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Question 1
Incorrect
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A 28-year-old female presents with palpitations, chest pain, and shortness of breath that radiates to her left arm. These symptoms began six weeks ago after she witnessed her father's death from a heart attack. Over the past decade, she has undergone various investigations for abdominal pain, headaches, joint pains, and dyspareunia, but no significant cause has been identified for these symptoms. What is the probable diagnosis?
Your Answer: Depressive episode
Correct Answer: Somatisation disorder
Explanation:Somatisation Disorder as the Most Likely Diagnosis
Somatisation disorder is the most probable diagnosis for the given scenario, although it lacks sufficient criteria for a complete diagnosis. This disorder is characterised by recurring pains, gastrointestinal, sexual, and pseudo-neurologic symptoms that persist for years. To meet the diagnostic criteria, the patient’s physical complaints must not be intentionally induced and must result in medical attention or significant impairment in social, occupational, or other important areas of functioning. Typically, the first symptoms appear during adolescence, and the full criteria are met by the age of 30.
Among the other disorders, factitious disorder is the least likely explanation. The other three disorders are possible explanations, but they are not as likely as somatisation disorder.
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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 67-year-old, diabetic man, presents to the Emergency Department with central crushing chest pain which radiates to his left arm and jaw. He has experienced several episodes of similar pain, usually on exercise. Increasingly he has found the pain beginning while he is at rest. A diagnosis of angina pectoris is made.
Which branch of the coronary arteries supplies the left atrium of the heart?Your Answer:
Correct Answer: Circumflex artery
Explanation:Coronary Arteries and their Branches
The heart is supplied with blood by the coronary arteries. There are two main coronary arteries: the left and right coronary arteries. These arteries branch off into smaller arteries that supply different parts of the heart. Here are some of the main branches and their functions:
1. Circumflex artery: This artery supplies the left atrium.
2. Sinoatrial (SA) nodal artery: This artery supplies the SA node, which is responsible for initiating the heartbeat. In most people, it arises from the right coronary artery, but in some, it comes from the left circumflex artery.
3. Left anterior descending artery: This artery comes from the left coronary artery and supplies the interventricular septum and both ventricles.
4. Left marginal artery: This artery is a branch of the circumflex artery and supplies the left ventricle.
5. Posterior interventricular branch: This artery comes from the right coronary artery and supplies both ventricles and the interventricular septum.
Understanding the different branches of the coronary arteries is important for diagnosing and treating heart conditions.
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This question is part of the following fields:
- Cardiology
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Question 3
Incorrect
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A radiologist examined a coronary angiogram of a 75-year-old man with long-standing heart disease and identified stenosis of the right coronary artery resulting in reduced perfusion of the myocardium of the right atrium. Which structure related to the right atrium is most likely to have been impacted by the decreased blood flow?
Your Answer:
Correct Answer: Sinoatrial node
Explanation:Coronary Arteries and their Supply to Cardiac Conduction System
The heart’s conduction system is responsible for regulating the heartbeat. The following are the coronary arteries that supply blood to the different parts of the cardiac conduction system:
Sinoatrial Node
The sinoatrial node, which is the primary pacemaker of the heart, is supplied by the right coronary artery in 60% of cases through a sinoatrial nodal branch.Atrioventricular Node
The atrioventricular node, which is responsible for delaying the electrical impulse before it reaches the ventricles, is supplied by the right coronary artery in 80% of individuals through the atrioventricular nodal branch.Atrioventricular Bundle
The atrioventricular bundle, which conducts the electrical impulse from the atria to the ventricles, is supplied by numerous septal arteries that mostly arise from the anterior interventricular artery, a branch of the left coronary artery.Left Bundle Branch
The left bundle branch, which conducts the electrical impulse to the left ventricle, is supplied by numerous subendocardial bundle arteries that originate from the left coronary artery.Right Bundle Branch
The right bundle branch, which conducts the electrical impulse to the right ventricle, is supplied by numerous subendocardial bundle arteries that originate from the right coronary artery. -
This question is part of the following fields:
- Cardiology
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Question 4
Incorrect
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A 68-year-old male patient presents with bilateral ankle oedema. On examination, the jugular venous pressure (JVP) is elevated at 7 cm above the sternal angle and there are large V-waves. On auscultation of the heart, a soft pansystolic murmur is audible at the left sternal edge.
