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  • Question 1 - A 45-year-old man presents with palpitations and is found to have atrial fibrillation....

    Incorrect

    • A 45-year-old man presents with palpitations and is found to have atrial fibrillation. You are requested to evaluate his ECG.
      Which of the following statements is correct regarding the ECG findings in atrial fibrillation?

      Your Answer: The disorganised electrical activity usually originates at the root of the aorta

      Correct Answer: Some impulses are filtered out by the AV node

      Explanation:

      The classic ECG features of atrial fibrillation include an irregularly irregular rhythm, the absence of p-waves, an irregular ventricular rate, and the presence of fibrillation waves. This irregular rhythm occurs because the atrial impulses are filtered out by the AV node.

      In addition, Ashman beats may be observed in atrial fibrillation. These beats are characterized by wide complex QRS complexes, often with a morphology resembling right bundle branch block. They occur after a short R-R interval that is preceded by a prolonged R-R interval. Fortunately, Ashman beats are generally considered harmless.

      The disorganized electrical activity in atrial fibrillation typically originates at the root of the pulmonary veins.

    • This question is part of the following fields:

      • Cardiology
      46.6
      Seconds
  • Question 2 - Your hospital’s neurology department is currently evaluating the utility of a triple marker...

    Correct

    • Your hospital’s neurology department is currently evaluating the utility of a triple marker test for use in diagnosing patients with suspected stroke. The test will use brain natriuretic peptide (BNP), neuron-specific enolase (NSE), and S100B protein.
      How long after a stroke do levels of glial fibrillary acidic protein (GFAP) start to increase?

      Your Answer: 4-8 hours

      Explanation:

      The timing of the initial rise, peak, and return to normality of various cardiac enzymes can serve as a helpful guide. Creatine kinase, the main cardiac isoenzyme, typically experiences an initial rise within 4-8 hours, reaches its peak at 18 hours, and returns to normal within 2-3 days. Myoglobin, which lacks specificity due to its association with skeletal muscle damage, shows an initial rise within 1-4 hours, peaks at 6-7 hours, and returns to normal within 24 hours. Troponin I, known for its sensitivity and specificity, exhibits an initial rise within 3-12 hours, reaches its peak at 24 hours, and returns to normal within 3-10 days. HFABP, or heart fatty acid binding protein, experiences an initial rise within 1.5 hours, peaks at 5-10 hours, and returns to normal within 24 hours. Lastly, LDH, predominantly found in cardiac muscle, shows an initial rise at 10 hours, peaks at 24-48 hours, and returns to normal within 14 days.

    • This question is part of the following fields:

      • Cardiology
      15.1
      Seconds
  • Question 3 - A 68 year old male is brought to the emergency department by a...

    Incorrect

    • A 68 year old male is brought to the emergency department by a concerned coworker who noticed that the patient seemed unsteady on his feet and very short of breath when walking to his car. The patient tells you they usually feel a bit short of breath when doing things like walking to their car or going up the stairs. On examination you note a regular pulse, rate 88 bpm, but an audible ejection systolic murmur loudest at the left sternal edge. Blood pressure is 148/94 mmHg. What is the likely diagnosis?

      Your Answer: Aortic regurgitation

      Correct Answer: Aortic stenosis

      Explanation:

      Severe aortic stenosis (AS) is characterized by several distinct features. These include a slow rising pulse, an ejection systolic murmur that is heard loudest in the aortic area and may radiate to the carotids, and a soft or absent S2 heart sound. Additionally, patients with severe AS often have a narrow pulse pressure and may exhibit an S4 heart sound.

      AS is commonly caused by hypertension, although blood pressure findings can vary. In severe cases, patients may actually be hypotensive due to impaired cardiac output. Symptoms of severe AS typically include Presyncope or syncope, exertional chest pain, and shortness of breath. These symptoms can be remembered using the acronym SAD (Syncope, Angina, Dyspnoea).

      It is important to note that aortic stenosis primarily affects older individuals, as it is a result of scarring and calcium buildup in the valve. Age-related AS typically begins after the age of 60, but symptoms may not appear until patients are in their 70s or 80s.

      Diastolic murmurs, on the other hand, are associated with conditions such as aortic regurgitation, pulmonary regurgitation, and mitral stenosis.

      Further Reading:

      Valvular heart disease refers to conditions that affect the valves of the heart. In the case of aortic valve disease, there are two main conditions: aortic regurgitation and aortic stenosis.

      Aortic regurgitation is characterized by an early diastolic murmur, a collapsing pulse (also known as a water hammer pulse), and a wide pulse pressure. In severe cases, there may be a mid-diastolic Austin-Flint murmur due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams. The first and second heart sounds (S1 and S2) may be soft, and S2 may even be absent. Additionally, there may be a hyperdynamic apical pulse. Causes of aortic regurgitation include rheumatic fever, infective endocarditis, connective tissue diseases like rheumatoid arthritis and systemic lupus erythematosus, and a bicuspid aortic valve. Aortic root diseases such as aortic dissection, spondyloarthropathies like ankylosing spondylitis, hypertension, syphilis, and genetic conditions like Marfan’s syndrome and Ehler-Danlos syndrome can also lead to aortic regurgitation.

      Aortic stenosis, on the other hand, is characterized by a narrow pulse pressure, a slow rising pulse, and a delayed ESM (ejection systolic murmur). The second heart sound (S2) may be soft or absent, and there may be an S4 (atrial gallop) that occurs just before S1. A thrill may also be felt. The duration of the murmur is an important factor in determining the severity of aortic stenosis. Causes of aortic stenosis include degenerative calcification (most common in older patients), a bicuspid aortic valve (most common in younger patients), William’s syndrome (supravalvular aortic stenosis), post-rheumatic disease, and subvalvular conditions like hypertrophic obstructive cardiomyopathy (HOCM).

      Management of aortic valve disease depends on the severity of symptoms. Asymptomatic patients are generally observed, while symptomatic patients may require valve replacement. Surgery may also be considered for asymptomatic patients with a valvular gradient greater than 40 mmHg and features such as left ventricular systolic dysfunction. Balloon valvuloplasty is limited to patients with critical aortic stenosis who are not fit for valve replacement.

    • This question is part of the following fields:

      • Cardiology
      10.2
      Seconds
  • Question 4 - A 60-year-old woman with a history of congestive cardiac failure is experiencing severe...

    Incorrect

    • A 60-year-old woman with a history of congestive cardiac failure is experiencing severe central chest pain when reclining. The pain is relieved by assuming an upright position. She has a documented history of severe coronary artery disease.

      What is the SINGLE most probable diagnosis?

      Your Answer: Takotsubo cardiomyopathy

      Correct Answer: Decubitus angina

      Explanation:

      Decubitus angina typically occurs in individuals who have congestive heart failure and significant coronary artery disease. When the patient assumes a lying position, the heightened volume of blood within the blood vessels puts stress on the heart, leading to episodes of chest pain.

    • This question is part of the following fields:

      • Cardiology
      15.5
      Seconds
  • Question 5 - You are called to cardiac arrest in the resus area of your Emergency...

