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Question 1
Incorrect
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A 55-year-old woman with type II diabetes is urgently sent to the Emergency Department by her General Practitioner (GP). The patient had seen her GP that morning and reported an episode of chest pain that she had experienced the day before. The GP suspected the pain was due to gastro-oesophageal reflux but had performed an electrocardiogram (ECG) and sent a troponin level to be certain. The ECG was normal, but the troponin level came back that afternoon as raised. The GP advised the patient to go to Accident and Emergency, given the possibility of reduced sensitivity to the symptoms of a myocardial infarction (MI) in this diabetic patient.
Patient Normal range
High-sensitivity troponin T 20 ng/l <14 ng/l
What should be done based on this test result?Your Answer: Admission to Coronary Care Unit (CCU)
Correct Answer: Repeat troponin level
Explanation:Management of Suspected Myocardial Infarction
Explanation:
When a patient presents with symptoms suggestive of myocardial infarction (MI), a troponin level should be checked. If the level is only slightly raised, it does not confirm a diagnosis of MI, but neither does it rule it out. Therefore, a repeat troponin level should be performed at least 3 hours after the first level and sent as urgent.
In an MI, cardiac enzymes are released from dead myocytes into the blood, causing enzyme levels to rise and eventually fall as they are cleared from blood. If the patient has had an MI, the repeat troponin level should either be further raised or further reduced. If the level remains roughly constant, then an alternative cause should be sought, such as pulmonary embolism, chronic kidney disease, acute kidney injury, pericarditis, heart failure, or sepsis/systemic infection.
Admission to the Coronary Care Unit (CCU) is not warranted yet. Further investigations should be performed to ascertain whether an admission is needed or whether alternative diagnoses should be explored.
Safety-netting and return to the GP should include a repeat troponin level to see if the level is stable (arguing against an MI) or is rising/falling. A repeat electrocardiogram (ECG) should be performed, and a thorough history and examination should be obtained to identify any urgent diagnoses that need to be explored before the patient is discharged.
Thrombolysis carries a risk for bleeding, so it requires a clear indication, which has not yet been obtained. Therefore, it should not be administered without proper evaluation.
The alanine transaminase (ALT) level has been used as a marker of MI in the past, but it has been since superseded as it is not specific for myocardial damage. In fact, it is now used as a component of liver function tests.
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This question is part of the following fields:
- Cardiology
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Question 2
Incorrect
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Various cardiac diseases necessitate the use of pacemakers to maintain regular heartbeats and sustain the patient's life. The following are three types of pacemakers, labeled 1-3: AAI, VVI, and DDD. Can you correctly match each pacemaker to the condition it is typically used to treat?
Your Answer: AAI – ventricular systolic dysfunction; VVI – atrial fibrillation (AF); DDD – long QT syndrome
Correct Answer: AAI – sinus node dysfunction; VVI – AF; DDD – second-degree heart block
Explanation:Understanding Pacemaker Coding and Indications
Pacemakers are electronic devices that are implanted in the chest to regulate the heartbeat. They are used to treat a variety of heart conditions, including sinus node dysfunction, atrial fibrillation (AF), and heart block. Pacemakers are coded based on the chambers they pace, sense, and respond to, as well as their ability to modulate heart rate and provide multisite pacing.
AAI pacemakers are used to pace the atria in patients with sinus node dysfunction and intact AV conduction. VVI pacemakers are used in patients with chronic atrial impairment, such as AF. DDD pacemakers are used to pace both the atria and ventricles in patients with second-degree heart block.
It is important to note that AAI pacemakers would not be effective in treating ventricular systolic dysfunction, and DDD pacemakers cannot be used in the treatment of long QT syndrome. However, pacemakers can be used in long QT syndrome if clinically necessary, and DDD pacing may be appropriate for some patients with first-degree heart block.
In summary, understanding pacemaker coding and indications is crucial for selecting the appropriate device for each patient’s unique heart condition.
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This question is part of the following fields:
- Cardiology
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Question 3
Incorrect
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A 68-year-old man presents with severe epigastric pain and nausea. He reports not having a bowel movement in 3 days, despite normal bowel habits prior to this. The patient has a history of coronary stents placed after a heart attack 10 years ago. He has been asymptomatic since then and takes aspirin for his cardiac condition and NSAIDs for knee arthritis. He has not consumed alcohol in the past 5 years due to a previous episode of acute gastritis.
