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  • Question 1 - An 80-year-old man visits his GP with complaints of worsening shortness of breath,...

    Correct

    • An 80-year-old man visits his GP with complaints of worsening shortness of breath, dry cough, and fatigue over the past 6 weeks. The patient reports having to stop multiple times during his daily walk to catch his breath and sleeping with an extra pillow at night to aid his breathing. He has a medical history of hypertension and a smoking history of 30 pack-years. His current medications include ramipril, amlodipine, and atorvastatin.

      During the examination, the GP observes end-inspiratory crackles at both lung bases. The patient's oxygen saturation is 94% on room air, his pulse is regular at 110 /min, and his respiratory rate is 24 /min.

      What is the most probable underlying diagnosis?

      Your Answer: Chronic heart failure

      Explanation:

      Orthopnoea is a useful indicator to distinguish between heart failure and COPD.

      The Framingham diagnostic criteria for heart failure include major criteria such as acute pulmonary oedema and cardiomegaly, as well as minor criteria like ankle oedema and dyspnoea on exertion. Other minor criteria include hepatomegaly, nocturnal cough, pleural effusion, tachycardia (>120 /min), neck vein distension, and a third heart sound.

      In this case, the patient exhibits orthopnoea (needing an extra pillow to alleviate breathlessness), rales (crackles heard during inhalation), and dyspnoea on exertion, all of which are indicative of heart failure.

      While COPD can present with similar symptoms such as coughing, fatigue, shortness of breath, and desaturation, the presence of orthopnoea helps to differentiate between the two conditions.

      Pulmonary fibrosis, on the other hand, does not typically present with orthopnoea.

      Features of Chronic Heart Failure

      Chronic heart failure is a condition that affects the heart’s ability to pump blood effectively. It is characterized by several features that can help in its diagnosis. Dyspnoea, or shortness of breath, is a common symptom of chronic heart failure. Patients may also experience coughing, which can be worse at night and accompanied by pink or frothy sputum. Orthopnoea, or difficulty breathing while lying down, and paroxysmal nocturnal dyspnoea, or sudden shortness of breath at night, are also common symptoms.

      Another feature of chronic heart failure is the presence of a wheeze, known as a cardiac wheeze. Patients may also experience weight loss, known as cardiac cachexia, which occurs in up to 15% of patients. However, this may be hidden by weight gained due to oedema. On examination, bibasal crackles may be heard, and signs of right-sided heart failure, such as a raised JVP, ankle oedema, and hepatomegaly, may be present.

      In summary, chronic heart failure is a condition that can be identified by several features, including dyspnoea, coughing, orthopnoea, paroxysmal nocturnal dyspnoea, wheezing, weight loss, bibasal crackles, and signs of right-sided heart failure. Early recognition and management of these symptoms can help improve outcomes for patients with chronic heart failure.

    • This question is part of the following fields:

      • Cardiovascular System
      20.9
      Seconds
  • Question 2 - A 70-year-old man has a brain mass, but there is no rise in...

    Incorrect

    • A 70-year-old man has a brain mass, but there is no rise in intracranial pressure. What could be the reason for the absence of increased intracranial pressure?

      Your Answer: Reduced systolic blood pressure

      Correct Answer: Reduced CSF as dictated by the Monro-Kelly Doctrine

      Explanation:

      The Monro-Kelly Doctrine views the brain as a closed box, where any increase in one of the three components within the skull (brain, CSF, and blood) must be compensated by a decrease in one of the other components or else intracranial pressure will rise. To maintain intracranial pressure, changes in CSF volume can offset initial increases in brain volume. The CNS has the ability to regulate its own blood supply, so changes in diastolic and systolic pressure do not affect cerebral pressure. Cushing’s triad, which includes hypertension, bradycardia, and irregular breathing, is a set of symptoms that typically occur in the final stages of acute head injury due to increased intracranial pressure.

      Understanding Cerebral Blood Flow and Angiography

      Cerebral blood flow is regulated by the central nervous system, which can adjust its own blood supply. Various factors can affect cerebral pressure, including CNS metabolism, trauma, pressure, and systemic carbon dioxide levels. The most potent mediator is PaCO2, while acidosis and hypoxemia can also increase cerebral blood flow to a lesser degree. In patients with head injuries, increased intracranial pressure can impair blood flow. The Monro-Kelly Doctrine governs intracerebral pressure, which considers the brain as a closed box, and changes in pressure are offset by the loss of cerebrospinal fluid. However, when this is no longer possible, intracranial pressure rises.

      Cerebral angiography is an invasive test that involves injecting contrast media into the carotid artery using a catheter. Radiographs are taken as the dye works its way through the cerebral circulation. This test can be used to identify bleeding aneurysms, vasospasm, and arteriovenous malformations, as well as differentiate embolism from large artery thrombosis. Understanding cerebral blood flow and angiography is crucial in diagnosing and treating various neurological conditions.

