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  • Question 1 - A 62-year-old woman is being evaluated on the medical ward due to increasing...

    Incorrect

    • 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: Left ventricular failure

      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.

    • This question is part of the following fields:

      • Cardiology
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  • Question 2 - A 55-year-old woman arrives at the emergency department with a two hour history...

    Correct

    • A 55-year-old woman arrives at the emergency department with a two hour history of central crushing chest pain. She has a history of ischaemic heart disease and poorly controlled diabetes. The ECG shows ST-elevation in V1, V2 and V3, and her serum troponin levels are elevated. What is the most suitable definitive management approach?

      Your Answer: Primary percutaneous coronary intervention (PCI)

      Explanation:

      Treatment Options for ST-Elevation Myocardial Infarction (STEMI)

      ST-Elevation Myocardial Infarction (STEMI) is a medical emergency that requires immediate intervention. The diagnosis of STEMI is confirmed through cardiac sounding chest pain and evidence of ST-elevation on the ECG. The primary treatment option for STEMI is immediate revascularization through primary percutaneous coronary intervention (PCI) and placement of a cardiac stent.

      Therapeutic alteplase, a thrombolytic agent, used to be a common treatment option for STEMI, but it has been largely replaced by primary PCI due to its superior therapeutic outcomes. Aspirin is routinely given in myocardial infarction, and clopidogrel may also be given, although many centers are now using ticagrelor instead.

      High-flow oxygen and intravenous morphine may be used for adequate analgesia and resuscitation, but the primary treatment remains primary PCI and revascularization. Routine use of high flow oxygen in non-hypoxic patients with an acute coronary syndrome is no longer advocated.

      It is crucial to avoid delaying treatment for STEMI, as it can lead to further deterioration of the patient and increase the risk of cardiac arrhythmia or arrest. Therefore, waiting for troponin results before further management is not an appropriate option. The diagnosis of STEMI can be made through history and ECG findings, and immediate intervention is necessary for optimal outcomes.

    • This question is part of the following fields:

      • Cardiology
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  • Question 3 - A 50-year-old man who is a known alcoholic is brought to the Emergency...

    Incorrect

    • A 50-year-old man who is a known alcoholic is brought to the Emergency Department after being found unconscious. Over several hours, he regains consciousness. His blood alcohol level is high and a head computerised tomography (CT) scan is negative, so you diagnose acute intoxication. A routine chest X-ray demonstrated an enlarged globular heart. An echocardiogram revealed a left ventricular ejection fraction of 45%.
      What is the most likely cause of his cardiac pathology, and what might gross examination of his heart reveal?

      Your Answer: Alcohol and dilation of the left ventricle with normal atria and right ventricle

      Correct Answer: Alcohol and dilation of all four chambers of the heart

      Explanation:

      Alcohol and its Effects on Cardiomyopathy: Understanding the Relationship

      Alcohol consumption has been linked to various forms of cardiomyopathy, a condition that affects the heart muscle. One of the most common types of cardiomyopathy is dilated cardiomyopathy, which is characterized by the dilation of all four chambers of the heart. This condition results in increased end-diastolic volume, decreased contractility, and depressed ejection fraction. Chronic alcohol use is a significant cause of dilated cardiomyopathy, along with viral infections, toxins, genetic mutations, and trypanosome infections.

      Chagas’ disease, caused by trypanosomes, can lead to cardiomyopathy, resulting in the dilation of all four chambers of the heart. On the other hand, alcoholic cardiomyopathy leads to the dilation of all four chambers of the heart, including the atria. Alcohol consumption can also cause concentric hypertrophy of the left ventricle, which is commonly seen in long-term hypertension. Asymmetric hypertrophy of the interventricular septum is another form of cardiomyopathy that can result from alcohol consumption. This condition is known as hypertrophic cardiomyopathy, a genetic disease that can lead to sudden cardiac death in young athletes.

      In conclusion, understanding the relationship between alcohol consumption and cardiomyopathy is crucial in preventing and managing this condition. It is essential to limit alcohol intake and seek medical attention if any symptoms of cardiomyopathy are present.