Which one of the following is the most likely diagnosis?Your Answer:
Correct Answer: Tricuspid regurgitation
Explanation:Common Heart Murmurs and their Characteristics
Heart murmurs are abnormal sounds heard during the cardiac cycle. They can be caused by a variety of conditions, including valve disorders. Here are some common heart murmurs and their characteristics:
Tricuspid Regurgitation: This condition leads to an elevated jugular venous pressure (JVP) with large V-waves and a pan-systolic murmur at the left sternal edge. Other features include pulsatile hepatomegaly and left parasternal heave.
Tricuspid Stenosis: Tricuspid stenosis causes a mid-diastolic murmur heard best at the left sternal border.
Pulmonary Stenosis: Pulmonary stenosis causes an ejection systolic murmur in the second left intercostal space.
Mitral Regurgitation: Mitral regurgitation causes a pan-systolic murmur at the apex, which radiates to the axilla.
Mitral Stenosis: Mitral stenosis causes a mid-diastolic murmur at the apex, and severe cases may have secondary pulmonary hypertension (a cause of tricuspid regurgitation).
Knowing the characteristics of these murmurs can aid in their diagnosis and management. It is important to consult with a healthcare professional if you suspect you may have a heart murmur.
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This question is part of the following fields:
- Cardiology
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Question 5
Incorrect
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A patient in their 60s was diagnosed with disease of a heart valve located between the left ventricle and the ascending aorta. Which of the following is most likely to describe the cusps that comprise this heart valve?
Your Answer:
Correct Answer: Right, left and posterior cusps
Explanation:Different Cusps of Heart Valves
The heart has four valves that regulate blood flow through the chambers. Each valve is composed of cusps, which are flaps that open and close to allow blood to pass through. Here are the different cusps of each heart valve:
Aortic Valve: The aortic valve is made up of a right, left, and posterior cusp. It is located at the junction between the left ventricle and the ascending aorta.
Mitral Valve: The mitral valve is usually the only bicuspid valve and is composed of anterior and posterior cusps. It is located between the left atrium and the left ventricle.
Tricuspid Valve: The tricuspid valve has three cusps – anterior, posterior, and septal. It is located between the right atrium and the right ventricle.
Pulmonary Valve: The pulmonary valve is made up of right, left, and anterior cusps. It is located at the junction between the right ventricle and the pulmonary artery.
Understanding the different cusps of heart valves is important in diagnosing and treating heart conditions.
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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 60-year-old man is seen at cardiology outpatients 6 weeks after an anterior myocardial infarction. His wife complains that she cannot sleep at night due to his constant coughing and throat clearing.
Which medication is likely causing these symptoms?Your Answer:
Correct Answer: Perindopril
Explanation:Common Side-Effects of Cardiovascular Medications
Cardiovascular medications are commonly prescribed to manage various heart conditions. However, they can also cause side-effects that can affect a patient’s quality of life. Here are some common side-effects of popular cardiovascular medications:
Perindopril: This medication can cause a dry, persistent cough, as well as hyperkalaemia, fatigue, dizziness, and hypotension.
Amiodarone: Side-effects of this medication include dizziness, visual disturbance, unco-ordination, tremors, paraesthesia, deranged liver function tests (LFTs), deranged thyroid function tests (TFTs), and lung fibrosis.
Atenolol: β-blockers like atenolol can cause fatigue, Raynaud’s phenomenon, bronchospasm, change in bowel habit, and sexual dysfunction.
Atorvastatin: Statins like atorvastatin can cause myopathy/myositis, derangement of glucose control, and deranged LFTs.
Candesartan: Angiotensin receptor blockers like candesartan can cause dizziness, headache, hyperkalaemia, and first-dose orthostatic hypotension. They are often prescribed to patients who are intolerant of ACE inhibitors due to dry cough.
In conclusion, patients taking cardiovascular medications should be aware of these potential side-effects and report any concerns to their healthcare provider.
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This question is part of the following fields:
- Cardiology
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Question 7
Incorrect
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A 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:
Correct 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 8
Incorrect
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A 70-year-old male presents with abdominal pain.
He has a past medical history of stroke and myocardial infarction. During examination, there was noticeable distension of the abdomen and the stools were maroon in color. The lactate level was found to be 5 mmol/L, which is above the normal range of <2.2 mmol/L.
What is the most probable diagnosis for this patient?Your Answer:
Correct Answer: Acute mesenteric ischaemia
Explanation:Acute Mesenteric Ischaemia
Acute mesenteric ischaemia is a condition that occurs when there is a disruption in blood flow to the small intestine or right colon. This can be caused by arterial or venous disease, with arterial disease further classified as non-occlusive or occlusive. The classic triad of symptoms associated with acute mesenteric ischaemia includes gastrointestinal emptying, abdominal pain, and underlying cardiac disease.
