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Question 1
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During a routine GP check-up, a 33-year-old woman is found to have a mid-diastolic rumbling murmur accompanied by a loud first heart sound. What valvular abnormality is likely causing this?
Your Answer: Mitral stenosis
Explanation:Valvular Murmurs
Valvular murmurs are a common topic in medical exams, and it is crucial to have a good of them. The easiest way to approach them is by classifying them into systolic and diastolic murmurs. If the arterial valves, such as the aortic or pulmonary valves, are narrowed, ventricular contraction will cause turbulent flow, resulting in a systolic murmur. On the other hand, if these valves are incompetent, blood will leak back through the valve during diastole, causing a diastolic murmur.
Similarly, the atrioventricular valves, such as the mitral and tricuspid valves, can be thought of in the same way. If these valves are leaky, blood will be forced back into the atria during systole, causing a systolic murmur. If they are narrowed, blood will not flow freely from the atria to the ventricles during diastole, causing a diastolic murmur.
Therefore, a diastolic murmur indicates either aortic/pulmonary regurgitation or mitral/tricuspid stenosis. The loud first heart sound is due to increased force in closing the mitral or tricuspid valve, which suggests stenosis. the different types of valvular murmurs and their causes is essential for medical professionals to diagnose and treat patients accurately.
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This question is part of the following fields:
- Cardiology
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Question 2
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A 54-year-old man comes to his doctor for a regular check-up after experiencing a heart attack 6 weeks ago. During the examination, he appears unwell, sweaty, and clammy, and mentions feeling constantly feverish. His recent blood work reveals an elevated erythrocyte sedimentation rate (ESR) and anemia. What is the most probable post-heart attack complication that this man is experiencing?
Your Answer: Dressler’s syndrome
Explanation:Complications Following Myocardial Infarction
One of the complications that can occur 2-6 weeks after a myocardial infarction (MI) is Dressler’s syndrome. This autoimmune reaction happens as the myocardium heals and can present with pyrexia, pleuritic chest pain, and an elevated ESR. Pulmonary embolism is not suggested by this presentation. Another complication is myomalacia cordis, which occurs 3-14 days post-MI and involves the softening of dead muscles leading to rupture and death. Ventricular aneurysm may also form due to weakened myocardium, resulting in persistent ST elevation and left ventricular failure. Anticoagulation is necessary to prevent thrombus formation within the aneurysm and reduce the risk of stroke. Heart failure is unlikely to cause the above presentation and blood test results.
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This question is part of the following fields:
- Cardiology
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Question 3
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A 68-year-old man experienced acute kidney injury caused by rhabdomyolysis after completing his first marathon. He was started on haemodialysis due to uraemic pericarditis. What symptom or sign would indicate the presence of cardiac tamponade?
Your Answer: Pulsus paradoxus
Explanation:Understanding Pericarditis and Related Symptoms
Pericarditis is a condition characterized by inflammation of the pericardium, the sac surrounding the heart. One of the signs of pericarditis is pulsus paradoxus, which is a drop in systolic blood pressure of more than 10 mmHg during inspiration. This occurs when the pericardial effusion normalizes the wall pressures across all the chambers, causing the septum to bulge into the left ventricle, reducing stroke volume and blood pressure. Pleuritic chest pain is not a common symptom of pericarditis, and confusion is not related to pericarditis or incipient tamponade. A pericardial friction rub is an audible medical sign used in the diagnosis of pericarditis, while a pericardial knock is a pulse synchronous sound that can be heard in constrictive pericarditis. Understanding these symptoms can aid in the diagnosis and management of pericarditis.
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This question is part of the following fields:
- Cardiology
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Question 4
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You are asked to see a 63-year-old man who has been admitted overnight following a road traffic accident. He sustained extensive bruising to his chest from the steering wheel. The nurses are concerned as he has become hypotensive and tachycardic. There is a history of a previous inferior myocardial infarction some 7 years ago, but nil else of note. On examination his BP is 90/50 mmHg, pulse is 95/min and regular. He looks peripherally shut down. There are muffled heart sounds and pulsus paradoxus.
Investigations – arterial blood gas - reveal:
Investigation Result Normal Value
pH 7.29 7.35–7.45
pO2 11.9 kPa 11.2–14.0 kPa
pCO2 6.1 kPa 4.7–6.0 kPa
ECG Widespread anterior T wave inversion
Which of the following is the most likely diagnosis?Your Answer: Cardiac tamponade
Explanation:Differential Diagnosis for a Patient with Hypotension, Tachycardia, and Muffled Heart Sounds Following a Road Traffic Accident: Cardiac Tamponade, Myocarditis, NSTEMI, Pericarditis, and STEMI
A 67-year-old man presents with hypotension, tachycardia, and poor peripheral perfusion following a road traffic accident with a steering wheel injury. On examination, muffled heart sounds and pulsus paradoxus are noted, and an ECG shows widespread anterior T-wave inversion. The patient has a history of inferior wall MI seven years ago. Arterial blood gas analysis reveals respiratory acidosis.
