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Question 1
Incorrect
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With respect to the basilic vein, which statement is not true?
Your Answer: It joins the brachial vein to form the axillary vein
Correct Answer: Its deep anatomical location makes it unsuitable for use as an arteriovenous access site in fistula surgery
Explanation:A basilic vein transposition is a surgical procedure that utilizes it during arteriovenous fistula surgery.
The Basilic Vein: A Major Pathway of Venous Drainage for the Arm and Hand
The basilic vein is one of the two main pathways of venous drainage for the arm and hand, alongside the cephalic vein. It begins on the medial side of the dorsal venous network of the hand and travels up the forearm and arm. Most of its course is superficial, but it passes deep under the muscles midway up the humerus. Near the region anterior to the cubital fossa, the basilic vein joins the cephalic vein.
At the lower border of the teres major muscle, the anterior and posterior circumflex humeral veins feed into the basilic vein. It is often joined by the medial brachial vein before draining into the axillary vein. The basilic vein is continuous with the palmar venous arch distally and the axillary vein proximally. Understanding the path and function of the basilic vein is important for medical professionals in diagnosing and treating conditions related to venous drainage in the arm and hand.
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This question is part of the following fields:
- Cardiovascular System
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Question 2
Incorrect
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A 45-year-old patient has a cardiac output of 6 L/min and a heart rate of 60/min. Her end-diastolic left ventricular volume is 200ml. What is her left ventricular ejection fraction (LVEF)?
Your Answer: 25%
Correct Answer: 50%
Explanation:Cardiovascular physiology involves the study of the functions and processes of the heart and blood vessels. One important measure of heart function is the left ventricular ejection fraction, which is calculated by dividing the stroke volume (the amount of blood pumped out of the left ventricle with each heartbeat) by the end diastolic LV volume (the amount of blood in the left ventricle at the end of diastole) and multiplying by 100%. Another key measure is cardiac output, which is the amount of blood pumped by the heart per minute and is calculated by multiplying stroke volume by heart rate.
Pulse pressure is another important measure of cardiovascular function, which is the difference between systolic pressure (the highest pressure in the arteries during a heartbeat) and diastolic pressure (the lowest pressure in the arteries between heartbeats). Factors that can increase pulse pressure include a less compliant aorta (which can occur with age) and increased stroke volume.
Finally, systemic vascular resistance is a measure of the resistance to blood flow in the systemic circulation and is calculated by dividing mean arterial pressure (the average pressure in the arteries during a heartbeat) by cardiac output. Understanding these measures of cardiovascular function is important for diagnosing and treating cardiovascular diseases.
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This question is part of the following fields:
- Cardiovascular System
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Question 3
Incorrect
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An 85-year-old woman arrives at the emergency department with complaints of palpitations and difficulty breathing. During the examination, you observe an irregularly irregular pulse. After conducting an ECG, you discover the absence of P waves and a ventricular rate of 94 beats per minute. What specific part of the heart prevents a rapid atrial rate from transmitting to the ventricles?
Your Answer: Bundle of His
Correct Answer: Atrioventricular node
Explanation:The correct answer is the atrioventricular (AV) node, which is located within the atrioventricular septum near the septal cusp of the tricuspid valve. It regulates the spread of excitation from the atria to the ventricles.
The sinoatrial (SA) node is situated in the right atrium, at the top of the crista terminalis where the right atrium meets the superior vena cava. It is where cardiac impulses originate in a healthy heart.
The bundle of His is a group of specialized cardiac myocytes that transmit the electrical impulse from the AV node to the ventricles.
The Purkinje fibers are a collection of fibers that distribute the cardiac impulse throughout the muscular ventricular walls.
The bundle of Kent is not present in a healthy heart. It refers to the accessory pathway between the atria and ventricles that exists in Wolff-Parkinson-White (WPW) syndrome. This additional conduction pathway allows for fast conduction of impulses between the atria and ventricles, without the additional control of the AV node. This results in a type of supraventricular tachycardia known as an atrioventricular re-entrant tachycardia.
The patient in the above question has presented with palpitations and shortness of breath. An irregularly irregular pulse is highly indicative of atrial fibrillation (AF). ECG signs of atrial fibrillation include an irregularly irregular rhythm and absent P waves. In AF, the impulses from the fibrillating heart are typically prevented from reaching the ventricles by the AV node.
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.
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This question is part of the following fields:
- Cardiovascular System
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Question 4
Incorrect
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A 32-year-old male engineer presents to the emergency department after falling at work while climbing a flight of stairs. He reports experiencing shortness of breath during exertion for the past week, but denies chest pain, vomiting, or coughing up blood. The symptoms are not affected by changes in position or respiration.
The patient has no significant medical history except for a recent bout of self-resolving diarrhea. He is not taking any regular medications and has no known drug allergies. There is no relevant family history. He was recently informed that asbestos has been found in his apartment complex, where he has lived for eight years.
During the examination, the patient appears comfortable at rest. His heart rate is 87 beats per minute, blood pressure is 124/94 mmHg, oxygen saturation is 99% on room air, respiratory rate is 16 breaths per minute, and temperature is 39.1ºC.