The hallmark symptom of mesenteric ischaemia is severe abdominal pain, which may be accompanied by other symptoms such as nausea, vomiting, abdominal distention, ileus, peritonitis, blood in the stool, and shock. Advanced ischaemia is characterized by the presence of these symptoms.
There are several risk factors associated with acute mesenteric ischaemia, including congestive heart failure, cardiac arrhythmias (especially atrial fibrillation), recent myocardial infarction, atherosclerosis, hypercoagulable states, and hypovolaemia. It is important to be aware of these risk factors and to seek medical attention promptly if any symptoms of acute mesenteric ischaemia are present.
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This question is part of the following fields:
- Cardiology
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Question 9
Incorrect
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A 27-year-old Asian woman complains of palpitations, shortness of breath on moderate exertion and a painful and tender knee. During auscultation, a mid-diastolic murmur with a loud S1 is heard. Echocardiography reveals valvular heart disease with a normal left ventricular ejection fraction.
What is the most probable valvular disease?Your Answer:
Correct Answer: Mitral stenosis
Explanation:Differentiating Heart Murmurs: Causes and Characteristics
Heart murmurs are abnormal sounds heard during a heartbeat and can indicate underlying heart conditions. Here are some common causes and characteristics of heart murmurs:
Mitral Stenosis: This condition is most commonly caused by rheumatic fever in childhood and is rare in developed countries. Patients with mitral stenosis will have a loud S1 with an associated opening snap. However, if the mitral valve is calcified or there is severe stenosis, the opening snap may be absent and S1 soft.
Mitral Regurgitation and Ventricular Septal Defect: These conditions cause a pan-systolic murmur, which is not the correct option for differentiating heart murmurs.
Aortic Regurgitation: This condition leads to an early diastolic murmur.
Aortic Stenosis: Aortic stenosis causes an ejection systolic murmur.
Ventricular Septal Defect: As discussed, a ventricular septal defect will cause a pan-systolic murmur.
By understanding the causes and characteristics of different heart murmurs, healthcare professionals can better diagnose and treat underlying heart conditions.
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This question is part of the following fields:
- Cardiology
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Question 10
Incorrect
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A 50-year-old patient with hypertension arrives at the Emergency Department complaining of central chest pain that feels heavy. The pain does not radiate, and there are no other risk factors for atherosclerosis. Upon examination, the patient's vital signs are normal, including pulse, temperature, and oxygen saturation. The patient appears sweaty, but cardiovascular and respiratory exams are unremarkable. The patient experiences tenderness over the sternum at the site of the chest pain, and the resting electrocardiogram (ECG) is normal.
What is the most appropriate course of action for managing this patient?Your Answer:
Correct Answer: Arrange a 12-h troponin T assay before deciding whether or not to discharge the patient
Explanation:Management of Chest Pain in a Patient with Risk Factors for Cardiac Disease
Chest pain is a common presenting complaint in primary care and emergency departments. However, it is important to consider the possibility of an acute coronary syndrome in patients with risk factors for cardiac disease. Here are some management strategies for a patient with chest pain and risk factors for cardiac disease:
Arrange a 12-h troponin T assay before deciding whether or not to discharge the patient. A normal troponin assay would make a diagnosis of acute coronary syndrome unlikely, but further investigation may be required to determine if the patient has underlying coronary artery disease.
Do not discharge the patient with a diagnosis of costochondritis based solely on chest wall tenderness. This should only be used in low-risk patients with tenderness that accurately reproduces the pain they have been feeling on minimal palpation.
Do not discharge the patient if serial resting ECGs are normal. A normal ECG does not rule out an acute cardiac event.
Admit the patient to the Coronary Care Unit for monitoring and further assessment only if the 12-h troponin comes back elevated.
Do not discharge the patient and arrange an outpatient exercise tolerance test until further investigation has been done to rule out an acute cardiac event.
In summary, it is important to consider the possibility of an acute coronary syndrome in patients with chest pain and risk factors for cardiac disease. Further investigation, such as a 12-h troponin assay, may be required before deciding on appropriate management strategies.
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This question is part of the following fields:
- Cardiology
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Question 11
Incorrect
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A 38-year-old man presents to the Emergency Department with a 2-day history of flu-like symptoms. He reports experiencing sharp central chest pain that worsens with coughing and improves when he sits forwards. Upon examination, he is found to be tachycardic and has a temperature of 39 °C. A third heart sound is heard upon auscultation. What is the most probable cause of this patient's chest pain?
