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  • Question 1 - A 78-year-old female comes to the cardiology clinic complaining of persistent shortness of...

    Incorrect

    • A 78-year-old female comes to the cardiology clinic complaining of persistent shortness of breath that is hindering her daily activities. She has a medical history of dilated cardiomyopathy and is currently taking candesartan, bisoprolol, and furosemide. An echocardiogram reveals a left ventricular ejection fraction of 40%. What would be the most suitable long-term treatment to enhance this patient's prognosis?

      Your Answer: Ramipril

      Correct Answer: Spironolactone

      Explanation:

      The initial management for heart failure with reduced ejection fraction involves prescribing an ACE inhibitor (or ARB, as in this patient’s case) and a beta-blocker. However, since the patient’s symptoms are not under control despite taking these medications, it is recommended to add spironolactone (a mineralocorticoid receptor antagonist) to their treatment plan.

      Bendroflumethiazide is not a suitable long-term management option for heart failure, as thiazide and thiazide-like diuretics are not recommended.
      Diltiazem, a calcium channel blocker, is contraindicated for chronic heart failure.
      Dobutamine, an inotrope, may be used in acute decompensated heart failure but is not appropriate for stable management of chronic heart failure.
      Ramipril is not a suitable option for this patient as they are already taking candesartan, another angiotensin II receptor blocker.

      Drug Management for Chronic Heart Failure: NICE Guidelines

      Chronic heart failure is a serious condition that requires proper management to improve patient outcomes. In 2018, the National Institute for Health and Care Excellence (NICE) updated their guidelines on drug management for chronic heart failure. The guidelines recommend first-line therapy with both an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Second-line therapy involves the use of aldosterone antagonists, which should be monitored for hyperkalaemia. SGLT-2 inhibitors are also increasingly being used to manage heart failure with a reduced ejection fraction. Third-line therapy should be initiated by a specialist and may include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, or cardiac resynchronisation therapy. Other treatments such as annual influenza and one-off pneumococcal vaccines are also recommended.

      Overall, the NICE guidelines provide a comprehensive approach to drug management for chronic heart failure. It is important to note that loop diuretics have not been shown to reduce mortality in the long-term, and that ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction. Healthcare professionals should carefully consider the patient’s individual needs and circumstances when determining the appropriate drug therapy for chronic heart failure.

    • This question is part of the following fields:

      • Cardiovascular
      14.1
      Seconds
  • Question 2 - A 56-year-old female presents with an acutely painful hand. She has a history...

    Incorrect

    • A 56-year-old female presents with an acutely painful hand. She has a history of hypertension, Raynaud's phenomenon, and has smoked twenty cigarettes a day since she was twenty-two years old. She describes the pain as 'different from her usual Raynaud's,' there has been no relief of symptoms despite wearing gloves and making sure her hands are warm.

      Upon examination, her blood pressure is 158/80 mmHg, her right hand is blanched white and feels cold, and the colour of her forearm is normal. The radial pulse is not palpable at the wrist. What is the most likely explanation for her symptoms?

      Your Answer: Raynaud's phenomenon

      Correct Answer: Buerger's disease

      Explanation:

      If a patient with extremity ischaemia is diagnosed with Raynaud’s phenomenon, Buerger’s disease should be considered as a possible underlying condition. Buerger’s disease is a condition where the small and medium arteries in the hands and feet become inflamed and thrombosed, leading to acute or chronic progressive ischaemic changes and potentially gangrene. It is strongly associated with smoking. Osteoarthritis, on the other hand, presents with joint pain and swelling, typically in the wrist, knee, hip, or thumb base, and is more common with age. Radial artery dissection is unlikely in the given scenario as there is no history of traumatic injury. Raynaud’s phenomenon, which is characterised by transient vasospasm of the digits triggered by cold, is usually treated conservatively with warmth and sometimes calcium channel blockers in severe cases. It is mostly idiopathic but can be associated with underlying connective tissue disease.

      Understanding Buerger’s Disease

      Buerger’s disease, also known as thromboangiitis obliterans, is a type of vasculitis that affects the small and medium-sized blood vessels. This condition is strongly linked to smoking and can cause a range of symptoms, including extremity ischemia, intermittent claudication, ischaemic ulcers, superficial thrombophlebitis, and Raynaud’s phenomenon.

      Individuals with Buerger’s disease may experience reduced blood flow to their limbs, which can lead to pain, numbness, and tingling sensations. This can make it difficult to walk or perform other activities, and may even result in the development of ulcers or sores on the skin.

      Superficial thrombophlebitis, or inflammation of the veins close to the surface of the skin, is another common symptom of Buerger’s disease. This can cause redness, swelling, and tenderness in the affected area.

      Raynaud’s phenomenon, which is characterized by the narrowing of blood vessels in the fingers and toes, is also associated with Buerger’s disease. This can cause the affected areas to turn white or blue and feel cold and numb.

    • This question is part of the following fields:

      • Cardiovascular
      25.8
      Seconds
  • Question 3 - A 55-year-old caucasian man comes in for his annual hypertension check-up. He has...

    Correct

    • A 55-year-old caucasian man comes in for his annual hypertension check-up. He has already completed a blood pressure diary at home, which shows an average daytime reading of 160/100 mmHg. During his visit today, his blood pressure is measured at 174/110 mmHg. He is currently taking ramipril 10mg daily and is fully compliant with his medication.

      In addition to hypertension, he has a history of recurrent gout and takes allopurinol for it. He has no other medical issues. Since his hypertension diagnosis, he has quit smoking and has taken steps to improve his lifestyle.

      What would be the most appropriate course of action?

      Your Answer: Add nifedipine

      Explanation:

      If a patient with hypertension is already on an ACE inhibitor and has a history of gout, it would be more appropriate to prescribe a calcium channel blocker rather than a thiazide as the next step in treatment. Nifedipine is the recommended choice for this patient. The target blood pressure for adults under 80 years old with hypertension is below 140/90 mmHg. If a single medication is not controlling the patient’s blood pressure, a second agent should be considered after checking treatment adherence. For a Caucasian man under 55 years old, the first step in treatment is an ACE inhibitor or an ARB. The second step is the addition of a CCB or thiazide-like diuretic, depending on clinical factors. However, in this case, the patient’s history of gout makes nifedipine a more appropriate choice than bendroflumethiazide. Doxazosin is not recommended for stage 2 hypertension, and losartan should not be used together with an ACE inhibitor. Lifestyle changes and repeat blood pressure in 3 months are not sufficient at this stage, as a single medication may not be enough to control hypertension.

      NICE Guidelines for Managing Hypertension

      Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

      The guidelines also provide a flow chart for the diagnosis and management of hypertension. Lifestyle advice, such as reducing salt intake, caffeine intake, and alcohol consumption, as well as exercising more and losing weight, should not be forgotten and is frequently tested in exams. Treatment options depend on the patient’s age, ethnicity, and other factors, and may involve a combination of drugs.

      NICE recommends treating stage 1 hypertension in patients under 80 years old if they have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For patients with stage 2 hypertension, drug treatment should be offered regardless of age. The guidelines also provide step-by-step treatment options, including adding a third or fourth drug if necessary.