The differential diagnosis includes cardiac tamponade, myocarditis, NSTEMI, pericarditis, and STEMI. While myocarditis can cause similar symptoms and ECG changes, the presence of muffled heart sounds and pulsus paradoxus suggests fluid in the pericardium and cardiac tamponade. NSTEMI and STEMI can also cause acute onset of symptoms and ECG changes, but the absence of ST elevation and the history of trauma make cardiac tamponade more likely. Pericarditis can cause muffled heart sounds and pulsus paradoxus, but the absence of peripheral hypoperfusion and the presence of non-specific ST-T changes on ECG make it less likely.
In conclusion, the clinical scenario is most consistent with traumatic cardiac tamponade, which requires urgent echocardiography for confirmation and possible guided pericardiocentesis.
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This question is part of the following fields:
- Cardiology
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Question 5
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A 55-year-old man is experiencing chest pain and shortness of breath three weeks after a myocardial infarction that was treated with percutaneous coronary intervention (PCI) for a proximal left anterior descending artery occlusion. On examination, he has a loud friction rub over the praecordium, bilateral pleural effusions on chest x-ray, and ST elevation on ECG. What is the most probable diagnosis?
Your Answer: Dressler's syndrome
Explanation:Dressler’s Syndrome
Dressler’s syndrome is a type of pericarditis that typically develops between two to six weeks after a person has experienced an anterior myocardial infarction or undergone heart surgery. This condition is believed to be caused by an autoimmune response to myocardial antigens. In simpler terms, the body’s immune system mistakenly attacks the heart tissue, leading to inflammation of the pericardium, which is the sac that surrounds the heart.
The symptoms of Dressler’s syndrome can vary from person to person, but they often include chest pain, fever, fatigue, and shortness of breath. In some cases, patients may also experience a cough, abdominal pain, or joint pain. Treatment for this condition typically involves the use of nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and manage pain. In severe cases, corticosteroids may be prescribed to help suppress the immune system.
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This question is part of the following fields:
- Cardiology
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Question 6
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You are urgently requested to assess a 23-year-old male who has presented to the Emergency department after confessing to consuming 14 units of alcohol and taking 2 ecstasy tablets tonight. He is alert and oriented but is experiencing palpitations. He denies any chest pain or difficulty breathing.
The patient's vital signs are as follows: heart rate of 180 beats per minute, regular rhythm, blood pressure of 115/80 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 99% on room air. An electrocardiogram (ECG) is performed and reveals an atrioventricular nodal re-entry tachycardia (SVT).
What would be your first course of action in terms of treatment?Your Answer: Vagal manoeuvres
Explanation:SVT is a type of arrhythmia that occurs above the ventricles and is commonly seen in patients in their 20s with alcohol and drug use as precipitating factors. Early evaluation of ABC is important, and vagal manoeuvres are recommended as the first line of treatment. Adenosine is the drug of choice if vagal manoeuvres fail, and DC cardioversion is required if signs of decompensation are present. Amiodarone is not a first-line treatment for regular narrow complex SVT.
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This question is part of the following fields:
- Cardiology
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Question 7
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A man in his early 40s comes to you with a rash. Upon examination, you notice that he has eruptive xanthoma. What is the most probable diagnosis?
Your Answer: Familial hypertriglyceridaemia
Explanation:Eruptive Xanthoma and its Association with Hypertriglyceridaemia and Diabetes Mellitus
Eruptive xanthoma is a skin condition that can occur in individuals with hypertriglyceridaemia and uncontrolled diabetes mellitus. Hypertriglyceridaemia is a condition characterized by high levels of triglycerides in the blood, which can be caused by a number of factors including genetics, diet, and lifestyle. Eruptive xanthoma is a type of xanthoma that appears as small, yellowish bumps on the skin, often in clusters.
Of the conditions listed, familial hypertriglyceridaemia is the most likely to be associated with eruptive xanthoma. This is a genetic condition that causes high levels of triglycerides in the blood, and can lead to a range of health problems including cardiovascular disease. Uncontrolled diabetes mellitus, which is characterized by high blood sugar levels, can also be a risk factor for eruptive xanthoma.
It is important for individuals with hypertriglyceridaemia or diabetes mellitus to manage their condition through lifestyle changes and medication, in order to reduce the risk of complications such as eruptive xanthoma. Regular monitoring and treatment can help to prevent the development of this skin condition and other related health problems.