On examination, there is mild tenderness over the epigastrium but no guarding. Bowel sounds are normal. An erect CXR and abdominal X-ray are unremarkable. Blood gases and routine blood tests (FBC, U&E, LFTs) are normal, with a normal amylase. Upper GI endoscopy reveals gastric erosions.
What is the most important differential diagnosis to consider for this patient?Your Answer: Ischaemic bowel
Correct Answer: Myocardial infarction
Explanation:Possible Diagnoses for a Patient with Epigastric Pain and History of Cardiac Stents
Introduction:
A patient with a history of cardiac stents presents with epigastric pain. The following are possible diagnoses that should be considered.Myocardial Infarction:
Due to the patient’s history of cardiac stents, ruling out a myocardial infarction (MI) is crucial. An electrocardiogram (ECG) should be performed early to treat any existing cardiac condition without delay.Duodenal Ulcer:
A duodenal ulcer would have likely been visualized on an oesophagogastroduodenoscopy (OGD). However, a normal erect CXR and absence of peritonitis exclude a perforated duodenal ulcer.Acute Gastritis:
Given the patient’s history of aspirin and NSAID use, as well as the gastric erosions visualized on endoscopy, acute gastritis is the most likely diagnosis. However, it is important to first exclude MI as a cause of the patient’s symptoms due to their history of MI and presentation of epigastric pain.Pancreatitis:
Pancreatitis is unlikely, given the normal amylase. However, on occasion, this can be normal in cases depending on the timing of the blood test or whether the pancreas has had previous chronic inflammation.Ischaemic Bowel:
Ischaemic bowel would present with more generalized abdominal pain and metabolic lactic acidosis on blood gas. Therefore, it is less likely to be the cause of the patient’s symptoms. -
This question is part of the following fields:
- Cardiology
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Question 4
Incorrect
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A 25-year-old woman attends a new patient health check at the General Practice surgery she has recently joined. She mentions she occasionally gets episodes of palpitations and light-headedness and has done so for several years. Her pulse is currently regular, with a rate of 70 bpm, and her blood pressure is 110/76 mmHg. A full blood count is sent, which comes back as normal. The general practitioner requests an electrocardiogram (ECG), which shows a widened QRS complex with a slurred upstroke and a shortened PR interval.
Which of the following is the most likely diagnosis?Your Answer: Mobitz type II atrioventricular block
Correct Answer: Wolff–Parkinson–White syndrome
Explanation:Common Cardiac Conditions and Their ECG Findings
Wolff-Parkinson-White syndrome is a condition that affects young people and is characterized by episodes of syncope and palpitations. It is caused by an accessory pathway from the atria to the ventricles that bypasses the normal atrioventricular node. The ECG shows a slurred upstroke to the QRS complex, known as a delta wave, which reflects ventricular pre-excitation. Re-entry circuits can form, leading to tachyarrhythmias and an increased risk of ventricular fibrillation.
Hypertrophic cardiomyopathy is an inherited condition that presents in young adulthood and is the most common cause of sudden cardiac death in the young. Symptoms include syncope, dyspnea, palpitations, and abnormal ECG findings, which may include conduction abnormalities, arrhythmias, left ventricular hypertrophy, and ST or T wave changes.
First-degree heart block is characterized by a prolonged PR interval and may be caused by medication, electrolyte imbalances, or post-myocardial infarction. It may also be a normal variant in young, healthy individuals.
Ebstein’s anomaly typically presents in childhood and young adulthood with fatigue, palpitations, cyanosis, and breathlessness on exertion. The ECG shows right bundle branch block and signs of atrial enlargement, such as tall, broad P waves.
Mobitz type II atrioventricular block is a type of second-degree heart block that is characterized by a stable PR interval with some non-conducted beats. It often progresses to complete heart block. Mobitz type I (Wenckebach) block, on the other hand, is characterized by a progressively lengthening PR interval, followed by a non-conducted beat and a reset of the PR interval back to a shorter value.
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This question is part of the following fields:
- Cardiology
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Question 5
Incorrect
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A 55-year-old man was brought to the Emergency Department following a car accident. Upon examination, there are no visible signs of external bleeding, but his blood pressure is 90/40 mmHg and his heart rate is 120 bpm. He presents with distended neck veins and muffled heart sounds.