      New drugs, such as direct renin inhibitors like Aliskiren, may have a role in patients who are intolerant of more established antihypertensive drugs. However, trials have only investigated the fall in blood pressure and no mortality data is available yet. Patients who fail to respond to step 4 measures should be referred to a specialist. The guidelines also provide blood pressure targets for different age groups.

    • This question is part of the following fields:

      • Cardiovascular
      28.5
      Seconds
  • Question 4 - A 48-year-old man comes to the emergency department complaining of sudden onset chest...

    Correct

    • A 48-year-old man comes to the emergency department complaining of sudden onset chest pain. The patient has a medical history of hypertension and is currently taking ramipril. His vital signs are as follows: BP 153/90 mmHg in his right arm and 130/80 in his left arm, heart rate 89/minute, temperature 37.2ºC, respiration rate 17/minute, and oxygen saturation 98% on room air. Upon examination, the patient has absent pulses in his right leg and diminished pulses in his left leg.

      What is the recommended diagnostic test for this patient's presentation?

      Your Answer: CT angiography chest/abdomen/pelvis

      Explanation:

      When a patient presents with symptoms of thoracic aortic dissection and is stable, CT angiography is the preferred diagnostic test. This imaging technique provides a clear view of the aorta and helps plan surgical intervention if necessary. In cases of proximal aortic dissection, inter-arm blood pressure measurements may reveal a difference of over 20 mmHg, with the right arm showing higher pressure due to its proximity to the heart. The absence or reduction of femoral pulses on one or both sides is also a common finding. While a chest x-ray may show signs associated with aortic dissection, it is not specific enough for diagnosis. Transesophageal echocardiography (TOE) is used to confirm the diagnosis if CT angiography is inconclusive or if the patient is unstable. Transthoracic echocardiography (TTE) is less sensitive and specific than TOE for detecting aortic dissection.

      Understanding Aortic Dissection: Classification, Investigation, and Management

      Aortic dissection is a serious medical condition that requires prompt diagnosis and management. It is classified according to the location of the tear in the aorta, with type A affecting the ascending aorta in two-thirds of cases, and type B affecting the descending aorta distal to the left subclavian origin in one-third of cases. The DeBakey classification further divides aortic dissection into type I, which originates in the ascending aorta and propagates to at least the aortic arch, and type II, which is confined to the ascending aorta. Type III originates in the descending aorta and rarely extends proximally but will extend distally.

      To diagnose aortic dissection, imaging studies such as chest x-ray and CT angiography of the chest, abdomen, and pelvis are essential. Transoesophageal echocardiography (TOE) may be more suitable for unstable patients who cannot undergo CT scanning. Management of type A aortic dissection requires surgical intervention, but blood pressure should be controlled to a target systolic of 100-120 mmHg while awaiting surgery. Type B aortic dissection can be managed conservatively with bed rest and IV labetalol to reduce blood pressure and prevent progression.

      Complications of aortic dissection depend on the location of the tear. Backward tears can lead to aortic incompetence/regurgitation and myocardial infarction, while forward tears can cause unequal arm pulses and blood pressure, stroke, and renal failure. Endovascular repair of type B aortic dissection may have a role in the future. It is important to remember that patients may present acutely and be clinically unstable, so the choice of investigations and management should take this into account.

    • This question is part of the following fields:

      • Cardiovascular
      18.6
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  • Question 5 - A 50-year-old man presents to you after experiencing a heart attack 4 weeks...

    Correct

    • A 50-year-old man presents to you after experiencing a heart attack 4 weeks ago. He has been prescribed ramipril, bisoprolol, aspirin, and clopidogrel following the event. Although he was offered a statin, he declined it at the time, feeling that he was being asked to take too many medications simultaneously. He has since read about the advantages of being on a statin and wishes to begin statin therapy. What is the appropriate statin for this patient to start on?

      Your Answer: Atorvastatin 80mg

      Explanation:

      For primary prevention of cardiovascular disease, a dosage of 20mg of atorvastatin is recommended. However, for secondary prevention, a higher dosage of 80 mg is recommended.

      Statins are drugs that inhibit the action of an enzyme called HMG-CoA reductase, which is responsible for producing cholesterol in the liver. However, they can cause some adverse effects such as myopathy, which includes muscle pain, weakness, and damage, and liver impairment. Myopathy is more common in lipophilic statins than in hydrophilic ones. Statins may also increase the risk of intracerebral hemorrhage in patients who have had a stroke before. Therefore, they should be avoided in these patients. Statins should not be taken during pregnancy and should be stopped if the patient is taking macrolides.

      Statins are recommended for people with established cardiovascular disease, those with a 10-year cardiovascular risk of 10% or more, and patients with type 2 diabetes mellitus. Patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago, are over 40 years old, or have established nephropathy should also take statins. It is recommended to take statins at night as this is when cholesterol synthesis takes place. Atorvastatin 20mg is recommended for primary prevention, and the dose should be increased if non-HDL has not reduced for 40% or more. Atorvastatin 80 mg is recommended for secondary prevention. The graphic shows the different types of statins available.

    • This question is part of the following fields:

      • Cardiovascular
      21.1
      Seconds
  • Question 6 - A 56-year-old male with no previous medical history presents with a sprained ankle...

    Incorrect

    • A 56-year-old male with no previous medical history presents with a sprained ankle and is incidentally found to be in atrial fibrillation. He denies any symptoms of palpitations or shortness of breath. Despite discussing treatment options, he declines cardioversion. Cardiovascular examination is otherwise normal, with a blood pressure of 118/76 mmHg. As per the most recent NICE guidelines, what is the recommended treatment for this patient if he remains in chronic atrial fibrillation?

      Your Answer: Aspirin + dipyridamole

      Correct Answer: No treatment

      Explanation:

      NICE recommends using the CHA2DS2-VASc score to determine the need for anticoagulation in patients with any history of AF. The ORBIT scoring system should be used to assess bleeding risk, but anticoagulation should not be withheld solely on the grounds of age or risk of falls. DOACs are now recommended as the first-line anticoagulant for patients with AF, with warfarin used second-line if a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.

    • This question is part of the following fields:

      • Cardiovascular
      23.9
      Seconds
  • Question 7 - A 63-year-old man presents to the Emergency Department with central crushing chest pain....

    Incorrect

    • A 63-year-old man presents to the Emergency Department with central crushing chest pain. Upon arrival, an ECG reveals ST-elevation in leads II, III and aVF. The patient has a history of hypertension and is currently taking ramipril, aspirin and simvastatin. What is the most effective course of action for managing this patient?

      Your Answer: Aspirin + clopidogrel + LMWH + repeat ECG in 20 minutes

      Correct Answer: Aspirin + clopidogrel + IV heparin + immediate percutaneous coronary intervention

      Explanation:

      Immediate percutaneous coronary intervention with aspirin, clopidogrel, and IV heparin is recommended.

      Myocardial infarction, specifically ST-elevation myocardial infarction (STEMI), can be managed using evidence-based approaches. Patients without contraindications should be given aspirin and a P2Y12-receptor antagonist, with ticagrelor being preferred over clopidogrel due to improved outcomes despite slightly higher bleeding rates. Unfractionated heparin is typically given to patients undergoing percutaneous coronary intervention (PCI), but low-molecular weight heparin can also be used. Oxygen therapy should not be routinely administered, but supplemental oxygen can be given to patients with oxygen saturation levels below 94% or those with chronic obstructive pulmonary disease at risk of hypercapnic respiratory failure.