    • This question is part of the following fields:

      • Cardiovascular System
      43
      Seconds
  • Question 3 - A 20-year-old man undergoes a routine ECG during his employment health check. The...

    Incorrect

    • A 20-year-old man undergoes a routine ECG during his employment health check. The ECG reveals sinus arrhythmia with varying P-P intervals and slight changes in the ventricular rate. The P waves exhibit normal morphology, and the P-R interval remains constant. The patient has a history of asthma and has been using inhalers more frequently due to an increase in running mileage. What is the probable cause of this rhythm, and how would you reassure the patient about the ECG results?

      Your Answer: Use of salbutamol inhaler before appointment

      Correct Answer: Ventricular rate changes with ventilation

      Explanation:

      Sinus arrhythmia is a natural occurrence that is commonly observed in young and healthy individuals. It is characterized by a fluctuation in heart rate during breathing, with an increase in heart rate during inhalation and a decrease during exhalation. This is due to a decrease in vagal tone during inspiration and an increase during expiration. The P-R interval remains constant, indicating no heart block, while the varying P-P intervals reflect changes in the ventricular heart rate.

      While anxiety may cause tachycardia, it cannot explain the fluctuation in P-P intervals. Similarly, salbutamol may cause a brief increase in heart rate, but this would not result in varying P-P and P-R intervals. In healthy and fit individuals, there should be no variation in the firing of the sino-atrial node.

      Understanding the Normal ECG

      The electrocardiogram (ECG) is a diagnostic tool used to assess the electrical activity of the heart. The normal ECG consists of several waves and intervals that represent different phases of the cardiac cycle. The P wave represents atrial depolarization, while the QRS complex represents ventricular depolarization. The ST segment represents the plateau phase of the ventricular action potential, and the T wave represents ventricular repolarization. The Q-T interval represents the time for both ventricular depolarization and repolarization to occur.

      The P-R interval represents the time between the onset of atrial depolarization and the onset of ventricular depolarization. The duration of the QRS complex is normally 0.06 to 0.1 seconds, while the duration of the P wave is 0.08 to 0.1 seconds. The Q-T interval ranges from 0.2 to 0.4 seconds depending upon heart rate. At high heart rates, the Q-T interval is expressed as a ‘corrected Q-T (QTc)’ by taking the Q-T interval and dividing it by the square root of the R-R interval.

      Understanding the normal ECG is important for healthcare professionals to accurately interpret ECG results and diagnose cardiac conditions. By analyzing the different waves and intervals, healthcare professionals can identify abnormalities in the electrical activity of the heart and provide appropriate treatment.

    • This question is part of the following fields:

      • Cardiovascular System
      183.6
      Seconds
  • Question 4 - A 63-year-old woman is prescribed furosemide for ankle swelling. During routine monitoring, a...

    Correct

    • A 63-year-old woman is prescribed furosemide for ankle swelling. During routine monitoring, a blood test reveals an abnormality and an ECG shows new U waves, which were not present on a previous ECG. What electrolyte imbalance could be responsible for these symptoms and ECG changes?

      Your Answer: Hypokalaemia

      Explanation:

      The correct answer is hypokalaemia, which can be a side effect of furosemide. This condition is characterized by U waves on ECG, as well as small or absent T waves, prolonged PR interval, ST depression, and/or long QT. Hypercalcaemia, on the other hand, can cause shortening of the QT interval and J waves in severe cases. Hyperkalaemia is associated with tall-tented T waves, loss of P waves, broad QRS complexes, sinusoidal wave pattern, and/or ventricular fibrillation, and can be caused by various factors such as acute or chronic kidney disease, medications, diabetic ketoacidosis, and Addison’s disease. Hypernatraemia, which can be caused by dehydration or diabetes insipidus, does not typically result in ECG changes.

      Hypokalaemia, a condition characterized by low levels of potassium in the blood, can be detected through ECG features. These include the presence of U waves, small or absent T waves (which may occasionally be inverted), a prolonged PR interval, ST depression, and a long QT interval. The ECG image provided shows typical U waves and a borderline PR interval. To remember these features, one user suggests the following rhyme: In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT.

    • This question is part of the following fields:

      • Cardiovascular System
      16.3
      Seconds
  • Question 5 - Which section of the ECG indicates atrial depolarization? ...

    Correct

    • Which section of the ECG indicates atrial depolarization?

      Your Answer: P wave

      Explanation:

      The depolarization of the atria is represented by the P wave. It should be noted that the QRS complex makes it difficult to observe the repolarization of the atria.

      Understanding the Normal ECG

      The electrocardiogram (ECG) is a diagnostic tool used to assess the electrical activity of the heart. The normal ECG consists of several waves and intervals that represent different phases of the cardiac cycle. The P wave represents atrial depolarization, while the QRS complex represents ventricular depolarization. The ST segment represents the plateau phase of the ventricular action potential, and the T wave represents ventricular repolarization. The Q-T interval represents the time for both ventricular depolarization and repolarization to occur.