    Correct

    • You are called to cardiac arrest in the resus area of your Emergency Department. As part of your management, a dose of amiodarone is administered.
      Amiodarone should be administered at which of the following points during a pediatric VF arrest?

      Your Answer: After the 3rd shock

      Explanation:

      Amiodarone is recommended to be administered after the third shock in a shockable cardiac arrest (Vf/pVT) while performing chest compressions. The prescribed dose is 300 mg, which should be given as an intravenous bolus. To ensure proper administration, the medication should be diluted in 20 mL of 5% dextrose solution.

      In cases where VF/pVT continues after five defibrillation attempts, an additional dose of 150 mg of Amiodarone should be administered. It is important to note that Amiodarone is not suitable for treating PEA or asystole, and its use is specifically indicated for shockable cardiac arrest situations.

    • This question is part of the following fields:

      • Cardiology
      14.3
      Seconds
  • Question 6 - You conduct a cardiovascular examination on a 72-year-old man who complains of difficulty...

    Correct

    • You conduct a cardiovascular examination on a 72-year-old man who complains of difficulty breathing. He informs you that he has a known heart valve issue. During the examination, you observe a faint first heart sound (S1).
      What is the most probable cause of this finding?

      Your Answer: Tricuspid regurgitation

      Explanation:

      The first heart sound (S1) is created by vibrations produced when the mitral and tricuspid valves close. It occurs at the end of diastole and the start of ventricular systole, coming before the upstroke of the carotid pulsation.

      A sample of the normal heart sounds can be listened to here (courtesy of Littman stethoscopes).

      A loud S1 can be associated with the following conditions:
      – Increased transvalvular gradient (e.g. mitral stenosis, tricuspid stenosis)
      – Increased force of ventricular contraction (e.g. tachycardia, hyperdynamic states like fever and thyrotoxicosis)
      – Shortened PR interval (e.g. Wolff-Parkinson-White syndrome)
      – Mitral valve prolapse
      – Thin individuals

      A soft S1 can be associated with the following conditions:
      – Inappropriate apposition of the AV valves (e.g. mitral regurgitation, tricuspid regurgitation)
      – Prolonged PR interval (e.g. heart block, digoxin toxicity)
      – Decreased force of ventricular contraction (e.g. myocarditis, myocardial infarction)
      – Increased distance from the heart (e.g. obesity, emphysema, pericardial effusion)

      A split S1 can be associated with the following conditions:
      – Right bundle branch block
      – LV pacing
      – Ebstein anomaly

    • This question is part of the following fields:

      • Cardiology
      30.3
      Seconds
  • Question 7 - A 25-year-old woman arrives at the emergency department with complaints of palpitations and...

    Incorrect

    • A 25-year-old woman arrives at the emergency department with complaints of palpitations and difficulty breathing. During triage, the patient reveals that she was previously diagnosed with narrow complex tachycardia a couple of years ago after experiencing palpitations during a night out. You order an ECG. What are the specific criteria used to define narrow complex tachycardia?

      Your Answer: Pulse rate greater than 120 beats per minute and QRS duration less than 0.2 seconds

      Correct Answer: Pulse rate greater than 100 beats per minute and QRS duration less than 0.12 seconds

      Explanation:

      Narrow QRS complex tachycardia is a term used to describe a fast heart rhythm with a pulse rate over 100 bpm and a QRS duration shorter than 120 ms.

      Further Reading:

      Supraventricular tachycardia (SVT) is a type of tachyarrhythmia that originates from the atria or above the bundle of His in the heart. It includes all atrial and junctional tachycardias, although atrial fibrillation is often considered separately. SVT typically produces a narrow QRS complex tachycardia on an electrocardiogram (ECG), unless there is an underlying conduction abnormality below the atrioventricular (AV) node. Narrow complex tachycardias are considered SVTs, while some broad complex tachycardias can also be SVTs with co-existent conduction delays.

      SVT can be classified into three main subtypes based on where it arises: re-entrant accessory circuits (the most common type), atrial tachycardias, and junctional tachycardias. The most common SVTs are AVNRT (AV nodal re-entry tachycardia) and AVRT (AV re-entry tachycardia), which arise from accessory circuits within the heart. AVNRT involves an accessory circuit within the AV node itself, while AVRT involves an accessory pathway between the atria and ventricles that allows additional electrical signals to trigger the AV node.

      Atrial tachycardias originate from abnormal foci within the atria, except for the SA node, AV node, or accessory pathway. Junctional tachycardias arise in the AV junction. The ECG features of SVTs vary depending on the type. Atrial tachycardias may have abnormal P wave morphology, an isoelectric baseline between P waves (in atrial flutter), and inverted P waves in certain leads. AVNRT may show pseudo R waves in V1 or pseudo S waves in certain leads, with an RP interval shorter than the PR interval. AVRT (WPW) may exhibit a delta wave on a resting ECG and retrograde P waves in the ST segment, with an RP interval shorter than the PR interval. Junctional tachycardias may have retrograde P waves before, during, or after the QRS complex, with inverted P waves in certain leads and upright P waves in others.

      Treatment of SVT follows the 2021 resuscitation council algorithm for tachycardia with a pulse. The algorithm provides guidelines for managing stable patients with SVT.

    • This question is part of the following fields:

      • Cardiology
      14.3
      Seconds
  • Question 8 - A 68 year old male presents to the emergency department by ambulance due...

    Incorrect

    • A 68 year old male presents to the emergency department by ambulance due to worsening shortness of breath over the past 6 hours. The patient's wife informs you that he had complained of chest discomfort earlier in the day but attributed it to 'indigestion'. The patient is visibly breathing rapidly from the end of the bed and examination reveals crackling sounds throughout both lungs with no breath sounds and dullness when tapping the lower parts of the lungs. The following observations are noted:

      Blood pressure 100/60 mmHg
      Pulse rate 110 bpm
      Respiration rate 26 bpm
      Oxygen saturation 95% on 15L O2
      Temperature 37.2ºC

      You diagnose pulmonary edema as a result of acute heart failure secondary to cardiogenic shock. What is the mortality rate associated with this condition during hospitalization?

      Your Answer: 15%

      Correct Answer: 50%

      Explanation:

      The mortality rate associated with pulmonary edema as a result of acute heart failure secondary to cardiogenic shock during hospitalization is 50%.

      Further Reading:

      Cardiac failure, also known as heart failure, is a clinical syndrome characterized by symptoms and signs resulting from abnormalities in the structure or function of the heart. This can lead to reduced cardiac output or high filling pressures at rest or with stress. Heart failure can be caused by various problems such as myocardial, valvular, pericardial, endocardial, or arrhythmic issues.

      The most common causes of heart failure in the UK are coronary heart disease and hypertension. However, there are many other possible causes, including valvular heart disease, structural heart disease, cardiomyopathies, certain drugs or toxins, endocrine disorders, nutritional deficiencies, infiltrative diseases, infections, and arrhythmias. Conditions that increase peripheral demand on the heart, such as anemia, pregnancy, sepsis, hyperthyroidism, Paget’s disease of bone, arteriovenous malformations, and beriberi, can also lead to high-output cardiac failure.