    • This question is part of the following fields:

      • Cardiology
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  • Question 4 - A 50-year-old man with hypertension and type II diabetes mellitus presented to the...

    Incorrect

    • A 50-year-old man with hypertension and type II diabetes mellitus presented to the Emergency Department with diaphoresis, severe central chest pain, and breathlessness. An ECG showed ST elevation in leads II, III, and aVF. Where is the probable location of the responsible arterial stenosis?

      Your Answer: Left anterior descending artery

      Correct Answer: Right coronary artery

      Explanation:

      Coronary Arteries and Their Associated Leads

      The heart is supplied with blood by the coronary arteries. Each artery supplies a specific area of the heart and can be identified by the leads on an electrocardiogram (ECG).

      The right coronary artery supplies the inferior part of the left ventricle, interventricular septum, and right ventricle. The circumflex artery predominantly supplies the left free wall of the left ventricle and would be picked up by leads I, aVL, and V5–6. The left anterior descending artery supplies the septum, apex, and anterior wall of the left ventricle and would be picked up by leads V1–4.

      Proximal aortic stenosis is very rare and would cause problems of perfusion in distal organs before reducing enough blood supply to the heart to cause a myocardial infarction. The left main stem splits into both the circumflex and left anterior descending arteries. Acute occlusion at this location would be catastrophic and a person is unlikely to survive to hospital. It would be picked up by leads V1–6, I, and aVL.

      Understanding the specific areas of the heart supplied by each coronary artery and their associated leads on an ECG can aid in the diagnosis and treatment of cardiac conditions.

    • This question is part of the following fields:

      • Cardiology
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  • Question 5 - A 54-year-old man comes to his doctor for a regular check-up after experiencing...

    Incorrect

    • 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: Myomalacia cordis

      Correct 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.

    • This question is part of the following fields:

      • Cardiology
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  • Question 6 - A 42-year-old man presents with central chest pain which is worse unless sitting...

    Incorrect

    • A 42-year-old man presents with central chest pain which is worse unless sitting forward. He says that the pain gets worse when he takes a deep breath in. There is no previous cardiac history and he is a non-smoker. Over the past few days, he has had a fever with cold and flu type symptoms.
      On examination, his blood pressure is 130/80 mmHg, and he has an audible pericardial rub.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 135 g/l 135–175 g/l
      Erythrocyte sedimentation rate (ESR) 40 mm/h 0–10mm in the 1st hour
      White cell count (WCC) 8.5 × 109/l 4–11 × 109/l
      Platelets 320 × 109/l 150–400 × 109/l
      Creatine kinase (CK) 190 IU/l 23–175 IU/l
      Total cholesterol 4.9 mmol/l < 5.2 mmol/l
      Electrocardiogram – saddle-shaped ST elevation across all leads.
      Which of the following diagnoses fits best with this clinical picture?

      Your Answer: Cardiac tamponade

      Correct Answer: Acute pericarditis

      Explanation:

      Differential Diagnosis of Chest Pain: Acute Pericarditis, Cardiac Tamponade, Myocarditis, Acute Myocardial Infarction, and Unstable Angina

      Chest pain can have various causes, and it is important to differentiate between them to provide appropriate treatment. In this case, the clinical history suggests acute pericarditis, which can be caused by viral infections or other factors. Management involves rest and analgesia, with non-steroidals being particularly effective. If there is no improvement, a tapering course of oral prednisolone may be helpful.

      Cardiac tamponade is another possible cause of chest pain, which is caused by fluid accumulation in the pericardial space. Patients may present with shortness of breath, hypotension, and muffled heart sounds. Beck’s triad includes a falling blood pressure, a rising JVP, and a small, quiet heart.

      Myocarditis can present with signs of heart failure but does not typically cause pain unless there is concurrent pericarditis. Acute myocardial infarction, on the other hand, typically presents with central chest pain that is not affected by inspiration. Unstable angina also causes central chest pain or discomfort at rest, which worsens over time if untreated. However, in this case, the patient has no risk factors for ischaemic heart disease, making it unlikely to be the cause of their symptoms.