A systolic and diastolic murmur is audible throughout the praecordium, with radiations to the axilla. There is tenderness over both nipples where he recently had them pierced, but no pain over the ribs.
The patient has visible needle marks over his antecubital fossa and reports being in recovery from intravenous drug use for the past four years. He admits to recreational marijuana smoking and consuming 24 units of alcohol per week.
An ECG taken on admission shows regular sinus rhythm. An echocardiogram reveals vegetations over the aortic and mitral valve, and blood cultures are positive for Staphylococcus aureus.
Based on the likely diagnosis, which feature in the patient's history is a potential risk factor?Your Answer: Binge alcohol consumption
Correct Answer: New piercing
Explanation:Infective endocarditis is the likely diagnosis, which can be suspected if there is a fever and a murmur. The presence of vegetations on echo and positive blood cultures that meet Duke criteria can confirm the diagnosis. Of the given options, the only known risk factor for infective endocarditis is getting a new piercing. Alcohol binging can increase the risk of alcoholic liver disease and dilated cardiomyopathy, while asbestos exposure can lead to asbestosis and mesothelioma. Marijuana smoking may be associated with psychosis and paranoia.
Aetiology of Infective Endocarditis
Infective endocarditis is a condition that affects patients with previously normal valves, rheumatic valve disease, prosthetic valves, congenital heart defects, intravenous drug users, and those who have recently undergone piercings. The strongest risk factor for developing infective endocarditis is a previous episode of the condition. The mitral valve is the most commonly affected valve.
The most common cause of infective endocarditis is Staphylococcus aureus, particularly in acute presentations and intravenous drug users. Historically, Streptococcus viridans was the most common cause, but this is no longer the case except in developing countries. Coagulase-negative Staphylococci such as Staphylococcus epidermidis are commonly found in indwelling lines and are the most common cause of endocarditis in patients following prosthetic valve surgery. Streptococcus bovis is associated with colorectal cancer, with the subtype Streptococcus gallolyticus being most linked to the condition.
Culture negative causes of infective endocarditis include prior antibiotic therapy, Coxiella burnetii, Bartonella, Brucella, and HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella). It is important to note that systemic lupus erythematosus and malignancy, specifically marantic endocarditis, can also cause non-infective endocarditis.
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This question is part of the following fields:
- Cardiovascular System
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Question 5
Incorrect
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A 30-year-old male arrives at the emergency department complaining of sudden dizziness and palpitations. His medical history reveals that he had infectious diarrhea a week ago and was prescribed a 10-day course of erythromycin. Upon examination, an ECG confirms fast atrial fibrillation. The physician decides to use amiodarone to convert the patient into sinus rhythm. What is one potential risk associated with the use of amiodarone in this patient?
Your Answer: Orange discoloration of body fluids
Correct Answer: Ventricular arrhythmias
Explanation:The risk of ventricular arrhythmias is increased when amiodarone and erythromycin are used together due to their ability to prolong the QT interval. Manufacturers advise against using multiple drugs that prolong QT interval to avoid this risk. WPW syndrome is a congenital condition that involves abnormal conductive cardiac tissue and can lead to reentrant tachycardia circuit in association with SVT. Amiodarone can cause a slate-grey appearance of the skin, while drugs like rifampicin can cause orange discoloration of body fluids. COPD is associated with multifocal atrial tachycardia.
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.
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This question is part of the following fields:
- Cardiovascular System
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Question 6
Incorrect
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A 65-year-old man presents to his GP with worsening breathlessness. He reports difficulty climbing stairs and sleeping, and finds it easier to sleep in his living room chair. He used to manage stairs fine a year ago, but now has to stop twice on the way up.
When asked about other symptoms, he reports feeling slightly wheezy and occasionally coughing up white sputum. He denies any weight loss. His medical history includes angina, non-diabetic hyperglycaemia, and hypertension. He has smoked 15 cigarettes per day since he was 25 and drinks around 5 pints of lager every Friday and Saturday night.
On examination, his oxygen saturations are 96%, respiratory rate 16/min at rest, heart rate 78/min, and blood pressure 141/88 mmHg. Bibasal crackles are heard on auscultation of his lungs.
What is the most likely diagnosis?Your Answer: Lung cancer
Correct Answer: Heart failure
Explanation:Orthopnoea is a distinguishing symptom that can help differentiate between heart failure and COPD in patients. While the symptoms may be non-specific, the presence of orthopnoea, or breathlessness when lying down, is a key indicator of heart failure rather than COPD.
Although the patient has a significant history of smoking, there are no other signs of lung cancer such as weight loss, persistent cough, or coughing up blood. However, it is recommended to conduct an urgent chest X-ray to rule out any serious underlying conditions.
In cases of occupational asthma, symptoms tend to worsen when exposed to triggers in the workplace and improve during time off. However, in this patient’s case, the symptoms have been gradually worsening over time.
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.
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This question is part of the following fields:
- Cardiovascular System
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Question 7
Incorrect
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A 50-year-old woman comes to you complaining of increased urinary frequency and lower abdominal pain. She has a medical history of hypertension that is managed with a high dose of ramipril.