      The P-R interval represents the time between the onset of atrial depolarization and the onset of ventricular depolarization. The duration of the QRS complex is normally 0.06 to 0.1 seconds, while the duration of the P wave is 0.08 to 0.1 seconds. The Q-T interval ranges from 0.2 to 0.4 seconds depending upon heart rate. At high heart rates, the Q-T interval is expressed as a ‘corrected Q-T (QTc)’ by taking the Q-T interval and dividing it by the square root of the R-R interval.

      Understanding the normal ECG is important for healthcare professionals to accurately interpret ECG results and diagnose cardiac conditions. By analyzing the different waves and intervals, healthcare professionals can identify abnormalities in the electrical activity of the heart and provide appropriate treatment.

    • This question is part of the following fields:

      • Cardiovascular System
      6.6
      Seconds
  • Question 6 - A 78-year-old male patient with AF, who is on appropriate medication for rate...

    Incorrect

    • A 78-year-old male patient with AF, who is on appropriate medication for rate control, is admitted with dig toxicity after receiving antibiotics for a UTI. What ECG finding is most probable?

      Your Answer: Increased QT interval

      Correct Answer: Reverse tick abnormality

      Explanation:

      Dig Toxicity and its Treatment

      Dig Toxicity can occur as a result of taking antibiotics that inhibit enzymes, especially if the prescribing physician does not take this into account. One of the most common signs of dig toxicity is the reverse tick abnormality, which can be detected through an electrocardiogram (ECG).

      To treat dig toxicity, it is important to first address any electrolyte imbalances that may be present. In more severe cases, a monoclonal antibody called digibind may be administered to help alleviate symptoms. Overall, it is important for healthcare providers to be aware of the potential for dig toxicity and to take appropriate measures to prevent and treat it.

    • This question is part of the following fields:

      • Cardiovascular System
      24.3
      Seconds
  • Question 7 - An 80-year-old man is admitted to the acute medical ward after experiencing a...

    Correct

    • An 80-year-old man is admitted to the acute medical ward after experiencing a myocardial infarction. During examination, it is discovered that his heart rate is 40 beats per minute. The consultant explains that this is due to damage to the conduction pathways between the sinoatrial and atrioventricular (AV) node, resulting in the AV node pacing his ventricles exclusively.

      In most patients, what is the blood supply to the AV node?

      Your Answer: Right coronary artery

      Explanation:

      The AV node is typically supplied by the right coronary artery in right-dominant hearts, while in left-dominant hearts it is supplied by the left circumflex artery. The left circumflex artery also supplies the left atrium and some of the left ventricle, while the right marginal artery supplies the right ventricle, the posterior descending artery supplies the posterior third of the interventricular septum, and the left anterior descending artery supplies the left ventricle.

      The walls of each cardiac chamber are made up of the epicardium, myocardium, and endocardium. The heart and roots of the great vessels are related anteriorly to the sternum and the left ribs. The coronary sinus receives blood from the cardiac veins, and the aortic sinus gives rise to the right and left coronary arteries. The left ventricle has a thicker wall and more numerous trabeculae carnae than the right ventricle. The heart is innervated by autonomic nerve fibers from the cardiac plexus, and the parasympathetic supply comes from the vagus nerves. The heart has four valves: the mitral, aortic, pulmonary, and tricuspid valves.

    • This question is part of the following fields:

      • Cardiovascular System
      107.6
      Seconds
  • Question 8 - A 4-year-old boy is observed by his mother to turn blue around the...

    Incorrect

    • A 4-year-old boy is observed by his mother to turn blue around the lips abruptly after crying. This has occurred several times before and the child promptly assumes the squatting position to alleviate his symptoms. During previous check-ups, the child was found to have various heart issues, including a boot-shaped heart on his chest x-ray.

      What is the probable diagnosis for his condition and what is the underlying cause?

      Your Answer: Failure of the endocardial cushion to develop

      Correct Answer: Failed migration of the neural crest cells

      Explanation:

      The division of the truncus arteriosus into the aorta and pulmonary trunk is dependent on the migration of neural crest cells from the pharyngeal arches. If this process is disrupted, it can lead to Tetralogy of Fallot, which is likely the condition that the patient in question is experiencing. The patient’s frequent ‘tet’ spells and adoption of a squatting position are indicative of this condition, as is the boot-shaped heart seen on chest x-ray due to right ventricular hypertrophy. Other conditions that can result from failed neural crest cell migration include transposition of the great vessels and persistent truncus arteriosus.

      On the other hand, a VSD is associated with a failure of the endocardial cushion, but this would not explain all of the patient’s malformations. Similarly, defects in the ostium primum or secundum would result in an ASD, which is often asymptomatic.