      Primary PCI is the preferred treatment for STEMI, but it may not be available in all centers. Thrombolysis can be performed in patients without access to primary PCI, with tissue plasminogen activator (tPA) offering clear mortality benefits over streptokinase. Tenecteplase is easier to administer and has non-inferior efficacy to alteplase with a similar adverse effect profile. An ECG should be performed 90 minutes following thrombolysis to assess whether there has been a greater than 50% resolution in the ST elevation. If there has not been adequate resolution, rescue PCI is superior to repeat thrombolysis. For patients successfully treated with thrombolysis, PCI has been shown to be beneficial, but the optimal timing is still being investigated.

      For patients with diabetes mellitus, NICE recommends using a dose-adjusted insulin infusion with regular monitoring of blood glucose levels to keep glucose below 11.0 mmol/l. Intensive insulin therapy regimes are not recommended routinely.

    • This question is part of the following fields:

      • Cardiovascular
      34.7
      Seconds
  • Question 8 - A 68-year-old patient with known stable angina is currently managed on atenolol and...

    Correct

    • A 68-year-old patient with known stable angina is currently managed on atenolol and isosorbide mononitrate (on an as required or PRN basis). He is experiencing more frequent episodes of angina on exertion.
      What is the most appropriate treatment that can be added to his current regimen to alleviate his symptoms?

      Your Answer: Nifedipine

      Explanation:

      Medications for Angina: Nifedipine, Aspirin, Dabigatran, ISMN, and Spironolactone

      When it comes to treating angina, the first-line anti-anginal treatment should be either a β blocker or a calcium channel blocker like nifedipine, according to NICE guidelines. If this proves ineffective, an alternative or combination of the two should be used. Nifedipine is the calcium channel blocker with the most vasodilating properties.

      Aspirin can also be used to reduce the risk of a myocardial infarction (MI) in angina patients, but it does not provide any symptomatic relief. NICE recommends considering aspirin for all patients with angina.

      Dabigatran, an anticoagulant, is useful for reducing the risk of strokes in patients with atrial fibrillation, but it does not provide any symptomatic benefit for angina.

      If symptoms are not controlled on a combination of β blocker and calcium channel blocker, or if one of these cannot be tolerated, NICE advises considering long-acting nitrates like ISMN.

      Spironolactone, an aldosterone antagonist, can be used in heart failure secondary to left ventricular systolic dysfunction (LVSD), especially after a myocardial infarction (MI). NICE recommends starting with either a β blocker or a calcium channel blocker, and switching or combining if ineffective. If one of these medications cannot be tolerated or the combination is ineffective, long-acting nitrate, nicorandil, or ivabradine should be considered.

    • This question is part of the following fields:

      • Cardiovascular
      21.5
      Seconds
  • Question 9 - A 40-year-old man comes to the emergency department after experiencing syncope. Upon conducting...

    Incorrect

    • A 40-year-old man comes to the emergency department after experiencing syncope. Upon conducting an ECG, it is found that he has sinus rhythm with a rate of 85 bpm. The QRS duration is 110 ms, PR interval is 180 ms, and corrected QT interval is 500ms. What is the reason for the abnormality observed on the ECG?

      Your Answer: Subdural haemorrhage

      Correct Answer: Hypokalaemia

      Explanation:

      Long QT syndrome can be caused by hypokalaemia, which is an electrolyte imbalance that leads to a prolonged corrected QT interval on an ECG. This condition is often seen in young people and can present as cardiac syncope, tachyarrhythmias, palpitations, or cardiac arrest. Long QT syndrome can be inherited or acquired, with hypokalaemia being one of the acquired causes. Other causes include medications, CNS lesions, malnutrition, and hypothermia. It’s important to note that hypercalcaemia is associated with a shortened QT interval, not a prolonged one.

      Understanding Long QT Syndrome

      Long QT syndrome (LQTS) is a genetic condition that causes delayed repolarization of the ventricles, which can lead to ventricular tachycardia and sudden death. The most common types of LQTS are caused by defects in the alpha subunit of the slow delayed rectifier potassium channel. A normal corrected QT interval is less than 430 ms in males and 450 ms in females.

      There are various causes of a prolonged QT interval, including congenital factors, drugs, and other medical conditions. Some drugs that can prolong the QT interval include amiodarone, tricyclic antidepressants, and selective serotonin reuptake inhibitors. Electrolyte imbalances, acute myocardial infarction, and subarachnoid hemorrhage can also cause a prolonged QT interval.

      LQTS may be picked up on routine ECG or following family screening. The symptoms and events associated with LQTS can vary depending on the type of LQTS. Long QT1 is usually associated with exertional syncope, while Long QT2 is often associated with syncope following emotional stress or exercise. Long QT3 events often occur at night or at rest.

      Management of LQTS involves avoiding drugs that prolong the QT interval and other precipitants if appropriate. Beta-blockers may be used, and in high-risk cases, implantable cardioverter defibrillators may be necessary. It is important to recognize and manage LQTS to prevent sudden cardiac death.

    • This question is part of the following fields:

      • Cardiovascular
      22.1
      Seconds
  • Question 10 - A 26-year-old male with no significant medical history is brought to the operating...

    Incorrect

    • A 26-year-old male with no significant medical history is brought to the operating room for an emergency appendectomy. He is induced with sevoflurane and maintained on sevoflurane and propofol. Suddenly, an alert on the anesthesia machine pops up, indicating elevated end-tidal CO2. The patient's condition appears to have worsened, with skin mottling and excessive sweating.

      What could be the probable cause of this sudden change in the patient's condition?

      Your Answer: Endobronchial intubation

      Correct Answer: Malignant hyperthermia

      Explanation:

      Volatile liquid anaesthetics (isoflurane, desflurane, sevoflurane) can cause malignant hyperthermia, a rare genetic disorder that causes skeletal muscle to contract rapidly and can lead to acidosis, increased CO2, and elevated body temperature. This is the likely cause of the patient’s acute deterioration after receiving sevoflurane. Other potential causes, such as cardiac arrest, endobronchial intubation, normal anion gap metabolic acidosis, and spontaneous appendix perforation, do not explain the specific symptoms observed.

      Overview of General Anaesthetics

      General anaesthetics are drugs used to induce a state of unconsciousness in patients undergoing surgical procedures. There are two main types of general anaesthetics: inhaled and intravenous. Inhaled anaesthetics, such as isoflurane, desflurane, sevoflurane, and nitrous oxide, are administered through inhalation. These drugs work by acting on various receptors in the brain, including GABAA, glycine, NDMA, nACh, and 5-HT3 receptors. Inhaled anaesthetics can cause adverse effects such as myocardial depression, malignant hyperthermia, and hepatotoxicity.

      Intravenous anaesthetics, such as propofol, thiopental, etomidate, and ketamine, are administered through injection. These drugs work by potentiating GABAA receptors or blocking NDMA receptors. Intravenous anaesthetics can cause adverse effects such as pain on injection, hypotension, laryngospasm, myoclonus, and disorientation. However, they are often preferred over inhaled anaesthetics in cases of haemodynamic instability.