Your Answer:
Correct Answer: Pericarditis
Explanation:Differential Diagnosis of Chest Pain: Pericarditis, Aortic Dissection, Myocardial Ischaemia, Oesophageal Reflux, and Pneumonia
Chest pain is a common presenting symptom in clinical practice. It can be caused by a variety of conditions, including pericarditis, aortic dissection, myocardial ischaemia, oesophageal reflux, and pneumonia.
Pericarditis is an acute inflammation of the pericardial sac, which contains the heart. It typically presents with central or left-sided chest pain that is relieved by sitting forwards and worsened by coughing and lying flat. Other signs include tachycardia, raised temperature, and pericardial friction rub. Investigations include blood tests, electrocardiography, chest X-ray, and echocardiography. Treatment aims to address the underlying cause and manage symptoms, such as analgesia and bed rest.
Aortic dissection is characterized by central chest or epigastric pain radiating to the back. It is associated with Marfan syndrome, and symptoms of this condition should be sought when assessing patients.
Myocardial ischaemia is unlikely in a 35-year-old patient without risk factors such as illegal drug use or family history. Ischaemic pain is typically central and heavy/’crushing’ in character, with radiation to the jaw or arm.
Oesophageal reflux disease (GORD) typically presents with chest pain associated with reflux after eating. Patients do not typically have a fever or history of recent illness.
Pneumonia is a possible cause of chest pain, but it is unlikely in the absence of a productive cough. Pleuritic chest pain associated with pneumonia is also unlikely to be relieved by sitting forward, which is a classical sign of pericarditis.
In conclusion, a thorough history and examination, along with appropriate investigations, are necessary to differentiate between the various causes of chest pain and provide appropriate management.
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This question is part of the following fields:
- Cardiology
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Question 12
Incorrect
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A 72-year-old man is brought by ambulance to the Accident and Emergency department. He is visibly distressed but gives a history of sudden onset central compressive chest pain radiating to his left upper limb. He is also nauseous and very sweaty. He has had previous myocardial infarctions (MI) in the past and claims the pain is identical to those episodes. ECG reveals an anterior ST elevation MI.
Which of the following is an absolute contraindication to thrombolysis?Your Answer:
Correct Answer: Brain neoplasm
Explanation:Relative and Absolute Contraindications to Thrombolysis
Thrombolysis is a treatment option for patients with ongoing cardiac ischemia and presentation within 12 hours of onset of pain. However, there are both relative and absolute contraindications to this treatment.
Absolute contraindications include internal or heavy PV bleeding, acute pancreatitis or severe liver disease, esophageal varices, active lung disease with cavitation, recent trauma or surgery within the past 2 weeks, severe hypertension (>200/120 mmHg), suspected aortic dissection, recent hemorrhagic stroke, cerebral neoplasm, and previous allergic reaction.
Relative contraindications include prolonged CPR, history of CVA, bleeding diathesis, anticoagulation, blood pressure of 180/100 mmHg, peptic ulcer, and pregnancy or recent delivery.
It is important to consider these contraindications before administering thrombolysis as they can increase the risk of complications. Primary percutaneous coronary intervention is the preferred treatment option, but if not available, thrombolysis can be a viable alternative. The benefit of thrombolysis decreases over time, and a target time of <30 minutes from admission for commencement of thrombolysis is typically recommended.
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This question is part of the following fields:
- Cardiology
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Question 13
Incorrect
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A 75-year-old man comes to the clinic with a complaint of experiencing severe dizziness upon standing quickly. He is currently taking atenolol 100 mg OD for hypertension. Upon measuring his blood pressure while lying down and standing up, the readings are 146/88 mmHg and 108/72 mmHg, respectively. What is the main cause of his postural hypotension?
Your Answer:
Correct Answer: Impaired baroreceptor reflex
Explanation:Postural Hypotension
Postural hypotension is a common condition that affects many people, especially the elderly and those with refractory hypertension. When standing up, blood tends to pool in the lower limbs, causing a temporary drop in blood pressure. Baroreceptors in the aortic arch and carotid sinus detect this change and trigger a sympathetic response, which includes venoconstriction, an increase in heart rate, and an increase in stroke volume. This response helps to restore cardiac output and blood pressure, usually before any awareness of hypotension. However, a delay in this response can cause dizziness and presyncope.
In some cases, the reflex response is partially impaired by medications such as beta blockers. This means that increased adrenaline release, decreased pH (via chemoreceptors), or pain (via a sympathetic response) can lead to an increase in blood pressure rather than a decrease. postural hypotension and its underlying mechanisms can help individuals manage their symptoms and prevent complications.
