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  • Question 1 - A 63-year-old man presents with increasing shortness of breath on exertion. On examination,...

    Incorrect

    • A 63-year-old man presents with increasing shortness of breath on exertion. On examination, bibasilar wet pulmonary crackles are noted with mild bilateral lower limb pitting oedema. His jugular vein is slightly distended. An S4 sound is audible on cardiac auscultation. An electrocardiogram (ECG) shows evidence of left ventricular (LV) hypertrophy. Chest radiography shows bilateral interstitial oedema without cardiomegaly.
      Which one of the following findings is most likely to be found in this patient?

      Your Answer: Impaired LV contraction – increased LV end-diastolic pressure – increased LV end-systolic volume

      Correct Answer: Impaired LV relaxation – increased LV end-diastolic pressure – normal LV end-systolic volume

      Explanation:

      Understanding the Different Types of Left Ventricular Dysfunction in Heart Failure

      Left ventricular (LV) dysfunction can result in heart failure, which is a clinical diagnosis that can be caused by systolic or diastolic dysfunction, or both. Diastolic dysfunction is characterized by impaired LV relaxation, resulting in increased LV end-diastolic pressure but normal LV end-systolic volume. This type of dysfunction can be caused by factors such as LV hypertrophy from poorly controlled hypertension. On the other hand, impaired LV contraction results in systolic dysfunction, which is characterized by LV dilation, increased LV end-systolic and end-diastolic volumes, and increased LV end-diastolic pressure. It is important to differentiate between these types of LV dysfunction in order to properly diagnose and manage heart failure.

    • This question is part of the following fields:

      • Cardiology
      23.7
      Seconds
  • Question 2 - A 70-year-old man experiences an acute myocardial infarction and subsequently develops a bundle...

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Cardiology
      7.5
      Seconds
  • Question 3 - An 82-year-old man presents with increasing shortness of breath, tiredness, intermittent chest pain...

    Incorrect

    • An 82-year-old man presents with increasing shortness of breath, tiredness, intermittent chest pain and leg swelling for the last 6 months. His past medical history includes hypertension, gout and a previous myocardial infarction 5 years ago. His current medications are as follows:
      diltiazem 60 mg orally (po) twice daily (bd)
      spironolactone 100 mg po once daily (od)
      allopurinol 100 mg po od
      paracetamol 1 g po four times daily (qds) as required (prn)
      lisinopril 20 mg po od.
      Given this man’s likely diagnosis, which of the above medications should be stopped?

      Your Answer: Spironolactone

      Correct Answer: Diltiazem

      Explanation:

      Medications for Heart Failure: Uses and Contraindications

      Diltiazem is a calcium channel blocker that can treat angina and hypertension, but it should be stopped in patients with chronic heart disease and heart failure due to its negative inotropic effects.

      Spironolactone can alleviate leg swelling and is one of the three drugs that have been shown to reduce mortality in heart failure, along with ACE inhibitors and β-blockers.

      Allopurinol is safe to use in heart failure patients as it is used for the prevention of gout and has no detrimental effect on the heart.

      Paracetamol does not affect the heart and is safe to use in heart failure patients.

      Lisinopril is an ACE inhibitor used to treat hypertension and angina, and stopping it can worsen heart failure. It is also one of the three drugs that have been shown to reduce mortality in heart failure. The mechanism by which ACE inhibitors reduce mortality is not fully understood.

    • This question is part of the following fields:

      • Cardiology
      32.5
      Seconds
  • Question 4 - A 16-year-old girl is referred to cardiology outpatients with intermittent palpitations. She describes...

    Correct

    • A 16-year-old girl is referred to cardiology outpatients with intermittent palpitations. She describes occasional spontaneous episodes of being abnormally aware of her heart. She says her heart rate is markedly increased during episodes. She has no significant medical or family history. She is on the oral contraceptive pill. ECG is performed. She is in sinus rhythm at 80 beats per min. PR interval is 108 ms. A slurring slow rise of the initial portion of the QRS complex is noted; QRS duration is 125 ms.
      What is the correct diagnosis?

      Your Answer: Wolff–Parkinson–White syndrome

      Explanation:

      Understanding Wolff-Parkinson-White Syndrome: An Abnormal Congenital Accessory Pathway with Tachyarrhythmia Episodes

      Wolff-Parkinson-White (WPW) syndrome is a rare condition with an incidence of about 1.5 per 1000. It is characterized by the presence of an abnormal congenital accessory pathway that bypasses the atrioventricular node, known as the Bundle of Kent, and episodes of tachyarrhythmia. While the condition may be asymptomatic or subtle, it can increase the risk of sudden cardiac death.

      The presence of a pre-excitation pathway in WPW results in specific ECG changes, including shortening of the PR interval, a Delta wave, and QRS prolongation. The ST segment and T wave may also be discordant to the major component of the QRS complex. These features may be more pronounced with increased vagal tone.

      Upon diagnosis of WPW, risk stratification is performed based on a combination of history, ECG, and invasive cardiac electrophysiology studies. Treatment is only offered to those who are considered to have significant risk of sudden cardiac death. Definitive treatment involves the destruction of the abnormal electrical pathway by radiofrequency catheter ablation, which has a high success rate but is not without complication. Patients who experience regular tachyarrhythmias may be offered pharmacological treatment based on the specific arrhythmia.

      Other conditions, such as first-degree heart block, pulmonary embolism, hyperthyroidism, and Wenckebach syndrome, have different ECG findings and are not associated with WPW. Understanding the specific features of WPW can aid in accurate diagnosis and appropriate management.

    • This question is part of the following fields:

      • Cardiology
      21.2
      Seconds
  • Question 5 - A 40-year-old male patient complains of shortness of breath, weight loss, and night...

    Incorrect

    • A 40-year-old male patient complains of shortness of breath, weight loss, and night sweats for the past six weeks. Despite being generally healthy, he is experiencing these symptoms. During the examination, the patient's fingers show clubbing, and his temperature is 37.8°C. His pulse is 88 beats per minute, and his blood pressure is 128/80 mmHg. Upon listening to his heart, a pansystolic murmur is audible. What signs are likely to be found in this patient?

      Your Answer: Cyanosis

      Correct Answer: Splinter haemorrhages

      Explanation:

      Symptoms and Diagnosis of Infective Endocarditis

      This individual has a lengthy medical history of experiencing night sweats and has developed clubbing of the fingers, along with a murmur. These symptoms are indicative of infective endocarditis. In addition to splinter hemorrhages in the nails, other symptoms that may be present include Roth spots in the eyes, Osler’s nodes and Janeway lesions in the palms and fingers of the hands, and splenomegaly instead of cervical lymphadenopathy. Cyanosis is not typically associated with clubbing and may suggest idiopathic pulmonary fibrosis or cystic fibrosis in younger individuals. However, this individual has no prior history of cystic fibrosis and has only been experiencing symptoms for six weeks.

    • This question is part of the following fields:

      • Cardiology
      10.1
      Seconds
  • Question 6 - A 66-year-old patient visits her General Practitioner (GP) with complaints of chest pain...

    Incorrect

    • A 66-year-old patient visits her General Practitioner (GP) with complaints of chest pain and shortness of breath when climbing stairs. She reports no other health issues. During the examination, the GP notes a slow-rising pulse, a blood pressure reading of 130/100 mmHg, and detects a murmur on auscultation.
      What is the most probable type of murmur heard in this patient?

      Your Answer: Early diastolic murmur (EDM)

      Correct Answer: Ejection systolic murmur (ESM)

      Explanation:

      Common Heart Murmurs and Their Associations

      Heart murmurs are abnormal sounds heard during a heartbeat. They can be innocent or pathological, and their characteristics can provide clues to the underlying condition. Here are some common heart murmurs and their associations:

      1. Ejection systolic murmur (ESM): This murmur is associated with aortic stenosis and is related to the ventricular outflow tract. It may be innocent in children and high-output states, but pathological causes include aortic stenosis and sclerosis, pulmonary stenosis, and hypertrophic obstructive cardiomyopathy.

      2. Mid-diastolic murmur: This murmur is commonly associated with tricuspid or mitral stenosis and starts after the second heart sound and ends before the first heart sound. Rheumatic fever is a common cause of mitral valve stenosis.

      3. Pansystolic murmur: This murmur is associated with mitral regurgitation and is of uniform intensity that starts immediately after S1 and merges with S2. It is also found in tricuspid regurgitation and ventricular septal defects.

      4. Early diastolic murmur (EDM): This high-pitched murmur occurs in pulmonary and aortic regurgitation and is caused by blood flowing through a dysfunctional valve back into the ventricle. It may be accentuated by asking the patient to lean forward.

      5. Continuous murmur: This murmur is commonly associated with a patent ductus arteriosus (PDA), a connection between the aorta and the pulmonary artery. It causes a continuous murmur, sometimes described as a machinery murmur, heard throughout both systole and diastole.