      It is important to note that the exact mechanism of action of general anaesthetics is not fully understood. Additionally, the choice of anaesthetic depends on various factors such as the patient’s medical history, the type of surgery, and the anaesthetist’s preference. Overall, general anaesthetics play a crucial role in modern medicine by allowing for safe and painless surgical procedures.

    • This question is part of the following fields:

      • Cardiovascular
      16.7
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  • Question 11 - A 70-year-old man presents to the GP for a blood pressure review after...

    Correct

    • A 70-year-old man presents to the GP for a blood pressure review after a clinic reading of 154/100 mmHg. He has a medical history of type 2 diabetes and COPD, which are managed with inhalers. His home blood pressure readings over the past week have averaged at 140/96 mmHg. What is the initial intervention that should be considered?

      Your Answer: Ramipril

      Explanation:

      Regardless of age, ACE inhibitors/A2RBs are the first-line treatment for hypertension in diabetics.

      Blood Pressure Management in Diabetes Mellitus

      Patients with diabetes mellitus have traditionally been managed with lower blood pressure targets to reduce their overall cardiovascular risk. However, a 2013 Cochrane review found that there was little difference in outcomes between patients who had tight blood pressure control (targets < 130/85 mmHg) and those with more relaxed control (< 140-160/90-100 mmHg), except for a slightly reduced rate of stroke in the former group. As a result, NICE recommends a blood pressure target of < 140/90 mmHg for type 2 diabetics, the same as for patients without diabetes. For patients with type 1 diabetes, NICE recommends a blood pressure target of 135/85 mmHg unless they have albuminuria or two or more features of metabolic syndrome, in which case the target should be 130/80 mmHg. ACE inhibitors or angiotensin-II receptor antagonists (A2RBs) are the first-line antihypertensive regardless of age, as they have a renoprotective effect in diabetes. A2RBs are preferred for black African or African-Caribbean diabetic patients. Further management then follows that of non-diabetic patients. It is important to note that autonomic neuropathy may result in more postural symptoms in patients taking antihypertensive therapy. Therefore, the routine use of beta-blockers in uncomplicated hypertension should be avoided, particularly when given in combination with thiazides, as they may cause insulin resistance, impair insulin secretion, and alter the autonomic response to hypoglycemia.

    • This question is part of the following fields:

      • Cardiovascular
      31.9
      Seconds
  • Question 12 - A 42-year-old woman is brought to the Emergency Room with a 3-day history...

    Correct

    • A 42-year-old woman is brought to the Emergency Room with a 3-day history of flu-like symptoms. She is now experiencing severe central chest pain that worsens with coughing and improves when she sits upright. Upon examination, she has a rapid heart rate and a temperature of 38.5 °C. A third heart sound is heard upon auscultation.
      What is the probable cause of this patient's chest pain?

      Your Answer: Pericarditis

      Explanation:

      Pericarditis is an inflammation of the sac surrounding the heart, causing chest pain that is relieved by sitting forward and worsened by lying flat or coughing. Patients may display signs of infection, and a pericardial friction rub may be heard during examination. Blood tests, electrocardiography, chest X-ray, and echocardiography are used to diagnose pericarditis. Causes include viral, bacterial, and fungal infections, as well as other conditions. Treatment aims to address the underlying cause and may include analgesia and bed rest. Aortic dissection, myocardial ischemia, gastroesophageal reflux disease, and pneumonia are other possible causes of chest pain, but each has distinct symptoms and characteristics.

    • This question is part of the following fields:

      • Cardiovascular
      43.8
      Seconds
  • Question 13 - A woman with a history of asthma who is 25 weeks pregnant is...

    Correct

    • A woman with a history of asthma who is 25 weeks pregnant is found to have consistent blood pressure readings >170/95 mmHg. She is admitted under Gynaecology.
      Which of the following antihypertensives would you initiate for this patient?

      Your Answer: Nifedipine

      Explanation:

      Safe and Effective Treatment Options for Gestational Hypertension

      Gestational hypertension is a serious condition that requires prompt medical attention. According to NICE guidelines, labetalol is the first-line treatment for gestational hypertension. However, if the patient has asthma, labetalol is contraindicated. In such cases, nifedipine is listed as the second-line treatment, followed by methyldopa if necessary.

      Diltiazem is not usually used in gestational hypertension, and the role of this medication in pregnancy is unclear. Bendroflumethiazide is relatively contraindicated in pregnancy, while ACE inhibitors and ARBs are absolutely contraindicated due to their potential adverse effects on fetal blood pressure and renal function.

      In cases of gestational hypertension, it is crucial to rule out pre-eclampsia. If the patient’s blood pressure is above 160/110, NICE guidelines recommend admission until the blood pressure is below this level.

      Calcium channel blockers, such as nifedipine, are safe and effective in pregnancy, while the role of diltiazem is uncertain. Bendroflumethiazide is relatively contraindicated, while ACE inhibitors and ARBs are absolutely contraindicated. It is essential to choose the appropriate medication based on the patient’s medical history and individual circumstances.

    • This question is part of the following fields:

      • Cardiovascular
      46.5
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  • Question 14 - A 63-year-old male with a recent myocardial infarction experiences ventricular fibrillation while in...

    Correct

    • A 63-year-old male with a recent myocardial infarction experiences ventricular fibrillation while in the coronary care unit. The heart monitor records this event. An emergency call is made and a defibrillator is quickly brought to the scene. What is the best course of action to take?

      Your Answer: Administer three successive shocks, then commence CPR

      Explanation:

      In a witnessed cardiac arrest with VF/VT rhythm, up to three quick successive shocks should be given before starting chest compressions. This is regarded as the first shock in the ALS algorithm. Adrenaline should be given every 3-5 minutes and a praecordial thump should only be used if a defibrillator is not available. Commencing CPR after just one shock would miss the opportunity to deliver three rapid shocks.

      The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.

    • This question is part of the following fields:

      • Cardiovascular
      20.1
      Seconds
  • Question 15 - An 81-year-old woman arrives at the emergency department after her smartwatch ECG recorder...

    Incorrect

    • An 81-year-old woman arrives at the emergency department after her smartwatch ECG recorder detected atrial fibrillation for the past three days. She has experienced mild shortness of breath during physical activity in the last 24 hours. Upon examination, her heart rate is irregular, with a rate of 98 bpm, and her blood pressure is stable at 130/72 mmHg. She has no history of atrial fibrillation and only takes amlodipine for her grade I hypertension. What is the most appropriate treatment plan?

      Your Answer: Discharge on amiodarone and apixaban and arrange cardioversion in four weeks' time

      Correct Answer: Discharge on bisoprolol and apixaban and arrange cardioversion in four weeks

      Explanation:

      In cases of sudden atrial fibrillation, if the duration is 48 hours or more, the first step is to control the heart rate. If long-term rhythm control is being considered, it is important to wait at least 3 weeks after starting therapeutic anticoagulation before attempting cardioversion.

      Atrial fibrillation (AF) is a condition that requires careful management to prevent complications. The latest guidelines from NICE recommend that patients presenting with AF should be assessed for haemodynamic instability, and if present, electrically cardioverted. For haemodynamically stable patients, the management depends on how acute the AF is. If the AF has been present for less than 48 hours, rate or rhythm control may be considered. However, if it has been present for 48 hours or more, or the onset is uncertain, rate control is recommended. If long-term rhythm control is being considered, cardioversion should be delayed until the patient has been maintained on therapeutic anticoagulation for at least 3 weeks.