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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 20-year-old man, who recently immigrated to the United Kingdom from Eastern Europe, presents to his general practitioner with a history of intermittent dizzy spells. He reports having limited exercise capacity since childhood, but this has not been investigated before. Upon examination, the patient appears slight, has a dusky blue discoloration to his lips and tongue, and has finger clubbing. A murmur is also heard. The GP refers him to a cardiologist.
The results of a cardiac catheter study are as follows:
Anatomical site Oxygen saturation (%) Pressure (mmHg)
End systolic/End diastolic
Superior vena cava 58 -
Inferior vena cava 52 -
Right atrium (mean) 56 10
Right ventricle 55 105/9
Pulmonary artery - 16/8
Pulmonary capillary wedge pressure - 9
Left atrium 97 -
Left ventricle 84 108/10
Aorta 74 110/80
What is the most likely diagnosis?Your Answer:
Correct Answer: Fallot's tetralogy
Explanation:Fallot’s Tetralogy
Fallot’s tetralogy is a congenital heart defect that consists of four features: ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and an over-riding aorta. To diagnose this condition, doctors look for specific indicators. A step-down in oxygen saturation between the left atrium and left ventricle indicates a right to left shunt at the level of the ventricles, which is a sign of ventricular septal defect. Pulmonary stenosis is indicated by a significant gradient of 89 mmHg across the pulmonary valve, which is calculated by subtracting the right ventricular systolic pressure from the pulmonary artery systolic pressure. Right ventricular hypertrophy is diagnosed by high right ventricular pressures and a right to left shunt, as indicated by the oxygen saturations. Finally, an over-riding aorta is identified by a further step-down in oxygen saturation between the left ventricle and aorta. While this could also occur in cases of patent ductus arteriosus with right to left shunting, the presence of the other features of Fallot’s tetralogy makes an over-riding aorta the most likely cause of reduced oxygen saturation due to admixture of deoxygenated blood from the right ventricle entering the left heart circulation.
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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 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:
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 16
Incorrect
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A 65-year-old woman with ischaemic heart disease presents with sudden onset palpitations. She has no other complaints. On examination, a regular tachycardia is present. Her blood pressure is 150/90 mmHg. Chest is clear. ECG reveals a regular tachycardia with a QRS width of 80 ms and a rate of 149 beats per min in a sawtooth pattern.
What is the diagnosis?Your Answer:
Correct Answer: Atrial flutter
Explanation:Common Cardiac Arrhythmias: Types and Characteristics
Cardiac arrhythmias are abnormal heart rhythms that can cause serious health complications. Here are some common types of cardiac arrhythmias and their characteristics:
1. Atrial Flutter: A type of supraventricular tachycardia that is characterized by a sawtooth pattern on the ECG. It is caused by a premature electrical impulse in the atrium and can degenerate into atrial fibrillation. Treatment involves rate or rhythm control, and electrical cardioversion is more effective than in atrial fibrillation.
2. Fast Atrial Fibrillation: Another type of supraventricular tachycardia that presents as an irregularly irregular tachycardia.
3. Ventricular Tachycardia: A common arrhythmia in cardiopaths that is characterized by a wide-complex tachycardia on ECG.
4. Mobitz Type II: A form of second-degree heart block that is characterized by intermittent non-conducted P waves on ECG without progressive prolongation of the QRS interval.
5. Brugada Syndrome: A rare electrophysiological condition that causes sudden death in young adults. ECG findings usually show ST elevation in leads V1 to V3 with a right bundle branch block.
It is important to identify and treat cardiac arrhythmias promptly to prevent serious health complications.
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This question is part of the following fields:
- Cardiology
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Question 17
Incorrect
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What do T waves represent on an ECG?
Your Answer:
Correct Answer: Ventricular repolarisation
Explanation:The Electrical Activity of the Heart and the ECG
The ECG (electrocardiogram) is a medical test that records the electrical activity of the heart. This activity is responsible for different parts of the ECG. The first part is the atrial depolarisation, which is represented by the P wave. This wave conducts down the bundle of His to the ventricles, causing the ventricular depolarisation. This is shown on the ECG as the QRS complex. Finally, the ventricular repolarisation is represented by the T wave.
It is important to note that atrial repolarisation is not visible on the ECG. This is because it is of lower amplitude compared to the QRS complex. the different parts of the ECG and their corresponding electrical activity can help medical professionals diagnose and treat various heart conditions.
