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Question 1
Correct
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A 73-year-old man presents to the emergency department with complaints of severe cramping pain in his leg at rest. He has a medical history of peripheral vascular disease, chronic obstructive pulmonary disease, and hypertension.
During the examination, his blood pressure is measured at 138/92 mmHg, respiratory rate at 22/min, and oxygen saturations at 99%. The healthcare provider performs a neurovascular exam of the lower limbs and palpates the pulses.
Which area should be palpated first?Your Answer: First metatarsal space on dorsum of foot
Explanation:To assess lower leg pulses, it is recommended to start from the most distal point and move towards the proximal area. This helps to identify the location of any occlusion. The first pulse to be checked is the dorsalis pedis pulse, which is located on the dorsum of the foot in the first metatarsal space, lateral to the extensor hallucis longus tendon. Palpating behind the knee or in the fourth metatarsal space is incorrect, as no pulse can be felt there. The posterior tibial pulse can be felt posteriorly and inferiorly to the medial malleolus, but it should not be assessed first as it is not as distal as the dorsalis pedis pulse.
The anterior tibial artery starts opposite the lower border of the popliteus muscle and ends in front of the ankle, where it continues as the dorsalis pedis artery. As it descends, it runs along the interosseous membrane, the distal part of the tibia, and the front of the ankle joint. The artery passes between the tendons of the extensor digitorum and extensor hallucis longus muscles as it approaches the ankle. The deep peroneal nerve is closely related to the artery, lying anterior to the middle third of the vessel and lateral to it in the lower third.
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This question is part of the following fields:
- Cardiovascular System
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Question 2
Incorrect
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A 47-year-old woman is recuperating in the ICU after undergoing a Whipples surgery. She has a central venous line inserted. What will cause the 'y' descent on the waveform trace?
Your Answer: Opening of the pulmonary valve
Correct Answer: Emptying of the right atrium
Explanation:The JVP waveform consists of 3 upward deflections and 2 downward deflections. The upward deflections include the a wave, which represents atrial contraction, the c wave, which represents ventricular contraction, and the v wave, which represents atrial venous filling. The downward deflections include the x wave, which occurs when the atrium relaxes and the tricuspid valve moves down, and the y wave, which represents ventricular filling. The y descent in the waveform indicates the emptying of the atrium and the filling of the right ventricle.
The heart has four chambers and generates pressures of 0-25 mmHg on the right side and 0-120 mmHg on the left. The cardiac output is the product of heart rate and stroke volume, typically 5-6L per minute. The cardiac impulse is generated in the sino atrial node and conveyed to the ventricles via the atrioventricular node. Parasympathetic and sympathetic fibers project to the heart via the vagus and release acetylcholine and noradrenaline, respectively. The cardiac cycle includes mid diastole, late diastole, early systole, late systole, and early diastole. Preload is the end diastolic volume and afterload is the aortic pressure. Laplace’s law explains the rise in ventricular pressure during the ejection phase and why a dilated diseased heart will have impaired systolic function. Starling’s law states that an increase in end-diastolic volume will produce a larger stroke volume up to a point beyond which stroke volume will fall. Baroreceptor reflexes and atrial stretch receptors are involved in regulating cardiac output.
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This question is part of the following fields:
- Cardiovascular System
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Question 3
Correct
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The cephalic vein penetrates the clavipectoral fascia to end in which of the following veins mentioned below?
Your Answer: Axillary
Explanation:The Cephalic Vein: Path and Connections
The cephalic vein is a major blood vessel that runs along the lateral side of the arm. It begins at the dorsal venous arch, which drains blood from the hand and wrist, and travels up the arm, crossing the anatomical snuffbox. At the antecubital fossa, the cephalic vein is connected to the basilic vein by the median cubital vein. This connection is commonly used for blood draws and IV insertions.
After passing through the antecubital fossa, the cephalic vein continues up the arm and pierces the deep fascia of the deltopectoral groove to join the axillary vein. This junction is located near the shoulder and marks the end of the cephalic vein’s path.
Overall, the cephalic vein plays an important role in the circulation of blood in the upper limb. Its connections to other major veins in the arm make it a valuable site for medical procedures, while its path through the deltopectoral groove allows it to contribute to the larger network of veins that drain blood from the upper body.
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This question is part of the following fields:
- Cardiovascular System
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Question 4
Correct
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A young woman presents with sudden palpitations and difficulty breathing, and her ECG reveals tachycardia. Which cardiac component typically experiences the most rapid depolarization?
Your Answer: Sino-atrial node
Explanation:The heart’s conducting system is made up of specialized cardiac muscle cells and fibers that generate and rapidly transmit action potentials. This system is crucial for coordinating the contractions of the heart’s chambers during the cardiac cycle. When this system malfunctions due to conduction blockages or abnormal action potential sources, it can lead to arrhythmias.
The conducting system has five main components:
1. The sino-atrial (SAN) node, located in the right atrium, generates electrical signals.
2. These signals stimulate the atria to contract and travel to the atrio-ventricular (AVN) node in the interatrial septum.
3. After a delay, the stimulus diverges and is conducted through the left and right bundle of His.
4. The conduction then passes to the respective Purkinje fibers for each side of the heart.
5. Finally, the electrical signals reach the endocardium at the apex of the heart and the ventricular epicardium.Understanding the Cardiac Action Potential and Conduction Velocity
The cardiac action potential is a series of electrical events that occur in the heart during each heartbeat. It is responsible for the contraction of the heart muscle and the pumping of blood throughout the body. The action potential is divided into five phases, each with a specific mechanism. The first phase is rapid depolarization, which is caused by the influx of sodium ions. The second phase is early repolarization, which is caused by the efflux of potassium ions. The third phase is the plateau phase, which is caused by the slow influx of calcium ions. The fourth phase is final repolarization, which is caused by the efflux of potassium ions. The final phase is the restoration of ionic concentrations, which is achieved by the Na+/K+ ATPase pump.
Conduction velocity is the speed at which the electrical signal travels through the heart. The speed varies depending on the location of the signal. Atrial conduction spreads along ordinary atrial myocardial fibers at a speed of 1 m/sec. AV node conduction is much slower, at 0.05 m/sec. Ventricular conduction is the fastest in the heart, achieved by the large diameter of the Purkinje fibers, which can achieve velocities of 2-4 m/sec. This allows for a rapid and coordinated contraction of the ventricles, which is essential for the proper functioning of the heart. Understanding the cardiac action potential and conduction velocity is crucial for diagnosing and treating heart conditions.
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This question is part of the following fields:
- Cardiovascular System
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Question 5
Incorrect
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A 63-year-old man visits the clinic with complaints of palpitations and constipation that has been bothering him for the past 5 days. He reports passing gas but feels uneasy. The patient has a history of hypertension, and you recently prescribed bendroflumethiazide to manage it. To check for signs of hypokalaemia, you conduct an ECG. What is an ECG indication of hypokalaemia?