      During cardiovascular embryology, the heart undergoes significant development and differentiation. At around 14 days gestation, the heart consists of primitive structures such as the truncus arteriosus, bulbus cordis, primitive atria, and primitive ventricle. These structures give rise to various parts of the heart, including the ascending aorta and pulmonary trunk, right ventricle, left and right atria, and majority of the left ventricle. The division of the truncus arteriosus is triggered by neural crest cell migration from the pharyngeal arches, and any issues with this migration can lead to congenital heart defects such as transposition of the great arteries or tetralogy of Fallot. Other structures derived from the primitive heart include the coronary sinus, superior vena cava, fossa ovalis, and various ligaments such as the ligamentum arteriosum and ligamentum venosum. The allantois gives rise to the urachus, while the umbilical artery becomes the medial umbilical ligaments and the umbilical vein becomes the ligamentum teres hepatis inside the falciform ligament. Overall, cardiovascular embryology is a complex process that involves the differentiation and development of various structures that ultimately form the mature heart.

    • This question is part of the following fields:

      • Cardiovascular System
      18.2
      Seconds
  • Question 9 - A nursing student is being consented for a parathyroidectomy for symptomatic hyperparathyroidism. The...

    Incorrect

    • A nursing student is being consented for a parathyroidectomy for symptomatic hyperparathyroidism. The parathyroid gland consists of 2 superior and 2 inferior glands. The patient is informed that all four glands will be removed in order to achieve a complete resolution of her symptoms. You explain to her that the superior and inferior glands are derived from different structures.

      From which one of the following embryological structures are the superior parathyroid glands derived from?

      Your Answer: Fifth pharyngeal pouch

      Correct Answer: Fourth pharyngeal pouch

      Explanation:

      The superior parathyroid glands are formed from the fourth pharyngeal pouch during embryonic development. The pharyngeal pouches develop between the branchial arches, with the first pouch located between the first and second arches. There are four pairs of pouches, with the fifth pouch being either absent or very small. A helpful mnemonic to remember the derivatives of the four pharyngeal pouches is 1A, 2P, 3 TIP, 4 SUB. This stands for the auditory tube, middle ear cavity, and mastoid antrum for the first pouch; the crypts of the palatine tonsil for the second pouch; the thymus and inferior parathyroid gland for the third pouch; and the superior parathyroid gland and ultimobranchial body for the fourth pouch.

      Anatomy and Development of the Parathyroid Glands

      The parathyroid glands are four small glands located posterior to the thyroid gland within the pretracheal fascia. They develop from the third and fourth pharyngeal pouches, with those derived from the fourth pouch located more superiorly and associated with the thyroid gland, while those from the third pouch lie more inferiorly and may become associated with the thymus.

      The blood supply to the parathyroid glands is derived from the inferior and superior thyroid arteries, with a rich anastomosis between the two vessels. Venous drainage is into the thyroid veins. The parathyroid glands are surrounded by various structures, with the common carotid laterally, the recurrent laryngeal nerve and trachea medially, and the thyroid anteriorly. Understanding the anatomy and development of the parathyroid glands is important for their proper identification and preservation during surgical procedures.

    • This question is part of the following fields:

      • Cardiovascular System
      4.4
      Seconds
  • Question 10 - A 49-year-old male has sustained a facial burn at work. During the morning...

    Correct

    • A 49-year-old male has sustained a facial burn at work. During the morning ward round, it is observed in the surgeon's notes that the facial artery has good arterial blood supply, leading to hope for satisfactory healing. What is the name of the major artery that the facial artery branches off from?

      Your Answer: External carotid artery

      Explanation:

      The facial artery is the primary source of blood supply to the face, originating from the external carotid artery after the lingual artery. It follows a winding path and terminates as the angular artery at the inner corner of the eye.

      The internal carotid artery provides blood to the front and middle parts of the brain, while the vertebral artery, a branch of the subclavian artery, supplies the spinal cord, cerebellum, and back part of the brain. The brachiocephalic artery supplies the right side of the head and arm, giving rise to the subclavian and common carotid arteries on the right side.

      Anatomy of the External Carotid Artery

      The external carotid artery begins on the side of the pharynx and runs in front of the internal carotid artery, behind the posterior belly of digastric and stylohyoid muscles. It is covered by sternocleidomastoid muscle and passed by hypoglossal nerves, lingual and facial veins. The artery then enters the parotid gland and divides into its terminal branches within the gland.

      To locate the external carotid artery, an imaginary line can be drawn from the bifurcation of the common carotid artery behind the angle of the jaw to a point in front of the tragus of the ear.

      The external carotid artery has six branches, with three in front, two behind, and one deep. The three branches in front are the superior thyroid, lingual, and facial arteries. The two branches behind are the occipital and posterior auricular arteries. The deep branch is the ascending pharyngeal artery. The external carotid artery terminates by dividing into the superficial temporal and maxillary arteries within the parotid gland.

    • This question is part of the following fields:

      • Cardiovascular System
      7.9
      Seconds
  • Question 11 - The cephalic vein penetrates the clavipectoral fascia to end in which of the...

    Correct

    • The cephalic vein penetrates the clavipectoral fascia to end in which of the following veins mentioned below?