    • This question is part of the following fields:

      • Cardiology
      14
      Seconds
  • Question 7 - An 80-year-old man is hospitalized with acute coronary syndrome and is diagnosed with...

    Incorrect

    • An 80-year-old man is hospitalized with acute coronary syndrome and is diagnosed with a heart attack. After four days, he experiences another episode of chest pain with non-specific ST-T wave changes on the ECG. Which cardiac enzyme would be the most suitable for determining if this second episode was another heart attack?

      Your Answer: Troponin I

      Correct Answer: CK-MB

      Explanation:

      Evaluating Chest Pain after an MI

      When a patient experiences chest pain within ten days of a previous myocardial infarction (MI), it is important to evaluate the situation carefully. Troponin T levels remain elevated for ten days following an MI, which can make it difficult to determine if a second episode of chest pain is related to the previous event. To make a diagnosis, doctors will need to evaluate the patient’s creatine kinase (CK)-myoglobin (MB) levels. These markers rise over three days and can help form a diagnostic profile that can help determine if the chest pain is related to a new MI or another condition. By carefully evaluating these markers, doctors can provide the best possible care for patients who are experiencing chest pain after an MI.

    • This question is part of the following fields:

      • Cardiology
      11.2
      Seconds
  • Question 8 - A 75-year-old man presents to his General Practitioner with chest pain. The man...

    Incorrect

    • A 75-year-old man presents to his General Practitioner with chest pain. The man reports the pain as crushing in nature, exacerbated by exertion, particularly when climbing stairs in his home. The pain is typically relieved by rest, but he has experienced several episodes while watching television in the past two weeks. He has no other medical history and is generally in good health.
      What is the most suitable course of action?

      Your Answer: Send for percutaneous coronary intervention (PCI)

      Correct Answer: Refer to hospital for admission for observation and urgent elective angiogram

      Explanation:

      Appropriate Management for a Patient with Unstable Angina

      Unstable angina is a serious condition that requires urgent medical attention. In the case of a patient displaying textbook signs of unstable angina, such as crushing chest pain occurring at rest, admission to the hospital is necessary. Sending the patient home with only glyceryl trinitrate (GTN) spray is not appropriate, as the patient is at high risk of having a myocardial infarction (MI). Instead, the patient should be seen by Cardiology for consideration of an urgent elective angiogram.

      Prescribing ramipril and simvastatin is not indicated unless there is evidence of hypertension. Lifestyle advice, including exercise recommendation, is also not appropriate for a patient with unstable angina. The immediate problem should be addressed first, which is the need for an angiogram.

      It is important to differentiate between unstable and stable angina. Unstable angina presents with symptoms at rest, indicating a significant worsening of the patient’s cardiac disease. On the other hand, stable angina only presents with symptoms on exertion.

      Sending the patient for percutaneous coronary intervention (PCI) is not necessary unless there is evidence of an MI. The pain experienced due to angina will alleviate itself most commonly at rest, unless the angina is unstable. Therefore, an urgent elective angiogram is the appropriate management for a patient with unstable angina.

    • This question is part of the following fields:

      • Cardiology
      13.4
      Seconds
  • Question 9 - A 57-year-old male with a known history of rheumatic fever and frequent episodes...

    Incorrect

    • A 57-year-old male with a known history of rheumatic fever and frequent episodes of pulmonary oedema is diagnosed with pulmonary hypertension. During examination, an irregularly irregular pulse was noted and auscultation revealed a loud first heart sound and a rumbling mid-diastolic murmur. What is the most probable cause of this patient's pulmonary hypertension?

      Your Answer: Pulmonary stenosis

      Correct Answer: Mitral stenosis

      Explanation:

      Cardiac Valve Disorders: Mitral Stenosis, Mitral Regurgitation, Aortic Regurgitation, Pulmonary Stenosis, and Primary Pulmonary Hypertension

      Cardiac valve disorders are conditions that affect the proper functioning of the heart valves. Among these disorders are mitral stenosis, mitral regurgitation, aortic regurgitation, pulmonary stenosis, and primary pulmonary hypertension.

      Mitral stenosis is a narrowing of the mitral valve, usually caused by rheumatic fever. Symptoms include palpitations, dyspnea, and hemoptysis. Diagnosis is aided by electrocardiogram, chest X-ray, and echocardiography. Management may be medical or surgical.

      Mitral regurgitation is a systolic murmur that presents with a sustained apex beat displaced to the left and a left parasternal heave. On auscultation, there will be a soft S1, a loud S2, and a pansystolic murmur heard at the apex radiating to the left axilla.

      Aortic regurgitation presents with a collapsing pulse with a wide pulse pressure. On palpation of the precordium, there will be a sustained and displaced apex beat with a soft S2 and an early diastolic murmur at the left sternal edge.

      Pulmonary stenosis is associated with a normal pulse, with an ejection systolic murmur radiating to the lung fields. There may be a palpable thrill over the pulmonary area.

      Primary pulmonary hypertension most commonly presents with progressive weakness and shortness of breath. There is evidence of an underlying cardiac disease, meaning the underlying pulmonary hypertension is more likely to be secondary to another disease process.

    • This question is part of the following fields:

      • Cardiology
      14.2
      Seconds
  • Question 10 - A 72-year-old man presents to his GP for a routine check-up and is...

    Incorrect

    • A 72-year-old man presents to his GP for a routine check-up and is found to have a systolic murmur heard loudest in the aortic region. The murmur increases in intensity with deep inspiration and does not radiate. What is the most probable abnormality in this patient?

      Your Answer: Mitral regurgitation

      Correct Answer: Pulmonary stenosis

      Explanation:

      Systolic Valvular Murmurs

      A systolic valvular murmur can be caused by aortic/pulmonary stenosis or mitral/tricuspid regurgitation. It is important to note that the location where the murmur is heard loudest can be misleading. For instance, if it is aortic stenosis, the murmur is expected to radiate to the carotids. However, the significant factor to consider is that the murmur is heard loudest on inspiration. During inspiration, venous return to the heart increases, which exacerbates right-sided murmurs. Conversely, expiration reduces venous return and exacerbates left-sided murmurs. To remember this useful fact, the mnemonic RILE (Right on Inspiration, Left on Expiration) can be used.

      If a systolic murmur is enhanced on inspiration, it must be a right-sided murmur, which could be pulmonary stenosis or tricuspid regurgitation. However, in this case, only pulmonary stenosis is an option. systolic valvular murmurs and their characteristics is crucial in making an accurate diagnosis and providing appropriate treatment.

    • This question is part of the following fields:

      • Cardiology
      10.3
      Seconds
  • Question 11 - A 29-year-old woman presents with sudden-onset palpitation and chest pain that began 1...

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Cardiology
      7.5
      Seconds
  • Question 12 - A 65-year-old retiree visits his GP as he is becoming increasingly breathless and...

    Incorrect

    • A 65-year-old retiree visits his GP as he is becoming increasingly breathless and tired whilst walking. He has always enjoyed walking and usually walks 3 times a week. Over the past year he has noted that he can no longer manage the same distance that he used to be able to without getting breathless and needing to stop. He wonders if this is a normal part of ageing or if there could be an underlying medical problem.
      Which of the following are consistent with normal ageing with respect to the cardiovascular system?

      Your Answer: Left ventricular ejection fraction (LVEF) of 25–35%

      Correct Answer: Reduced VO2 max

      Explanation:

      Ageing and Cardiovascular Health: Understanding the Normal and Abnormal Changes

      As we age, our organs may still function normally at rest, but they may struggle to respond adequately to stressors such as exercise or illness. One of the key indicators of cardiovascular health is VO2 max, which measures the maximum rate of oxygen consumption during exercise. In normal ageing, VO2 max may decrease along with muscle strength, making intense exertion more difficult. However, significantly reduced VO2 max, left ventricular ejection fraction (LVEF), or stroke volume are not consistent with normal ageing. Additionally, hypotension or hypertension are not typical changes associated with ageing. Understanding these normal and abnormal changes can help us better monitor and manage our cardiovascular health as we age.

    • This question is part of the following fields:

      • Cardiology
      14
      Seconds
  • Question 13 - A 49-year-old woman presents to the Cardiology clinic with a heart murmur. During...

    Correct

    • A 49-year-old woman presents to the Cardiology clinic with a heart murmur. During the physical exam, the patient exhibits a collapsing pulse. Upon auscultation, a 2/5 early diastolic murmur is heard at the lower left sternal edge, which is more pronounced during expiration.
      What is the most probable clinical sign that will be observed?

      Your Answer: Corrigan’s sign

      Explanation:

      Cardiac Signs and Their Associated Conditions

      Corrigan’s Sign: This sign is characterized by an abrupt distension and collapse of the carotid arteries, indicating aortic incompetence. It is often seen in patients with a collapsing pulse and an early diastolic murmur, which are suggestive of aortic regurgitation. A wide pulse pressure may also be found.