Your Answer: Tall tented T waves
Correct Answer: Prolonged PR interval
Explanation:Hypokalaemia can be identified through a prolonged PR interval on an ECG. However, this same ECG sign may also be present in cases of hyperkalaemia. Additional ECG signs of hypokalaemia include small or absent P waves, tall tented T waves, and broad bizarre QRS complexes. On the other hand, hyperkalaemia can be identified through ECG signs such as long PR intervals, a sine wave pattern, and tall tented T waves, as well as broad bizarre QRS complexes.
Hypokalaemia, a condition characterized by low levels of potassium in the blood, can be detected through ECG features. These include the presence of U waves, small or absent T waves (which may occasionally be inverted), a prolonged PR interval, ST depression, and a long QT interval. The ECG image provided shows typical U waves and a borderline PR interval. To remember these features, one user suggests the following rhyme: In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT.
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This question is part of the following fields:
- Cardiovascular System
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Question 6
Correct
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Jill, a 54-year-old female, visits her doctor complaining of chest pain. She reports that the pain worsens when she walks and subsides when she rests.
Jill's medical history includes diabetes, hypercholesterolemia, and hypertension. She also has a family history of myocardial infarction.
Based on her symptoms, the doctor diagnoses Jill with angina and prescribes a nitrate spray.
At what stage of the cardiac cycle do the coronary arteries primarily fill?Your Answer: Ventricular diastole
Explanation:The filling of the coronary arteries takes place during ventricular diastole and not during ventricular systole, which is when isovolumetric contraction occurs.
Understanding Coronary Circulation
Coronary circulation refers to the blood flow that supplies the heart with oxygen and nutrients. The arterial supply of the heart is divided into two main branches: the left coronary artery (LCA) and the right coronary artery (RCA). The LCA originates from the left aortic sinus, while the RCA originates from the right aortic sinus. The LCA further divides into two branches, the left anterior descending (LAD) and the circumflex artery, while the RCA supplies the posterior descending artery.
The LCA supplies the left ventricle, left atrium, and interventricular septum, while the RCA supplies the right ventricle and the inferior wall of the left ventricle. The SA node, which is responsible for initiating the heartbeat, is supplied by the RCA in 60% of individuals, while the AV node, which is responsible for regulating the heartbeat, is supplied by the RCA in 90% of individuals.
On the other hand, the venous drainage of the heart is through the coronary sinus, which drains into the right atrium. During diastole, the coronary arteries fill with blood, allowing for the delivery of oxygen and nutrients to the heart muscles. Understanding the coronary circulation is crucial in the diagnosis and management of various heart diseases.
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This question is part of the following fields:
- Cardiovascular System
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Question 7
Correct
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You are shadowing a cardiologist during a clinic session and the first patient is an 80-year-old man who has come for his annual check-up. He reports experiencing swollen ankles, increased shortness of breath, and difficulty sleeping flat. He has a history of heart failure but has been stable for the past 10 years. He believes that his condition has worsened since starting a new medication, but he cannot recall the name of the drug. Unfortunately, the electronic medical records are down, and you cannot access his medication history. Which of the following medications is most likely responsible for his symptoms?
Your Answer: Hydralazine
Explanation:Hydralazine is unique among these drugs as it has been known to cause fluid retention by elevating the plasma concentration of renin. Conversely, the other drugs listed are recognized for their ability to reduce fluid overload and promote fluid elimination.
Hydralazine: An Antihypertensive with Limited Use
Hydralazine is an antihypertensive medication that is not commonly used nowadays. It is still prescribed for severe hypertension and hypertension in pregnancy. The drug works by increasing cGMP, which leads to smooth muscle relaxation. However, there are certain contraindications to its use, such as systemic lupus erythematosus and ischaemic heart disease/cerebrovascular disease.
Despite its potential benefits, hydralazine can cause adverse effects such as tachycardia, palpitations, flushing, fluid retention, headache, and drug-induced lupus. Therefore, it is not the first choice for treating hypertension in most cases. Overall, hydralazine is an older medication that has limited use due to its potential side effects and newer, more effective antihypertensive options available.
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This question is part of the following fields:
- Cardiovascular System
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Question 8
Incorrect
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A 65-year-old man presents to the Emergency Department with a 60-minute history of central chest pain that extends to his jaw. An ECG reveals an inferior ST-segment elevation myocardial infarction (STEMI). The QRS is positive in leads I and aVL but negative in leads II and aVF. What type of axis deviation is indicated by this finding?
Your Answer: Right
Correct Answer: Left
Explanation:To estimate the heart’s axis, one method is the quadrant method, which involves analyzing leads I and aVF. If lead I is positive and lead aVF is negative, this suggests a possible left axis deviation. To confirm left axis deviation, a second method using lead II can be used. If lead II is also negative, then left axis deviation is confirmed. Other types of axis deviation can be determined by analyzing the polarity of leads I and aVF.
ECG Axis Deviation: Causes of Left and Right Deviation
Electrocardiogram (ECG) axis deviation refers to the direction of the electrical activity of the heart. A normal axis is between -30 and +90 degrees. Deviation from this range can indicate underlying cardiac or pulmonary conditions.
Left axis deviation (LAD) can be caused by left anterior hemiblock, left bundle branch block, inferior myocardial infarction, Wolff-Parkinson-White syndrome with a right-sided accessory pathway, hyperkalaemia, congenital heart defects such as ostium primum atrial septal defect (ASD) and tricuspid atresia, and minor LAD in obese individuals.
On the other hand, right axis deviation (RAD) can be caused by right ventricular hypertrophy, left posterior hemiblock, lateral myocardial infarction, chronic lung disease leading to cor pulmonale, pulmonary embolism, ostium secundum ASD, Wolff-Parkinson-White syndrome with a left-sided accessory pathway, and minor RAD in tall individuals. It is also normal in infants less than one year old.
It is important to note that Wolff-Parkinson-White syndrome is a common cause of both LAD and RAD, depending on the location of the accessory pathway. Understanding the causes of ECG axis deviation can aid in the diagnosis and management of underlying conditions.
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This question is part of the following fields:
- Cardiovascular System
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Question 9
Incorrect
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A 39-year-old male arrives at the emergency department complaining of palpitations and is diagnosed with monomorphic ventricular tachycardia. What electrolyte is responsible for maintaining the resting potential of ventricular myocytes?
Your Answer:
Correct Answer: Potassium
Explanation:The resting potential of cardiac myocytes is maintained by potassium, while depolarization is initiated by a sudden influx of sodium ions and repolarization is caused by the outflow of potassium. The extended duration of a cardiac action potential, in contrast to skeletal muscle, is due to a gradual influx of calcium.
Understanding the Cardiac Action Potential and Conduction Velocity
The cardiac action potential is a series of electrical events that occur in the heart during each heartbeat. It is responsible for the contraction of the heart muscle and the pumping of blood throughout the body. The action potential is divided into five phases, each with a specific mechanism. The first phase is rapid depolarization, which is caused by the influx of sodium ions. The second phase is early repolarization, which is caused by the efflux of potassium ions. The third phase is the plateau phase, which is caused by the slow influx of calcium ions. The fourth phase is final repolarization, which is caused by the efflux of potassium ions. The final phase is the restoration of ionic concentrations, which is achieved by the Na+/K+ ATPase pump.