      Your Answer: Axillary

      Explanation:

      The Cephalic Vein: Path and Connections

      The cephalic vein is a major blood vessel that runs along the lateral side of the arm. It begins at the dorsal venous arch, which drains blood from the hand and wrist, and travels up the arm, crossing the anatomical snuffbox. At the antecubital fossa, the cephalic vein is connected to the basilic vein by the median cubital vein. This connection is commonly used for blood draws and IV insertions.

      After passing through the antecubital fossa, the cephalic vein continues up the arm and pierces the deep fascia of the deltopectoral groove to join the axillary vein. This junction is located near the shoulder and marks the end of the cephalic vein’s path.

      Overall, the cephalic vein plays an important role in the circulation of blood in the upper limb. Its connections to other major veins in the arm make it a valuable site for medical procedures, while its path through the deltopectoral groove allows it to contribute to the larger network of veins that drain blood from the upper body.

    • This question is part of the following fields:

      • Cardiovascular System
      16.2
      Seconds
  • Question 12 - A 57-year-old man is diagnosed with angina and prescribed medications for symptom control...

    Incorrect

    • A 57-year-old man is diagnosed with angina and prescribed medications for symptom control and secondary prevention. The doctor advises him to make dietary changes to address excess fat in the blood that can lead to angina. During the explanation, the doctor asks which apolipoprotein macrophages recognize to uptake lipids under normal circumstances?

      Your Answer: ApoA-II

      Correct Answer: ApoB100

      Explanation:

      Understanding Atherosclerosis and its Complications

      Atherosclerosis is a complex process that occurs over several years. It begins with endothelial dysfunction triggered by factors such as smoking, hypertension, and hyperglycemia. This leads to changes in the endothelium, including inflammation, oxidation, proliferation, and reduced nitric oxide bioavailability. As a result, low-density lipoprotein (LDL) particles infiltrate the subendothelial space, and monocytes migrate from the blood and differentiate into macrophages. These macrophages then phagocytose oxidized LDL, slowly turning into large ‘foam cells’. Smooth muscle proliferation and migration from the tunica media into the intima result in the formation of a fibrous capsule covering the fatty plaque.

      Once a plaque has formed, it can cause several complications. For example, it can form a physical blockage in the lumen of the coronary artery, leading to reduced blood flow and oxygen to the myocardium, resulting in angina. Alternatively, the plaque may rupture, potentially causing a complete occlusion of the coronary artery and resulting in a myocardial infarction. It is essential to understand the process of atherosclerosis and its complications to prevent and manage cardiovascular diseases effectively.

    • This question is part of the following fields:

      • Cardiovascular System
      4.2
      Seconds
  • Question 13 - Which one of the following is not considered a major branch of the...

    Incorrect

    • Which one of the following is not considered a major branch of the ascending thoracic aorta?

      Your Answer: Posterior intercostal artery

      Correct Answer: Inferior thyroid artery

      Explanation:

      The thyrocervical trunk, which is a branch of the subclavian artery, is typically the source of the inferior thyroid artery.

      Anatomy of the Thoracic Aorta

      The thoracic aorta is a major blood vessel that originates from the fourth thoracic vertebrae and terminates at the twelfth thoracic vertebrae. It is located in the chest cavity and has several important relations with surrounding structures. Anteriorly, it is related to the root of the left lung, the pericardium, the oesophagus, and the diaphragm. Posteriorly, it is related to the vertebral column and the azygos vein. On the right side, it is related to the hemiazygos veins and the thoracic duct, while on the left side, it is related to the left pleura and lung.

      The thoracic aorta has several branches that supply blood to different parts of the body. The lateral segmental branches are the posterior intercostal arteries, which supply blood to the muscles and skin of the back. The lateral visceral branches are the bronchial arteries, which supply blood to the bronchial walls and lung, excluding the alveoli. The midline branches are the oesophageal arteries, which supply blood to the oesophagus.

      In summary, the thoracic aorta is an important blood vessel that supplies blood to various structures in the chest cavity. Its anatomy and relations with surrounding structures are crucial for understanding its function and potential clinical implications.

    • This question is part of the following fields:

      • Cardiovascular System
      7.9
      Seconds
  • Question 14 - Each of the following increases the production of endothelin, except for which one?...

    Incorrect

    • Each of the following increases the production of endothelin, except for which one?

      Your Answer: Mechanical shearing force

      Correct Answer: Prostacyclin

      Explanation:

      Understanding Endothelin and Its Role in Various Diseases

      Endothelin is a potent vasoconstrictor and bronchoconstrictor that is secreted by the vascular endothelium. Initially, it is produced as a prohormone and later converted to ET-1 by the action of endothelin converting enzyme. Endothelin interacts with a G-protein linked to phospholipase C, leading to calcium release. This interaction is thought to be important in the pathogenesis of many diseases, including primary pulmonary hypertension, cardiac failure, hepatorenal syndrome, and Raynaud’s.