      Signs and symptoms of heart failure include edema, lung crepitations, tachycardia, tachypnea, hypotension, displaced apex beat, right ventricular heave, elevated jugular venous pressure, cyanosis, hepatomegaly, ascites, pleural effusions, breathlessness, fatigue, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough or wheeze, and Presyncope.

      To diagnose heart failure, NICE recommends three key tests: N-terminal pro-B-type natriuretic peptide (NT‑proBNP), transthoracic echocardiography, and ECG. Additional tests may include chest X-ray, blood tests (U&Es, thyroid function, LFT’s, lipid profile, HbA1C, FBC), urinalysis, and peak flow or spirometry.

      Management of cardiogenic pulmonary edema, a complication of heart failure, involves ensuring a patent airway, optimizing breathing with supplemental oxygen and non-invasive ventilation if necessary, and addressing circulation with loop diuretics to reduce preload, vasodilators to reduce preload and afterload, and inotropes if hypotension or signs of end organ hypoperfusion persist.

    • This question is part of the following fields:

      • Cardiology
      21.8
      Seconds
  • Question 9 - A 48 year old woman comes to the emergency department complaining of episodes...

    Incorrect

    • A 48 year old woman comes to the emergency department complaining of episodes of lightheadedness. She mentions that she is an avid jogger and noticed on her fitness tracker that her heart rate had dropped to 48 beats per minute. Which of the following characteristics would warrant drug intervention or transcutaneous pacing in a patient with bradycardia?

      Your Answer: Heart rate below 50 bpm

      Correct Answer: Myocardial ischaemia

      Explanation:

      Indications for drug treatment or pacing in patients with bradycardia include shock, syncope, myocardial ischemia, heart failure, and the presence of risk factors for asystole. If any of these adverse features are present, it is important to consider drug treatment or pacing. However, even if none of these adverse features are present, patients may still require drug treatment or pacing if they have risk factors for developing asystole, such as recent asystole, Mobitz II AV block, complete heart block with broad QRS, or a ventricular pause longer than 3 seconds.

      Further Reading:

      Causes of Bradycardia:
      – Physiological: Athletes, sleeping
      – Cardiac conduction dysfunction: Atrioventricular block, sinus node disease
      – Vasovagal & autonomic mediated: Vasovagal episodes, carotid sinus hypersensitivity
      – Hypothermia
      – Metabolic & electrolyte disturbances: Hypothyroidism, hyperkalaemia, hypermagnesemia
      – Drugs: Beta-blockers, calcium channel blockers, digoxin, amiodarone
      – Head injury: Cushing’s response
      – Infections: Endocarditis
      – Other: Sarcoidosis, amyloidosis

      Presenting symptoms of Bradycardia:
      – Presyncope (dizziness, lightheadedness)
      – Syncope
      – Breathlessness
      – Weakness
      – Chest pain
      – Nausea

      Management of Bradycardia:
      – Assess and monitor for adverse features (shock, syncope, myocardial ischaemia, heart failure)
      – Treat reversible causes of bradycardia
      – Pharmacological treatment: Atropine is first-line, adrenaline and isoprenaline are second-line
      – Transcutaneous pacing if atropine is ineffective
      – Other drugs that may be used: Aminophylline, dopamine, glucagon, glycopyrrolate

      Bradycardia Algorithm:
      – Follow the algorithm for management of bradycardia, which includes assessing and monitoring for adverse features, treating reversible causes, and using appropriate medications or pacing as needed.
      https://acls-algorithms.com/wp-content/uploads/2020/12/Website-Bradycardia-Algorithm-Diagram.pdf

    • This question is part of the following fields:

      • Cardiology
      18.9
      Seconds
  • Question 10 - A 35-year-old male presents to the emergency department complaining of gradual onset sharp...

    Correct

    • A 35-year-old male presents to the emergency department complaining of gradual onset sharp chest pain over the past 24 hours. The patient reports that the pain worsens with deep inspiration and feels more comfortable when sitting leaning forward. When asked about pain radiation, the patient confirms that the pain extends to the left side of the neck and points to the ridge of the trapezius. Physical examination reveals clear lung fields, regular rhythm with quiet heart sounds, and no murmurs. The patient's vital signs are as follows:

      Blood pressure: 108/66 mmHg
      Pulse rate: 94 bpm
      Respiratory rate: 18 rpm
      Temperature: 37.3ºC
      Oxygen saturations: 97% on room air

      What is the most likely diagnosis?

      Your Answer: Acute pericarditis

      Explanation:

      Radiation to the trapezius ridge is a distinct symptom of acute pericarditis. The patient in question exhibits characteristics that align with a diagnosis of pericarditis. Pericarditis is a common condition affecting the pericardium, and it is often considered as a potential cause for chest pain. It is worth noting that the specific radiation of pain to the trapezius ridge is highly indicative of pericarditis, as it occurs when the phrenic nerve, which also innervates the trapezius muscle, becomes irritated while passing through the pericardium.

      Further Reading:

      Pericarditis is an inflammation of the pericardium, which is the protective sac around the heart. It can be acute, lasting less than 6 weeks, and may present with chest pain, cough, dyspnea, flu-like symptoms, and a pericardial rub. The most common causes of pericarditis include viral infections, tuberculosis, bacterial infections, uremia, trauma, and autoimmune diseases. However, in many cases, the cause remains unknown. Diagnosis is based on clinical features, such as chest pain, pericardial friction rub, and electrocardiographic changes. Treatment involves symptom relief with nonsteroidal anti-inflammatory drugs (NSAIDs), and patients should avoid strenuous activity until symptoms improve. Complicated cases may require treatment for the underlying cause, and large pericardial effusions may need urgent drainage. In cases of purulent effusions, antibiotic therapy is necessary, and steroid therapy may be considered for pericarditis related to autoimmune disorders or if NSAIDs alone are ineffective.

    • This question is part of the following fields:

      • Cardiology
      16
      Seconds
  • Question 11 - You conduct a cardiovascular examination on a 62-year-old man who complains of shortness...

    Incorrect

    • You conduct a cardiovascular examination on a 62-year-old man who complains of shortness of breath. He informs you that he has a known heart valve issue. During auscultation, you observe reversed splitting of the second heart sound (S2).
      What is the most probable cause of this finding?

      Your Answer: Ventricular septal defect

      Correct Answer: Aortic stenosis

      Explanation:

      The second heart sound (S2) is created by vibrations produced when the aortic and pulmonary valves close. It marks the end of systole. It is normal to hear a split in the sound during inspiration.

      A loud S2 can be associated with certain conditions such as systemic hypertension (resulting in a loud A2), pulmonary hypertension (resulting in a loud P2), hyperdynamic states (like tachycardia, fever, or thyrotoxicosis), and atrial septal defect (which causes a loud P2).

      On the other hand, a soft S2 can be linked to decreased aortic diastolic pressure (as seen in aortic regurgitation), poorly mobile cusps (such as calcification of the aortic valve), aortic root dilatation, and pulmonary stenosis (which causes a soft P2).

