiomyopathy: This is a rare form of cardiomyopathy that is caused by diseases that restrict the heart’s ability to fill with blood during diastole.
3. Dilated cardiomyopathy: This is the most common type of cardiomyopathy, which causes the heart chambers to enlarge and weaken, leading to heart failure.
4. Mitral stenosis: This is a narrowing of the mitral valve, which can impede blood flow between the left atrium and ventricle.
In addition to these types of cardiomyopathy, there are also congenital heart defects, such as ventricular septal defect, which is the most common congenital heart defect. This condition creates a direct connection between the right and left ventricles, affecting the heart’s ability to pump blood effectively.
Understanding the different types of cardiomyopathy and congenital heart defects is important for proper diagnosis and treatment. If you experience symptoms such as chest pain, shortness of breath, or fatigue, it is important to seek medical attention promptly.
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This question is part of the following fields:
- Cardiology
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Question 17
Correct
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A 28-year-old man comes to the clinic complaining of intermittent sharp central chest pains over the past 48 hours. The pain worsens with exertion and when he lies down. He reports no difficulty breathing. The ECG reveals widespread ST elevation.
What is the most probable diagnosis?Your Answer: Pericarditis
Explanation:Distinguishing Pericarditis from Other Cardiac Conditions: A Clinical Overview
Pericarditis is a common cause of widespread ST elevation, characterized by chest pain that is often pleuritic and relieved by sitting forwards. Other symptoms include dry cough, dyspnoea, and flu-like symptoms, with the most important sign being pericardial rub. It can be caused by viral infections, post-MI, tuberculosis, or uraemia.
While pulmonary embolism may cause similar pleuritic pain, it would not result in the same ECG changes as pericarditis. Acute MI causes ST elevation in the affected coronary artery territory, with reciprocal ST depression. Hypertrophic cardiomyopathy presents with syncope or pre-syncope, and ECG changes consistent with left ventricular and septal hypertrophy. Ventricular aneurysm is another cause of ST elevation, but the clinical scenario and patient age align with a diagnosis of acute pericarditis.
In summary, recognizing the unique clinical presentation and ECG changes of pericarditis is crucial in distinguishing it from other cardiac conditions.
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This question is part of the following fields:
- Cardiology
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Question 18
Correct
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A 28-year-old male presents with a blood pressure reading of 170/100 mmHg. Upon examination, he exhibits a prominent aortic ejection click and murmurs are heard over the ribs anteriorly and over the back. Additionally, he reports experiencing mild claudication with exertion and has feeble pulses in his lower extremities. What is the most probable diagnosis?
Your Answer: Coarctation of the aorta
Explanation:Coarctation of the Aorta: Symptoms and Diagnosis
Coarctation of the aorta is a condition that can present with various symptoms. These may include headaches, nosebleeds, cold extremities, and claudication. However, hypertension is the most typical symptom. A mid-systolic murmur may also be present over the anterior part of the chest, back, spinous process, and a continuous murmur may also be heard.
One important radiographic finding in coarctation of the aorta is notching of the ribs. This is due to erosion by collaterals. It is important to diagnose coarctation of the aorta early on, as it can lead to serious complications such as heart failure, stroke, and aortic rupture.
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This question is part of the following fields:
- Cardiology
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Question 19
Incorrect
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A 67-year-old woman arrives at the Emergency Department by ambulance with chest pain that began 45 minutes ago. An ECG is performed and shows ST elevation in leads V1-V6, with ST depression in leads III and aVF. The closest facility capable of providing primary PCI is a 2 hour transfer time by ambulance. What is the most appropriate course of action for this patient?
Your Answer: Aspirin, clopidogrel, low-molecular-weight heparin, and transfer for PCI
Correct Answer: Administer thrombolysis and transfer for PCI
Explanation:Management of ST Elevation Myocardial Infarction in Remote Locations
ST elevation myocardial infarction (STEMI) is a medical emergency that requires prompt treatment. Percutaneous coronary intervention (PCI) is the gold standard first-line treatment for STEMI, but in remote locations, the patient may need to be taken to the nearest facility for initial assessment prior to transfer for PCI. In such cases, the most appropriate management strategy should be considered to minimize time delays and optimize patient outcomes.
Administer Thrombolysis and Transfer for PCI
In cases where the transfer time to the nearest PCI facility is more than 120 minutes, fibrinolysis prior to transfer should be strongly considered. This is particularly important for patients with anterior STEMI, where time is of the essence. Aspirin, clopidogrel, and low-molecular-weight heparin should also be administered, and the patient should be transferred to a PCI-delivering facility as soon as possible.