      Malar Flush: Mitral stenosis is associated with malar flush, a mid-diastolic murmur, loudest at the apex when the patient is in the left lateral position, and a tapping apex. A small-volume pulse is also typical.

      Tapping Apex: A tapping apex is a classical sign of mitral stenosis.

      Pulsatile Hepatomegaly: Severe tricuspid regurgitation can cause reverse blood flow to the liver during systole, resulting in pulsatile hepatomegaly.

      Clubbing: Clubbing is more commonly seen in lung pathology and is unlikely to present in aortic regurgitation. It is seen in congenital cyanotic heart disease.

    • This question is part of the following fields:

      • Cardiology
      6.8
      Seconds
  • Question 14 - A patient in their 60s with idiopathic pericarditis becomes increasingly unwell, with hypotension,...

    Correct

    • A patient in their 60s with idiopathic pericarditis becomes increasingly unwell, with hypotension, jugular venous distention and muffled heart sounds on auscultation. Echocardiogram confirms a pericardial effusion.
      At which of the following sites does this effusion occur?

      Your Answer: Between the visceral pericardium and the parietal pericardium

      Explanation:

      Understanding the Site of Pericardial Effusion

      Pericardial effusion is a condition where excess fluid accumulates in the pericardial cavity, causing compression of the heart. To understand the site of pericardial effusion, it is important to know the layers of the pericardium.

      The pericardium has three layers: the fibrous pericardium, the parietal pericardium, and the visceral pericardium. The pericardial fluid is located in between the visceral and parietal pericardium, which is the site where a pericardial effusion occurs.

      It is important to note that pericardial effusion does not occur between the parietal pericardium and the fibrous pericardium, the visceral pericardium and the myocardium, the fibrous pericardium and the mediastinal pleura, or the fibrous pericardium and the central tendon of the diaphragm.

      In summary, pericardial effusion occurs at the site where pericardial fluid is normally produced – between the parietal and visceral layers of the serous pericardium. Understanding the site of pericardial effusion is crucial in diagnosing and treating this condition.

    • This question is part of the following fields:

      • Cardiology
      19.3
      Seconds
  • Question 15 - A 55-year-old man was brought to the Emergency Department following a car accident....

    Incorrect

    • 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: Mitral regurgitation

      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.

    • This question is part of the following fields:

      • Cardiology
      19.7
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  • Question 16 - A 65-year-old man presents to the Emergency Department with sudden onset epigastric discomfort....

    Incorrect

    • A 65-year-old man presents to the Emergency Department with sudden onset epigastric discomfort. He has a significant past medical history of hypercholesterolaemia and type II diabetes mellitus, and he is a heavy smoker. On examination, his pulse is 30 bpm; he is hypotensive and has distended neck veins. The chest is clear to auscultation. Initial blood tests reveal an elevated troponin level, and an electrocardiogram (ECG) shows hyperacute T-waves in leads II, III and aVF.
      What is the most likely diagnosis?

      Your Answer: Anterior myocardial infarction (MI)

      Correct Answer: Right/inferior MI

      Explanation:

      Understanding the Different Types of Myocardial Infarction: A Guide to ECG Changes and Symptoms

      Myocardial infarction (MI) can occur in different areas of the heart, depending on which artery is occluded. Right/inferior MIs, which account for up to 40-50% of cases, are caused by occlusion of the RCA or, less commonly, a dominant left circumflex artery. Symptoms include bradycardia, hypotension, and a clear chest on auscultation. Conduction disturbances, particularly type II and III heart blocks, are also common. ECG changes include ST-segment elevation in leads II, III, and aVF, and reciprocal ST-segment depression in aVL (± lead I).

      Anterolateral MIs are possible, but less likely to present with bradycardia, hypotension, and a clear chest. An anterior MI, caused by occlusion of the LAD, is associated with tachycardia rather than bradycardia.

      Other conditions, such as acute pulmonary edema and pulmonary embolism, may present with similar symptoms but have different ECG changes and additional features. Understanding the ECG changes and symptoms associated with different types of MI can help with accurate diagnosis and appropriate treatment.

    • This question is part of the following fields:

      • Cardiology
      28.4
      Seconds
  • Question 17 - A patient in their 60s was diagnosed with disease of a heart valve...

    Incorrect

    • A patient in their 60s was diagnosed with disease of a heart valve located between the left ventricle and the ascending aorta. Which of the following is most likely to describe the cusps that comprise this heart valve?

      Your Answer: Anterior and posterior cusps

      Correct Answer: Right, left and posterior cusps

      Explanation:

      Different Cusps of Heart Valves

      The heart has four valves that regulate blood flow through the chambers. Each valve is composed of cusps, which are flaps that open and close to allow blood to pass through. Here are the different cusps of each heart valve:

      Aortic Valve: The aortic valve is made up of a right, left, and posterior cusp. It is located at the junction between the left ventricle and the ascending aorta.

      Mitral Valve: The mitral valve is usually the only bicuspid valve and is composed of anterior and posterior cusps. It is located between the left atrium and the left ventricle.

      Tricuspid Valve: The tricuspid valve has three cusps – anterior, posterior, and septal. It is located between the right atrium and the right ventricle.

      Pulmonary Valve: The pulmonary valve is made up of right, left, and anterior cusps. It is located at the junction between the right ventricle and the pulmonary artery.

      Understanding the different cusps of heart valves is important in diagnosing and treating heart conditions.

    • This question is part of the following fields:

      • Cardiology
      8
      Seconds
  • Question 18 - A 12-year-old girl is diagnosed with rheumatic fever after presenting with a 3-day...

    Incorrect

    • A 12-year-old girl is diagnosed with rheumatic fever after presenting with a 3-day history of fever and polyarthralgia. The patient’s mother is concerned about any potential lasting damage to the heart.
      What is the most common cardiac sequelae of rheumatic fever?

      Your Answer: Ventricular septal defect

      Correct Answer: Mitral stenosis

      Explanation:

      Rheumatic Fever and its Effects on Cardiac Valves

      Rheumatic fever is a condition caused by group A β-haemolytic streptococcal infection. To diagnose it, the revised Duckett-Jones criteria are used, which require evidence of streptococcal infection and the presence of certain criteria. While all four cardiac valves may be damaged as a result of rheumatic fever, the mitral valve is the most commonly affected, with major criteria including carditis, subcutaneous nodule, migratory polyarthritis, erythema marginatum, and Sydenham’s chorea. Minor criteria include arthralgia, fever, raised CRP or ESR, raised WCC, heart block, and previous rheumatic fever. Mitral stenosis is the most common result of rheumatic fever, but it is becoming less frequently seen in clinical practice. Pulmonary regurgitation, aortic sclerosis, and tricuspid regurgitation are also possible effects, but they are less common than mitral valve damage. Ventricular septal defect is not commonly associated with rheumatic fever.

    • This question is part of the following fields:

      • Cardiology
      16.9
      Seconds
  • Question 19 - An 82-year-old man has been experiencing increasing shortness of breath, tiredness, intermittent chest...

    Correct

    • An 82-year-old man has been experiencing increasing shortness of breath, tiredness, intermittent chest pain and leg swelling for the past 6 months. He recently underwent an echocardiogram as an outpatient which revealed evidence of heart failure. As the FY1 on the Medical Assessment Unit, you have been tasked with taking the patient's medical history. He has a history of hypertension and gout and is currently taking diltiazem (calcium-channel blocker) 60 mg po bd, furosemide (diuretic) 20 mg po od, Spironolactone 25mg od, allopurinol 100 mg po od, paracetamol 1 g po qds prn, and lisinopril 20 mg po od. Considering his likely diagnosis of heart failure, which medication should be discontinued?

      Your Answer: Diltiazem

      Explanation:

      Medications for Heart Failure: Understanding their Effects

      Heart failure is a complex condition that requires careful management, including the use of various medications. In this context, it is important to understand the effects of each drug and how they can impact the patient’s health. Here is a brief overview of some commonly used medications for heart failure and their effects:

      Diltiazem: This calcium-channel blocker can be used to treat angina and hypertension. However, it is advisable to stop calcium-channel blockers in patients with heart disease, as they can reduce the contractility of the heart, exacerbating the condition.

      Spironolactone: This drug can help alleviate leg swelling by reducing water retention. It is also one of the three drugs in heart failure that have been shown to reduce mortality, along with ACE inhibitors and b-blockers.

      Allopurinol: This medication is used in the prevention of gout long term and has no detrimental effect on the heart.

      Paracetamol: This drug does not have an effect on the heart.

      Lisinopril: This ACE inhibitor is used in the treatment of hypertension and the prophylactic treatment of angina. Stopping this medication is likely to worsen heart failure. Like spironolactone and b-blockers, ACE inhibitors have been shown to reduce mortality in heart failure, although the mechanisms behind this effect are not fully understood.