      A widely split S2 can occur during deep inspiration, right bundle branch block, prolonged right ventricular systole (seen in conditions like pulmonary stenosis or pulmonary embolism), and severe mitral regurgitation. However, in the case of atrial septal defect, the splitting is fixed and does not vary with respiration.

      Reversed splitting of S2, where P2 occurs before A2 (paradoxical splitting), can occur during deep expiration, left bundle branch block, prolonged left ventricular systole (as seen in hypertrophic cardiomyopathy), severe aortic stenosis, and right ventricular pacing.

    • This question is part of the following fields:

      • Cardiology
      10
      Seconds
  • Question 12 - A 68 year old male presents to the emergency department with central heavy...

    Incorrect

    • A 68 year old male presents to the emergency department with central heavy chest pain that began 10 hours ago while the patient was sitting down watching television. The patient has previously refused treatment for high cholesterol and stage 1 hypertension. Physical examination reveals a mildly elevated blood pressure of 156/94 mmHg, but is otherwise unremarkable. The ECG shows ST depression and T wave inversion in leads V1-V3. Initial troponin results are negative, and a second high sensitivity troponin assay performed 3 hours later also returns negative. What is the most likely diagnosis?

      Your Answer: Posterior NSTEMI

      Correct Answer: Unstable angina

      Explanation:

      Distinguishing between unstable angina and other acute coronary syndromes can be done by looking at normal troponin results. If serial troponin tests come back negative, it can rule out a diagnosis of myocardial infarction. Unstable angina is characterized by myocardial ischemia occurring at rest or with minimal exertion, without any acute damage or death of heart muscle cells. The patient in question shows ECG and biochemical features that align with this definition. Vincent’s angina, on the other hand, refers to an infection in the throat accompanied by ulcerative gingivitis.

      Further Reading:

      Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).

      The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.

      There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.

      The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.

      The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.

      The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.

    • This question is part of the following fields:

      • Cardiology
      28.4
      Seconds
  • Question 13 - A 45-year-old woman comes in with central chest pain that is spreading to...

    Correct

    • A 45-year-old woman comes in with central chest pain that is spreading to her left arm for the past 30 minutes. Her vital signs are as follows: heart rate of 80 beats per minute, blood pressure of 118/72, and oxygen saturation of 98% on room air. The ECG shows the following findings:
      ST depression in leads V1-V4 and aVR
      ST elevation in V5-V6, II, III, and aVF
      Positive R wave in V1 and V2
      What is the most likely diagnosis in this case?

      Your Answer: Acute inferoposterior myocardial infarction

      Explanation:

      The ECG shows the following findings:
      – There is ST depression in leads V1-V4 and aVR.
      – There is ST elevation in leads V5-V6, II, III, and aVF.
      – There is a positive R wave in leads V1 and V2, which indicates a reverse Q wave.
      These ECG changes indicate that there is an acute inferoposterior myocardial infarction.

    • This question is part of the following fields:

      • Cardiology
      15.5
      Seconds
  • Question 14 - A 65 year old male presents to the emergency department with a 3...

    Correct

    • A 65 year old male presents to the emergency department with a 3 hour history of severe chest pain that radiates to his left arm and neck. On examination, his chest is clear and his heart sounds are normal with a regular rhythm. No carotid bruits are heard. The following observations are noted:

      Blood pressure: 150/90 mmHg
      Pulse rate: 88 bpm
      Respiration rate: 18 rpm
      Oxygen saturation: 97% on room air
      Temperature: 37.2ºC

      An ECG reveals normal sinus rhythm and a chest X-ray shows no abnormalities. The patient's pain subsides after receiving buccal GTN (glyceryl trinitrate). Cardiac enzyme tests are pending. What is the most appropriate course of action for this patient?

      Your Answer: Administer 300 mg oral aspirin

      Explanation:

      For patients suspected of having acute coronary syndromes (ACS), it is recommended that they receive 300 mg of aspirin and pain relief in the form of glyceryl trinitrate (GTN) with the option of intravenous opioids such as morphine. However, if the patient is pain-free after taking GTN, there is no need to administer morphine. The next steps in medical management or intervention will be determined once the diagnosis is confirmed.

      Further Reading:

      Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).

      The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.

      There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.

      The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.

      The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.

      The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.

    • This question is part of the following fields:

      • Cardiology
      27.2
      Seconds
  • Question 15 - You are treating a 68 year old male who has been brought into...

    Incorrect

    • You are treating a 68 year old male who has been brought into the resuscitation bay by the ambulance crew. The patient was at home when he suddenly experienced dizziness and difficulty breathing. The ambulance crew presents the patient's ECG to you. You plan on administering atropine to address the patient's bradyarrhythmia.

      According to the resuscitation council, what is the maximum recommended total dose of atropine that should be administered?

      Your Answer: 12mg

      Correct Answer: 3mg

      Explanation:

      When treating adults with bradycardia, a maximum of 6 doses of atropine 500 mcg can be administered. Each dose is given intravenously every 3-5 minutes. The total dose should not exceed 3mg.

      Further Reading:

      Causes of Bradycardia:
      – Physiological: Athletes, sleeping
      – Cardiac conduction dysfunction: Atrioventricular block, sinus node disease
      – Vasovagal & autonomic mediated: Vasovagal episodes, carotid sinus hypersensitivity
      – Hypothermia
      – Metabolic & electrolyte disturbances: Hypothyroidism, hyperkalaemia, hypermagnesemia
      – Drugs: Beta-blockers, calcium channel blockers, digoxin, amiodarone
      – Head injury: Cushing’s response
      – Infections: Endocarditis
      – Other: Sarcoidosis, amyloidosis

      Presenting symptoms of Bradycardia:
      – Presyncope (dizziness, lightheadedness)
      – Syncope
      – Breathlessness
      – Weakness
      – Chest pain
      – Nausea

      Management of Bradycardia:
      – Assess and monitor for adverse features (shock, syncope, myocardial ischaemia, heart failure)
      – Treat reversible causes of bradycardia
      – Pharmacological treatment: Atropine is first-line, adrenaline and isoprenaline are second-line
      – Transcutaneous pacing if atropine is ineffective
      – Other drugs that may be used: Aminophylline, dopamine, glucagon, glycopyrrolate

      Bradycardia Algorithm:
      – Follow the algorithm for management of bradycardia, which includes assessing and monitoring for adverse features, treating reversible causes, and using appropriate medications or pacing as needed.
      https://acls-algorithms.com/wp-content/uploads/2020/12/Website-Bradycardia-Algorithm-Diagram.pdf

    • This question is part of the following fields:

      • Cardiology
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  • Question 16 - A 32-year-old man presents with an episode of atrial fibrillation (AF) that began...

    Correct

    • A 32-year-old man presents with an episode of atrial fibrillation (AF) that began a few hours ago. This is his first-ever episode, and he has no significant medical history.
      Which of the following accurately characterizes the type of AF he has experienced?

      Your Answer: Acute

      Explanation:

      In order to gain a comprehensive understanding of AF management, it is crucial to familiarize oneself with the terminology used to describe its various subtypes. These terms help categorize different episodes of AF based on their characteristics and outcomes.