Other Treatment Options
If PCI is not likely to be achievable within 120 minutes of when fibrinolysis could have been given, thrombolysis should be administered prior to transfer. Analgesia alone is not sufficient, and unfractionated heparin is not the optimum treatment for STEMI.
Conclusion
In remote locations, the management of STEMI requires careful consideration of the potential time delays involved in transferring the patient to a PCI-delivering facility. Administering thrombolysis prior to transfer can help minimize delays and improve patient outcomes. Aspirin, clopidogrel, and low-molecular-weight heparin should also be administered, and the patient should be transferred to a PCI-delivering facility as soon as possible.
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This question is part of the following fields:
- Cardiology
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Question 20
Incorrect
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A 59-year-old man is admitted to the Intensive Care Unit from the Coronary Care Ward. He has suffered from an acute myocardial infarction two days earlier. On examination, he is profoundly unwell with a blood pressure of 85/60 mmHg and a pulse rate of 110 bpm. He has crackles throughout his lung fields, with markedly decreased oxygen saturations; he has no audible cardiac murmurs. He is intubated and ventilated, and catheterised.
Investigations:
Investigation Result Normal value
Haemoglobin 121 g/l 135–175 g/l
White cell count (WCC) 5.8 × 109/l 4–11 × 109/l
Platelets 285 × 109/l 150–400 × 109/l
Sodium (Na+) 128 mmol/l 135–145 mmol/l
Potassium (K+) 6.2 mmol/l 3.5–5.0 mmol/l
Creatinine 195 μmol/l 50–120 µmol/l
Troponin T 5.8 ng/ml <0.1 ng/ml
Urine output 30 ml in the past 3 h
ECG – consistent with a myocardial infarction 48 h earlier
Chest X-ray – gross pulmonary oedema
Which of the following fits best with the clinical picture?Your Answer: Nesiritide reduces mortality and improves renal function in this situation
Correct Answer:
Explanation:Treatment Options for Cardiogenic Shock Following Acute Myocardial Infarction
Cardiogenic shock following an acute myocardial infarction is a serious condition that requires prompt and appropriate treatment. One potential treatment option is the use of an intra-aortic balloon pump, which can provide ventricular support without compromising blood pressure. High-dose dopamine may also be used to preserve renal function, but intermediate and high doses can have negative effects on renal blood flow. The chance of death in this situation is high, but with appropriate treatment, it can be reduced to less than 10%. Nesiritide, a synthetic natriuretic peptide, is not recommended as it can worsen renal function and increase mortality. Nitrate therapy should also be avoided as it can further reduce renal perfusion and worsen the patient’s condition. Overall, careful consideration of treatment options is necessary to improve outcomes for patients with cardiogenic shock following an acute myocardial infarction.
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This question is part of the following fields:
- Cardiology
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Question 21
Correct
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A 25-year-old man comes to the Emergency Department complaining of gastroenteritis. He has experienced severe cramps in his left calf and has vomited five times in the last 24 hours. Blood tests reveal hypokalaemia, and an electrocardiogram (ECG) is performed. Which ECG change is most commonly linked to hypokalaemia?
Your Answer: Prominent U waves
Explanation:ECG Changes Associated with Hypo- and Hyperkalaemia
Hypokalaemia, or low levels of potassium in the blood, can cause various changes in an electrocardiogram (ECG). One of the most prominent changes is the appearance of U waves, which follow T waves and usually have the same direction. Hypokalaemia can also cause increased amplitude and width of P waves, prolonged PR interval, T wave flattening and inversion, ST depression, and Q-T prolongation in severe cases.
On the other hand, hyperkalaemia, or high levels of potassium in the blood, can cause peaked T waves, which represent ventricular repolarisation. Hyperkalaemia is also associated with widening of the QRS complex, which can lead to life-threatening ventricular arrhythmias. Flattening of P waves and prolonged PR interval are other ECG changes seen in hyperkalaemia.
It is important to note that some of these ECG changes can overlap between hypo- and hyperkalaemia, such as prolonged PR interval. Therefore, other clinical and laboratory findings should be considered to determine the underlying cause of the ECG changes.
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This question is part of the following fields:
- Cardiology
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Question 22
Correct
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A 55-year-old woman has been suffering from significant pain in her lower limbs when walking more than 200 meters for the past six months. During physical examination, her legs appear pale and cool without signs of swelling or redness. The palpation of dorsalis pedis or posterior tibial pulses is not possible. The patient has a body mass index of 33 kg/m2 and has been smoking for 25 pack years. What is the most probable vascular abnormality responsible for these symptoms?