      In summary, understanding the effects of medications for heart failure is crucial for optimizing patient care and improving outcomes. Healthcare providers should carefully consider each drug’s benefits and risks and tailor treatment to the individual patient’s needs.

    • This question is part of the following fields:

      • Cardiology
      8.2
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  • Question 20 - A 27-year-old Asian woman complains of palpitations, shortness of breath on moderate exertion...

    Correct

    • A 27-year-old Asian woman complains of palpitations, shortness of breath on moderate exertion and a painful and tender knee. During auscultation, a mid-diastolic murmur with a loud S1 is heard. Echocardiography reveals valvular heart disease with a normal left ventricular ejection fraction.
      What is the most probable valvular disease?

      Your Answer: Mitral stenosis

      Explanation:

      Differentiating Heart Murmurs: Causes and Characteristics

      Heart murmurs are abnormal sounds heard during a heartbeat and can indicate underlying heart conditions. Here are some common causes and characteristics of heart murmurs:

      Mitral Stenosis: This condition is most commonly caused by rheumatic fever in childhood and is rare in developed countries. Patients with mitral stenosis will have a loud S1 with an associated opening snap. However, if the mitral valve is calcified or there is severe stenosis, the opening snap may be absent and S1 soft.

      Mitral Regurgitation and Ventricular Septal Defect: These conditions cause a pan-systolic murmur, which is not the correct option for differentiating heart murmurs.

      Aortic Regurgitation: This condition leads to an early diastolic murmur.

      Aortic Stenosis: Aortic stenosis causes an ejection systolic murmur.

      Ventricular Septal Defect: As discussed, a ventricular septal defect will cause a pan-systolic murmur.

      By understanding the causes and characteristics of different heart murmurs, healthcare professionals can better diagnose and treat underlying heart conditions.

    • This question is part of the following fields:

      • Cardiology
      17.4
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  • Question 21 - A 7-year-old girl comes to the clinic complaining of headaches, particularly during times...

    Incorrect

    • A 7-year-old girl comes to the clinic complaining of headaches, particularly during times of stress or physical activity. She has no significant medical history. During her neurological exam, no abnormalities are found. However, a systolic murmur is heard along the length of her left sternal edge and spine. Her chest is clear and her blood pressure is 156/88 mmHg in her left arm and 104/68 mmHg in her left leg. An ECG reveals sinus rhythm with evidence of left ventricular hypertrophy. What is the most likely diagnosis?

      Your Answer: Hypertrophic occlusive cardiomyopathy

      Correct Answer: Coarctation of the aorta

      Explanation:

      Coarctation of the Aorta and its Interventions

      Coarctation of the aorta is a condition where the aorta narrows, usually distal to the left subclavian artery. This can cause an asymptomatic difference in upper and lower body blood pressures and can lead to left ventricular hypertrophy. The severity of the restriction varies, with severe cases presenting early with cardiac failure, while less severe cases can go undiagnosed into later childhood.

      Interventions for coarctation of the aorta include stenting, excision and graft placement, and using the left subclavian artery to bypass the coarctation. An atrial septal defect and hypertrophic occlusive cardiomyopathy would not cause a blood pressure difference between the upper and lower body. Stress headaches and a flow murmur are not appropriate diagnoses for a child with hypertension, which should be thoroughly investigated for an underlying cause.

      In contrast, transposition of the great arteries is a major cyanotic cardiac abnormality that presents in infancy. It is important to diagnose and treat coarctation of the aorta to prevent complications such as left ventricular hypertrophy and cardiac failure.

    • This question is part of the following fields:

      • Cardiology
      34.4
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  • Question 22 - An 82-year-old woman is brought to the Emergency Department after experiencing a sudden...

    Correct

    • An 82-year-old woman is brought to the Emergency Department after experiencing a sudden loss of consciousness while shopping. Upon examination, she is fully alert and appears to be in good health.
      Her temperature is normal, and her blood glucose level is 5.8 mmol/l. Her cardiovascular system shows an irregular heart rate of 89 beats per minute with low volume, and her blood pressure is 145/120 mmHg while lying down and standing up. Her jugular venous pressure is not elevated, and her apex beat is forceful but undisplaced. Heart sounds include a soft S2 and a soft ejection systolic murmur that is loudest in the right second intercostal space, with a possible fourth heart sound heard. Her chest reveals occasional bibasal crackles that clear with coughing, and there is no peripheral edema. Based on these clinical findings, what is the most likely cause of her collapse?

      Your Answer: Aortic stenosis

      Explanation:

      Clinical Presentation of Aortic Stenosis

      Aortic stenosis is a condition that presents with symptoms of left ventricular failure, angina, and potential collapse or blackout if the stenosis is critical. A patient with significant aortic stenosis may exhibit several clinical signs, including a low-volume pulse, narrow pulse pressure, slow-rising carotid pulse, undisplaced sustained/forceful apex beat, soft or absent A2, ejection systolic murmur with a fourth heart sound, and pulmonary edema.

      It is important to note that aortic regurgitation would not cause the same examination findings as aortic stenosis. Aortic regurgitation typically presents with an early diastolic murmur and a collapsing pulse. Similarly, mixed mitral and aortic valve disease would not be evident in this clinical scenario, nor would mitral stenosis or mitral regurgitation. These conditions have distinct clinical presentations and diagnostic criteria.

    • This question is part of the following fields:

      • Cardiology
      26.5
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  • Question 23 - You are assisting in the anaesthesia of an 80-year-old man for a plastics...

    Correct

    • You are assisting in the anaesthesia of an 80-year-old man for a plastics procedure. He is having a large basal cell carcinoma removed from his nose. He has a history of ischaemic heart disease, having had three stents placed 2 years ago. He is otherwise healthy and still able to walk to the shops. His preoperative electrocardiogram (ECG) showed sinus rhythm. During the procedure, his heart rate suddenly increases to 175 bpm with a narrow complex, and you cannot see P waves on the monitor. You are having difficulty obtaining a blood pressure reading but are able to palpate a radial pulse with a systolic pressure of 75 mmHg. The surgeons have been using lidocaine with adrenaline around the surgical site. What is the next best course of action?

      Your Answer: 100% O2, synchronised cardioversion, 150-J biphasic shock

      Explanation:

      Treatment Options for a Patient with Narrow-Complex Tachycardia and Low Blood Pressure

      When a patient with a history of ischaemic heart disease presents with a narrow-complex tachycardia and low blood pressure, it is likely that they have gone into fast atrial fibrillation. In this case, the first step in resuscitation should be a synchronised direct current (DC) cardioversion with a 150-J biphasic shock. Administering 100% oxygen, a 500 ml Hartmann bolus, and 0.5 mg metaraminol may help increase the patient’s blood pressure, but it does not address the underlying cause of their haemodynamic instability.

      Amiodarone 300 mg stat is recommended for patients with narrow-complex tachycardia and haemodynamic instability. However, administering 10 mmol magnesium sulphate is not the first-line treatment for tachycardia unless the patient has torsades de pointes.

      Lastly, administering Intralipid® as per guideline for local anaesthetic toxicity is unlikely to be the main source of the patient’s hypotension and does not address their narrow-complex tachycardia. Therefore, it is important to prioritize the synchronised cardioversion and amiodarone administration in this patient’s treatment plan.

    • This question is part of the following fields:

      • Cardiology
      14.3
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  • Question 24 - A 29-year-old man with valvular heart disease is urgently admitted with fever, worsening...

    Correct

    • A 29-year-old man with valvular heart disease is urgently admitted with fever, worsening shortness of breath and a letter from his GP confirming the presence of a new murmur. During examination, a harsh pansystolic murmur and early diastolic murmur are detected, along with a temperature of 38.3 °C and bilateral fine basal crepitations. Initial blood cultures have been collected.
      What is the most pressing concern that needs to be addressed immediately?

      Your Answer: Administration of intravenous antibiotics

      Explanation:

      Prioritizing Interventions in Suspected Infective Endocarditis

      When dealing with suspected infective endocarditis, time is of the essence. The following interventions should be prioritized in order to limit valve destruction and improve patient outcomes.

      Administration of Intravenous Antibiotics
      Prompt initiation of intravenous antibiotics is crucial. An empirical regime of gentamicin and benzylpenicillin may be used until microbiological advice suggests any alternative.

      Electrocardiogram (ECG)
      An ECG provides important diagnostic information and should be performed as part of the initial work-up. However, it does not take priority over antibiotic administration.

      Echocardiogram (ECHO)
      An ECHO should be performed in all patients with suspected infective endocarditis, but it does not take priority over administration of antibiotics. A transoesophageal ECHO is more sensitive and should be considered if necessary.

      Throat Swab
      While a throat swab may be useful in identifying the causative organism of infective endocarditis, it should not take precedence over commencing antibiotics. Careful examination of a patient’s dentition is also crucial to evaluate for a possible infectious source.