Conduction velocity is the speed at which the electrical signal travels through the heart. The speed varies depending on the location of the signal. Atrial conduction spreads along ordinary atrial myocardial fibers at a speed of 1 m/sec. AV node conduction is much slower, at 0.05 m/sec. Ventricular conduction is the fastest in the heart, achieved by the large diameter of the Purkinje fibers, which can achieve velocities of 2-4 m/sec. This allows for a rapid and coordinated contraction of the ventricles, which is essential for the proper functioning of the heart. Understanding the cardiac action potential and conduction velocity is crucial for diagnosing and treating heart conditions.
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This question is part of the following fields:
- Cardiovascular System
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Question 10
Incorrect
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A patient in their 60s is diagnosed with first-degree heart block which is shown on their ECG by an elongated PR interval. The PR interval relates to a particular period in the electrical conductance of the heart.
What factors could lead to a decrease in the PR interval?Your Answer:
Correct Answer: Increased conduction velocity across the AV node
Explanation:An increase in sympathetic activation leads to a faster heart rate by enhancing the conduction velocity of the AV node. The PR interval represents the time between the onset of atrial depolarization (P wave) and the onset of ventricular depolarization (beginning of QRS complex). While atrial conduction occurs at a speed of 1m/s, the AV node only conducts at 0.05m/s. Consequently, the AV node is the limiting factor, and a reduction in the PR interval is determined by the conduction velocity across the AV node.
Understanding the Cardiac Action Potential and Conduction Velocity
The cardiac action potential is a series of electrical events that occur in the heart during each heartbeat. It is responsible for the contraction of the heart muscle and the pumping of blood throughout the body. The action potential is divided into five phases, each with a specific mechanism. The first phase is rapid depolarization, which is caused by the influx of sodium ions. The second phase is early repolarization, which is caused by the efflux of potassium ions. The third phase is the plateau phase, which is caused by the slow influx of calcium ions. The fourth phase is final repolarization, which is caused by the efflux of potassium ions. The final phase is the restoration of ionic concentrations, which is achieved by the Na+/K+ ATPase pump.
Conduction velocity is the speed at which the electrical signal travels through the heart. The speed varies depending on the location of the signal. Atrial conduction spreads along ordinary atrial myocardial fibers at a speed of 1 m/sec. AV node conduction is much slower, at 0.05 m/sec. Ventricular conduction is the fastest in the heart, achieved by the large diameter of the Purkinje fibers, which can achieve velocities of 2-4 m/sec. This allows for a rapid and coordinated contraction of the ventricles, which is essential for the proper functioning of the heart. Understanding the cardiac action potential and conduction velocity is crucial for diagnosing and treating heart conditions.
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This question is part of the following fields:
- Cardiovascular System
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Question 11
Incorrect
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During a routine visit, a 76-year-old man with a history of stable angina informs his GP about his recent hospitalization due to decompensated heart failure. The hospital staff had taken a brain natriuretic peptide (BNP) level which was found to be significantly elevated. He was treated with intravenous furosemide and responded positively. What are the cardiovascular impacts of BNP?
Your Answer:
Correct Answer: Decreases preload and afterload
Explanation:Brain natriuretic peptide is a peptide that is secreted by the myocardium in response to excessive stretching, typically seen in cases of heart failure. Its primary physiological roles include reducing systemic vascular resistance, thereby decreasing afterload, and increasing natriuresis and diuresis. This increased diuresis results in a decrease in venous blood volume, leading to a reduction in preload. The BNP level can be a valuable diagnostic tool for heart failure and may also serve as a prognostic indicator.
B-type natriuretic peptide (BNP) is a hormone that is primarily produced by the left ventricular myocardium in response to strain. Although heart failure is the most common cause of elevated BNP levels, any condition that causes left ventricular dysfunction, such as myocardial ischemia or valvular disease, may also raise levels. In patients with chronic kidney disease, reduced excretion may also lead to elevated BNP levels. Conversely, treatment with ACE inhibitors, angiotensin-2 receptor blockers, and diuretics can lower BNP levels.
BNP has several effects, including vasodilation, diuresis, natriuresis, and suppression of both sympathetic tone and the renin-angiotensin-aldosterone system. Clinically, BNP is useful in diagnosing patients with acute dyspnea. A low concentration of BNP (<100 pg/mL) makes a diagnosis of heart failure unlikely, but elevated levels should prompt further investigation to confirm the diagnosis. Currently, NICE recommends BNP as a helpful test to rule out a diagnosis of heart failure. In patients with chronic heart failure, initial evidence suggests that BNP is an extremely useful marker of prognosis and can guide treatment. However, BNP is not currently recommended for population screening for cardiac dysfunction.
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This question is part of the following fields:
- Cardiovascular System
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Question 12
Incorrect
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A 57-year-old male with a history of hypertension for six years presents to the Emergency department with complaints of severe chest pain that radiates to his back, which he describes as tearing in nature. He is currently experiencing tachycardia and hypertension, with a blood pressure reading of 185/95 mmHg. A soft early diastolic murmur is also noted. The ECG shows ST elevation of 2 mm in the inferior leads, and a small left-sided pleural effusion is visible on chest x-ray. Based on the patient's clinical history, what is the initial diagnosis that needs to be ruled out?
Your Answer:
Correct Answer: Aortic dissection
Explanation:Aortic Dissection in a Hypertensive Patient
This patient is experiencing an aortic dissection, which is a serious medical condition. The patient’s hypertension is a contributing factor, and the pain they are experiencing is typical for this condition. One of the key features of aortic dissection is radiation of pain to the back. Upon examination, the patient also exhibits hypertension, aortic regurgitation, and pleural effusion, which are all consistent with this diagnosis. The ECG changes in the inferior lead are likely due to the aortic dissection compromising the right coronary artery. To properly diagnose and treat this patient, it is crucial to thoroughly evaluate their peripheral pulses and urgently perform imaging of the aorta. Proper and timely medical intervention is necessary to prevent further complications and ensure the best possible outcome for the patient.
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This question is part of the following fields:
- Cardiovascular System
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Question 13
Incorrect
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A patient in their 60s develops complete heart block in hospital after experiencing a myocardial infarction. Their ECG displays a heart rate of 37 beats per minute and desynchronisation of atrial and ventricular contraction. What is the most probable coronary artery that is occluded in heart block during a myocardial infarction, indicating damage to the AV node?
Your Answer:
Correct Answer: RIght coronary artery
Explanation:The atrioventricular node is most likely supplied by the right coronary artery.
The left coronary artery gives rise to the left anterior descending and circumflex arteries.
An anterior myocardial infarction is caused by occlusion of the left anterior descending artery.
The coronary sinus is a venous structure that drains blood from the heart and returns it to the right atrium.