Your Answer: Atherosclerosis
Explanation:Arteriosclerosis and Related Conditions
Arteriosclerosis is a medical condition that refers to the hardening and loss of elasticity of medium or large arteries. Atherosclerosis, on the other hand, is a specific type of arteriosclerosis that occurs when fatty materials such as cholesterol accumulate in the artery walls, causing them to thicken. This chronic inflammatory response is caused by the accumulation of macrophages and white blood cells, and is often promoted by low-density lipoproteins. The formation of multiple plaques within the arteries characterizes atherosclerosis.
Medial calcific sclerosis is another form of arteriosclerosis that occurs when calcium deposits form in the middle layer of walls of medium-sized vessels. This condition is often not clinically apparent unless it is severe, and it is more common in people over 50 years old and in diabetics. It can be seen as opaque vessels on radiographs.
Lymphatic obstruction, on the other hand, is a blockage of the lymph vessels that drain fluid from tissues throughout the body. This condition may cause lymphoedema, and the most common reason for this is the removal or enlargement of the lymph nodes.
It is important to understand these conditions and their differences to properly diagnose and treat patients.
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This question is part of the following fields:
- Cardiology
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Question 23
Correct
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A 50-year-old male smoker presents with a 6-hour history of gradual-onset central chest pain. The chest pain is worse on inspiration and relieved by leaning forward. He reports recently suffering a fever which he attributed to a viral illness. He has no significant past medical history; however, both his parents suffered from ischaemic heart disease in their early 60s. An electrocardiogram (ECG) reveals PR depression and concave ST-segment elevation in most leads. He is haemodynamically stable.
What is the most appropriate management?Your Answer: Ibuprofen
Explanation:Treatment Options for Acute Pericarditis: Understanding the Clinical Scenario
Acute pericarditis can be caused by a variety of factors, including infection, inflammation, and metabolic issues. The condition is typically characterized by gradual-onset chest pain that worsens with inspiration and lying flat, but improves with leaning forward. ECG findings often show concave ST-segment elevation and PR depression in certain leads, along with reciprocal changes in others.
Understanding Treatment Options for Acute Pericarditis
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This question is part of the following fields:
- Cardiology
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Question 24
Correct
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A 54-year-old patient is evaluated in the Pre-Assessment Clinic before undergoing elective surgery for varicose veins. The patient is in good health, with the only significant medical history being well-controlled hypertension with lisinopril. During the examination, the clinician hears an early opening snap in diastole when listening to the patient's heart. What is the most probable cause of this finding?
Your Answer: Mitral stenosis
Explanation:Common Heart Murmurs and Their Characteristics
Heart murmurs are abnormal sounds heard during a heartbeat and can indicate underlying heart conditions. Here are some common heart murmurs and their characteristics:
Mitral Stenosis: This condition causes a mid-diastolic murmur that is best heard with the bell of the stethoscope over the apex while the patient is lying in the left lateral position. Severe mitral stenosis can also cause a quiet first heart sound and an early opening snap.
Pulmonary Stenosis: Pulmonary stenosis causes an ejection systolic murmur.
Ventricular Septal Defect: This condition causes a pan-systolic murmur.
Mitral Valve Prolapse: Mitral valve prolapse may cause a mid-systolic click, followed by a late systolic murmur.
Right Bundle Branch Block: This condition is a cause of wide splitting of the second heart sound.
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This question is part of the following fields:
- Cardiology
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Question 25
Incorrect
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At 15 years of age a boy develops rheumatic fever. Thirty-five years later, he is admitted to hospital with weight loss, palpitations, breathlessness and right ventricular hypertrophy. On examination he is found to have an audible pan systolic murmur.
Which heart valve is most likely to have been affected following rheumatic fever?Your Answer: Aortic
Correct Answer: Mitral
Explanation:Rheumatic Heart Disease and Valve Involvement
Rheumatic heart disease is a condition that results from acute rheumatic fever and causes progressive damage to the heart valves over time. The mitral valve is the most commonly affected valve, with damage patterns varying by age. Younger patients tend to have regurgitation, while those in adolescence have a mix of regurgitation and stenosis, and early adulthood onwards tend to have pure mitral stenosis. Aortic valve involvement can also occur later in life. In this case, the patient is likely experiencing mitral regurgitation, causing palpitations and breathlessness. While the pulmonary valve can be affected, it is rare, and tricuspid involvement is even rarer and only present in advanced stages. Aortic valve involvement can produce similar symptoms, but with different murmurs on examination. When the aortic valve is involved, all leaflets are affected.