What is the most probable echocardiogram finding in this case?Your Answer: Pleural effusion
Correct Answer: Pericardial effusion
Explanation:Differential Diagnosis for a Trauma Patient with Beck’s Triad
When a trauma patient presents with hypotension, tachycardia, distended neck veins, and muffled heart sounds, the clinician should suspect pericardial effusion, also known as cardiac tamponade. This condition occurs when fluid accumulates in the pericardial space, compressing the heart and impairing its function. In the context of chest trauma, pericardial effusion is a life-threatening emergency that requires prompt diagnosis and treatment.
Other conditions that may cause similar symptoms but have different underlying mechanisms include mitral regurgitation, pneumothorax, haemothorax, and pleural effusion. Mitral regurgitation refers to the backflow of blood from the left ventricle to the left atrium due to a faulty mitral valve. While it can be detected on an echocardiogram, it is unlikely to cause Beck’s triad as it does not involve fluid accumulation outside the heart.
Pneumothorax is the presence of air in the pleural space, which can cause lung collapse and respiratory distress. A tension pneumothorax, in which air accumulates under pressure and shifts the mediastinum, can also compress the heart and impair its function. However, it would not be visible on an echocardiogram, which focuses on the heart and pericardium.
Haemothorax is the accumulation of blood in the pleural space, usually due to chest trauma or surgery. Like pneumothorax, it can cause respiratory compromise and hypovolemia, but it does not affect the heart directly and would not cause Beck’s triad.
Pleural effusion is a generic term for any fluid accumulation in the pleural space, which can be caused by various conditions such as infection, cancer, or heart failure. While it may cause respiratory symptoms and chest pain, it does not affect the heart’s function and would not cause Beck’s triad or be visible on an echocardiogram.
In summary, a trauma patient with Beck’s triad should be evaluated for pericardial effusion as the most likely cause, but other conditions such as tension pneumothorax or haemothorax should also be considered depending on the clinical context. An echocardiogram can help confirm or rule out pericardial effusion and guide further management.
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This question is part of the following fields:
- Cardiology
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Question 6
Incorrect
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A 29-year-old woman presents with sudden-onset palpitation and chest pain that began 1 hour ago. The palpitation is constant and is not alleviated or aggravated by anything. She is worried that something serious is happening to her. She recently experienced conflict at home with her husband and left home the previous day to stay with her sister. She denies any medication or recreational drug use. Past medical history is unremarkable. Vital signs are within normal limits, except for a heart rate of 180 bpm. Electrocardiography shows narrow QRS complexes that are regularly spaced. There are no visible P waves preceding the QRS complexes. Carotid sinus massage results in recovery of normal sinus rhythm.
What is the most likely diagnosis?Your Answer: Sinus tachycardia
Correct Answer: Atrioventricular nodal re-entrant tachycardia
Explanation:Differentiating Types of Tachycardia
Paroxysmal supraventricular tachycardia (PSVT) is a sudden-onset tachycardia with a heart rate of 180 bpm, regularly spaced narrow QRS complexes, and no visible P waves preceding the QRS complexes. Carotid sinus massage or adenosine administration can diagnose PSVT, which is commonly caused by atrioventricular nodal re-entrant tachycardia.
Sinus tachycardia is characterized by normal P waves preceding each QRS complex. Atrial flutter is less common than atrioventricular nodal re-entrant tachycardia and generally does not respond to carotid massage. Atrial fibrillation is characterized by irregularly spaced QRS complexes and does not respond to carotid massage. Paroxysmal ventricular tachycardia is associated with wide QRS complexes.
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This question is part of the following fields:
- Cardiology
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Question 7
Incorrect
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A 70-year-old man with a history of chronic cardiac failure with reduced ventricular systolic function presents with recent onset of increasing breathlessness, and worsening peripheral oedema and lethargy. He is currently taking ramipril and bisoprolol alongside occasional paracetamol.
What is the most appropriate long-term management?Your Answer: Addition of furosemide
Correct Answer: Addition of spironolactone
Explanation:For the management of heart failure, first line options include ACE inhibitors, beta-blockers, and aldosterone antagonists. In this case, the patient was already on a beta-blocker and an ACE inhibitor which had been effective. The addition of an aldosterone antagonist such as spironolactone would be the best option as it prevents fluid retention and reduces pressure on the heart. Ivabradine is a specialist intervention that should only be considered after trying all other recommended options. Addition of furosemide would only provide symptomatic relief. Insertion of an implantable cardiac defibrillator device is a late-stage intervention. Encouraging regular exercise and a healthy diet is important but does not directly address the patient’s clinical deterioration.