      Acute AF refers to any episode that occurs within the previous 48 hours. It can manifest with or without symptoms and may or may not recur. On the other hand, paroxysmal AF describes episodes that spontaneously end within 7 days, typically within 48 hours. While these episodes are often recurrent, they can progress into a sustained form of AF.

      Recurrent AF is defined as experiencing two or more episodes of AF. If the episodes self-terminate, they are classified as paroxysmal AF. However, if the episodes do not self-terminate, they are categorized as persistent AF. Persistent AF lasts longer than 7 days or has occurred after a previous cardioversion. To terminate persistent AF, electrical or pharmacological intervention is required. In some cases, persistent AF can progress into permanent AF.

      Permanent AF, also known as Accepted AF, refers to episodes that cannot be successfully terminated, have relapsed after termination, or where cardioversion is not pursued. This subtype signifies a more chronic and ongoing form of AF.

      By understanding and utilizing these terms, healthcare professionals can effectively communicate and manage the different subtypes of AF.

    • This question is part of the following fields:

      • Cardiology
      20.4
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  • Question 17 - You evaluate a 45-year-old Asian man with a heart murmur. During auscultation, you...

    Correct

    • You evaluate a 45-year-old Asian man with a heart murmur. During auscultation, you observe a loud first heart sound and a mid-diastolic murmur at the apex. Upon examination, you observe that he has plum-red discoloration of his cheeks.
      What is the SINGLE most probable diagnosis?

      Your Answer: Mitral stenosis

      Explanation:

      The clinical symptoms of mitral stenosis include shortness of breath, which tends to worsen during exercise and when lying flat. Tiredness, palpitations, ankle swelling, cough, and haemoptysis are also common symptoms. Chest discomfort is rarely reported.

      The clinical signs of mitral stenosis can include a malar flush, an irregular pulse if atrial fibrillation is present, a tapping apex beat that can be felt as the first heart sound, and a left parasternal heave if there is pulmonary hypertension. The first heart sound is often loud, and a mid-diastolic murmur can be heard.

      The mid-diastolic murmur of mitral stenosis is a rumbling sound that is best heard at the apex, in the left lateral position during expiration, using the bell of the stethoscope.

      Mitral stenosis is typically caused by rheumatic heart disease, and it is more common in females, with about two-thirds of patients being female.

    • This question is part of the following fields:

      • Cardiology
      19.5
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  • Question 18 - A 55 year old female presents to the emergency department 3 hours after...

    Incorrect

    • A 55 year old female presents to the emergency department 3 hours after experiencing severe central chest pain that radiates to the back while gardening. The patient describes the pain as tearing and states it is the worst pain she has ever felt. You note a past medical history of poorly controlled hypertension. The patient's vital signs are as follows:

      Blood pressure 182/98 mmHg
      Pulse rate 94 bpm
      Respiration rate 22 rpm
      Oxygen saturation 97% on room air
      Temperature 37.3ºC

      An ECG is performed which shows normal sinus rhythm. Chest X-ray reveals a widened mediastinum and an abnormal aortic contour.

      What is the most appropriate initial treatment for this patient?

      Your Answer: Intravenous magnesium sulphate

      Correct Answer: Intravenous labetalol

      Explanation:

      The most appropriate initial treatment for this patient would be intravenous labetalol. Labetalol is a non-selective beta blocker with alpha-blocking properties. It is the preferred initial treatment for aortic dissection because it helps to reduce blood pressure and heart rate, which can help to decrease the shear forces acting on the aortic wall and prevent further dissection. Intravenous administration of labetalol allows for rapid and effective control of blood pressure.

      Other treatment options, such as intravenous magnesium sulphate, intravenous verapamil, GTN sublingual spray, and oral nifedipine, are not appropriate for the management of aortic dissection. Magnesium sulphate is used for the treatment of certain arrhythmias and pre-eclampsia, but it does not address the underlying issue of aortic dissection. Verapamil and nifedipine are calcium channel blockers that can lower blood pressure, but they can also cause reflex tachycardia, which can worsen the condition. GTN sublingual spray is used for the treatment of angina, but it does not address the underlying issue of aortic dissection.

      Further Reading:

      Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.

      The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.

      Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.

      Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.

    • This question is part of the following fields:

      • Cardiology
      28
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  • Question 19 - A 55-year-old male with a past medical history of high blood pressure arrives...

    Incorrect

    • A 55-year-old male with a past medical history of high blood pressure arrives at the emergency department complaining of sudden chest and interscapular pain that feels like tearing. You suspect aortic dissection. Which of the following signs and symptoms aligns with the diagnosis of aortic dissection?

      Your Answer: Bounding radial pulse

      Correct Answer: Blood pressure differential of more than 10 mmHg between left and right arms

      Explanation:

      A significant proportion of the population experiences a difference of 10 mmHg or more in blood pressure between their upper limbs. Pericarditis can be identified by the presence of saddle-shaped ST elevation and pain in the trapezius ridge. Aortic dissection is characterized by a diastolic murmur with a decrescendo pattern, which indicates aortic incompetence.

      Further Reading:

      Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.

      The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.

      Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.

      Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.

    • This question is part of the following fields:

      • Cardiology
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  • Question 20 - You are summoned to the resuscitation bay to provide assistance with a 72-year-old...

    Correct

    • You are summoned to the resuscitation bay to provide assistance with a 72-year-old patient who is undergoing treatment for cardiac arrest. After three shocks, the patient experiences a return of spontaneous circulation.

      What are the recommended blood pressure goals following a return of spontaneous circulation (ROSC) after cardiac arrest?

      Your Answer: Mean arterial pressure 65-100 mmHg

      Explanation:

      After the return of spontaneous circulation (ROSC), there are two specific blood pressure targets that need to be achieved. The first target is to maintain a systolic blood pressure above 100 mmHg. The second target is to maintain the mean arterial pressure (MAP) within the range of 65 to 100 mmHg.

      Further Reading:

      Cardiopulmonary arrest is a serious event with low survival rates. In non-traumatic cardiac arrest, only about 20% of patients who arrest as an in-patient survive to hospital discharge, while the survival rate for out-of-hospital cardiac arrest is approximately 8%. The Resus Council BLS/AED Algorithm for 2015 recommends chest compressions at a rate of 100-120 per minute with a compression depth of 5-6 cm. The ratio of chest compressions to rescue breaths is 30:2.

      After a cardiac arrest, the goal of patient care is to minimize the impact of post cardiac arrest syndrome, which includes brain injury, myocardial dysfunction, the ischaemic/reperfusion response, and the underlying pathology that caused the arrest. The ABCDE approach is used for clinical assessment and general management. Intubation may be necessary if the airway cannot be maintained by simple measures or if it is immediately threatened. Controlled ventilation is aimed at maintaining oxygen saturation levels between 94-98% and normocarbia. Fluid status may be difficult to judge, but a target mean arterial pressure (MAP) between 65 and 100 mmHg is recommended. Inotropes may be administered to maintain blood pressure. Sedation should be adequate to gain control of ventilation, and short-acting sedating agents like propofol are preferred. Blood glucose levels should be maintained below 8 mmol/l. Pyrexia should be avoided, and there is some evidence for controlled mild hypothermia but no consensus on this.