Understanding Coronary Circulation
Coronary circulation refers to the blood flow that supplies the heart with oxygen and nutrients. The arterial supply of the heart is divided into two main branches: the left coronary artery (LCA) and the right coronary artery (RCA). The LCA originates from the left aortic sinus, while the RCA originates from the right aortic sinus. The LCA further divides into two branches, the left anterior descending (LAD) and the circumflex artery, while the RCA supplies the posterior descending artery.
The LCA supplies the left ventricle, left atrium, and interventricular septum, while the RCA supplies the right ventricle and the inferior wall of the left ventricle. The SA node, which is responsible for initiating the heartbeat, is supplied by the RCA in 60% of individuals, while the AV node, which is responsible for regulating the heartbeat, is supplied by the RCA in 90% of individuals.
On the other hand, the venous drainage of the heart is through the coronary sinus, which drains into the right atrium. During diastole, the coronary arteries fill with blood, allowing for the delivery of oxygen and nutrients to the heart muscles. Understanding the coronary circulation is crucial in the diagnosis and management of various heart diseases.
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This question is part of the following fields:
- Cardiovascular System
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Question 14
Incorrect
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A 40-year-old woman comes to the clinic complaining of increasing fatigue and shortness of breath during physical activity over the past 6 months. She has no significant medical history and is not taking any medications.
During the examination, the lungs are clear upon auscultation, but a loud P2 heart sound is detected. An X-ray of the chest reveals enlarged shadows of the pulmonary artery.
What could be the underlying cause of this condition?Your Answer:
Correct Answer: Endothelin
Explanation:The cause of pulmonary vasoconstriction in primary pulmonary hypertension is endothelin, which is why antagonists are used to treat the condition. This is supported by the symptoms and diagnostic findings in a woman between the ages of 20 and 50. Other options such as bradykinin, iloprost, and nitric oxide are not vasoconstrictors and do not play a role in the development of pulmonary hypertension.
Understanding Endothelin and Its Role in Various Diseases
Endothelin is a potent vasoconstrictor and bronchoconstrictor that is secreted by the vascular endothelium. Initially, it is produced as a prohormone and later converted to ET-1 by the action of endothelin converting enzyme. Endothelin interacts with a G-protein linked to phospholipase C, leading to calcium release. This interaction is thought to be important in the pathogenesis of many diseases, including primary pulmonary hypertension, cardiac failure, hepatorenal syndrome, and Raynaud’s.
Endothelin is known to promote the release of angiotensin II, ADH, hypoxia, and mechanical shearing forces. On the other hand, it inhibits the release of nitric oxide and prostacyclin. Raised levels of endothelin are observed in primary pulmonary hypertension, myocardial infarction, heart failure, acute kidney injury, and asthma.
In recent years, endothelin antagonists have been used to treat primary pulmonary hypertension. Understanding the role of endothelin in various diseases can help in the development of new treatments and therapies.
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This question is part of the following fields:
- Cardiovascular System
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Question 15
Incorrect
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A 72-year-old male is admitted post myocardial infarction.
Suddenly, on day seven, he collapses without warning. The physician observes the presence of Kussmaul's sign.
What is the most probable complication of MI in this case?Your Answer:
Correct Answer: Ventricular rupture
Explanation:Complications of Myocardial Infarction: Cardiac Tamponade
Myocardial infarction can lead to a range of complications, including cardiac tamponade. This occurs when there is ventricular rupture, which can be life-threatening. One way to diagnose cardiac tamponade is through Kussmaul’s sign, which is the detection of a rising jugular venous pulse on inspiration. However, the classic diagnostic triad for cardiac tamponade is Beck’s triad, which includes hypotension, raised JVP, and muffled heart sounds.
It is important to note that Dressler’s syndrome, a type of pericarditis that can occur after a myocardial infarction, typically has a gradual onset and is associated with chest pain. Therefore, it is important to differentiate between these complications in order to provide appropriate treatment.
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This question is part of the following fields:
- Cardiovascular System
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Question 16
Incorrect
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As a medical student working in the emergency department, you come across a 75-year-old man with a medical history of hypertension, dyslipidaemia, and atrial fibrillation. He was brought in by ambulance after collapsing at home. During the examination, you notice that he is unable to raise his right arm and has reduced sensation on the right side of his body. The consultant suspects that the patient is having a stroke and orders an urgent CT head.
Upon reviewing the results, the consultant informs you that there is a significant area of ischaemia affecting the insula, somatosensory cortex, and part of the frontal cortex. Your task is to identify the artery that is most likely to be occluded by an infarct.Your Answer:
Correct Answer: Left middle cerebral artery
Explanation:The correct blood vessel supplying the frontal, temporal, and parietal lobes is the left middle cerebral artery. This is evident from the patient’s symptoms of right-sided loss of sensation and weakness, which are controlled by the contralateral somatosensory and motor cortex. The other options, such as the anterior spinal artery and the anterior cerebral arteries, are incorrect as they do not supply the brain or the specific areas affected in this patient.
The Circle of Willis is an anastomosis formed by the internal carotid arteries and vertebral arteries on the bottom surface of the brain. It is divided into two halves and is made up of various arteries, including the anterior communicating artery, anterior cerebral artery, internal carotid artery, posterior communicating artery, and posterior cerebral arteries. The circle and its branches supply blood to important areas of the brain, such as the corpus striatum, internal capsule, diencephalon, and midbrain.
The vertebral arteries enter the cranial cavity through the foramen magnum and lie in the subarachnoid space. They then ascend on the anterior surface of the medulla oblongata and unite to form the basilar artery at the base of the pons. The basilar artery has several branches, including the anterior inferior cerebellar artery, labyrinthine artery, pontine arteries, superior cerebellar artery, and posterior cerebral artery.
The internal carotid arteries also have several branches, such as the posterior communicating artery, anterior cerebral artery, middle cerebral artery, and anterior choroid artery. These arteries supply blood to different parts of the brain, including the frontal, temporal, and parietal lobes. Overall, the Circle of Willis and its branches play a crucial role in providing oxygen and nutrients to the brain.
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This question is part of the following fields:
- Cardiovascular System
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Question 17
Incorrect
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A 6-year-old boy is brought to the paediatrician by his parents due to a fever and sore throat that has been bothering him for the past 24 hours. The boy is experiencing significant discomfort in his throat and has been refusing to eat or drink. He does not report having a cough or a runny nose. The boy was delivered via spontaneous vaginal delivery and has been developing normally. He has two healthy older siblings. During the examination, the doctor observes that the boy's tonsils are inflamed and enlarged, with some white exudates, as well as enlarged cervical lymph nodes. The boy's temperature is 38.2 °C. The doctor informs the parents that the boy requires antibiotics to treat the current infection and prevent the risk of a severe complication commonly associated with this particular infection. What complication can be prevented with prompt antibiotic treatment?
Your Answer:
Correct Answer: Acute rheumatic fever
Explanation:Pharyngitis is the likely diagnosis for this patient based on their presenting symptoms. Group A streptococcus, also known as Streptococcus pyogenes, is a common cause of pharyngitis in young patients. One of the most concerning complications of this infection is acute rheumatic fever, which can lead to damage to the heart valves. Early antibiotic treatment can prevent the development of this serious condition.