      Rate control is the first-line treatment strategy for AF, except in certain cases. Medications such as beta-blockers, calcium channel blockers, and digoxin can be used to control the heart rate. However, digoxin is no longer considered first-line as it is less effective at controlling the heart rate during exercise. Rhythm control agents such as beta-blockers, dronedarone, and amiodarone can be used to maintain sinus rhythm in patients with a history of AF. Catheter ablation is recommended for those who have not responded to or wish to avoid antiarrhythmic medication.

      The aim of catheter ablation is to ablate the faulty electrical pathways that are causing AF. The procedure is performed percutaneously, typically via the groin, and can use radiofrequency or cryotherapy to ablate the tissue. Anticoagulation should be used 4 weeks before and during the procedure. It is important to note that catheter ablation controls the rhythm but does not reduce the stroke risk, so patients still require anticoagulation as per their CHA2DS2-VASc score. Complications of catheter ablation can include cardiac tamponade, stroke, and pulmonary vein stenosis. The success rate of the procedure is around 50% for early recurrence within 3 months, and around 55% of patients who’ve had a single procedure remain in sinus rhythm after 3 years. Of patients who’ve undergone multiple procedures, around 80% are in sinus rhythm.

    • This question is part of the following fields:

      • Cardiovascular
      112.9
      Seconds
  • Question 16 - A 67-year-old male experiences a cardiac arrest during coronary angiography in the catheter...

    Incorrect

    • A 67-year-old male experiences a cardiac arrest during coronary angiography in the catheter laboratory. His heart rate is 164 beats per minute and the 12-lead ECG monitor displays ventricular tachycardia. As you begin to assess him, you are unable to detect a pulse and immediately call for assistance.

      What is the next appropriate step to take?

      Your Answer: Give adrenaline 1mg IV and amiodarone 300mg IV

      Correct Answer: Deliver a maximum of three successive shocks

      Explanation:

      If a patient experiences cardiac arrest in VF/pulseless VT and is monitored, such as in a coronary care unit, critical care unit, or catheter laboratory, they should receive a maximum of three successive shocks instead of one shock followed by two minutes of CPR. After the shocks, chest compressions should be administered for two minutes. Once compressions restart, adrenaline 1mg IV and amiodarone 300 mg IV should be given for shockable rhythms (VT/pulseless VF). Adrenaline 1mg IV should be given after alternate shocks (every 3-5 minutes). For non-shockable rhythms (pulseless electrical activity/asystole), adrenaline 1mg IV should be given as soon as venous access is achieved and administered alongside CPR. Pulseless electrical activity is a type of cardiac arrest where there is electrical activity (other than ventricular tachycardia) that would normally have an associated pulse. Asystole is a complete cessation of any electrical and mechanical heart activity.

      The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.

    • This question is part of the following fields:

      • Cardiovascular
      16
      Seconds
  • Question 17 - A 70-year-old man comes to you with complaints of nocturnal dyspnea, intermittent palpitations,...

    Incorrect

    • A 70-year-old man comes to you with complaints of nocturnal dyspnea, intermittent palpitations, and chest tightness. During your examination, you observe a collapsing pulse and a displaced apex beat towards the left. Additionally, you notice his head nodding in sync with his pulse. What do you anticipate hearing upon auscultation of the precordium?

      Your Answer: An ejection systolic murmur

      Correct Answer: An early diastolic murmur

      Explanation:

      Aortic regurgitation is usually accompanied by an early diastolic murmur, along with Corrigan’s pulse and De Musset’s sign. Mitral regurgitation is characterized by a pansystolic murmur, while aortic stenosis is associated with an ejection systolic murmur. A patent ductus arteriosus is indicated by a continuous ‘machinery’ murmur, and mitral stenosis is associated with a late diastolic murmur.

      Aortic regurgitation is a condition where the aortic valve of the heart leaks, causing blood to flow in the opposite direction during ventricular diastole. This can be caused by disease of the aortic valve or by distortion or dilation of the aortic root and ascending aorta. In the developing world, rheumatic fever is the most common cause of AR, while in developed countries, calcific valve disease and connective tissue diseases like rheumatoid arthritis and SLE are more common causes. Symptoms of AR include an early diastolic murmur, collapsing pulse, wide pulse pressure, Quincke’s sign, and De Musset’s sign. Echocardiography is used to investigate suspected AR. Management includes medical management of any associated heart failure and surgery for symptomatic patients with severe AR or asymptomatic patients with severe AR who have LV systolic dysfunction.

    • This question is part of the following fields:

      • Cardiovascular
      38.7
      Seconds
  • Question 18 - A 55-year-old man is found to have an irregularly, irregular pulse during a...

    Incorrect

    • A 55-year-old man is found to have an irregularly, irregular pulse during a routine check-up. An ECG reveals absent P waves and irregular R-R intervals. The patient has moderate renal impairment. What is the most appropriate treatment option?

      Your Answer: Warfarin

      Correct Answer: No treatment

      Explanation:

      Understanding Anticoagulation Treatment for Atrial Fibrillation: A CHADS-VASc Scoring System Overview

      Atrial fibrillation (AF) is a common rhythm disturbance that can increase the risk of stroke. To determine the appropriate treatment for primary prevention of stroke, healthcare professionals use the CHADS-VASc scoring system. This system assigns points based on various risk factors, including age, sex, hypertension, diabetes, previous stroke or transient ischemic attack, and vascular disease.

      This score is based on a point system in which 2 points are assigned for a history of stroke or transient ischemic attack or age 75 years or more and 1 point each is assigned for age 65 to 74 years; a history of hypertension, diabetes, recent cardiac failure, vascular disease (myocardial infarction, complex aortic plaque, and peripheral arterial disease (PAD), including prior revascularization, amputation due to PAD, or angiographic evidence of PAD, etc.); and female gender, resulting in a maximum score of 9 points.

      Score Risk Anticoagulation Therapy
      0 (male) or 1 (female) Low No anticoagulant therapy
      1 (male) Moderate Oral anticoagulant should be considered
      2 or greater High Oral anticoagulant is recommended

      Aspirin is not recommended for primary prevention of stroke in patients with AF, but may be used for secondary prevention after a stroke. Clexane, a low-molecular-weight heparin, is not used for long-term treatment of AF. Dipyridamole may be used in combination with clopidogrel or aspirin for stroke treatment, but not for prevention in AF patients.

      It is important to accurately identify AF and assess the patient’s risk using the CHADS-VASc scoring system to determine the appropriate anticoagulation treatment. NOACs are only licensed for non-valvular AF, so patients with valvular AF should be treated with warfarin or seek advice from a specialist.

    • This question is part of the following fields:

      • Cardiovascular
      26.5
      Seconds
  • Question 19 - A 45-year-old man attends for a truck driver medical assessment. His blood pressure...

    Incorrect

    • A 45-year-old man attends for a truck driver medical assessment. His blood pressure (BP) is noted to be 190/100 mmHg. He is a heavy drinker. He is feeling generally well in himself. You request blood tests:
      Result Normal
      Sodium (mmol/l) 138 135-145
      Potassium (mmol/l) 4.0 3.5-5.0
      Urea (mmol/l) 4.8 1.7-8.3
      Creatinine (µmol/l) 152 59-104
      You decide to perform a work-up to exclude a secondary cause for his hypertension. An ultrasound scan of the renal tract reveals a small atrophic left kidney.
      Which of the following is the most likely diagnosis?