      Post ROSC investigations may include a chest X-ray, ECG monitoring, serial potassium and lactate measurements, and other imaging modalities like ultrasonography, echocardiography, CTPA, and CT head, depending on availability and skills in the local department. Treatment should be directed towards the underlying cause, and PCI or thrombolysis may be considered for acute coronary syndrome or suspected pulmonary embolism, respectively.

      Patients who are comatose after ROSC without significant pre-arrest comorbidities should be transferred to the ICU for supportive care. Neurological outcome at 72 hours is the best prognostic indicator of outcome.

    • This question is part of the following fields:

      • Cardiology
      24
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  • Question 21 - You evaluate a 56-year-old individual who arrives at the ER complaining of chest...

    Correct

    • You evaluate a 56-year-old individual who arrives at the ER complaining of chest discomfort and increasing swelling. Upon reviewing the patient's medical history, you discover that they underwent an echocardiogram a year ago, which revealed moderate-severe tricuspid regurgitation. Which of the following heart murmurs is commonly associated with tricuspid regurgitation?

      Your Answer: Low-frequency pansystolic murmur

      Explanation:

      Tricuspid regurgitation is characterized by a continuous murmur that spans the entire systolic phase of the cardiac cycle. This murmur is best audible at the lower left sternal edge and has a low frequency. Interestingly, the intensity of the murmur increases during inspiration and decreases during expiration, a phenomenon referred to as Carvallo’s sign.

      Further Reading:

      Tricuspid regurgitation (TR) is a condition where blood flows backwards through the tricuspid valve in the heart. It is classified as either primary or secondary, with primary TR being caused by abnormalities in the tricuspid valve itself and secondary TR being the result of other conditions outside of the valve. Mild TR is common, especially in young adults, and often does not cause symptoms. However, severe TR can lead to right-sided heart failure and the development of symptoms such as ascites, peripheral edema, and hepatomegaly.

      The causes of TR can vary. Primary TR can be caused by conditions such as rheumatic heart disease, myxomatous valve disease, or Ebstein anomaly. Secondary TR is often the result of right ventricular dilatation due to left heart failure or pulmonary hypertension. Other causes include endocarditis, traumatic chest injury, left ventricular systolic dysfunction, chronic lung disease, pulmonary thromboembolism, myocardial disease, left to right shunts, and carcinoid heart disease. In some cases, TR can occur as a result of infective endocarditis in IV drug abusers.

      Clinical features of TR can include a pansystolic murmur that is best heard at the lower left sternal edge, Carvallo’s sign (murmur increases with inspiration and decreases with expiration), an S3 heart sound, and the presence of atrial arrhythmias such as flutter or fibrillation. Other signs can include giant C-V waves in the jugular pulse, hepatomegaly (often pulsatile), and edema with lung crepitations or pleural effusions.

      The management of TR depends on the underlying cause and the severity of the condition. In severe cases, valve repair or replacement surgery may be necessary. Treatment may also involve addressing the underlying conditions contributing to TR, such as managing left heart failure or pulmonary hypertension.

    • This question is part of the following fields:

      • Cardiology
      20.1
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  • Question 22 - You conduct a cardiovascular examination on a 62-year-old man who complains of palpitations....

    Incorrect

    • You conduct a cardiovascular examination on a 62-year-old man who complains of palpitations. He informs you that he has a known heart valve issue. During auscultation, you observe a faint second heart sound (S2).
      What is the most probable cause of this finding?

      Your Answer: Atrial septal defect

      Correct Answer: Pulmonary stenosis

      Explanation:

      The second heart sound (S2) is created by vibrations produced when the aortic and pulmonary valves close. It marks the end of systole. It is normal to hear a split in the sound during inspiration.

      A loud S2 can be associated with certain conditions such as systemic hypertension (resulting in a loud A2), pulmonary hypertension (resulting in a loud P2), hyperdynamic states (like tachycardia, fever, or thyrotoxicosis), and atrial septal defect (which causes a loud P2).

      On the other hand, a soft S2 can be linked to decreased aortic diastolic pressure (as seen in aortic regurgitation), poorly mobile cusps (such as calcification of the aortic valve), aortic root dilatation, and pulmonary stenosis (which causes a soft P2).

      A widely split S2 can occur during deep inspiration, right bundle branch block, prolonged right ventricular systole (seen in conditions like pulmonary stenosis or pulmonary embolism), and severe mitral regurgitation. However, in the case of atrial septal defect, the splitting is fixed and does not vary with respiration.

      Reversed splitting of S2, where P2 occurs before A2 (paradoxical splitting), can occur during deep expiration, left bundle branch block, prolonged left ventricular systole (as seen in hypertrophic cardiomyopathy), severe aortic stenosis, and right ventricular pacing.

    • This question is part of the following fields:

      • Cardiology
      46.2
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  • Question 23 - You evaluate a 55-year-old woman with chest discomfort and suspect a diagnosis of...

    Incorrect

    • You evaluate a 55-year-old woman with chest discomfort and suspect a diagnosis of an acute coronary syndrome (ACS).
      Which ONE statement about ACS is NOT TRUE?

      Your Answer: Increased ventricular activation time is indicative of infarcted myocardium

      Correct Answer: Cardiac enzymes are usually elevated in unstable angina

      Explanation:

      Cardiac enzymes do not increase in unstable angina. However, if cardiac markers do rise, it is classified as a non-ST elevation myocardial infarction (NSTEMI). Both unstable angina and NSTEMI can have a normal ECG. An extended ventricular activation time indicates damage to the heart muscle. This occurs because infarcting myocardium conducts electrical impulses at a slower pace, resulting in a prolonged interval between the start of the QRS complex and the apex of the R wave. A positive troponin test indicates the presence of necrosis in cardiac myocytes.

      Summary:
      Marker | Initial Rise | Peak | Normal at
      Creatine kinase | 4-8 hours | 18 hours 2-3 days | CK-MB = main cardiac isoenzyme
      Myoglobin | 1-4 hours | 6-7 hours | 24 hours | Low specificity due to skeletal muscle damage
      Troponin I | 3-12 hours | 24 hours | 3-10 days | Appears to be the most sensitive and specific
      HFABP | 1-2 hours | 5-10 hours | 24 hours | HFABP = heart fatty acid binding protein
      LDH | 10 hours | 24-48 hours | 14 days | Cardiac muscle mainly contains LDH

    • This question is part of the following fields:

      • Cardiology
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  • Question 24 - A 58-year-old woman presents with abrupt intense chest discomfort that extends to her...

    Incorrect

    • A 58-year-old woman presents with abrupt intense chest discomfort that extends to her back. She is perspiring and experiencing nausea. During the examination, her blood pressure measures 176/96 in her right arm and 143/78 in her left arm. An early diastolic murmur is audible upon auscultation.

      What is the SINGLE most probable diagnosis?

      Your Answer: Myocardial infarction

      Correct Answer: Aortic dissection

      Explanation:

      Acute aortic dissection is characterized by the rapid formation of a false, blood-filled channel within the middle layer of the aorta. It is estimated to occur in 3 out of every 100,000 individuals per year.