1: Septicemia can result from various bacterial infections, but it is not typically associated with Group A streptococcal pharyngitis. Additionally, septicemia is rare in patients with this type of pharyngitis, as the condition usually resolves on its own without treatment.
2: Acute rheumatic fever is a serious complication of Group A streptococcal pharyngitis. It is an immune system reaction that damages the heart valves, particularly the mitral valve. Mitral valve regurgitation is common in the early stages of the disease, followed by mitral stenosis later on.
3: Post-streptococcal glomerulonephritis is another possible complication of Group A streptococcal pharyngitis. Unlike acute rheumatic fever, however, prompt antibiotic treatment does not prevent its development.
4: While Group A streptococcus can cause cellulitis, this is a separate condition from pharyngitis and is not a complication of the same bacterial infection.
5:
Rheumatic fever is a condition that occurs as a result of an immune response to a recent Streptococcus pyogenes infection, typically occurring 2-4 weeks after the initial infection. The pathogenesis of rheumatic fever involves the activation of the innate immune system, leading to antigen presentation to T cells. B and T cells then produce IgG and IgM antibodies, and CD4+ T cells are activated. This immune response is thought to be cross-reactive, mediated by molecular mimicry, where antibodies against M protein cross-react with myosin and the smooth muscle of arteries. This response leads to the clinical features of rheumatic fever, including Aschoff bodies, which are granulomatous nodules found in rheumatic heart fever.
To diagnose rheumatic fever, evidence of recent streptococcal infection must be present, along with 2 major criteria or 1 major criterion and 2 minor criteria. Major criteria include erythema marginatum, Sydenham’s chorea, polyarthritis, carditis and valvulitis, and subcutaneous nodules. Minor criteria include raised ESR or CRP, pyrexia, arthralgia, and prolonged PR interval.
Management of rheumatic fever involves antibiotics, typically oral penicillin V, as well as anti-inflammatories such as NSAIDs as first-line treatment. Any complications that develop, such as heart failure, should also be treated. It is important to diagnose and treat rheumatic fever promptly to prevent long-term complications such as rheumatic heart disease.
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This question is part of the following fields:
- Cardiovascular System
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Question 18
Incorrect
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A 32-year-old woman who is 33 weeks pregnant visits the clinic with a complaint of foot pain. The pain is mainly felt on the back of the sole of her foot and is most intense when she takes her first steps after getting out of bed in the morning. Upon examination, the area is tender to touch, and you suspect plantar fasciitis. While NSAIDs are a common treatment for this condition, you are aware that they are not recommended during pregnancy, particularly in the later stages. This is due to the potential risk of premature closure of the fetal vessel that connects which two major arteries?
Your Answer:
Correct Answer: Ductus arteriosus
Explanation:The correct answer is the ductus arteriosus, which connects the proximal descending aorta to the pulmonary artery, allowing blood to bypass the non-functioning lungs in utero. It closes at birth, forming the ligamentum arteriosum. A patent ductus arteriosus (PDA) occurs when it fails to close. Prostaglandins play a role in maintaining a PDA, and NSAIDs can be used to treat it, but are avoided in pregnancy to prevent early closure.
The ductus venosus, also known as Arantius’ duct, connects the umbilical vein to the inferior vena cava, bypassing the liver in utero. It usually closes within the first week of life, forming the ligamentum venosum.
The foramen ovale is an opening in the atrial septum that allows blood to flow from the right to the left atrium in utero. It usually closes at birth, but a patent foramen ovale can occur if it fails to close.
The umbilical vein carries oxygenated blood from the placenta to the fetus and closes within the first week of life, forming the round ligament of the liver.
The patient in the question is likely experiencing plantar fasciitis, which is caused by inflammation of the plantar fascia in the foot.
Understanding Patent Ductus Arteriosus
Patent ductus arteriosus is a type of congenital heart defect that is generally classified as ‘acyanotic’. However, if left uncorrected, it can eventually result in late cyanosis in the lower extremities, which is termed differential cyanosis. This condition is caused by a connection between the pulmonary trunk and descending aorta. Normally, the ductus arteriosus closes with the first breaths due to increased pulmonary flow, which enhances prostaglandins clearance. However, in some cases, this connection remains open, leading to patent ductus arteriosus.
This condition is more common in premature babies, those born at high altitude, or those whose mothers had rubella infection in the first trimester. The features of patent ductus arteriosus include a left subclavicular thrill, continuous ‘machinery’ murmur, large volume, bounding, collapsing pulse, wide pulse pressure, and heaving apex beat.
The management of patent ductus arteriosus involves the use of indomethacin or ibuprofen, which are given to the neonate. These medications inhibit prostaglandin synthesis and close the connection in the majority of cases. If patent ductus arteriosus is associated with another congenital heart defect amenable to surgery, then prostaglandin E1 is useful to keep the duct open until after surgical repair. Understanding patent ductus arteriosus is important for early diagnosis and management of this condition.
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This question is part of the following fields:
- Cardiovascular System
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Question 19
Incorrect
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A study investigates a novel diagnostic test for myocardial infarction (MI) in elderly patients. What metric would indicate the proportion of elderly patients without MI who received a negative test result?
Your Answer:
Correct Answer: Specificity
Explanation:The Specificity, Negative Predictive Value, Sensitivity, and Positive Predictive Value of a Medical Test
Medical tests are designed to accurately identify the presence or absence of a particular condition. In evaluating the effectiveness of a medical test, several measures are used, including specificity, negative predictive value, sensitivity, and positive predictive value. Specificity refers to the number of individuals without the condition who are accurately identified as such by the test. On the other hand, sensitivity refers to the number of individuals with the condition who are correctly identified by the test.
The negative predictive value of a medical test refers to the proportion of true negatives who are correctly identified by the test. This means that the test accurately identifies individuals who do not have the condition. The positive predictive value, on the other hand, refers to the proportion of true positives who are correctly identified by the test. This means that the test accurately identifies individuals who have the condition.
In summary, the specificity, negative predictive value, sensitivity, and positive predictive value of a medical test is crucial in evaluating its effectiveness in accurately identifying the presence or absence of a particular condition. These measures help healthcare professionals make informed decisions about patient care and treatment.
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This question is part of the following fields:
- Cardiovascular System
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Question 20
Incorrect
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A 67-year-old man arrives at the emergency department with abrupt onset left-sided foot and leg weakness and sensory loss. According to his wife, he stumbled and fell while they were out for dinner. Imaging results indicate an infarct in the anterior cerebral artery (ACA).
Which lobes of the brain are expected to be impacted the most?Your Answer:
Correct Answer: Frontal and parietal lobes
Explanation:The anterior cerebral artery is responsible for supplying blood to a portion of the frontal and parietal lobes. While this type of stroke is uncommon and may be challenging to diagnose through clinical means, imaging techniques can reveal affected vessels or brain regions. Damage to the frontal and parietal lobes can result in significant mood, personality, and movement disorders.