      Endothelin is known to promote the release of angiotensin II, ADH, hypoxia, and mechanical shearing forces. On the other hand, it inhibits the release of nitric oxide and prostacyclin. Raised levels of endothelin are observed in primary pulmonary hypertension, myocardial infarction, heart failure, acute kidney injury, and asthma.

      In recent years, endothelin antagonists have been used to treat primary pulmonary hypertension. Understanding the role of endothelin in various diseases can help in the development of new treatments and therapies.

    • This question is part of the following fields:

      • Cardiovascular System
      25.6
      Seconds
  • Question 15 - A 2-year-old toddler is brought to the cardiology clinic by her mother due...

    Correct

    • A 2-year-old toddler is brought to the cardiology clinic by her mother due to concerns of episodes of turning blue, especially when laughing or crying. During the examination, the toddler is observed to have clubbing of the fingernails and confirmed to be cyanotic. Further investigation with an echocardiogram reveals a large ventricular septal defect, leading to a diagnosis of Eisenmenger's syndrome. What is the ultimate treatment for this condition?

      Your Answer: Heart- lung transplant

      Explanation:

      The most effective way to manage Eisenmenger’s syndrome is through a heart-lung transplant. Calcium-channel blockers can be used to decrease the strain on the right side of the circulation by increasing the right to left shunt. Antibiotics are also useful in preventing endocarditis. However, the use of oxygen as a long-term treatment is still a topic of debate and is not considered a definitive solution. Patients with Eisenmenger’s syndrome may also experience significant polycythemia, which may require venesection as a treatment option.

      Understanding Eisenmenger’s Syndrome

      Eisenmenger’s syndrome is a medical condition that occurs when a congenital heart defect leads to pulmonary hypertension, causing a reversal of a left-to-right shunt. This happens when the left-to-right shunt is not corrected, leading to the remodeling of the pulmonary microvasculature, which eventually obstructs pulmonary blood and causes pulmonary hypertension. The condition is commonly associated with ventricular septal defect, atrial septal defect, and patent ductus arteriosus.

      The original murmur may disappear, and patients may experience cyanosis, clubbing, right ventricular failure, haemoptysis, and embolism. Management of Eisenmenger’s syndrome requires heart-lung transplantation. It is essential to diagnose and treat the condition early to prevent complications and improve the patient’s quality of life. Understanding the causes, symptoms, and management of Eisenmenger’s syndrome is crucial for healthcare professionals to provide appropriate care and support to patients with this condition.

    • This question is part of the following fields:

      • Cardiovascular System
      15.1
      Seconds
  • Question 16 - A 50-year-old male is brought to the trauma unit following a car accident,...

    Incorrect

    • A 50-year-old male is brought to the trauma unit following a car accident, with an estimated blood loss of 1200ml. His vital signs are as follows: heart rate of 125 beats per minute, blood pressure of 125/100 mmHg, and he feels cold to the touch.

      Which component of his cardiovascular system has played the biggest role in maintaining his blood pressure stability?

      Your Answer: Veins

      Correct Answer: Arterioles

      Explanation:

      The highest resistance in the cardiovascular system is found in the arterioles, which means they contribute the most to the total peripheral resistance. In cases of compensated hypovolaemic shock, such as in this relatively young patient, the body compensates by increasing heart rate and causing peripheral vasoconstriction to maintain blood pressure.

      Arteriole vasoconstriction in hypovolaemic shock patients leads to an increase in total peripheral resistance, which in turn increases mean arterial blood pressure. This has a greater effect on diastolic blood pressure, resulting in a narrowing of pulse pressure and clinical symptoms such as cold peripheries and delayed capillary refill time.

      Capillaries are microscopic channels that provide blood supply to the tissues and are the primary site for gas and nutrient exchange. Venules, on the other hand, are small veins with diameters ranging from 8-100 micrometers and join multiple capillaries exiting from a capillary bed.

      The heart has four chambers and generates pressures of 0-25 mmHg on the right side and 0-120 mmHg on the left. The cardiac output is the product of heart rate and stroke volume, typically 5-6L per minute. The cardiac impulse is generated in the sino atrial node and conveyed to the ventricles via the atrioventricular node. Parasympathetic and sympathetic fibers project to the heart via the vagus and release acetylcholine and noradrenaline, respectively. The cardiac cycle includes mid diastole, late diastole, early systole, late systole, and early diastole. Preload is the end diastolic volume and afterload is the aortic pressure. Laplace’s law explains the rise in ventricular pressure during the ejection phase and why a dilated diseased heart will have impaired systolic function. Starling’s law states that an increase in end-diastolic volume will produce a larger stroke volume up to a point beyond which stroke volume will fall. Baroreceptor reflexes and atrial stretch receptors are involved in regulating cardiac output.

    • This question is part of the following fields:

      • Cardiovascular System
      26.5
      Seconds
  • Question 17 - A 20-year-old man experienced recurrent episodes of breathlessness and palpitations lasting approximately 20...