      Your Answer: Phaeochromocytoma

      Correct Answer: Renal artery stenosis

      Explanation:

      Possible Causes of Hypertension: Differential Diagnosis

      Hypertension in a young patient may indicate a secondary cause, such as renovascular disease. In this case, a small kidney on ultrasound and elevated creatinine levels suggest renal artery stenosis as a possible cause. Other potential diagnoses, such as Cushing’s syndrome, acromegaly, and phaeochromocytoma, are less likely based on the absence of corresponding symptoms and signs. Polycystic kidney disease, which can also cause hypertension, would typically present with bilateral renal enlargement rather than atrophy. A thorough differential diagnosis is important to identify the underlying cause of hypertension and guide appropriate management.

    • This question is part of the following fields:

      • Cardiovascular
      33
      Seconds
  • Question 20 - A 62-year-old man visits his doctor with a complaint of ‘bulging blue veins’...

    Correct

    • A 62-year-old man visits his doctor with a complaint of ‘bulging blue veins’ on his legs. During the examination, you observe the presence of twisted, enlarged veins, along with brown patches of pigmentation and rough, flaky patches of skin. The diagnosis is varicose veins.
      Which vein is commonly affected in this condition?

      Your Answer: Long saphenous vein

      Explanation:

      Understanding the Venous System and Varicose Veins

      Varicose veins are a common condition that affects the superficial venous system. The long saphenous vein, which ascends the medial side of the leg and passes anteriorly to the medial malleolus of the ankle, is the most common cause of varicose veins. However, it is important to consider alternative diagnoses for limb swelling, such as deep vein thrombosis, which could occur in the popliteal vein, part of the deep venous system.

      The cephalic vein, although superficial, is an upper limb vein and is not likely to be affected by varicose veins. Similarly, insufficiencies in the deep venous system, such as the femoral vein, contribute to chronic venous insufficiency but do not cause varicose veins.

      Another main vein in the superficial venous system is the short saphenous vein, which ascends the posterior side of the leg and passes posteriorly to the lateral malleolus of the ankle. Insufficiency in this vein can also cause varicose veins, but it is not the most likely distribution.

      Understanding the different veins in the venous system and their potential for insufficiency can help in the diagnosis and treatment of varicose veins.

    • This question is part of the following fields:

      • Cardiovascular
      19.6
      Seconds
  • Question 21 - A 50-year-old man comes to the clinic complaining of palpitations that started about...

    Correct

    • A 50-year-old man comes to the clinic complaining of palpitations that started about 30 minutes ago. He mentions having a stressful day at work, but there doesn't seem to be any other obvious trigger. He denies experiencing any chest pain or difficulty breathing. Upon conducting an ECG, a regular tachycardia of 180 bpm with a QRS duration of 0.10s is observed. His blood pressure is 106/70 mmHg, and his oxygen saturation is 98% on room air. Despite performing the Valsalva manoeuvre, there is no effect on the rhythm. What is the most appropriate next step?

      Your Answer: Intravenous adenosine

      Explanation:

      In cases of haemodynamically stable patients with SVT who do not respond to vagal manoeuvres, the recommended course of action is to administer adenosine.

      Understanding Supraventricular Tachycardia

      Supraventricular tachycardia (SVT) is a type of tachycardia that originates above the ventricles. It is commonly associated with paroxysmal SVT, which is characterized by sudden onset of a narrow complex tachycardia, usually an atrioventricular nodal re-entry tachycardia (AVNRT). Other causes include atrioventricular re-entry tachycardias (AVRT) and junctional tachycardias.

      When it comes to acute management, vagal maneuvers such as the Valsalva maneuver or carotid sinus massage can be used. Intravenous adenosine is also an option, with a rapid IV bolus of 6mg given initially, followed by 12mg and then 18mg if necessary. However, adenosine is contraindicated in asthmatics, and verapamil may be a better option for them. Electrical cardioversion is another option.

      To prevent episodes of SVT, beta-blockers can be used. Radio-frequency ablation is also an option. It is important to work with a healthcare provider to determine the best course of treatment for each individual case.

      Overall, understanding SVT and its management options can help individuals with this condition better manage their symptoms and improve their quality of life.

    • This question is part of the following fields:

      • Cardiovascular
      28.1
      Seconds
  • Question 22 - A 70-year-old man is rushed to the hospital due to severe chest pain...

    Correct

    • A 70-year-old man is rushed to the hospital due to severe chest pain and nausea. His ECG reveals ST elevation in leads V1, V2, V3, and V4. Following angiography and percutaneous coronary intervention, his left anterior descending coronary artery is stented. The patient admits to avoiding doctors and not seeing his GP for more than two decades. He has been smoking 15 cigarettes daily since he was 18. What are the recommended medications for secondary prevention?

      Your Answer: Aspirin + prasugrel + lisinopril + bisoprolol + atorvastatin

      Explanation:

      Myocardial infarction (MI) is a serious condition that requires proper management to prevent further complications. In 2013, NICE released guidelines on the secondary prevention of MI. One of the key recommendations is the use of four drugs: dual antiplatelet therapy (aspirin plus a second antiplatelet agent), ACE inhibitor, beta-blocker, and statin. Patients are also advised to adopt a Mediterranean-style diet and engage in regular exercise. Sexual activity may resume four weeks after an uncomplicated MI, and PDE5 inhibitors may be used six months after the event.

      Most patients with acute coronary syndrome are now given dual antiplatelet therapy, with ticagrelor and prasugrel being the preferred options. The treatment period for these drugs is 12 months, after which they should be stopped. However, this period may be adjusted for patients at high risk of bleeding or further ischaemic events. Additionally, patients with heart failure and left ventricular systolic dysfunction should be treated with an aldosterone antagonist within 3-14 days of the MI, preferably after ACE inhibitor therapy.

      Overall, the NICE guidelines provide a comprehensive approach to the secondary prevention of MI. By following these recommendations, patients can reduce their risk of further complications and improve their overall health outcomes.

    • This question is part of the following fields:

      • Cardiovascular
      48.6
      Seconds
  • Question 23 - An 80-year-old man has been experiencing recurrent falls due to orthostatic hypotension. Despite...

    Incorrect

    • An 80-year-old man has been experiencing recurrent falls due to orthostatic hypotension. Despite trying conservative measures such as increasing fluid and salt intake, reviewing medications, and wearing compression stockings, he still experiences dizziness upon standing. What medication options are available to alleviate his symptoms?

      Your Answer: Doxazosin

      Correct Answer: Fludrocortisone

      Explanation:

      Fludrocortisone and midodrine are two medications that can be used to treat orthostatic hypotension. However, doxazosin, a medication used for hypertension, can actually worsen orthostatic hypotension. Prochlorperazine is used for vertigo and isoprenaline and dobutamine are not used for orthostatic hypotension as they are ionotropic agents used for patients in shock.

      Fludrocortisone works by increasing renal sodium reabsorption and plasma volume, which helps counteract the physiological orthostatic vasovagal reflex. Its effectiveness has been supported by two small observational studies and one small double-blind trial, leading the European Society of Cardiology to give it a Class IIa recommendation.