      Administration of Paracetamol
      Symptomatic relief is important, but administration of paracetamol should not take priority over antibiotic delivery. Both interventions should be given as soon as possible to improve patient outcomes.

    • This question is part of the following fields:

      • Cardiology
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  • Question 25 - A 51-year-old woman with a history of hypothyroidism experiences a collapse during her...

    Incorrect

    • A 51-year-old woman with a history of hypothyroidism experiences a collapse during her yoga class. She has been reporting occasional chest pains and difficulty breathing during exercise in the past few weeks. During her physical examination, an ejection systolic murmur is detected at the right upper sternal edge, and her second heart sound is faint. Additionally, she has a slow-rising pulse. What is the most probable cause of her symptoms?

      Your Answer: Aortic valve regurgitation

      Correct Answer: Bicuspid aortic valve

      Explanation:

      Differentiating Aortic and Mitral Valve Disorders

      When evaluating a patient with a heart murmur, it is important to consider the characteristics of the murmur and associated symptoms to determine the underlying valve disorder. In a patient under 70 years old, a slow-rising and weak pulse with a history of collapse is indicative of critical stenosis caused by a bicuspid aortic valve. On the other hand, calcific aortic stenosis is more common in patients over 70 years old and presents differently. Aortic valve regurgitation is characterized by a murmur heard during early diastole and a collapsing pulse, but it is less likely to cause syncope. Mitral valve regurgitation causes a pan-systolic murmur at the apex with a laterally displaced apex beat, but it may present with congestive heart failure rather than syncope or angina. Mitral valve prolapse may cause a mid-systolic click, but a pan-systolic murmur at the apex may be present if there is coexisting mitral regurgitation. By understanding the unique features of each valve disorder, clinicians can make an accurate diagnosis and provide appropriate treatment.

    • This question is part of the following fields:

      • Cardiology
      17.4
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  • Question 26 - A 68-year-old man experienced acute kidney injury caused by rhabdomyolysis after completing his...

    Incorrect

    • A 68-year-old man experienced acute kidney injury caused by rhabdomyolysis after completing his first marathon. He was started on haemodialysis due to uraemic pericarditis. What symptom or sign would indicate the presence of cardiac tamponade?

      Your Answer: Pericardial rub

      Correct Answer: Pulsus paradoxus

      Explanation:

      Understanding Pericarditis and Related Symptoms

      Pericarditis is a condition characterized by inflammation of the pericardium, the sac surrounding the heart. One of the signs of pericarditis is pulsus paradoxus, which is a drop in systolic blood pressure of more than 10 mmHg during inspiration. This occurs when the pericardial effusion normalizes the wall pressures across all the chambers, causing the septum to bulge into the left ventricle, reducing stroke volume and blood pressure. Pleuritic chest pain is not a common symptom of pericarditis, and confusion is not related to pericarditis or incipient tamponade. A pericardial friction rub is an audible medical sign used in the diagnosis of pericarditis, while a pericardial knock is a pulse synchronous sound that can be heard in constrictive pericarditis. Understanding these symptoms can aid in the diagnosis and management of pericarditis.

    • This question is part of the following fields:

      • Cardiology
      11.1
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  • Question 27 - A patient presents to the Emergency Department following a fracture dislocation of his...

    Incorrect

    • A patient presents to the Emergency Department following a fracture dislocation of his ankle after a night out drinking vodka red-bulls. His blood pressure is low at 90/50 mmHg. He insists that it is never normally that low.
      Which one of these is a possible cause for this reading?

      Your Answer: Alcohol and caffeine

      Correct Answer: Incorrect cuff size (cuff too large)

      Explanation:

      Common Factors Affecting Blood Pressure Readings

      Blood pressure readings can be affected by various factors, including cuff size, alcohol and caffeine consumption, white coat hypertension, pain, and more. It is important to be aware of these factors to ensure accurate readings.

      Incorrect Cuff Size:
      Using a cuff that is too large can result in an underestimation of blood pressure, while a cuff that is too small can cause a falsely elevated reading.

      Alcohol and Caffeine:
      Both alcohol and caffeine can cause a temporary increase in blood pressure.

      White Coat Hypertension:
      Many patients experience elevated blood pressure in medical settings due to anxiety. To obtain an accurate reading, blood pressure should be measured repeatedly on separate occasions.

      Pain:
      Pain is a common cause of blood pressure increase and should be taken into consideration during medical procedures. A significant rise in blood pressure during a procedure may indicate inadequate anesthesia.

      Factors Affecting Blood Pressure Readings

    • This question is part of the following fields:

      • Cardiology
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  • Question 28 - A 65-year-old man visits his doctor complaining of a persistent cough with yellow...

    Correct

    • A 65-year-old man visits his doctor complaining of a persistent cough with yellow sputum, mild breathlessness, and fever for the past three days. He had a heart attack nine months ago and received treatment with a bare metal stent during angioplasty. Due to his penicillin allergy, the doctor prescribed oral clarithromycin 500 mg twice daily for a week to treat his chest infection. However, after five days, the patient returns to the doctor with severe muscle pains in his thighs and shoulders, weakness, lethargy, nausea, and dark urine. Which medication has interacted with clarithromycin to cause these symptoms?

      Your Answer: Simvastatin

      Explanation:

      Clarithromycin and its Drug Interactions

      Clarithromycin is an antibiotic used to treat various bacterial infections. It is effective against many Gram positive and some Gram negative bacteria that cause community acquired pneumonias, atypical pneumonias, upper respiratory tract infections, and skin infections. Unlike other macrolide antibiotics, clarithromycin is highly stable in acidic environments and has fewer gastric side effects. It is also safe to use in patients with penicillin allergies.

      However, clarithromycin can interact with other drugs by inhibiting the hepatic cytochrome P450 enzyme system. This can lead to increased levels of other drugs that are metabolized via this route, such as warfarin, aminophylline, and statin drugs. When taken with statins, clarithromycin can cause muscle breakdown and rhabdomyolysis, which can lead to renal failure. Elderly patients who take both drugs may experience reduced mobility and require prolonged rehabilitation physiotherapy.

      To avoid these interactions, it is recommended that patients taking simvastatin or another statin drug discontinue its use during the course of clarithromycin treatment and for one week after. Clarithromycin can also potentially interact with clopidogrel, a drug used to prevent stent thrombosis, by reducing its efficacy. However, clarithromycin does not have any recognized interactions with bisoprolol, lisinopril, or aspirin.

      In summary, while clarithromycin is an effective antibiotic, it is important to be aware of its potential drug interactions, particularly with statin drugs and clopidogrel. Patients should always inform their healthcare provider of all medications they are taking to avoid any adverse effects.

    • This question is part of the following fields:

      • Cardiology
      24
      Seconds
  • Question 29 - A 33-year-old known intravenous drug user presents to your GP clinic with complaints...

    Incorrect

    • A 33-year-old known intravenous drug user presents to your GP clinic with complaints of fatigue, night sweats and joint pain. During the examination, you observe a new early-diastolic murmur. What is the probable causative organism for this patient's condition?

      Your Answer: Group B streptococci

      Correct Answer: Staphylococcus aureus

      Explanation:

      Common Causes of Infective Endocarditis and their Characteristics

      Infective endocarditis is a serious condition that can lead to severe complications if left untreated. The most common causative organism of acute infective endocarditis is Staphylococcus aureus, especially in patients with risk factors such as prosthetic valves or intravenous drug use. Symptoms and signs consistent with infective endocarditis include fever, heart murmur, and arthritis, as well as pathognomonic signs like splinter hemorrhages, Osler’s nodes, Roth spots, Janeway lesions, and petechiae.

      Group B streptococci is less common than Staphylococcus aureus but has a high mortality rate of 70%. Streptococcus viridans is not the most common cause of infective endocarditis, but it does cause 50-60% of subacute cases. Group D streptococci is the third most common cause of infective endocarditis. Pseudomonas aeruginosa is not the most common cause of infective endocarditis and usually requires surgery for cure.

      In summary, knowing the characteristics of the different causative organisms of infective endocarditis can help in the diagnosis and treatment of this serious condition.

    • This question is part of the following fields:

      • Cardiology
      11.9
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  • Question 30 - A 65-year-old man presents with a 1-hour history of chest pain and is...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Cardiology
      29
      Seconds
  • Question 31 - An 82-year-old woman is brought to the Emergency Department after experiencing a sudden...

    Incorrect

    • An 82-year-old woman is brought to the Emergency Department after experiencing a sudden loss of consciousness while grocery shopping. Upon examination, she is fully alert and appears to be in good health.