It’s important to note that the occipital lobe and cerebellum receive their blood supply from the posterior cerebral artery and cerebellar arteries (which originate from the basilar and vertebral arteries), respectively. Therefore, they would not be impacted by an ACA stroke. Similarly, the middle cerebral artery is responsible for supplying blood to the temporal lobe, so damage to the ACA would not affect this area.
The Circle of Willis is an anastomosis formed by the internal carotid arteries and vertebral arteries on the bottom surface of the brain. It is divided into two halves and is made up of various arteries, including the anterior communicating artery, anterior cerebral artery, internal carotid artery, posterior communicating artery, and posterior cerebral arteries. The circle and its branches supply blood to important areas of the brain, such as the corpus striatum, internal capsule, diencephalon, and midbrain.
The vertebral arteries enter the cranial cavity through the foramen magnum and lie in the subarachnoid space. They then ascend on the anterior surface of the medulla oblongata and unite to form the basilar artery at the base of the pons. The basilar artery has several branches, including the anterior inferior cerebellar artery, labyrinthine artery, pontine arteries, superior cerebellar artery, and posterior cerebral artery.
The internal carotid arteries also have several branches, such as the posterior communicating artery, anterior cerebral artery, middle cerebral artery, and anterior choroid artery. These arteries supply blood to different parts of the brain, including the frontal, temporal, and parietal lobes. Overall, the Circle of Willis and its branches play a crucial role in providing oxygen and nutrients to the brain.
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This question is part of the following fields:
- Cardiovascular System
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Question 21
Incorrect
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A 13-year-old boy collapses at home and is taken to the hospital. After all tests come back normal, what is the underlying mechanism behind a vasovagal episode?
Your Answer:
Correct Answer: Peripheral vasodilation and venous pooling
Explanation:Vasovagal syncope is a common type of fainting that is often seen in adolescents and older adults. It typically occurs when a person with a predisposition to this condition is exposed to a specific trigger. Before losing consciousness, the individual may experience symptoms such as lightheadedness, nausea, sweating, or ringing in the ears. When they faint, they fall down, which helps restore blood flow to the brain by eliminating the effects of gravity and allowing the person to regain consciousness.
The mechanism behind a vasovagal episode involves a cardioinhibitory response that causes a decrease in heart rate (negative chronotropic effect) and contractility (negative inotropic effect), leading to a reduction in cardiac output and peripheral vasodilation. These effects result in the pooling of blood in the lower limbs.
Understanding Syncope: Causes and Evaluation
Syncope is a temporary loss of consciousness caused by a sudden decrease in blood flow to the brain. It is a common condition that can affect people of all ages. Syncope can be caused by various factors, including reflex syncope, orthostatic syncope, and cardiac syncope. Reflex syncope is the most common cause of syncope in all age groups, while orthostatic and cardiac causes become more common in older patients.
Reflex syncope is triggered by emotional stress, pain, or other stimuli. Situational syncope can be caused by coughing, urination, or gastrointestinal issues. Carotid sinus syncope is another type of reflex syncope that occurs when pressure is applied to the carotid artery in the neck.
Orthostatic syncope occurs when a person stands up too quickly, causing a sudden drop in blood pressure. This can be caused by primary or secondary autonomic failure, drug-induced factors, or volume depletion.
Cardiac syncope is caused by arrhythmias, structural issues, or pulmonary embolism. Bradycardias and tachycardias are common types of arrhythmias that can cause syncope.
To diagnose syncope, doctors may perform a cardiovascular examination, postural blood pressure readings, an ECG, carotid sinus massage, tilt table test, or a 24-hour ECG. These tests can help determine the underlying cause of syncope and guide treatment options.
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This question is part of the following fields:
- Cardiovascular System
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Question 22
Incorrect
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A 75-year-old woman complains of increasing shortness of breath in the past few months, especially when lying down at night. She has a history of type 2 diabetes and high blood pressure, which is managed with ramipril. She smokes 15 cigarettes per day. Her heart rate is 76 bpm, blood pressure is 160/95 mmHg, and oxygen saturation is 94% on room air. An ECG reveals sinus rhythm and left ventricular hypertrophy. On physical examination, there are no heart murmurs, but there is wheezing throughout the chest and coarse crackles at both bases. She has pitting edema in both ankles. Her troponin T level is 0.01 (normal range <0.02). What is the diagnosis for this patient?
Your Answer:
Correct Answer: Biventricular failure
Explanation:Diagnosis and Assessment of Biventricular Failure
This patient is exhibiting symptoms of both peripheral and pulmonary edema, indicating biventricular failure. The ECG shows left ventricular hypertrophy, which is likely due to her long-standing hypertension. While she is at an increased risk for a myocardial infarction as a diabetic and smoker, her low troponin T levels suggest that this is not the immediate cause of her symptoms. However, it is important to rule out acute coronary syndromes in diabetics, as they may not experience pain.
Mitral stenosis, if present, would be accompanied by a diastolic murmur and left atrial hypertrophy. In severe cases, back-pressure can lead to pulmonary edema. Overall, a thorough assessment and diagnosis of biventricular failure is crucial in determining the appropriate treatment plan for this patient.
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This question is part of the following fields:
- Cardiovascular System
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Question 23
Incorrect
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A 25-year-old man comes to the clinic complaining of chest pain in the center of his chest. Based on his symptoms, pericarditis is suspected as the cause. The patient is typically healthy, but recently had a viral throat infection according to his primary care physician.
What is the most probable observation in this patient?Your Answer:
Correct Answer: Chest pain which is relieved on leaning forwards
Explanation:Pericarditis is inflammation of the pericardium, a sac surrounding the heart. It can be caused by various factors, including viral infections. The typical symptom of pericarditis is central chest pain that is relieved by sitting up or leaning forward. ST-segment depression on a 12-lead ECG is not a sign of pericarditis, but rather a sign of subendocardial tissue ischemia. A pansystolic cardiac murmur heard on auscultation is also not associated with pericarditis, as it is caused by valve defects. Additionally, pericarditis is not typically associated with bradycardia, but rather tachycardia.
Acute Pericarditis: Causes, Features, Investigations, and Management
Acute pericarditis is a possible diagnosis for patients presenting with chest pain. The condition is characterized by chest pain, which may be pleuritic and relieved by sitting forwards. Other symptoms include non-productive cough, dyspnoea, and flu-like symptoms. Tachypnoea and tachycardia may also be present, along with a pericardial rub.
The causes of acute pericarditis include viral infections, tuberculosis, uraemia, trauma, post-myocardial infarction, Dressler’s syndrome, connective tissue disease, hypothyroidism, and malignancy.
Investigations for acute pericarditis include ECG changes, which are often global/widespread, as opposed to the ‘territories’ seen in ischaemic events. The ECG may show ‘saddle-shaped’ ST elevation and PR depression, which is the most specific ECG marker for pericarditis. All patients with suspected acute pericarditis should have transthoracic echocardiography.
Management of acute pericarditis involves treating the underlying cause. A combination of NSAIDs and colchicine is now generally used as first-line treatment for patients with acute idiopathic or viral pericarditis.