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This question is part of the following fields:
- Cardiology
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Question 18
Incorrect
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A 68-year-old woman presents to the hospital with complaints of shortness of breath, extreme weakness, and epigastric pain that started 30 minutes ago while she was using the restroom. She is still experiencing these symptoms and is sweating profusely. Her heart rate is 150 bpm, and her blood pressure is 180/110 mmHg. An ECG is ordered, which shows elevated ST segments in consecutive leads and Q waves. What is the most probable cause of this woman's condition?
Your Answer:
Correct Answer: Completely occlusive thrombus
Explanation:Causes of Chest Pain: Understanding Myocardial Infarction and Other Conditions
Chest pain can be a symptom of various conditions, including myocardial infarction, coronary artery stenosis, coronary vasospasm, partially occlusive thrombus, and pulmonary embolism. Understanding the differences between these conditions is crucial for accurate diagnosis and treatment.
Myocardial Infarction
Myocardial infarction, or heart attack, is a serious condition that occurs when a completely occlusive thrombus blocks blood flow to the heart. Women are more likely to experience atypical symptoms such as shortness of breath, weakness, and fatigue, rather than the typical substernal chest pain. However, heart rate, blood pressure, and ECG changes indicate a myocardial infarction.
Coronary Artery Stenosis
Coronary artery stenosis causes stable angina, which subsides with rest. It is characterized by a narrowing of the coronary arteries that supply blood to the heart.
Coronary Vasospasm
Coronary vasospasm is the cause of Prinzmetal’s angina, which presents as intermittent chest pain at rest. It is caused by the sudden constriction of the coronary arteries.
Partially Occlusive Thrombus
A partially occlusive thrombus may present similarly to a completely occlusive thrombus, but it does not usually cause an elevation in the ST segment.
Pulmonary Embolism
A pulmonary embolism is an occlusion of circulation in the lungs and presents as severe shortness of breath. However, it does not typically cause the specific ECG changes seen in myocardial infarction.
Understanding the differences between these conditions can help healthcare professionals accurately diagnose and treat chest pain.
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This question is part of the following fields:
- Cardiology
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Question 19
Incorrect
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A 72-year-old man has been hospitalized with crushing chest pain. An ECG trace shows ischaemia of the inferior part of the heart. What is the term that best describes the artery or arterial branch that provides blood supply to the inferior aspect of the heart?
Your Answer:
Correct Answer: Posterior interventricular branch
Explanation:Coronary Artery Branches and Circulation Dominance
The coronary artery is responsible for supplying blood to the heart muscles. It branches out into several smaller arteries, each with a specific area of the heart to supply. Here are some of the main branches of the coronary artery:
1. Posterior Interventricular Branch: This branch supplies the inferior aspect of the heart, with ischaemic changes presenting in leads II, III and aVF. In 90% of the population, it arises as a branch of the right coronary artery, while in 10%, it arises as a branch of the left coronary artery.
2. Circumflex Branch: This branch supplies the anterolateral area of the heart.
3. Left Coronary Artery: This artery gives off two branches – the left anterior descending artery supplying the anteroseptal and anteroapical parts of the heart, and the circumflex artery supplying the anterolateral heart. In 10% of the population, the left coronary artery gives off a left anterior interventricular branch that supplies the inferior part of the heart.
4. Marginal Branch: This branch is a branch of the right coronary artery supplying the right ventricle.
5. Right Coronary Artery: This artery branches out into the marginal artery and, in 90% of the population, the posterior interventricular branch. These individuals are said to have a right dominant circulation.
Understanding the different branches of the coronary artery and the circulation dominance can help in diagnosing and treating heart conditions.
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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 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:
Correct 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 21
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:
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 22
Incorrect
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A 25-year-old female with Down's syndrome presents with a systolic murmur on clinical examination. What is the most prevalent cardiac anomaly observed in individuals with Down's syndrome that could account for this murmur?
Your Answer:
Correct Answer: Atrioventricular septal defect
Explanation:Endocardial Cushion Defects
Endocardial cushion defects, also referred to as atrioventricular (AV) canal or septal defects, are a group of abnormalities that affect the atrial septum, ventricular septum, and one or both of the AV valves. These defects occur during fetal development when the endocardial cushions, which are responsible for separating the heart chambers and forming the valves, fail to develop properly. As a result, there may be holes or gaps in the septum, or the AV valves may not close properly, leading to a mix of oxygenated and deoxygenated blood in the heart. This can cause a range of symptoms, including shortness of breath, fatigue, poor growth, and heart failure. Treatment for endocardial cushion defects typically involves surgery to repair the defects and improve heart function.