      Her vital signs are normal, with a CBG of 5.8 mmol/l. However, her cardiovascular system shows an irregular, low volume heart rate of 90-110 beats per minute, and her blood pressure is 145/120 mmHg while lying down and standing up. Her JVP is raised by 5 cm, and her apex beat is displaced to the mid-axillary line, with diffuse heart sounds. A loud pansystolic murmur is heard at the apex, radiating to the axilla and at the lower left sternal edge, along with a mid-diastolic rumble best heard at the apex. There are occasional bibasal crackles in her chest, which clear up with coughing. Additionally, she has mild peripheral edema up to the mid-calf.

      Based on these clinical findings, what is the most likely cause of her collapse?

      Your Answer: Mitral stenosis

      Correct Answer: Mixed mitral valve disease

      Explanation:

      This patient exhibits features of mixed mitral valve disease, which can be challenging to diagnose due to contradictory signs. She has a mid-diastolic rumble, low-volume pulse, and atrial fibrillation, indicating mitral stenosis. However, she also has a displaced apex beat and a pan-systolic murmur, indicating mitral regurgitation. Mixed aortic valve disease is also common in these patients. Aortic stenosis and mixed aortic valve disease are unlikely diagnoses based on the clinical findings, while mitral stenosis and mitral regurgitation alone do not fully explain the examination results.

    • This question is part of the following fields:

      • Cardiology
      30.5
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  • Question 32 - A 70-year-old woman was recently diagnosed with essential hypertension and started on a...

    Incorrect

    • A 70-year-old woman was recently diagnosed with essential hypertension and started on a medication to lower her blood pressure. She then stopped taking the medication as she reported ankle swelling. Her blood pressure readings usually run at 160/110 mmHg. She denies any headache, palpitation, chest pain, leg claudication or visual problems. She was diagnosed with osteoporosis with occasional back pain and has been admitted to the hospital for a hip fracture on two occasions over the last 3 years. There is no history of diabetes mellitus, coronary artery disease or stroke. She has no known drug allergy. Her vital signs are within normal limits, other than high blood pressure. The S1 is loud. The S2 is normal. There is an S4 sound without a murmur, rub or gallop. The peripheral pulses are normal and symmetric. The serum electrolytes (sodium, potassium, calcium and chloride), creatinine and urea nitrogen are within normal range.
      What is the most appropriate antihypertensive medication for this patient?

      Your Answer: Amlodipine

      Correct Answer: Indapamide

      Explanation:

      The best medication for the patient in the scenario would be indapamide, a thiazide diuretic that blocks the Na+/Cl− cotransporter in the distal convoluted tubules, increasing calcium reabsorption and reducing the risk of osteoporotic fractures. Common side-effects include hyponatraemia, hypokalaemia, hypercalcaemia, hyperglycaemia, hyperuricaemia, gout, postural hypotension and hypochloraemic alkalosis. Prazosin is used for benign prostatic hyperplasia, enalapril is not preferred for patients over 55 years old and can increase osteoporosis risk, propranolol is not a preferred initial treatment for hypertension, and amlodipine can cause ankle swelling and should be avoided in patients with myocardial infarction and symptomatic heart failure.

    • This question is part of the following fields:

      • Cardiology
      15.1
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  • Question 33 - A previously healthy 58-year-old man collapsed while playing with his grandchildren. Although he...

    Correct

    • A previously healthy 58-year-old man collapsed while playing with his grandchildren. Although he quickly regained consciousness and became fully alert, his family called an ambulance. The emergency medical team found no abnormalities on the electrocardiogram. Physical examination was unremarkable. However, the patient was admitted to the Coronary Care Unit of the local hospital. During the evening, the patient was noted to have a fast rhythm with a wide complex on his monitor, followed by hypotension and loss of consciousness.
      After electrical cardioversion with 200 watt-seconds of direct current, which one of the following may possible therapy include?

      Your Answer: Amiodarone

      Explanation:

      The patient in the scenario is experiencing a fast rhythm with wide complexes, which is likely ventricular tachycardia (VT). As the patient is unstable, electrical cardioversion was attempted first, as recommended by the Resuscitation Council Guideline. If cardioversion fails and the patient remains unstable, intravenous amiodarone can be used as a loading dose of 300 mg over 10-20 minutes, followed by an infusion of 900 mg/24 hours. Amiodarone is a class III anti-arrhythmic agent that prolongs the repolarization phase of the cardiac action potential by blocking potassium efflux. Side-effects associated with amiodarone include deranged thyroid and liver function tests, nausea, vomiting, bradycardia, interstitial lung disease, jaundice, and sleep disorders.

      Epinephrine is used in the treatment of acute anaphylaxis and cardiopulmonary resuscitation. It acts on adrenergic receptors, causing bronchodilation and vasoconstriction. Side-effects associated with epinephrine include palpitations, arrhythmias, headache, tremor, and hypertension.

      Intravenous propranolol is a non-selective β-adrenergic receptor blocker that has limited use in treating arrhythmias and thyrotoxic crisis. It is contraindicated in patients with severe hypotension, asthma, COPD, bradycardia, sick sinus rhythm, atrioventricular block, and cardiogenic shock. Side-effects associated with propranolol include insomnia, nightmares, nausea, diarrhea, bronchospasm, exacerbation of Raynaud’s, bradycardia, hypotension, and heart block.

      Digoxin, a cardiac glycoside extracted from the plant genus Digitalis, can be used in the treatment of supraventricular arrhythmias and heart failure. However, it is of no use in this scenario as the patient is experiencing a broad complex tachycardia. Digoxin has a narrow therapeutic window, and even small changes in dosing can lead to toxicity. Side-effects associated with digoxin include nausea, vomiting, diarrhea, bradycardia, dizziness, yellow vision, and eosinophilia.

      Diltiazem, a non-dihydropyridine calcium channel blocker, is normally used for hypertension and prophylaxis and treatment of ang

    • This question is part of the following fields:

      • Cardiology
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  • Question 34 - A 55-year-old man presents with sudden onset of severe chest pain and difficulty...

    Incorrect

    • A 55-year-old man presents with sudden onset of severe chest pain and difficulty breathing. The pain started while he was eating and has been constant for the past three hours. It radiates to his back and interscapular region.

      The patient has a history of hypertension for three years, alcohol abuse, and is a heavy smoker of 30 cigarettes per day. On examination, he is cold and clammy with a heart rate of 130/min and a blood pressure of 80/40 mm Hg. JVP is normal, but breath sounds are decreased at the left lung base and a chest x-ray reveals a left pleural effusion.

      What is the most likely diagnosis?

      Your Answer: Acute myocardial infarction

      Correct Answer: Acute aortic dissection

      Explanation:

      Acute Aortic Dissection: Symptoms, Diagnosis, and Imaging

      Acute aortic dissection is a medical emergency that causes sudden and severe chest pain. The pain is often described as tearing and may be felt in the front or back of the chest, as well as in the neck. Other symptoms and signs depend on the arteries involved and nearby organs affected. In severe cases, it can lead to hypovolemic shock and sudden death.

      A chest x-ray can show a widened mediastinum, cardiomegaly, pleural effusion, and intimal calcification separated more than 6 mm from the edge. However, aortography is the gold standard for diagnosis, which shows the origin of arteries from true or false lumen. CT scan and MRI are also commonly used for diagnosis. Transoesophageal echo (TEE) is best for the descending aorta, while transthoracic echo (TTE) is best for the ascending aorta and arch.

      In summary, acute aortic dissection is a serious condition that requires prompt diagnosis and treatment. Symptoms include sudden and severe chest pain, which may be accompanied by other signs depending on the arteries involved. Imaging techniques such as chest x-ray, aortography, CT scan, MRI, TEE, and TTE can aid in diagnosis.

    • This question is part of the following fields:

      • Cardiology
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  • Question 35 - A 42-year-old man presents to the Emergency Department with severe central chest pain...

    Incorrect

    • A 42-year-old man presents to the Emergency Department with severe central chest pain that worsens when lying down, is relieved by sitting forward, and radiates to his left shoulder. He has a history of prostate cancer and has recently completed two cycles of radiotherapy. On examination, his blood pressure is 96/52 mmHg (normal <120/80 mmHg), his JVP is elevated, and his pulse is 98 bpm with a decrease in amplitude during inspiration. Heart sounds are faint. The ECG shows low-voltage QRS complexes. What is the most appropriate initial management for this patient?

      Your Answer: Glyceryl trinitrate (GTN) spray, morphine, clopidogrel, aspirin

      Correct Answer: Urgent pericardiocentesis

      Explanation:

      The patient is experiencing cardiac tamponade, which is caused by fluid in the pericardial sac compressing the heart and reducing ventricular filling. This is likely due to pericarditis caused by recent radiotherapy. Beck’s triad of low blood pressure, raised JVP, and muffled heart sounds are indicative of tamponade. Urgent pericardiocentesis is necessary to aspirate the pericardial fluid, preferably under echocardiographic guidance. A fluid challenge with sodium chloride is not recommended as it may worsen the pericardial fluid. Ibuprofen is not effective in severe cases of pericardial effusion. GTN spray, morphine, clopidogrel, and aspirin are useful in managing myocardial infarction, which is a differential diagnosis to rule out. LMWH is not appropriate for tamponade and may worsen the condition if caused by haemopericardium.