In summary, acute pericarditis is a possible diagnosis for patients presenting with chest pain. The condition is characterized by chest pain, which may be pleuritic and relieved by sitting forwards, along with other symptoms. The causes of acute pericarditis are varied, and investigations include ECG changes and transthoracic echocardiography. Management involves treating the underlying cause and using a combination of NSAIDs and colchicine as first-line treatment.
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This question is part of the following fields:
- Cardiovascular System
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Question 24
Incorrect
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A 57-year-old man has recently passed away in hospital after being admitted with acute shortness of breath upon exertion and bilateral pedal pitting edema. He is known to be suffering from congestive heart failure for the past 5 years.
His medical history includes well-controlled hypertension, mitral insufficiency and a complicated sore throat as a child. He has no significant past family history. There is no previous history of any heart surgery or interventional procedures. The pathology report confirms the findings of granulomatous nodules consisting of giant cells around areas of fibrinoid necrosis in the heart of the patient.
What is the causative agent for the pathology described in the heart of this patient?Your Answer:
Correct Answer: Streptococcus pyogenes
Explanation:Aschoff bodies, which are granulomatous nodules consisting of giant cells around areas of fibrinoid necrosis, are pathognomonic for rheumatic heart disease. This condition is often a sequela of acute rheumatic heart fever, which occurs due to molecular mimicry where antibodies to the bacteria causing a pharyngeal infection react with the cardiac myocyte antigen resulting in valve destruction. The bacterial organism responsible for the pharyngeal infection leading to rheumatic heart disease is the group A β-hemolytic Streptococcus pyogenes.
In contrast, Staphylococcus aureus is a gram-positive, coagulase-positive bacteria that often causes acute bacterial endocarditis with large vegetations on previously normal cardiac valves. Bacterial endocarditis typically presents with a fever and new-onset murmur, and may be associated with other signs such as Roth spots, Osler nodes, Janeway lesions, and splinter hemorrhages. Staphylococcus epidermidis, on the other hand, is a gram-positive, coagulase-negative bacteria that often causes bacterial endocarditis on prosthetic valves. Streptococcus viridans, a gram-positive, α-hemolytic bacteria, typically causes subacute bacterial endocarditis in individuals with a diseased or previously abnormal valve, with smaller vegetations compared to acute bacterial endocarditis.
Rheumatic fever is a condition that occurs as a result of an immune response to a recent Streptococcus pyogenes infection, typically occurring 2-4 weeks after the initial infection. The pathogenesis of rheumatic fever involves the activation of the innate immune system, leading to antigen presentation to T cells. B and T cells then produce IgG and IgM antibodies, and CD4+ T cells are activated. This immune response is thought to be cross-reactive, mediated by molecular mimicry, where antibodies against M protein cross-react with myosin and the smooth muscle of arteries. This response leads to the clinical features of rheumatic fever, including Aschoff bodies, which are granulomatous nodules found in rheumatic heart fever.
To diagnose rheumatic fever, evidence of recent streptococcal infection must be present, along with 2 major criteria or 1 major criterion and 2 minor criteria. Major criteria include erythema marginatum, Sydenham’s chorea, polyarthritis, carditis and valvulitis, and subcutaneous nodules. Minor criteria include raised ESR or CRP, pyrexia, arthralgia, and prolonged PR interval.
Management of rheumatic fever involves antibiotics, typically oral penicillin V, as well as anti-inflammatories such as NSAIDs as first-line treatment. Any complications that develop, such as heart failure, should also be treated. It is important to diagnose and treat rheumatic fever promptly to prevent long-term complications such as rheumatic heart disease.
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This question is part of the following fields:
- Cardiovascular System
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Question 25
Incorrect
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A 50-year-old woman is currently receiving antibiotics for bacterial endocarditis and is worried about her future health. She asks about the common complications associated with her condition.
Which of the following is a typical complication of bacterial endocarditis?Your Answer:
Correct Answer: Stroke
Explanation:The risk of emboli is heightened by infective endocarditis. This is due to the formation of thrombus at the site of the lesion, which can result in the release of septic emboli. Other complications mentioned in the options are not typically associated with infective endocarditis.
Aetiology of Infective Endocarditis
Infective endocarditis is a condition that affects patients with previously normal valves, rheumatic valve disease, prosthetic valves, congenital heart defects, intravenous drug users, and those who have recently undergone piercings. The strongest risk factor for developing infective endocarditis is a previous episode of the condition. The mitral valve is the most commonly affected valve.
The most common cause of infective endocarditis is Staphylococcus aureus, particularly in acute presentations and intravenous drug users. Historically, Streptococcus viridans was the most common cause, but this is no longer the case except in developing countries. Coagulase-negative Staphylococci such as Staphylococcus epidermidis are commonly found in indwelling lines and are the most common cause of endocarditis in patients following prosthetic valve surgery. Streptococcus bovis is associated with colorectal cancer, with the subtype Streptococcus gallolyticus being most linked to the condition.
Culture negative causes of infective endocarditis include prior antibiotic therapy, Coxiella burnetii, Bartonella, Brucella, and HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella). It is important to note that systemic lupus erythematosus and malignancy, specifically marantic endocarditis, can also cause non-infective endocarditis.
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This question is part of the following fields:
- Cardiovascular System
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Question 26
Incorrect
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A 45-year-old woman has varicose veins originating from the short saphenous vein. During mobilization of the vein near its origin, which structure is at the highest risk of injury?
Your Answer:
Correct Answer: Sural nerve
Explanation:Litigation often arises from damage to the sural nerve, which is closely associated with this structure. While the other structures may also sustain injuries, the likelihood of such occurrences is comparatively lower.
Anatomy of the Popliteal Fossa
The popliteal fossa is a diamond-shaped space located at the back of the knee joint. It is bound by various muscles and ligaments, including the biceps femoris, semimembranosus, semitendinosus, and gastrocnemius. The floor of the popliteal fossa is formed by the popliteal surface of the femur, posterior ligament of the knee joint, and popliteus muscle, while the roof is made up of superficial and deep fascia.
The popliteal fossa contains several important structures, including the popliteal artery and vein, small saphenous vein, common peroneal nerve, tibial nerve, posterior cutaneous nerve of the thigh, genicular branch of the obturator nerve, and lymph nodes. These structures are crucial for the proper functioning of the lower leg and foot.
Understanding the anatomy of the popliteal fossa is important for healthcare professionals, as it can help in the diagnosis and treatment of various conditions affecting the knee joint and surrounding structures.
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This question is part of the following fields:
- Cardiovascular System
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Question 27
Incorrect
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A 49-year-old man named Mr. Johnson visits his GP surgery to review his blood pressure as he has been diagnosed with type II diabetes mellitus. His blood pressure is 150/112 mmHg and his heart rate is 82 bpm. Mr. Johnson smokes 20 cigarettes a day, drinks three pints of beer most nights, and has a diet high in saturated fat. He drives to work, even though his office is only one mile away from his house. He appears anxious and worried about having a heart attack soon. What would be your first step in treating his hypertension?