      To manage orthostatic hypotension, patients should be educated on lifestyle measures such as staying hydrated and increasing salt intake. Vasoactive drugs like nitrates, antihypertensives, neuroleptic agents, or dopaminergic drugs should be discontinued if possible. If symptoms persist, compression garments, fludrocortisone, midodrine, counter-pressure manoeuvres, and head-up tilt sleeping can be considered.

      Understanding Syncope: Causes and Evaluation

      Syncope is a temporary loss of consciousness caused by a sudden decrease in blood flow to the brain. This condition is characterized by a rapid onset, short duration, and complete recovery without any medical intervention. It is important to note that syncope is different from other causes of collapse, such as epilepsy. To better understand syncope, the European Society of Cardiology has classified it into three categories: reflex syncope, orthostatic syncope, and cardiac syncope.

      Reflex syncope, also known as neurally mediated syncope, is the most common cause of syncope in all age groups. It can be triggered by emotional stress, pain, or other situational factors such as coughing or gastrointestinal issues. Orthostatic syncope occurs when there is a sudden drop in blood pressure upon standing up, and it is more common in older patients. Cardiac syncope is caused by heart-related issues such as arrhythmias, structural abnormalities, or pulmonary embolism.

      To evaluate syncope, doctors may perform a series of tests, including a cardiovascular examination, postural blood pressure readings, ECG, carotid sinus massage, tilt table test, and 24-hour ECG monitoring. These tests help to identify the underlying cause of syncope and determine the appropriate treatment plan. By understanding the causes and evaluation of syncope, patients and healthcare providers can work together to manage this condition effectively.

    • This question is part of the following fields:

      • Cardiovascular
      28
      Seconds
  • Question 24 - A 75-year-old man presents to the ambulatory care unit with complaints of tenderness...

    Incorrect

    • A 75-year-old man presents to the ambulatory care unit with complaints of tenderness in his calf. His GP referred him for evaluation. Upon examination, there is no visible swelling, and the leg appears symmetrical to the other leg. However, he experiences tenderness when the deep veins of the calf are palpated. The patient has no significant medical history. What is the initial management option recommended for this patient?

      Your Answer: Start anticoagulant treatment, whilst arranging a proximal leg vein ultrasound scan

      Correct Answer: Arrange a D dimer test with results available within 4 hours

      Explanation:

      If a patient has a Wells’ score of 1 or less for a suspected DVT, the first step is to arrange a D dimer test with results available within 4 hours, according to NICE guidelines. In this case, the score of 1 is due to localized tenderness along the deep venous system, with no other risk factors present. A proximal leg vein ultrasound scan is not the first-line investigation option for a Wells’ score of 1 or less, and anticoagulant treatment should not be started without a D dimer test. If the D dimer results cannot be obtained within 4 hours, low molecular weight heparin injection may be considered, but therapeutic dose apixaban should not be started without a D dimer test.

      NICE updated their guidelines on the investigation and management of venous thromboembolism (VTE) in 2020. The use of direct oral anticoagulants (DOACs) is recommended as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. Routine cancer screening is no longer recommended following a VTE diagnosis. The cornerstone of VTE management is anticoagulant therapy, with DOACs being the preferred choice. All patients should have anticoagulation for at least 3 months, with the length of anticoagulation being determined by whether the VTE was provoked or unprovoked.

    • This question is part of the following fields:

      • Cardiovascular
      21.8
      Seconds
  • Question 25 - A 65-year-old woman has a significant anterior non-ST-elevation myocardial infarction (MI) but recovers...

    Incorrect

    • A 65-year-old woman has a significant anterior non-ST-elevation myocardial infarction (MI) but recovers well in hospital. Her predischarge echocardiogram shows her to have an ejection fraction of 40%. She is otherwise asymptomatic.
      Which of the following should her medications on discharge include?

      Your Answer: Aspirin, bisoprolol, ramipril, and a statin

      Correct Answer: Aspirin, ticagrelor, bisoprolol, ramipril and a statin

      Explanation:

      Medication Options for Post-Myocardial Infarction Patients

      After a myocardial infarction (MI), it is important for patients to receive appropriate medication to prevent further cardiovascular events. The National Institute for Health and Care Excellence (NICE) guidelines recommend the use of aspirin, ticagrelor, bisoprolol, ramipril, and a statin for dual antiplatelet therapy, β-blocker, ACE inhibitor, and cholesterol-lowering medication. The β-blocker and ACE inhibitor should be increased to the maximum tolerated dose.

      While isosorbide mononitrate (ISMN) is a useful anti-anginal medication, it is not indicated for post-MI patients. Instead, aspirin, bisoprolol, ramipril, losartan, and a statin may be prescribed. However, the use of an ACE inhibitor alongside an angiotensin receptor blocker (ARB) is not recommended due to their similar mechanism of action. Nitrates, such as ISMN, are also used as anti-anginals, but ACE inhibitors are preferred over ARBs.

      For patients on aspirin, bisoprolol, ramipril, and a statin, a second antiplatelet medication, such as clopidogrel, may be added for the first 12 months following an MI, unless there is a contraindication such as concomitant use of warfarin. It is important for healthcare providers to carefully consider the appropriate medication regimen for each post-MI patient to optimize their cardiovascular health.

    • This question is part of the following fields:

      • Cardiovascular
      12
      Seconds
  • Question 26 - An 83-year-old man who resides in a nursing home arrives at the Emergency...

    Correct

    • An 83-year-old man who resides in a nursing home arrives at the Emergency Department with symptoms of diarrhoea and vomiting. He has been experiencing 8 watery bowel movements per day for the past 3 days and seems disoriented and dehydrated. The patient has a medical history of atrial fibrillation, type II diabetes, and dementia. His heart rate is elevated at 110/min, and his electrocardiogram displays noticeable U waves. What is the probable reason for his ECG alterations?

      Your Answer: Hypokalaemia

      Explanation:

      The ECG changes observed in this scenario are most likely due to hypokalaemia. The patient’s electrolyte balance has been disrupted by vomiting and loose stools, resulting in a depletion of potassium that should be rectified through intravenous replacement. While hypocalcaemia and hypothermia can also cause U waves, they are less probable in this case. Non-ischaemic ST elevation changes may be caused by hyponatraemia. QT prolongation is a common effect of tricyclic antidepressant toxicity.

      ECG Features of Hypokalaemia

      Hypokalaemia is a condition characterized by low levels of potassium in the blood. This condition can be detected through an electrocardiogram (ECG) which shows specific features. The ECG features of hypokalaemia include U waves, small or absent T waves, prolonged PR interval, ST depression, and long QT. The U waves are particularly noticeable and are accompanied by a borderline PR interval.

      To remember these features, one registered user suggests the following rhyme: In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT. It is important to detect hypokalaemia early as it can lead to serious complications such as cardiac arrhythmias and even cardiac arrest. Therefore, regular monitoring of potassium levels and ECGs is crucial for individuals at risk of hypokalaemia.

    • This question is part of the following fields:

      • Cardiovascular
      4.8
      Seconds
  • Question 27 - A 65-year-old man presents to the emergency department in the middle of the...