    Correct

    • A 20-year-old man experienced recurrent episodes of breathlessness and palpitations lasting approximately 20 minutes and resolving gradually. No unusual physical signs were observed. What is the probable cause of these symptoms?

      Your Answer: Panic attacks

      Explanation:

      Likely Diagnosis for Sudden Onset of Symptoms

      When considering the sudden onset of symptoms, drug abuse is an unlikely cause as the symptoms are short-lived and not accompanied by other common drug abuse symptoms. Paroxysmal SVT would present with sudden starts and stops, rather than a gradual onset. Personality disorder and thyrotoxicosis would both lead to longer-lasting symptoms and other associated symptoms. Therefore, the most likely diagnosis for sudden onset symptoms would be panic disorder. It is important to consider all possible causes and seek medical attention to properly diagnose and treat any underlying conditions.

    • This question is part of the following fields:

      • Cardiovascular System
      15.6
      Seconds
  • Question 18 - A 6-year-old boy is brought to the paediatrician by his parents due to...

    Correct

    • A 6-year-old boy is brought to the paediatrician by his parents due to a fever and sore throat that has been bothering him for the past 24 hours. The boy is experiencing significant discomfort in his throat and has been refusing to eat or drink. He does not report having a cough or a runny nose. The boy was delivered via spontaneous vaginal delivery and has been developing normally. He has two healthy older siblings. During the examination, the doctor observes that the boy's tonsils are inflamed and enlarged, with some white exudates, as well as enlarged cervical lymph nodes. The boy's temperature is 38.2 °C. The doctor informs the parents that the boy requires antibiotics to treat the current infection and prevent the risk of a severe complication commonly associated with this particular infection. What complication can be prevented with prompt antibiotic treatment?

      Your Answer: Acute rheumatic fever

      Explanation:

      Pharyngitis is the likely diagnosis for this patient based on their presenting symptoms. Group A streptococcus, also known as Streptococcus pyogenes, is a common cause of pharyngitis in young patients. One of the most concerning complications of this infection is acute rheumatic fever, which can lead to damage to the heart valves. Early antibiotic treatment can prevent the development of this serious condition.

      1: Septicemia can result from various bacterial infections, but it is not typically associated with Group A streptococcal pharyngitis. Additionally, septicemia is rare in patients with this type of pharyngitis, as the condition usually resolves on its own without treatment.

      2: Acute rheumatic fever is a serious complication of Group A streptococcal pharyngitis. It is an immune system reaction that damages the heart valves, particularly the mitral valve. Mitral valve regurgitation is common in the early stages of the disease, followed by mitral stenosis later on.

      3: Post-streptococcal glomerulonephritis is another possible complication of Group A streptococcal pharyngitis. Unlike acute rheumatic fever, however, prompt antibiotic treatment does not prevent its development.

      4: While Group A streptococcus can cause cellulitis, this is a separate condition from pharyngitis and is not a complication of the same bacterial infection.

      5:

      Rheumatic fever is a condition that occurs as a result of an immune response to a recent Streptococcus pyogenes infection, typically occurring 2-4 weeks after the initial infection. The pathogenesis of rheumatic fever involves the activation of the innate immune system, leading to antigen presentation to T cells. B and T cells then produce IgG and IgM antibodies, and CD4+ T cells are activated. This immune response is thought to be cross-reactive, mediated by molecular mimicry, where antibodies against M protein cross-react with myosin and the smooth muscle of arteries. This response leads to the clinical features of rheumatic fever, including Aschoff bodies, which are granulomatous nodules found in rheumatic heart fever.

      To diagnose rheumatic fever, evidence of recent streptococcal infection must be present, along with 2 major criteria or 1 major criterion and 2 minor criteria. Major criteria include erythema marginatum, Sydenham’s chorea, polyarthritis, carditis and valvulitis, and subcutaneous nodules. Minor criteria include raised ESR or CRP, pyrexia, arthralgia, and prolonged PR interval.

      Management of rheumatic fever involves antibiotics, typically oral penicillin V, as well as anti-inflammatories such as NSAIDs as first-line treatment. Any complications that develop, such as heart failure, should also be treated. It is important to diagnose and treat rheumatic fever promptly to prevent long-term complications such as rheumatic heart disease.

    • This question is part of the following fields:

      • Cardiovascular System
      173.5
      Seconds
  • Question 19 - A 23-year-old male university student presents to the emergency department with lightheadedness and...

    Incorrect

    • A 23-year-old male university student presents to the emergency department with lightheadedness and a fall an hour earlier, associated with loss of consciousness. He admits to being short of breath on exertion with chest pain for several months. The patient denies vomiting or haemoptysis. The symptoms are not exacerbated or relieved by any positional changes or during phases of respiration.

      He has no relevant past medical history, is not on any regular medications, and has no documented drug allergies. There is no relevant family history. He is a non-smoker and drinks nine unite of alcohol a week. He denies any recent travel or drug use.