    • This question is part of the following fields:

      • Cardiology
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  • Question 36 - A 51-year-old man passed away from a massive middle cerebral artery stroke. He...

    Incorrect

    • A 51-year-old man passed away from a massive middle cerebral artery stroke. He had no previous medical issues. Upon autopsy, it was discovered that his heart weighed 400 g and had normal valves and coronary arteries. The atria and ventricles were not enlarged. The right ventricular walls were normal, while the left ventricular wall was uniformly hypertrophied to 20-mm thickness. What is the probable reason for these autopsy results?

      Your Answer: Idiopathic dilated cardiomyopathy

      Correct Answer: Essential hypertension

      Explanation:

      Differentiating Cardiac Conditions: Causes and Risks

      Cardiac conditions can have varying causes and risks, making it important to differentiate between them. Essential hypertension, for example, is characterized by uniform left ventricular hypertrophy and is a major risk factor for stroke. On the other hand, atrial fibrillation is a common cause of stroke but does not cause left ventricular hypertrophy and is rarer with normal atrial size. Hypertrophic obstructive cardiomyopathy, which is more common in men and often has a familial tendency, typically causes asymmetric hypertrophy of the septum and apex and can lead to arrhythmogenic or unexplained sudden cardiac death. Dilated cardiomyopathies, such as idiopathic dilated cardiomyopathy, often have no clear precipitant but cause a dilated left ventricular size, increasing the risk for a mural thrombus and an embolic risk. Finally, tuberculous pericarditis is difficult to diagnose due to non-specific features such as cough, dyspnoea, sweats, and weight loss, with typical constrictive pericarditis findings being very late features with fluid overload and severe dyspnoea. Understanding the causes and risks associated with these cardiac conditions can aid in their proper diagnosis and management.

    • This question is part of the following fields:

      • Cardiology
      22.1
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  • Question 37 - A 42-year-old man is admitted with a 30-min history of severe central ‘crushing’...

    Incorrect

    • A 42-year-old man is admitted with a 30-min history of severe central ‘crushing’ chest pain radiating down the left arm. He is profusely sweating and looks ‘grey’. The electrocardiogram (ECG) shows sinus tachycardia and 3-mm ST elevation in V3–V6.
      Which of the following is the most appropriate treatment?

      Your Answer: Give the patient nitrates, aspirin and ticagrelor, and await cardiac enzymes

      Correct Answer: Give the patient aspirin, ticagrelor and low-molecular-weight heparin, followed by a primary percutaneous coronary intervention (PCI)

      Explanation:

      Treatment Options for ST Elevation Myocardial Infarction (STEMI)

      When a patient presents with a ST elevation myocardial infarction (STEMI), prompt and appropriate treatment is crucial. The gold standard treatment for a STEMI is a primary percutaneous coronary intervention (PCI), which should be performed as soon as possible. In the absence of contraindications, all patients should receive aspirin, ticagrelor, and low-molecular-weight heparin before undergoing PCI.

      Delaying PCI by treating the pain with sublingual glyceryl trinitrate (GTN), aspirin, and oxygen, and reviewing the patient in 15 minutes is not recommended. Similarly, giving the patient aspirin, ticagrelor, and low molecular weight heparin without performing PCI is incomplete management.

      Thrombolysis therapy can be performed on patients without access to primary PCI. However, if primary PCI is available, it is the preferred treatment option.

      It is important to note that waiting for cardiac enzymes is not recommended as it would only result in a delay in definitive management. Early and appropriate treatment is crucial in improving outcomes for patients with STEMI.

    • This question is part of the following fields:

      • Cardiology
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  • Question 38 - A foundation year 1 (FY1) doctor on the cardiology wards is teaching a...

    Incorrect

    • A foundation year 1 (FY1) doctor on the cardiology wards is teaching a group of first year medical students. She asks the students to work out the heart rate of a patient by interpreting his ECG taken during an episode of tachycardia.
      What is the duration, in seconds, of one small square on an ECG?

      Your Answer: 0.2 seconds

      Correct Answer: 0.04 seconds

      Explanation:

      Understanding ECG Time Measurements

      When reading an electrocardiogram (ECG), it is important to understand the time measurements represented on the grid paper. The horizontal axis of the ECG represents time, with each small square measuring 1 mm in length and representing 40 milliseconds (0.04 seconds). A large square on the ECG grid has a length of 5 mm and represents 0.2 seconds. Five large squares covering a length of 25 mm on the grid represent 1 second of time. It is important to note that each small square has a length of 1 mm and equates to 40 milliseconds, not 4 seconds. Understanding these time measurements is crucial for accurately interpreting an ECG.

    • This question is part of the following fields:

      • Cardiology
      6.8
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  • Question 39 - A 56-year-old man presents to the Emergency Department with chest pain. He has...

    Incorrect

    • A 56-year-old man presents to the Emergency Department with chest pain. He has a medical history of angina, hypertension, high cholesterol, and is a current smoker. Upon arrival, a 12-lead electrocardiogram (ECG) is conducted, revealing ST elevation in leads II, III, and aVF. Which coronary artery is most likely responsible for this presentation?

      Your Answer: Left coronary artery

      Correct Answer: Right coronary artery

      Explanation:

      ECG Changes and Localisation of Infarct in Coronary Artery Disease

      Patients with chest pain and multiple risk factors for cardiac disease require prompt evaluation to determine the underlying cause. Electrocardiogram (ECG) changes can help localise the infarct to a particular territory, which can aid in diagnosis and treatment.

      Inferior infarcts are often due to lesions in the right coronary artery, as evidenced by ST elevation in leads II, III, and aVF. However, in 20% of cases, this can also be caused by an occlusion of a dominant left circumflex artery.

      Lateral infarcts involve branches of the left anterior descending (LAD) and left circumflex arteries, and are characterised by ST elevation in leads I, aVL, and V5-6. It is unusual for a lateral STEMI to occur in isolation, and it usually occurs as part of a larger territory infarction.

      Anterior infarcts are caused by blockage of the LAD artery, and are characterised by ST elevation in leads V1-V6.

      Blockage of the right marginal artery does not have a specific pattern of ECG changes associated with it, and it is not one of the major coronary vessels.

      In summary, understanding the ECG changes associated with different coronary arteries can aid in localising the infarct and guiding appropriate treatment.

    • This question is part of the following fields:

      • Cardiology
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  • Question 40 - Which congenital cardiac defect is correctly matched with its associated syndrome from the...

    Incorrect

    • Which congenital cardiac defect is correctly matched with its associated syndrome from the following options?

      Your Answer: Marfan syndrome and ventricular septal defect (VSD)

      Correct Answer: Turner syndrome and coarctation of the aorta

      Explanation:

      Common Cardiovascular Abnormalities Associated with Genetic Syndromes

      Various genetic syndromes are associated with cardiovascular abnormalities. Turner syndrome is linked with coarctation of the aorta, aortic stenosis, bicuspid aortic valve, aortic dilation, and dissection. Marfan syndrome is associated with aortic root dilation, mitral valve prolapse, mitral regurgitation, and aortic dissection. Kartagener syndrome can lead to bicuspid aortic valve, dextrocardia, bronchiectasis, and infertility. However, congenital adrenal hyperplasia is not associated with congenital cardiac conditions. Finally, congenital rubella syndrome is linked with patent ductus arteriosus, atrial septal defect, and pulmonary stenosis.

    • This question is part of the following fields:

      • Cardiology
      4.8
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  • Question 41 - A 55-year-old woman comes to you with complaints of worsening shortness of breath,...

    Incorrect

    • A 55-year-old woman comes to you with complaints of worsening shortness of breath, weakness, lethargy, and a recent episode of syncope after running to catch a bus. She has a history of atrial flutter and takes bisoprolol regularly. During the physical examination, you notice a high-pitched, diastolic decrescendo murmur that intensifies during inspiration. She also has moderate peripheral edema. A chest X-ray shows no abnormalities. What is the best course of action for this patient?

      Your Answer: Aortic valve replacement followed by aspirin, clopidogrel and simvastatin

      Correct Answer: Diuretics, oxygen therapy, bosentan

      Explanation:

      Treatment Options for Pulmonary Hypertension

      Pulmonary hypertension (PAH) is a condition that can cause shortness of breath, weakness, and tiredness. A high-pitched decrescendo murmur may indicate pulmonary regurgitation and PAH. Diuretics can help reduce the pressure on the right ventricle and remove excess fluid. Oxygen therapy can improve exercise tolerance, and bosentan can slow the progression of PAH by inhibiting vasoconstriction. Salbutamol and ipratropium inhalers are appropriate for COPD, but not for PAH. Salbutamol nebulizer and supplemental oxygen are appropriate for acute exacerbations of asthma or COPD, but not for PAH. Aortic valve replacement is not indicated for PAH. Antiplatelets may be helpful for reducing the risk of thrombosis. Increasing bisoprolol may be helpful for atrial flutter, but not for PAH. High-dose calcium-channel blockers may be used for PAH with right heart failure under senior supervision/consultation.