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This question is part of the following fields:
- Cardiology
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Question 26
Correct
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The cardiologist is examining a 48-year-old man with chest pain and is using his stethoscope to listen to the heart. Which part of the chest is most likely to correspond to the location of the heart's apex?
Your Answer: Left fifth intercostal space
Explanation:Anatomy of the Heart: Intercostal Spaces and Auscultation Positions
The human heart is a vital organ responsible for pumping blood throughout the body. Understanding its anatomy is crucial for medical professionals to diagnose and treat various heart conditions. In this article, we will discuss the intercostal spaces and auscultation positions related to the heart.
Left Fifth Intercostal Space: Apex of the Heart
The apex of the heart is located deep to the left fifth intercostal space, approximately 8-9 cm from the mid-sternal line. This is an important landmark for cardiac examination and procedures.Left Fourth Intercostal Space: Left Ventricle
The left ventricle, one of the four chambers of the heart, is located superior to the apex and can be auscultated in the left fourth intercostal space.Right Fourth Intercostal Space: Right Atrium
The right atrium, another chamber of the heart, is located immediately lateral to the right sternal margin at the right fourth intercostal space.Left Second Intercostal Space: Pulmonary Valve
The pulmonary valve, which regulates blood flow from the right ventricle to the lungs, can be auscultated in the left second intercostal space, immediately lateral to the left sternal margin.Right Fifth Intercostal Space: Incorrect Location
The right fifth intercostal space is an incorrect location for cardiac examination because the apex of the heart is located on the left side.In conclusion, understanding the intercostal spaces and auscultation positions related to the heart is essential for medical professionals to accurately diagnose and treat various heart conditions.
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This question is part of the following fields:
- Cardiology
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Question 27
Incorrect
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You are fast-bleeped to the ward where you find a 46-year-old woman in ventricular tachycardia. She had a witnessed syncopal episode while walking to the toilet with nursing staff and currently has a blood pressure of 85/56 mmHg. She is orientated to time, place and person but is complaining of feeling light-headed.
How would you manage this patient’s ventricular tachycardia?Your Answer: Amiodarone 300 mg loading dose intravenously (iv), followed by 900 mg over 24 hours
Correct Answer: Synchronised direct current (DC) cardioversion
Explanation:Treatment Options for Ventricular Tachycardia: Synchronised Cardioversion and Amiodarone
Ventricular tachycardia is a serious condition that requires immediate treatment. The Resuscitation Council tachycardia guideline recommends synchronised electrical cardioversion as the first-line treatment for unstable patients with ventricular tachycardia who exhibit adverse features such as shock, myocardial ischaemia, syncope, or heart failure. Synchronised cardioversion is timed to coincide with the R or S wave of the QRS complex, reducing the risk of ventricular fibrillation or cardiac arrest.
Administering an unsynchronised shock could coincide with the T wave, triggering fibrillation of the ventricles and leading to a cardiac arrest. If three attempts of synchronised cardioversion fail to restore sinus rhythm, a loading dose of amiodarone 300 mg iv should be given over 10–20 minutes, followed by another attempt of cardioversion.
Amiodarone is the first-line treatment for uncompromised patients with tachycardia. A loading dose of 300 mg is given iv, followed by an infusion of 900 mg over 24 hours. Digoxin and metoprolol are not recommended for the treatment of ventricular tachycardia. Digoxin is used for atrial fibrillation, while metoprolol should be avoided in patients with significant hypotension, as it can further compromise the patient’s condition.
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This question is part of the following fields:
- Cardiology
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Question 28
Incorrect
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A 60-year-old man presents to cardiology outpatients after being lost to follow-up for 2 years. He has a significant cardiac history, including two previous myocardial infarctions, peripheral vascular disease, and three transient ischemic attacks. He is also a non-insulin-dependent diabetic. During examination, his JVP is raised by 2 cm, and he has peripheral pitting edema to the mid-calf bilaterally and bilateral basal fine inspiratory crepitations. His last ECHO, performed 3 years ago, showed moderately impaired LV function and mitral regurgitation. He is currently taking bisoprolol, aspirin, simvastatin, furosemide, ramipril, and gliclazide. Which medication, if added, would provide prognostic benefit?