      In summary, chest pain can have various causes, and it is important to consider the patient’s clinical history and risk factors to make an accurate diagnosis and provide appropriate treatment.

    • This question is part of the following fields:

      • Cardiology
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  • Question 7 - A 45-year-old man visits his GP for a routine check-up. He reports feeling...

    Incorrect

    • 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: Idiopathic pulmonary hypertension

      Correct 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.

    • This question is part of the following fields:

      • Cardiology
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  • Question 8 - A 72-year-old man is brought by ambulance to the Accident and Emergency department....

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Cardiology
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  • Question 9 - A 65-year-old moderately obese man is brought to the Emergency Department with complaints...

    Incorrect

    • A 65-year-old moderately obese man is brought to the Emergency Department with complaints of severe chest pain and shortness of breath. Upon physical examination, a pericardial tamponade is suspected and confirmed by an electrocardiogram (ECG) showing total electrical alternans and an echocardiogram revealing pericardial effusion. Which jugular vein is typically the most reliable indicator of central venous pressure (CVP)?

      Your Answer:

      Correct Answer: Right internal

      Explanation:

      The Best Vein for Measuring Central Venous Pressure

      Pericardial tamponade can lead to compression of the heart by the pericardium, resulting in decreased intracardiac diastolic pressure and reduced blood flow to the right atrium. This can cause distension of the jugular veins, making the right internal jugular vein the best vein for measuring central venous pressure (CVP). Unlike the right external vein, which joins the right internal vein at an oblique angle, the right internal vein has a straight continuation with the right brachiocephalic vein and the superior vena cava, making CVP measurement more accurate. On the other hand, the left internal jugular vein makes an oblique union with the left brachiocephalic vein and the external jugular veins, making it a less reliable indicator of CVP. Similarly, the left external vein also joins the left internal vein at an oblique angle, making CVP reading less reliable.

    • This question is part of the following fields:

      • Cardiology
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  • Question 10 - A 25-year-old woman attends a new patient health check at the General Practice...

    Incorrect

    • A 25-year-old woman attends a new patient health check at the General Practice surgery she has recently joined. She mentions she occasionally gets episodes of palpitations and light-headedness and has done so for several years. Her pulse is currently regular, with a rate of 70 bpm, and her blood pressure is 110/76 mmHg. A full blood count is sent, which comes back as normal. The general practitioner requests an electrocardiogram (ECG), which shows a widened QRS complex with a slurred upstroke and a shortened PR interval.
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Wolff–Parkinson–White syndrome

      Explanation:

      Common Cardiac Conditions and Their ECG Findings

      Wolff-Parkinson-White syndrome is a condition that affects young people and is characterized by episodes of syncope and palpitations. It is caused by an accessory pathway from the atria to the ventricles that bypasses the normal atrioventricular node. The ECG shows a slurred upstroke to the QRS complex, known as a delta wave, which reflects ventricular pre-excitation. Re-entry circuits can form, leading to tachyarrhythmias and an increased risk of ventricular fibrillation.

      Hypertrophic cardiomyopathy is an inherited condition that presents in young adulthood and is the most common cause of sudden cardiac death in the young. Symptoms include syncope, dyspnea, palpitations, and abnormal ECG findings, which may include conduction abnormalities, arrhythmias, left ventricular hypertrophy, and ST or T wave changes.

      First-degree heart block is characterized by a prolonged PR interval and may be caused by medication, electrolyte imbalances, or post-myocardial infarction. It may also be a normal variant in young, healthy individuals.

      Ebstein’s anomaly typically presents in childhood and young adulthood with fatigue, palpitations, cyanosis, and breathlessness on exertion. The ECG shows right bundle branch block and signs of atrial enlargement, such as tall, broad P waves.

      Mobitz type II atrioventricular block is a type of second-degree heart block that is characterized by a stable PR interval with some non-conducted beats. It often progresses to complete heart block. Mobitz type I (Wenckebach) block, on the other hand, is characterized by a progressively lengthening PR interval, followed by a non-conducted beat and a reset of the PR interval back to a shorter value.

    • This question is part of the following fields:

      • Cardiology
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SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiology (1/7) 14%
Passmed