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This question is part of the following fields:
- Cardiology
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Question 8
Incorrect
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A 70-year-old man experiences an acute myocardial infarction and subsequently develops a bundle branch block. Which coronary artery is the most probable culprit?
Your Answer: Acute marginal branch of the right coronary artery
Correct Answer: Left anterior descending artery
Explanation:Coronary Artery Branches and Their Functions
The heart is supplied with blood by the coronary arteries, which branch off the aorta. These arteries are responsible for delivering oxygen and nutrients to the heart muscle. Here are some of the main branches of the coronary arteries and their functions:
1. Left Anterior Descending Artery: This artery supplies the front and left side of the heart, including the interventricular septum. It is one of the most important arteries in the heart.
2. Acute Marginal Branch of the Right Coronary Artery: This branch supplies the right ventricle of the heart.
3. Circumflex Branch of the Left Coronary Artery: This artery supplies the left atrium, left ventricle, and the sinoatrial node in some people.
4. Obtuse Marginal Branch of the Circumflex Artery: This branch supplies the left ventricle.
5. Atrioventricular Nodal Branch of the Right Coronary Artery: This branch supplies the atrioventricular node. Blockage of this branch can result in heart block.
Understanding the functions of these coronary artery branches is crucial for diagnosing and treating heart conditions.
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This question is part of the following fields:
- Cardiology
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Question 9
Incorrect
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A 65-year-old man presents with a 1-hour history of chest pain and is found to have an acute ST elevation inferior myocardial infarct. His blood pressure is 126/78 mmHg and has a pulse of 58 bpm. He is loaded with anti-platelets, and the cardiac monitor shows second-degree heart block (Wenckebach’s phenomenon).
What would you consider next for this patient?Your Answer: Primary percutaneous intervention (PCI)
Correct Answer: Temporary pacing and primary PCI
Explanation:Management of Heart Block in Acute Myocardial Infarction
Wenckebach’s phenomenon is usually not a cause for concern in patients with normal haemodynamics. However, if it occurs alongside acute myocardial infarction, complete heart block, or symptomatic Mobitz type II block, temporary pacing is necessary. Even with complete heart block, revascularisation can improve conduction if the patient is haemodynamically stable. Beta blockers should be avoided in second- and third-degree heart block as they can worsen the situation. Temporary pacing is required before proceeding to primary percutaneous intervention (PCI). A permanent pacemaker may be necessary for patients with irreversible heart block, but revascularisation should be prioritised as it may improve conduction. The block may be complete or second- or third-degree. If the heart block is reversible, temporary pacing should be followed by an assessment for permanent pacing.
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This question is part of the following fields:
- Cardiology
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Question 10
Incorrect
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A 35-year-old woman presents to her Accident and Emergency with visual loss. She has known persistently uncontrolled hypertension, previously managed in the community. Blood tests are performed as follows:
Investigation Patient Normal value
Sodium (Na+) 148 mmol/l 135–145 mmol/l
Potassium (K+) 2.7 mmol/l 3.5–5.0 mmol/l
Creatinine 75 μmol/l 50–120 µmol/
Chloride (Cl–) 100 mEq/l 96–106 mEq/l
What is the next most appropriate investigation?Your Answer: CT angiogram of renal arteries
Correct Answer: Aldosterone-to-renin ratio
Explanation:Investigating Hypertension in a Young Patient: The Importance of Aldosterone-to-Renin Ratio
Hypertension in a young patient with hypernatraemia and hypokalaemia can be caused by renal artery stenosis or an aldosterone-secreting adrenal adenoma. To determine the cause, measuring aldosterone levels alone is not enough. Both renin and aldosterone levels should be measured, and the aldosterone-to-renin ratio should be evaluated. If hyperaldosteronism is confirmed, CT or MRI of the adrenal glands is done to locate the cause. If both are normal, adrenal vein sampling may be performed. MR angiogram of renal arteries is not a first-line investigation. Similarly, CT angiogram of renal arteries should not be the first choice. 24-hour urine metanephrine levels are not useful in this scenario. The electrolyte abnormalities point towards elevated aldosterone levels, not towards a phaeochromocytoma.
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This question is part of the following fields:
- Cardiology
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