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This question is part of the following fields:
- Cardiology
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Question 23
Incorrect
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A 57-year-old man arrives at the Emergency Department with sudden onset central crushing chest pain. The patient reports feeling pain in his neck and jaw as well. He has no significant medical history, but he does smoke socially and consumes up to 60 units of alcohol per week. An ECG is performed, revealing widespread ST elevation indicative of an acute coronary syndrome.
What is the earliest point at which the microscopic changes of acute MI become apparent?Your Answer:
Correct Answer: 12-24 hours after the infarct
Explanation:The Pathological Progression of Myocardial Infarction: A Timeline of Changes
Myocardial infarction, commonly known as a heart attack, is a serious medical condition that occurs when blood flow to the heart is blocked, leading to tissue damage and potentially life-threatening complications. The pathological progression of myocardial infarction follows a predictable sequence of events, with macroscopic and microscopic changes occurring over time.
Immediately after the infarct occurs, there are usually no visible changes to the myocardium. However, within 3-6 hours, maximal inflammatory changes occur, with the most prominent changes occurring between 24-72 hours. During this time, coagulative necrosis and acute inflammatory responses are visible, with marked infiltration by neutrophils.
Between 3-10 days, the infarcted area begins to develop a hyperaemic border, and the process of organisation and repair begins. Granulation tissue replaces dead muscle, and dying neutrophils are replaced by macrophages. Disintegration and phagocytosis of dead myofibres occur during this time.
If a patient survives an acute infarction, the infarct heals through the formation of scar tissue. However, scar tissue does not possess the usual contractile properties of normal cardiac muscle, leading to contractile dysfunction or congestive cardiac failure. The entire process from coagulative necrosis to the formation of well-formed scar tissue takes 6-8 weeks.
In summary, understanding the timeline of changes that occur during myocardial infarction is crucial for early diagnosis and effective treatment. By recognising the macroscopic and microscopic changes that occur over time, healthcare professionals can provide appropriate interventions to improve patient outcomes.
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This question is part of the following fields:
- Cardiology
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Question 24
Incorrect
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Which of the options below is not a cause of mid-diastolic murmur?
Your Answer:
Correct Answer: Aortic stenosis
Explanation:Causes of Heart Murmurs
Heart murmurs are abnormal sounds heard during a heartbeat. Aortic stenosis, a condition where the aortic valve narrows, causes an ejection systolic murmur. On the other hand, left atrial myxomas and right atrial myxomas, which are rare tumors, can cause a mid-diastolic murmur by blocking the valve orifice during diastole. Mitral stenosis, which is often the result of rheumatic fever or a congenital defect, causes mid-diastolic murmurs. Lastly, tricuspid stenosis, which is also commonly caused by rheumatic fever, can cause a mid-diastolic murmur. the causes of heart murmurs is important in diagnosing and treating heart conditions.
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This question is part of the following fields:
- Cardiology
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Question 25
Incorrect
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A 55-year-old man presents to the clinic with complaints of chest pain and difficulty breathing. He had been hospitalized four weeks ago for acute coronary syndrome and was discharged on bisoprolol, simvastatin, aspirin, and ramipril. During the examination, a narrow complex tachycardia is observed. What is the absolute contraindication in this scenario?
Your Answer:
Correct Answer: Verapamil
Explanation:Verapamil and Beta Blockers: A Dangerous Combination
Verapamil is a type of medication that blocks calcium channels in the heart, leading to a decrease in cardiac output and a slower heart rate. However, it also has negative effects on the heart’s ability to contract, making it a highly negatively inotropic drug. Additionally, it may impair the conduction of electrical signals between the atria and ventricles of the heart.
According to the British National Formulary (BNF), verapamil should not be given to patients who are already taking beta blockers. This is because the combination of these two drugs can lead to dangerously low blood pressure and even asystole, a condition where the heart stops beating altogether.
Therefore, it is important for healthcare professionals to carefully consider a patient’s medication history before prescribing verapamil. If a patient is already taking beta blockers, alternative treatments should be considered to avoid the potentially life-threatening consequences of combining these two drugs.
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This question is part of the following fields:
- Cardiology
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Question 26
Incorrect
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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:
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
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This question is part of the following fields:
- Cardiology
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Question 27
Incorrect
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A 32-year-old woman presents with dyspnoea on exertion and palpitations. She has an irregularly irregular and tachycardic pulse, and a systolic murmur is heard on auscultation. An ECG reveals atrial fibrillation and right axis deviation, while an echocardiogram shows an atrial septal defect.