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This question is part of the following fields:
- Cardiology
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Question 8
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An 82-year-old woman presents to her general practitioner with increasing shortness of breath on exertion and swelling of her ankles and lower legs. During examination, she appears alert and oriented, but has significant erythema of her malar area. Her cardiovascular system shows an irregular heart rate of 92-104 beats per minute with low volume, and a blood pressure of 145/90 mmHg lying and standing. Her jugular venous pressure is raised with a single waveform, and her apex beat is undisplaced and forceful in character. There is a soft mid-diastolic murmur heard during heart sounds 1 + 2. Bibasal crackles are present in her chest, and she has pitting peripheral edema to the mid-calf. Based on these findings, what is the most likely cause of her collapse?
Your Answer: Mitral stenosis
Explanation:Distinguishing Mitral Stenosis from Other Valvular Diseases: Exam Findings
Mitral stenosis is a condition that presents with symptoms of left and right ventricular failure, atrial fibrillation, and its complications. When examining a patient suspected of having mitral stenosis, there are several significant signs to look out for. These include a low-volume pulse, atrial fibrillation, normal pulse pressure and blood pressure, loss of ‘a’ waves and large v waves in the jugular venous pressure, an undisplaced, discrete/forceful apex beat, and a mid-diastolic murmur heard best with the bell at the apex. Additionally, patients with mitral stenosis often have signs of right ventricular dilation and secondary tricuspid regurgitation.
It is important to distinguish mitral stenosis from other valvular diseases, such as mixed mitral and aortic valve disease, aortic stenosis, aortic regurgitation, and mitral regurgitation. The examination findings for these conditions differ from those of mitral stenosis. For example, mixed mitral and aortic valve disease would not present with the same signs as mitral stenosis. Aortic stenosis presents with symptoms of left ventricular failure, angina, and an ejection systolic murmur radiating to the carotids. Aortic regurgitation causes an early diastolic murmur and a collapsing pulse on examination. Finally, mitral regurgitation causes a pan-systolic murmur radiating to the axilla. By understanding the unique examination findings for each valvular disease, healthcare professionals can accurately diagnose and treat their patients.
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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 25-year-old with cystic fibrosis was evaluated for cor pulmonale to determine eligibility for a deceased donor double-lung transplant.
What is the surface landmark used to identify right ventricular hypertrophy?Your Answer: Fifth intercostal space, mid-clavicular line
Correct Answer: Fourth intercostal space, left parasternal area
Explanation:Anatomical Landmarks for Cardiac Examination
When examining the heart, it is important to know the anatomical landmarks for locating specific valves and ventricles. Here are some key locations to keep in mind:
1. Fourth intercostal space, left parasternal area: This is the correct location for examining the tricuspid valve and the right ventricle, particularly when detecting a right ventricular heave.
2. Second intercostal space, left parasternal area: The pulmonary valve can be found at this location.
3. Second intercostal space, right parasternal area: The aortic valve is located here.
4. Fourth intercostal space, right parasternal area: In cases of true dextrocardia, the tricuspid valve and a right ventricular heave can be found at this location.
5. Fifth intercostal space, mid-clavicular line: This is the location of the apex beat, which can be examined for a left ventricular heave and the mitral valve.
Knowing these landmarks can help healthcare professionals accurately assess and diagnose cardiac conditions.
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This question is part of the following fields:
- Cardiology
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Question 10
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A 45-year-old man visits his GP for a routine check-up. He reports feeling well today but has a history of chronic respiratory tract infections and lung issues. He is immunocompetent.
During the examination, his temperature and blood pressure are normal. His heart rate is regular and his breathing is effortless. The GP detects a diastolic murmur with a snap that is most audible at the right fifth intercostal space in the mid-clavicular line.
What is the most probable diagnosis?Your Answer: Primary ciliary dyskinesia
Explanation:Possible Diagnosis for a Patient with Chronic Respiratory Infections and a Heart Murmur
Primary Ciliary Dyskinesia: A Congenital Syndrome of Ciliary Dysfunction
The patient described in the case likely has primary ciliary dyskinesia, also known as Kartagener’s syndrome, which is a congenital syndrome of ciliary dysfunction. This disorder affects the proper beating of Ciliary, leading to the accumulation of infectious material within the respiratory tree and abnormal cell migration during development, resulting in situs inversus. Additionally, abnormal Ciliary can lead to non-motile sperm and infertility.
Other Possible Diagnoses
Although the GP noticed a diastolic murmur suggestive of mitral stenosis, the patient does not have symptoms of congestive heart failure. Asthma could be associated with chronic lung and respiratory tract infections, but it would not explain the heart murmur. Squamous cell lung cancer is less likely in a man who is 40 years old with a normal respiratory examination and would not explain the heart murmur. Idiopathic pulmonary hypertension usually causes progressive breathlessness, a dry cough, and fine inspiratory crepitations on examination, rather than the picture here.
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This question is part of the following fields:
- Cardiology
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