      Patients with aortic dissection typically experience intense chest pain that spreads to the area between the shoulder blades. The pain is often described as tearing or ripping and may also extend to the neck. Sweating, paleness, and rapid heartbeat are commonly observed at the time of presentation. Other possible symptoms include focal neurological deficits, weak pulses, fainting, and reduced blood flow to organs.

      A significant difference in blood pressure between the arms, greater than 20 mmHg, is a highly sensitive indicator. If the dissection extends backward, it can involve the aortic valve, leading to the early diastolic murmur of aortic regurgitation.

      Risk factors for aortic dissection include hypertension, atherosclerosis, aortic coarctation, the use of sympathomimetic drugs like cocaine, Marfan syndrome, Ehlers-Danlos syndrome, Turner’s syndrome, tertiary syphilis, and pre-existing aortic aneurysm.

      Aortic dissection can be classified according to the Stanford classification system:
      – Type A affects the ascending aorta and the arch, accounting for 60% of cases. These cases are typically managed surgically and may result in the blockage of coronary arteries and aortic regurgitation.
      – Type B begins distal to the left subclavian artery and accounts for approximately 40% of cases. These cases are usually managed with medication to control blood pressure.

    • This question is part of the following fields:

      • Cardiology
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  • Question 25 - A 35-year-old woman with a history of paroxysmal supraventricular tachycardia is found to...

    Incorrect

    • A 35-year-old woman with a history of paroxysmal supraventricular tachycardia is found to have a diagnosis of Lown-Ganong-Levine (LGL) syndrome.
      Which of the following statements about LGL syndrome is NOT true?

      Your Answer: P waves are usually normal or inverted

      Correct Answer: It is caused by an accessory pathway for conduction

      Explanation:

      Lown-Ganong-Levine (LGL) syndrome is a condition that affects the electrical conducting system of the heart. It is classified as a pre-excitation syndrome, similar to the more well-known Wolff-Parkinson-White (WPW) syndrome. However, unlike WPW syndrome, LGL syndrome does not involve an accessory pathway for conduction. Instead, it is believed that there may be accessory fibers present that bypass all or part of the atrioventricular node.

      When looking at an electrocardiogram (ECG) of a patient with LGL syndrome in sinus rhythm, there are several characteristic features to observe. The PR interval, which represents the time it takes for the electrical signal to travel from the atria to the ventricles, is typically shortened and measures less than 120 milliseconds. The QRS duration, which represents the time it takes for the ventricles to contract, is normal. The P wave, which represents the electrical activity of the atria, may be normal or inverted. However, what distinguishes LGL syndrome from other pre-excitation syndromes is the absence of a delta wave, which is a slurring of the initial rise in the QRS complex.

      It is important to note that LGL syndrome predisposes individuals to paroxysmal supraventricular tachycardia (SVT), a rapid heart rhythm that originates above the ventricles. However, it does not increase the risk of developing atrial fibrillation or flutter, which are other types of abnormal heart rhythms.

    • This question is part of the following fields:

      • Cardiology
      15
      Seconds
  • Question 26 - You are asked to evaluate a 62-year-old patient who has come in with...

    Incorrect

    • You are asked to evaluate a 62-year-old patient who has come in with complaints of chest discomfort. The nurse has handed you the ECG report, which states 'unspecified age septal infarction' in the comments section.

      Which leads would you anticipate observing ST elevation in an acute septal STEMI?

      Your Answer: I and AVL

      Correct Answer: V1, V2

      Explanation:

      The septum, which is a part of the heart, can be best identified by examining leads V1 and V2. The septum receives its blood supply from the proximal left anterior descending artery (LAD). The LAD is responsible for supplying blood to the anterior myocardium and also contributes to the blood supply of the lateral myocardium. If the LAD becomes blocked, it can result in ST elevation in all the chest leads.

      Further Reading:

      Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).

      The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.

      There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.

      The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.

      The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.

      The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.

    • This question is part of the following fields:

      • Cardiology
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  • Question 27 - A 68 year old man is brought to the emergency department due to...

    Incorrect

    • A 68 year old man is brought to the emergency department due to sudden difficulty in breathing. You observe that the patient was diagnosed with mitral regurgitation a year ago. Which arrhythmia is commonly seen in individuals with chronic mitral regurgitation?

      Your Answer: Atrial flutter

      Correct Answer: Atrial fibrillation

      Explanation:

      People with chronic mitral regurgitation often experience atrial fibrillation.

      Mitral Stenosis:
      – Causes: Rheumatic fever, Mucopolysaccharidoses, Carcinoid, Endocardial fibroelastosis
      – Features: Mid-late diastolic murmur, loud S1, opening snap, low volume pulse, malar flush, atrial fibrillation, signs of pulmonary edema, tapping apex beat
      – Features of severe mitral stenosis: Length of murmur increases, opening snap becomes closer to S2
      – Investigation findings: CXR may show left atrial enlargement, echocardiography may show reduced cross-sectional area of the mitral valve

      Mitral Regurgitation:
      – Causes: Mitral valve prolapse, Myxomatous degeneration, Ischemic heart disease, Rheumatic fever, Connective tissue disorders, Endocarditis, Dilated cardiomyopathy
      – Features: pansystolic murmur radiating to left axilla, soft S1, S3, laterally displaced apex beat with heave
      – Signs of acute MR: Decompensated congestive heart failure symptoms
      – Signs of chronic MR: Leg edema, fatigue, arrhythmia (atrial fibrillation)
      – Investigation findings: Doppler echocardiography to detect regurgitant flow and pulmonary hypertension, ECG may show signs of LA enlargement and LV hypertrophy, CXR may show LA and LV enlargement in chronic MR and pulmonary edema in acute MR.

    • This question is part of the following fields:

      • Cardiology
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  • Question 28 - A 65 year old male is brought to the emergency department following a...

    Correct

    • A 65 year old male is brought to the emergency department following a fall which occurred while the patient was getting out of bed. The patient complains of feeling dizzy as he got out of bed before experiencing tunnel vision and briefly losing consciousness. The patient is certain he only blacked out for a few seconds as the time on the bedside clock had not changed. The patient informs you that he has had several similar episodes over the past few months when getting out of bed, but most of the time he only feels dizzy and doesn't faint. He denies any loss of bladder or bowel control or biting his tongue. An ECG is performed which shows normal sinus rhythm. You note the patient takes the following medication:
      Lisinopril 10 mg OD
      Fluoxetine 20 mg OD

      What is the most likely diagnosis?