What is true about the development of the atrial septum?Your Answer:
Correct Answer: The septum secundum grows down to the right of the septum primum
Explanation:During embryonic development, the septum primum grows down from the roof of the primitive atrium and fuses with the endocardial cushions. It initially has a hole called the ostium primum, which closes as the septum grows downwards. However, a second hole called the ostium secundum develops in the septum primum before fusion can occur. The septum secundum then grows downwards and to the right of the septum primum and ostium secundum. The foramen ovale is a passage through the septum secundum that allows blood to shunt from the right to the left atrium in the fetus, bypassing the pulmonary circulation. This defect closes at birth due to a drop in pressure within the pulmonary circulation after the infant takes a breath. If there is overlap between the foramen ovale and ostium secundum or if the ostium primum fails to close, an atrial septal defect results. This defect does not cause cyanosis because oxygenated blood flows from left to right through the defect.
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This question is part of the following fields:
- Cardiology
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Question 28
Incorrect
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A fourth year medical student on a ward round with your team is inquiring about pacemakers.
Which of the following WOULD BE an indication for permanent pacemaker implantation?Your Answer:
Correct Answer: Third degree AV block (complete heart block)
Explanation:Understanding Indications for Permanent Pacemaker Insertion
A third degree AV block, also known as complete heart block, occurs when the atria and ventricles contract independently of each other. This can lead to syncope, chest pain, or signs of heart failure. Definitive treatment is the insertion of a permanent pacemaker. Other arrhythmias that may require permanent pacing include type 2 second-degree heart block (Mobitz II), sick sinus syndrome, and symptomatic slow atrial fibrillation. Ventricular tachycardia and ventricular fibrillation are not indications for pacing. Type 1 second degree (Mobitz I) AV block is a benign condition that does not require specific treatment. It is important to understand these indications for permanent pacemaker insertion for both exam and clinical purposes.
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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 62-year-old woman is being evaluated on the medical ward due to increasing episodes of dyspnoea, mainly on exertion. She has been experiencing fatigue more frequently over the past few months. Upon examination, she exhibits slight wheezing and bilateral pitting ankle oedema. Her medical history includes type I diabetes, rheumatoid arthritis, hypertension, recurrent UTIs, and hypothyroidism. Her current medications consist of insulin, methotrexate, nitrofurantoin, and amlodipine. She has never smoked, drinks two units of alcohol per week, and does not use recreational drugs. Blood tests reveal a haemoglobin level of 152 g/l, a white cell count of 4.7 × 109/l, a sodium level of 142 mmol/l, a potassium level of 4.6 mmol/l, a urea level of 5.4 mmol/l, and a creatinine level of 69 µmol/l. Additionally, her N-terminal pro-B-type natriuretic peptide (NT-proBNP) level is 350 pg/ml, which is higher than the normal value of < 100 pg/ml. What is the most probable diagnosis?
Your Answer:
Correct Answer: Cor pulmonale
Explanation:Differential Diagnosis: Cor Pulmonale vs. Other Conditions
Cor pulmonale, or right ventricular failure due to pulmonary heart disease, is the most likely diagnosis for a patient presenting with symptoms such as wheeze, increasing fatigue, and pitting edema. The patient’s history of taking drugs known to cause pulmonary fibrosis, such as methotrexate and nitrofurantoin, supports this diagnosis. Aortic stenosis, asthma, COPD, and left ventricular failure are all possible differential diagnoses, but each has distinguishing factors that make them less likely. Aortic stenosis would not typically present with peripheral edema, while asthma and COPD do not fit with the patient’s lack of risk factors and absence of certain symptoms. Left ventricular failure is also less likely due to the absence of signs such as decreased breath sounds and S3 gallop on heart auscultation. Overall, cor pulmonale is the most likely diagnosis for this patient.
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This question is part of the following fields:
- Cardiology
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Question 30
Incorrect
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Which congenital cardiac defect is correctly matched with its associated syndrome from the following options?
Your Answer:
Correct Answer: Turner syndrome and coarctation of the aorta
Explanation:Common Cardiovascular Abnormalities Associated with Genetic Syndromes
Various genetic syndromes are associated with cardiovascular abnormalities. Turner syndrome is linked with coarctation of the aorta, aortic stenosis, bicuspid aortic valve, aortic dilation, and dissection. Marfan syndrome is associated with aortic root dilation, mitral valve prolapse, mitral regurgitation, and aortic dissection. Kartagener syndrome can lead to bicuspid aortic valve, dextrocardia, bronchiectasis, and infertility. However, congenital adrenal hyperplasia is not associated with congenital cardiac conditions. Finally, congenital rubella syndrome is linked with patent ductus arteriosus, atrial septal defect, and pulmonary stenosis.
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This question is part of the following fields:
- Cardiology
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