    Incorrect

    • A 65-year-old man presents to the emergency department in the middle of the night with worsening pain in his left leg. The pain began at rest approximately 2 hours ago and has now become severe. The patient has a history of peripheral arterial disease and continues to smoke 10 cigarettes per day. Upon examination, the left lower limb appears pale and feels cold with no signs of edema or trauma. The dorsalis pedis and posterior tibial pulses are absent on palpation and inaudible on a doppler exam, while the right lower limb pulses are palpable. The patient has received IV morphine. What is the most appropriate initial management for this individual?

      Your Answer: Low molecular weight heparin, ankle-brachial pressure index, and CT lower limb angiography

      Correct Answer: IV unfractionated heparin and urgent vascular review

      Explanation:

      The appropriate initial management for acute limb ischaemia involves urgent vascular review and administration of IV unfractionated heparin for anticoagulation. The patient’s sudden onset of symptoms and absence of pulses on Doppler examination suggest arterial thrombosis, which is a surgical emergency. Low molecular weight heparin and a lower limb venous ultrasound scan are not indicated, as the thrombus is likely arterial. Similarly, ankle-brachial pressure index and imaging studies such as CT or lower limb arterial Doppler ultrasound should not delay urgent vascular review in this critical situation.

      Peripheral arterial disease can present in three main ways: intermittent claudication, critical limb ischaemia, and acute limb-threatening ischaemia. The latter is characterized by one or more of the 6 P’s: pale, pulseless, painful, paralysed, paraesthetic, and perishing with cold. Initial investigations include a handheld arterial Doppler examination and an ankle-brachial pressure index (ABI) if Doppler signals are present. It is important to determine whether the ischaemia is due to a thrombus or embolus, as this will guide management. Thrombus is suggested by pre-existing claudication with sudden deterioration, reduced or absent pulses in the contralateral limb, and evidence of widespread vascular disease. Embolus is suggested by a sudden onset of painful leg (<24 hours), no history of claudication, clinically obvious source of embolus, and no evidence of peripheral vascular disease. Initial management includes an ABC approach, analgesia, intravenous unfractionated heparin, and vascular review. Definitive management options include intra-arterial thrombolysis, surgical embolectomy, angioplasty, bypass surgery, or amputation for irreversible ischaemia.

    • This question is part of the following fields:

      • Cardiovascular
      42.3
      Seconds
  • Question 28 - A 35-year-old man presents to the Emergency Department with a sudden onset of...

    Incorrect

    • A 35-year-old man presents to the Emergency Department with a sudden onset of central abdominal pain. He claims this is radiating to his back and that it started this afternoon. He is currently still in pain and has been started on some analgesia. His blood pressure is 135/80 mmHg and his heart rate is 100 bpm.
      His past medical history includes amputation of the big toe on the left lower limb and femoral-popliteal bypass on the right. He smokes around 20 cigarettes daily.
      Which of the following tests should be done urgently to determine the underlying cause of his symptomatology?

      Your Answer: Computed tomography (CT) scan of the abdomen

      Correct Answer: Bedside abdominal ultrasound (US)

      Explanation:

      Bedside Abdominal Ultrasound for Ruptured Abdominal Aortic Aneurysm: Diagnosis and Management

      This patient is likely experiencing a ruptured abdominal aortic aneurysm (AAA), a life-threatening medical emergency. Bedside abdominal ultrasound (US) is the best initial diagnostic test for ruling out AAA as a cause of abdominal or back pain, as it provides an instant, objective measurement of aortic diameter. An AAA is a dilatation of the abdominal aorta greater than 3 cm in diameter, with a significant risk of rupture at diameters greater than 5 cm. Risk factors for AAA include smoking and co-existing vascular disease. Symptoms of a ruptured AAA include pain, cardiovascular failure, and distal ischemia. Once diagnosed, a CT angiogram is the gold-standard imaging for planning surgery to repair the aneurysm. Endoscopic retrograde cholangiopancreatography and liver function tests are not indicated in this case, while serum amylase or lipase should be measured in all patients presenting with acute abdominal or upper back pain to exclude acute pancreatitis as a differential diagnosis.

    • This question is part of the following fields:

      • Cardiovascular
      26.5
      Seconds
  • Question 29 - An emergency buzzer sounds on the coronary care unit and you are the...

    Incorrect

    • An emergency buzzer sounds on the coronary care unit and you are the first doctor to respond. A healthcare assistant on an observation round has found a 72-year-old man unresponsive. You perform a head tilt and chin lift and check for a carotid pulse for 10 seconds while listening for breath sounds, but you detect neither.

      Telemetry attached to the patient shows sinus rhythm at a rate of 110 bpm. The crash team is being summoned, and the crash trolley is being brought to the bedside. You are unaware of any DNACPR orders.

      What is the most appropriate initial step?

      Your Answer: Administer 1mg adrenaline

      Correct Answer: Start chest compressions at a rate of 30:2

      Explanation:

      For a patient in cardiac arrest with a non-shockable rhythm (pulseless-electrical activity), the recommended ratio of chest compressions to ventilation is 30:2. Therefore, the initial action should be to start chest compressions at this rate. Administering 1 mg adrenaline or 300 mg amiodarone is inappropriate as the first step. Adrenaline may be given once chest compressions have started. Amiodarone is only indicated for patients in ventricular fibrillation or pulseless ventricular tachycardia. Delivering a single synchronised DC shock or three quick successive stacked unsynchronised DC shocks followed by 2 minutes of 30:2 compressions is incorrect for a patient in PEA, as these are only appropriate for a shockable rhythm while on telemetry.

      The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.

    • This question is part of the following fields:

      • Cardiovascular
      6.8
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  • Question 30 - A 64-year-old male with a history of mitral regurgitation is scheduled for dental...

    Correct

    • A 64-year-old male with a history of mitral regurgitation is scheduled for dental polishing. He has a documented penicillin allergy. What is the recommended prophylaxis for preventing infective endocarditis?

      Your Answer: No antibiotic prophylaxis needed

      Explanation:

      In the UK, it is no longer standard practice to use antibiotics as a preventative measure against infective endocarditis during dental or other procedures, as per the 2008 NICE guidelines which have brought about a significant shift in approach.

      Infective endocarditis is a serious infection of the heart lining and valves. The 2008 guidelines from NICE have changed the list of procedures for which antibiotic prophylaxis is recommended. According to NICE, dental procedures, gastrointestinal, genitourinary, and respiratory tract procedures do not require prophylaxis. However, if a person at risk of infective endocarditis is receiving antimicrobial therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site where there is a suspected infection, they should be given an antibiotic that covers organisms that cause infective endocarditis. It is important to note that these recommendations differ from the American Heart Association/European Society of Cardiology guidelines, which still advocate antibiotic prophylaxis for high-risk patients undergoing dental procedures.

      The guidelines suggest that any episodes of infection in people at risk of infective endocarditis should be investigated and treated promptly to reduce the risk of endocarditis developing. It is crucial to follow these guidelines to prevent the development of infective endocarditis, which can lead to severe complications and even death. It is also important to note that these guidelines may change over time as new research and evidence become available. Therefore, healthcare professionals should stay up-to-date with the latest recommendations to provide the best possible care for their patients.

    • This question is part of the following fields:

      • Cardiovascular
      2.3
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiovascular (13/30) 43%
Passmed