      On examination, the patient appears to be comfortable at rest. His heart rate is 68/min, blood pressure 112/84 mmHg, oxygen saturation 99% on air, respiratory rate of 16 breaths per minute, temperature 36.7ºC.

      An ejection systolic murmur is audible throughout the praecordium, loudest over the sternum bilaterally. No heaves or thrills are palpable, and there are no radiations. The murmur gets louder when the patient is asked to perform the Valsalva manoeuvre. The murmur is noted as grade II. Lung fields are clear on auscultation. The abdomen is soft and non-tender, with bowel sounds present. His body mass index is 20 kg/m².

      His ECG taken on admission reveals sinus rhythm, with generalised deep Q waves and widespread T waves. There is evidence of left ventricular hypertrophy.

      What is the most likely diagnosis?

      Your Answer: Brugada syndrome

      Correct Answer: Hypertrophic obstructive cardiomyopathy

      Explanation:

      The patient’s symptoms and findings suggest the possibility of hypertrophic obstructive cardiomyopathy (HOCM), which is characterized by exertional dyspnea, chest pain, syncope, and ejection systolic murmur that is louder during Valsalva maneuver and quieter during squatting. The ECG changes observed are also consistent with HOCM. Given the patient’s young age, it is crucial to rule out this diagnosis as HOCM is a leading cause of sudden cardiac death in young individuals.

      Brugada syndrome, an autosomal dominant cause of sudden cardiac death in young people, may also present with unexplained falls. However, the absence of a family history of cardiac disease and the unlikely association with the murmur and ECG changes described make this diagnosis less likely. It is important to note that performing Valsalva maneuver in a patient with Brugada syndrome can be life-threatening due to the risk of arrhythmias such as ventricular fibrillation.

      Chagas disease, a parasitic disease prevalent in South America, is caused by an insect bite and has a long dormant period before causing ventricular damage. However, the patient’s age and absence of exposure to the disease make this diagnosis less likely.

      Myocardial infarction can cause central chest pain and ECG changes, but it is rare for it to present with falls. Moreover, the ECG changes observed are not typical of myocardial infarction. The patient’s young age and lack of cardiac risk factors also make this diagnosis less likely.

      Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disorder that affects muscle tissue and is inherited in an autosomal dominant manner. It is caused by mutations in genes that encode contractile proteins, with the most common defects involving the β-myosin heavy chain protein or myosin-binding protein C. HOCM is characterized by left ventricle hypertrophy, which leads to decreased compliance and cardiac output, resulting in predominantly diastolic dysfunction. Biopsy findings show myofibrillar hypertrophy with disorganized myocytes and fibrosis. HOCM is often asymptomatic, but exertional dyspnea, angina, syncope, and sudden death can occur. Jerky pulse, systolic murmurs, and double apex beat are also common features. HOCM is associated with Friedreich’s ataxia and Wolff-Parkinson White. ECG findings include left ventricular hypertrophy, non-specific ST segment and T-wave abnormalities, and deep Q waves. Atrial fibrillation may occasionally be seen.

    • This question is part of the following fields:

      • Cardiovascular System
      137.7
      Seconds
  • Question 20 - A 67-year-old woman has been prescribed amiodarone. She has been advised to take...

    Correct

    • A 67-year-old woman has been prescribed amiodarone. She has been advised to take higher doses initially and then switch to a lower maintenance dose for long-term use.

      What is the rationale behind this initial dosing regimen?

      Your Answer: Slow metabolism of amiodarone due to extensive lipid binding

      Explanation:

      A loading dose is necessary for amiodarone to achieve therapeutic levels quickly before transitioning to a maintenance dose. This is because a 50mg once daily maintenance dose would take a long time to reach the required 1000mg for therapeutic effect. The fast metabolism of amiodarone due to extensive protein binding, extensive hepatic P450 breakdown, and slow absorption via the enteral route are not the reasons for a loading regime.

      Amiodarone is a medication used to treat various types of abnormal heart rhythms. It works by blocking potassium channels, which prolongs the action potential and helps to regulate the heartbeat. However, it also has other effects, such as blocking sodium channels. Amiodarone has a very long half-life, which means that loading doses are often necessary. It should ideally be given into central veins to avoid thrombophlebitis. Amiodarone can cause proarrhythmic effects due to lengthening of the QT interval and can interact with other drugs commonly used at the same time. Long-term use of amiodarone can lead to various adverse effects, including thyroid dysfunction, corneal deposits, pulmonary fibrosis/pneumonitis, liver fibrosis/hepatitis, peripheral neuropathy, myopathy, photosensitivity, a ‘slate-grey’ appearance, thrombophlebitis, injection site reactions, and bradycardia. Patients taking amiodarone should be monitored regularly with tests such as TFT, LFT, U&E, and CXR.

    • This question is part of the following fields:

      • Cardiovascular System
      43.3
      Seconds

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