      Your Answer: Orthostatic hypotension

      Explanation:

      Orthostatic hypotension is a condition where patients feel lightheaded and may experience tunnel vision when they stand up from a lying down position. These symptoms are often worse in the morning. The patient’s history of recurrent episodes after being in a supine position for a long time strongly suggests orthostatic hypotension. There are no signs of epilepsy, such as deja-vu or jambs vu prodrome, tongue biting, loss of bladder or bowel control, or postictal confusion. The normal ECG and consistent timing of symptoms make postural orthostatic tachycardia syndrome (PAF) less likely. There are no neurological deficits to suggest a transient ischemic attack (TIA). The prodromal symptoms, such as tunnel vision and lightheadedness, align more with orthostatic hypotension rather than vasovagal syncope, which typically occurs after long periods of standing and is characterized by feeling hot and sweaty. Although carotid sinus syndrome could be considered as a differential diagnosis, as the patient’s head turning on getting out of bed may trigger symptoms, it is not one of the options.

      Further Reading:

      Blackouts, also known as syncope, are defined as a spontaneous transient loss of consciousness with complete recovery. They are most commonly caused by transient inadequate cerebral blood flow, although epileptic seizures can also result in blackouts. There are several different causes of blackouts, including neurally-mediated reflex syncope (such as vasovagal syncope or fainting), orthostatic hypotension (a drop in blood pressure upon standing), cardiovascular abnormalities, and epilepsy.

      When evaluating a patient with blackouts, several key investigations should be performed. These include an electrocardiogram (ECG), heart auscultation, neurological examination, vital signs assessment, lying and standing blood pressure measurements, and blood tests such as a full blood count and glucose level. Additional investigations may be necessary depending on the suspected cause, such as ultrasound or CT scans for aortic dissection or other abdominal and thoracic pathology, chest X-ray for heart failure or pneumothorax, and CT pulmonary angiography for pulmonary embolism.

      During the assessment, it is important to screen for red flags and signs of any underlying serious life-threatening condition. Red flags for blackouts include ECG abnormalities, clinical signs of heart failure, a heart murmur, blackouts occurring during exertion, a family history of sudden cardiac death at a young age, an inherited cardiac condition, new or unexplained breathlessness, and blackouts in individuals over the age of 65 without a prodrome. These red flags indicate the need for urgent assessment by an appropriate specialist.

      There are several serious conditions that may be suggested by certain features. For example, myocardial infarction or ischemia may be indicated by a history of coronary artery disease, preceding chest pain, and ECG signs such as ST elevation or arrhythmia. Pulmonary embolism may be suggested by dizziness, acute shortness of breath, pleuritic chest pain, and risk factors for venous thromboembolism. Aortic dissection may be indicated by chest and back pain, abnormal ECG findings, and signs of cardiac tamponade include low systolic blood pressure, elevated jugular venous pressure, and muffled heart sounds. Other conditions that may cause blackouts include severe hypoglycemia, Addisonian crisis, and electrolyte abnormalities.

    • This question is part of the following fields:

      • Cardiology
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  • Question 29 - A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations....

    Incorrect

    • A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations. She informs you that she was recently diagnosed with type A Wolff-Parkinson-White syndrome. You proceed to perform an ECG.
      Which of the following ECG characteristics is NOT observed in type A Wolff-Parkinson-White (WPW) syndrome?

      Your Answer: Predominantly positive delta waves in the praecordial leads

      Correct Answer: Predominantly negative QRS complexes in leads V1 and V2

      Explanation:

      Wolff-Parkinson-White (WPW) syndrome is a condition that affects the electrical system of the heart. It occurs when there is an abnormal pathway, known as the bundle of Kent, between the atria and the ventricles. This pathway can cause premature contractions of the ventricles, leading to a type of rapid heartbeat called atrioventricular re-entrant tachycardia (AVRT).

      In a normal heart rhythm, the electrical signals travel through the bundle of Kent and stimulate the ventricles. However, in WPW syndrome, these signals can cause the ventricles to contract prematurely. This can be seen on an electrocardiogram (ECG) as a shortened PR interval, a slurring of the initial rise in the QRS complex (known as a delta wave), and a widening of the QRS complex.

      There are two distinct types of WPW syndrome that can be identified on an ECG. Type A is characterized by predominantly positive delta waves and QRS complexes in the praecordial leads, with a dominant R wave in V1. This can sometimes be mistaken for right bundle branch block (RBBB). Type B, on the other hand, shows predominantly negative delta waves and QRS complexes in leads V1 and V2, and positive in the other praecordial leads, resembling left bundle branch block (LBBB).

      Overall, WPW syndrome is a condition that affects the electrical conduction system of the heart, leading to abnormal heart rhythms. It can be identified on an ECG by specific features such as shortened PR interval, delta waves, and widened QRS complex.

    • This question is part of the following fields:

      • Cardiology
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  • Question 30 - A 35 year old male presents to the emergency department with complaints of...

    Incorrect

    • A 35 year old male presents to the emergency department with complaints of palpitations. An ECG is conducted, revealing a regular narrow complex supraventricular tachycardia with a rate of around 160 bpm. There are no signs of ST elevation or depression. The patient's vital signs are as follows:

      Blood pressure: 128/76 mmHg
      Pulse rate: 166
      Respiration rate: 19
      Oxygen saturations: 97% on room air

      What would be the most appropriate initial treatment for this patient?

      Your Answer: Adenosine 6 mg IV

      Correct Answer: Vagal manoeuvres

      Explanation:

      In stable patients with SVT, it is recommended to first try vagal manoeuvres before resorting to drug treatment. This approach is particularly applicable to patients who do not exhibit any adverse features, as mentioned in the case above.

      Further Reading:

      Supraventricular tachycardia (SVT) is a type of tachyarrhythmia that originates from the atria or above the bundle of His in the heart. It includes all atrial and junctional tachycardias, although atrial fibrillation is often considered separately. SVT typically produces a narrow QRS complex tachycardia on an electrocardiogram (ECG), unless there is an underlying conduction abnormality below the atrioventricular (AV) node. Narrow complex tachycardias are considered SVTs, while some broad complex tachycardias can also be SVTs with co-existent conduction delays.

      SVT can be classified into three main subtypes based on where it arises: re-entrant accessory circuits (the most common type), atrial tachycardias, and junctional tachycardias. The most common SVTs are AVNRT (AV nodal re-entry tachycardia) and AVRT (AV re-entry tachycardia), which arise from accessory circuits within the heart. AVNRT involves an accessory circuit within the AV node itself, while AVRT involves an accessory pathway between the atria and ventricles that allows additional electrical signals to trigger the AV node.

      Atrial tachycardias originate from abnormal foci within the atria, except for the SA node, AV node, or accessory pathway. Junctional tachycardias arise in the AV junction. The ECG features of SVTs vary depending on the type. Atrial tachycardias may have abnormal P wave morphology, an isoelectric baseline between P waves (in atrial flutter), and inverted P waves in certain leads. AVNRT may show pseudo R waves in V1 or pseudo S waves in certain leads, with an RP interval shorter than the PR interval. AVRT (WPW) may exhibit a delta wave on a resting ECG and retrograde P waves in the ST segment, with an RP interval shorter than the PR interval. Junctional tachycardias may have retrograde P waves before, during, or after the QRS complex, with inverted P waves in certain leads and upright P waves in others.

      Treatment of SVT follows the 2021 resuscitation council algorithm for tachycardia with a pulse. The algorithm provides guidelines for managing stable patients with SVT.

    • This question is part of the following fields:

      • Cardiology
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