Upon conducting a urine dipstick test, the results indicate a urinary tract infection. You prescribe a 5-day course of trimethoprim.
What blood test will require monitoring in this patient?Your Answer: Creatinine kinase
Correct Answer: Urea and electrolytes
Explanation:Patients taking ACE-inhibitors should be cautious when using trimethoprim as it can lead to life-threatening hyperkalaemia, which may result in sudden death. Therefore, it is essential to monitor the potassium levels regularly by conducting urea and electrolyte tests.
When using trimethoprim with methotrexate, it is crucial to monitor the complete blood count regularly due to the increased risk of myelosuppression. However, if the patient is only taking trimethoprim, there is no need to monitor troponins and creatine kinase.
Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.
While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.
Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.
The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.
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This question is part of the following fields:
- Cardiovascular System
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Question 8
Incorrect
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Where is the site of action of bendroflumethiazide in elderly patients?
Your Answer: Proximal convoluted tubules
Correct Answer: Proximal part of the distal convoluted tubules
Explanation:Thiazides and thiazide-like medications, such as indapamide, work by blocking the Na+-Cl− symporter at the start of the distal convoluted tubule, which inhibits the reabsorption of sodium.
Thiazide diuretics are medications that work by blocking the thiazide-sensitive Na+-Cl− symporter, which inhibits sodium reabsorption at the beginning of the distal convoluted tubule (DCT). This results in the loss of potassium as more sodium reaches the collecting ducts. While thiazide diuretics are useful in treating mild heart failure, loop diuretics are more effective in reducing overload. Bendroflumethiazide was previously used to manage hypertension, but recent NICE guidelines recommend other thiazide-like diuretics such as indapamide and chlorthalidone.
Common side effects of thiazide diuretics include dehydration, postural hypotension, and electrolyte imbalances such as hyponatremia, hypokalemia, and hypercalcemia. Other potential adverse effects include gout, impaired glucose tolerance, and impotence. Rare side effects may include thrombocytopenia, agranulocytosis, photosensitivity rash, and pancreatitis.
It is worth noting that while thiazide diuretics may cause hypercalcemia, they can also reduce the incidence of renal stones by decreasing urinary calcium excretion. According to current NICE guidelines, the management of hypertension involves the use of thiazide-like diuretics, along with other medications and lifestyle changes, to achieve optimal blood pressure control and reduce the risk of cardiovascular disease.
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This question is part of the following fields:
- Cardiovascular System
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Question 9
Incorrect
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A 68-year-old woman arrives at the emergency department with complaints of shortness of breath and palpitations. During the examination, you observe an irregularly irregular pulse. To check for signs of atrial fibrillation, you opt to conduct an ECG. In a healthy individual, where is the SA node located in the heart?
Your Answer: Left ventricle
Correct Answer: Right atrium
Explanation:The SA node is situated at the junction of the superior vena cava and the right atrium, and is responsible for initiating cardiac impulses in a healthy heart. The AV node, located in the atrioventricular septum, regulates the spread of excitation from the atria to the ventricles. The patient’s symptoms of palpitations and shortness of breath, along with an irregularly irregular pulse, strongly indicate atrial fibrillation. ECG findings consistent with atrial fibrillation include an irregularly irregular rhythm and the absence of P waves.
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.
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This question is part of the following fields:
- Cardiovascular System
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Question 10
Incorrect
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A man in his 50s arrives at the emergency department exhibiting signs of a stroke. After undergoing a CT angiogram, it is revealed that there is a constriction in the artery that provides blood to the right common carotid.
What is the name of the affected artery?Your Answer: Ascending aorta
Correct Answer: Brachiocephalic artery
Explanation:The largest branch from the aortic arch is the brachiocephalic artery, which originates from it. This artery gives rise to both the right subclavian artery and the right common carotid arteries. The brachiocephalic artery is supplied by the aortic arch, while the coronary arteries are supplied by the ascending aorta. Additionally, the coeliac trunk is a branch that stems from the abdominal aorta.
The Brachiocephalic Artery: Anatomy and Relations
The brachiocephalic artery is the largest branch of the aortic arch, originating at the apex of the midline. It ascends superiorly and posteriorly to the right, lying initially anterior to the trachea and then on its right-hand side. At the level of the sternoclavicular joint, it divides into the right subclavian and right common carotid arteries.
In terms of its relations, the brachiocephalic artery is anterior to the sternohyoid, sterno-thyroid, thymic remnants, left brachiocephalic vein, and right inferior thyroid veins. Posteriorly, it is related to the trachea, right pleura, right lateral, right brachiocephalic vein, superior part of the SVC, left lateral, thymic remnants, origin of left common carotid, inferior thyroid veins, and trachea at a higher level.
The brachiocephalic artery typically has no branches, but it may have the thyroidea ima artery. Understanding the anatomy and relations of the brachiocephalic artery is important for medical professionals, as it is a crucial vessel in the human body.
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This question is part of the following fields:
- Cardiovascular System
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