Your Answer:
Correct Answer: Lifestyle advice and review
Explanation:Importance of Confirming Persistent High Blood Pressure
While reducing high blood pressure is crucial, it is important to confirm that it is persistent and not just a one-time occurrence. Anxiety or other factors could artificially elevate blood pressure readings. Therefore, it is necessary to conduct multiple tests to confirm the diagnosis. Additionally, lifestyle changes such as exercise, healthy eating, and stress reduction can help lower blood pressure and improve overall health. Prescribing medication should only be done when necessary, as it can lead to side effects, drug interactions, and poor adherence. It is important to consider the risks and benefits before prescribing medication and to prioritize non-pharmacological interventions whenever possible. For more information, refer to the NICE guidelines on hypertension.
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This question is part of the following fields:
- Cardiovascular System
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Question 28
Incorrect
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Linda is a 54-year-old woman who was admitted with a 3-day history of worsening shortness of breath. On her last admission 6 months ago, she was treated for a ST-elevation myocardial infarction (STEMI).
She does not experience any significant chest pain. A chest X-ray shows minor bibasal consolidation suggestive of mild pulmonary oedema. Her blood tests are as follow:
Na+ 138 mmol/L (135 - 145)
K+ 4.0 mmol/L (3.5 - 5.0)
Urea 5.8 mmol/L (2.0 - 7.0)
Creatinine 100 µmol/L (55 - 120)
A 12-lead electrocardiogram shows sinus rhythm. An echocardiogram shows reduced left ventricular (LV) contraction with an LV ejection fraction of 40%.
Which of the following treatments should be prescribed to reduce mortality?Your Answer:
Correct Answer: Ramipril
Explanation:For patients diagnosed with heart failure with reduced LVEF, the initial treatment should involve administering a beta blocker and an ACE inhibitor. In the case of the patient in question, the symptoms and echocardiogram results indicate the onset of LV failure, which is likely due to their previous STEMI. Therefore, the recommended course of action is to prescribe an ACE inhibitor and beta-blocker as the primary therapy. This will help alleviate the symptoms of heart failure by reducing the after-load on the heart.
Chronic heart failure can be managed through drug treatment, according to updated guidelines issued by NICE in 2018. While loop diuretics are useful in managing fluid overload, they do not reduce mortality in the long term. The first-line treatment for all patients is a combination of an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Aldosterone antagonists are recommended as second-line treatment, but potassium levels should be monitored as both ACE inhibitors and aldosterone antagonists can cause hyperkalaemia. Third-line treatment should be initiated by a specialist and may include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, and cardiac resynchronisation therapy. Other treatments include annual influenzae and one-off pneumococcal vaccines. Those with asplenia, splenic dysfunction, or chronic kidney disease may require a booster every 5 years.
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This question is part of the following fields:
- Cardiovascular System
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Question 29
Incorrect
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An 80-year-old man presents with progressive shortness of breath, easy fatigue, and ankle swelling over the past few weeks. He has a significant smoking history of 50 pack-years. Physical examination reveals bibasilar crackles, and echocardiography shows no valvular disease and a non-dilated left ventricle with an ejection fraction of 55%. What is the most likely cause of the patient's current condition?
Your Answer:
Correct Answer: Increased left ventricular afterload
Explanation:The correct answer is increased left ventricular afterload. HFpEF, which is characterized by diastolic dysfunction, often develops due to prolonged systemic hypertension, leading to increased afterload on the left ventricle.
Glomerular hyper-filtration is not the correct answer as heart failure leads to decreased renal perfusion pressure and glomerular hypo-filtration.
Increased left ventricular compliance is also not the correct answer as diastolic dysfunction involves a decrease in LV compliance. LV compliance may increase with eccentric hypertrophy, which occurs in response to left ventricular volume overload.
Left ventricular thrombus formation is not typically associated with diastolic dysfunction and HFpEF. It typically results from localized stagnation of blood, which can occur with a left ventricular aneurysm or in the setting of a severely dilated left ventricle cavity with systolic dysfunction.
Types of Heart Failure
Heart failure is a clinical syndrome where the heart cannot pump enough blood to meet the body’s metabolic needs. It can be classified in multiple ways, including by ejection fraction, time, and left/right side. Patients with heart failure may have a normal or abnormal left ventricular ejection fraction (LVEF), which is measured using echocardiography. Reduced LVEF is typically defined as < 35 to 40% and is termed heart failure with reduced ejection fraction (HF-rEF), while preserved LVEF is termed heart failure with preserved ejection fraction (HF-pEF). Heart failure can also be described as acute or chronic, with acute heart failure referring to an acute exacerbation of chronic heart failure. Left-sided heart failure is more common and may be due to increased left ventricular afterload or preload, while right-sided heart failure is caused by increased right ventricular afterload or preload. High-output heart failure is another type of heart failure that occurs when a normal heart is unable to pump enough blood to meet the body's metabolic needs. By classifying heart failure in these ways, healthcare professionals can better understand the underlying causes and tailor treatment plans accordingly. It is important to note that many guidelines for the management of heart failure only cover HF-rEF patients and do not address the management of HF-pEF patients. Understanding the different types of heart failure can help healthcare professionals provide more effective care for their patients.
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This question is part of the following fields:
- Cardiovascular System
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Question 30
Incorrect
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A 30-year-old man arrived at the emergency department following a syncopal episode during a game of basketball. He is typically healthy with no prior medical history, but he does mention experiencing occasional palpitations, which he believes may be due to alcohol or caffeine consumption. Upon further inquiry, he reveals that his father passed away suddenly at the age of 40 due to a heart condition. What is the underlying pathophysiological alteration in this patient?
Your Answer:
Correct Answer: Asymmetric septal hypertrophy
Explanation:When a young patient presents with symptoms of syncope and chest discomfort, along with a family history of hypertrophic cardiomyopathy (HOCM), it is important to consider the possibility of this condition. Asymmetric septal hypertrophy and systolic anterior movement (SAM) of the anterior leaflet of the mitral valve on echocardiogram or cMR are supportive of HOCM. This condition is caused by a genetic defect in the beta-myosin heavy chain protein gene. While Brugada syndrome may also be a consideration, it is not listed as a possible answer due to its underlying mechanism of sodium channelopathy.
Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disorder that affects muscle tissue and is inherited in an autosomal dominant manner. It is caused by mutations in genes that encode contractile proteins, with the most common defects involving the β-myosin heavy chain protein or myosin-binding protein C. HOCM is characterized by left ventricle hypertrophy, which leads to decreased compliance and cardiac output, resulting in predominantly diastolic dysfunction. Biopsy findings show myofibrillar hypertrophy with disorganized myocytes and fibrosis. HOCM is often asymptomatic, but exertional dyspnea, angina, syncope, and sudden death can occur. Jerky pulse, systolic murmurs, and double apex beat are also common features. HOCM is associated with Friedreich’s ataxia and Wolff-Parkinson White. ECG findings include left ventricular hypertrophy, non-specific ST segment and T-wave abnormalities, and deep Q waves. Atrial fibrillation may occasionally be seen.
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This question is part of the following fields:
- Cardiovascular System
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