Your Answer: Digoxin
Correct Answer: Spironolactone
Explanation:Heart Failure Medications: Prognostic and Symptomatic Benefits
Heart failure is a prevalent disease that can be managed with various medications. These medications can be divided into two categories: those with prognostic benefits and those with symptomatic benefits. Prognostic medications help improve long-term outcomes, while symptomatic medications provide relief from symptoms.
Prognostic medications include selective beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II antagonists, and spironolactone. In the RALES trial, spironolactone was shown to reduce all-cause mortality by 30% in patients with heart failure and an ejection fraction of less than 35%.
Symptomatic medications include loop diuretics, digoxin, and vasodilators such as nitrates and hydralazine. These medications provide relief from symptoms but do not improve long-term outcomes.
Other medications, such as nifedipine, sotalol, and naftidrofuryl, are used to manage other conditions such as angina, hypertension, and peripheral and cerebrovascular disorders, but are not of prognostic benefit in heart failure.
Treatment for heart failure can be tailored to each individual case, and heart transplant remains a limited option for certain patient groups. Understanding the benefits and limitations of different medications can help healthcare providers make informed decisions about the best course of treatment for their patients.
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This question is part of the following fields:
- Cardiology
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Question 29
Incorrect
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A 61-year-old man comes to his General Practitioner complaining of increasing exertional dyspnoea accompanied by bilateral peripheral oedema. He reports feeling extremely fatigued lately. During the physical examination, his lungs are clear, but he has ascites. On auscultation of his heart sounds, you detect a holosystolic murmur with a high pitch at the left sternal edge, extending to the right sternal edge. What is the probable reason for this patient's symptoms?
Your Answer: Mitral regurgitation
Correct Answer: Tricuspid regurgitation
Explanation:Differentiating Heart Murmurs and Symptoms
Tricuspid regurgitation is characterized by signs of right heart failure, such as dyspnea and peripheral edema, and a classical murmur. The backflow of blood to the right atrium leads to right heart dilation, weakness, and eventually failure, resulting in ascites and poor ejection fraction causing edema.
Mitral regurgitation has a similar murmur to tricuspid regurgitation but is heard best at the apex.
Aortic regurgitation is identified by an early diastolic decrescendo murmur at the left sternal edge.
Aortic stenosis does not typically result in ascites, and its murmur is ejection systolic.
Pulmonary stenosis is characterized by a mid-systolic crescendo-decrescendo murmur best heard over the pulmonary post and not a holosystolic murmur at the left sternal edge.
Understanding Heart Murmurs and Symptoms
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This question is part of the following fields:
- Cardiology
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Question 30
Correct
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A 28-year-old man presents with chest pain, 5/10 in intensity, which is aggravated by breathing deeply and improved by leaning forward. The chest pain is not radiating. He has a mild fever but denies nausea, vomiting, cough or haemoptysis. He has self-medicated for a common cold and sore throat 5 days previously. On the electrocardiogram (ECG), there is diffuse, mild ST segment elevation (on leads II, aVF and V2–V6) and PR depression.
Which of the following findings is most likely to be observed on physical examination?Your Answer: Triphasic systolic and diastolic rub
Explanation:Common Heart Murmurs and Their Characteristics
Pericarditis: Triphasic Systolic and Diastolic Rub
Pericarditis is characterized by pleuritic chest pain that improves by leaning forward. A pericardial friction rub, with a scratchy, rubbing quality, is the classic cardiac auscultatory finding of pericarditis. It is often a high-pitched, triphasic systolic and diastolic murmur due to friction between the pericardial and visceral pericardium during ventricular contraction, ventricular filling, and atrial contraction.Mitral Regurgitation: High-Pitched Apical Pan-Systolic Murmur Radiating to the Axilla
A high-pitched apical pan-systolic murmur radiating to the axilla is heard in mitral regurgitation.Coarctation of the Aorta: Continuous Systolic and Diastolic Murmur Obscuring S2 Sound and Radiating to the Back
A continuous systolic and diastolic murmur obscuring S2 sound and radiating to the back is heard in coarctation of the aorta.Mitral Stenosis: Apical Opening Snap and Diastolic Rumble
An apical diastolic rumble and opening snap are heard in mitral stenosis.Aortic Regurgitation: Soft-Blowing Early Diastolic Decrescendo Murmur, Loudest at the Third Left Intercostal Space
A soft-blowing early diastolic decrescendo murmur, loudest at the second or third left intercostal space, is heard in aortic regurgitation. -
This question is part of the following fields:
- Cardiology
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