    • This question is part of the following fields:

      • Cardiology
      14.5
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  • Question 42 - The cardiologist is examining a 48-year-old man with chest pain and is using...

    Correct

    • The cardiologist is examining a 48-year-old man with chest pain and is using his stethoscope to listen to the heart. Which part of the chest is most likely to correspond to the location of the heart's apex?

      Your Answer: Left fifth intercostal space

      Explanation:

      Anatomy of the Heart: Intercostal Spaces and Auscultation Positions

      The human heart is a vital organ responsible for pumping blood throughout the body. Understanding its anatomy is crucial for medical professionals to diagnose and treat various heart conditions. In this article, we will discuss the intercostal spaces and auscultation positions related to the heart.

      Left Fifth Intercostal Space: Apex of the Heart
      The apex of the heart is located deep to the left fifth intercostal space, approximately 8-9 cm from the mid-sternal line. This is an important landmark for cardiac examination and procedures.

      Left Fourth Intercostal Space: Left Ventricle
      The left ventricle, one of the four chambers of the heart, is located superior to the apex and can be auscultated in the left fourth intercostal space.

      Right Fourth Intercostal Space: Right Atrium
      The right atrium, another chamber of the heart, is located immediately lateral to the right sternal margin at the right fourth intercostal space.

      Left Second Intercostal Space: Pulmonary Valve
      The pulmonary valve, which regulates blood flow from the right ventricle to the lungs, can be auscultated in the left second intercostal space, immediately lateral to the left sternal margin.

      Right Fifth Intercostal Space: Incorrect Location
      The right fifth intercostal space is an incorrect location for cardiac examination because the apex of the heart is located on the left side.

      In conclusion, understanding the intercostal spaces and auscultation positions related to the heart is essential for medical professionals to accurately diagnose and treat various heart conditions.

    • This question is part of the following fields:

      • Cardiology
      10.2
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  • Question 43 - A 70-year-old man with a history of hyperlipidaemia, hypertension and angina arrives at...

    Incorrect

    • A 70-year-old man with a history of hyperlipidaemia, hypertension and angina arrives at the Emergency Department with severe chest pain that radiates down his left arm. He is sweating heavily and the pain does not subside with rest or sublingual nitroglycerin. An electrocardiogram (ECG) reveals ST segment elevation in leads II, III and avF.

      What is the leading cause of death within the first hour after the onset of symptoms in this patient?

      Your Answer: Cardiac tamponade

      Correct Answer: Arrhythmia

      Explanation:

      After experiencing an inferior-wall MI, the most common cause of death within the first hour is a lethal arrhythmia, such as ventricular fibrillation. This can be caused by various factors, including ischaemia, toxic metabolites, or autonomic stimulation. If ventricular fibrillation occurs within the first 48 hours, it may be due to transient causes and not affect long-term prognosis. However, if it occurs after 48 hours, it is usually indicative of permanent dysfunction and associated with a worse long-term prognosis. Other complications that may occur after an acute MI include emboli from a left ventricular thrombus, cardiac tamponade, ruptured papillary muscle, and pericarditis. These complications typically occur at different time frames after the acute MI and present with different symptoms.

    • This question is part of the following fields:

      • Cardiology
      6.9
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  • Question 44 - A 72-year-old man has been hospitalized with crushing chest pain. An ECG trace...

    Incorrect

    • A 72-year-old man has been hospitalized with crushing chest pain. An ECG trace shows ischaemia of the inferior part of the heart. What is the term that best describes the artery or arterial branch that provides blood supply to the inferior aspect of the heart?

      Your Answer: Left coronary artery

      Correct Answer: Posterior interventricular branch

      Explanation:

      Coronary Artery Branches and Circulation Dominance

      The coronary artery is responsible for supplying blood to the heart muscles. It branches out into several smaller arteries, each with a specific area of the heart to supply. Here are some of the main branches of the coronary artery:

      1. Posterior Interventricular Branch: This branch supplies the inferior aspect of the heart, with ischaemic changes presenting in leads II, III and aVF. In 90% of the population, it arises as a branch of the right coronary artery, while in 10%, it arises as a branch of the left coronary artery.

      2. Circumflex Branch: This branch supplies the anterolateral area of the heart.

      3. Left Coronary Artery: This artery gives off two branches – the left anterior descending artery supplying the anteroseptal and anteroapical parts of the heart, and the circumflex artery supplying the anterolateral heart. In 10% of the population, the left coronary artery gives off a left anterior interventricular branch that supplies the inferior part of the heart.

      4. Marginal Branch: This branch is a branch of the right coronary artery supplying the right ventricle.

      5. Right Coronary Artery: This artery branches out into the marginal artery and, in 90% of the population, the posterior interventricular branch. These individuals are said to have a right dominant circulation.

      Understanding the different branches of the coronary artery and the circulation dominance can help in diagnosing and treating heart conditions.

    • This question is part of the following fields:

      • Cardiology
      9.4
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  • Question 45 - A 72-year-old woman visits her GP for a routine check-up. During the examination,...

    Incorrect

    • A 72-year-old woman visits her GP for a routine check-up. During the examination, she seems generally healthy but slightly fatigued and experiences some breathlessness at rest. Her pulse is irregularly irregular and measures 72 bpm, while her blood pressure is 126/78 mmHg. Upon further examination, no concerning issues are found. The patient has no significant medical history and is not taking any regular medications.
      What is the probable reason for this woman's development of atrial fibrillation (AF)?

      Your Answer: Ischaemic heart disease

      Correct Answer: Lone AF

      Explanation:

      Management of Atrial Fibrillation: The ABCD Approach

      Atrial fibrillation (AF) is a common arrhythmia that can be classified as paroxysmal, persistent, or permanent. Treatment options for AF depend on the classification and can be categorized into rate control, rhythm control, and anticoagulation. The ABCD approach is a useful tool for managing AF.

      A – Anticoagulation: Patients with AF are at an increased risk for thromboembolic disease, and anticoagulation should be considered in high-risk patients where the benefit outweighs the risk of hemorrhage.

      B – Better symptom control: Rate control is aimed at controlling the ventricular response rate to improve symptoms. Rhythm control is aimed at restoring and maintaining sinus rhythm to improve symptoms.

      C – Cardiovascular risk factor management: Management of underlying cardiovascular risk factors such as hypertension, diabetes, and hyperlipidemia can help reduce the risk of AF recurrence and complications.

      D – Disease management: Management of underlying conditions associated with AF, such as valvular heart disease and heart failure, can help improve AF outcomes.

      In summary, the ABCD approach to managing AF involves anticoagulation, better symptom control, cardiovascular risk factor management, and disease management. This approach can help improve outcomes and reduce the risk of complications in patients with AF.

    • This question is part of the following fields:

      • Cardiology
      17.4
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  • Question 46 - A 65-year-old woman with ischaemic heart disease presents with sudden onset palpitations. She...

    Incorrect

    • A 65-year-old woman with ischaemic heart disease presents with sudden onset palpitations. She has no other complaints. On examination, a regular tachycardia is present. Her blood pressure is 150/90 mmHg. Chest is clear. ECG reveals a regular tachycardia with a QRS width of 80 ms and a rate of 149 beats per min in a sawtooth pattern.
      What is the diagnosis?

      Your Answer: Mobitz type II

      Correct Answer: Atrial flutter

      Explanation:

      Common Cardiac Arrhythmias: Types and Characteristics

      Cardiac arrhythmias are abnormal heart rhythms that can cause serious health complications. Here are some common types of cardiac arrhythmias and their characteristics:

      1. Atrial Flutter: A type of supraventricular tachycardia that is characterized by a sawtooth pattern on the ECG. It is caused by a premature electrical impulse in the atrium and can degenerate into atrial fibrillation. Treatment involves rate or rhythm control, and electrical cardioversion is more effective than in atrial fibrillation.

      2. Fast Atrial Fibrillation: Another type of supraventricular tachycardia that presents as an irregularly irregular tachycardia.

      3. Ventricular Tachycardia: A common arrhythmia in cardiopaths that is characterized by a wide-complex tachycardia on ECG.

      4. Mobitz Type II: A form of second-degree heart block that is characterized by intermittent non-conducted P waves on ECG without progressive prolongation of the QRS interval.

      5. Brugada Syndrome: A rare electrophysiological condition that causes sudden death in young adults. ECG findings usually show ST elevation in leads V1 to V3 with a right bundle branch block.

      It is important to identify and treat cardiac arrhythmias promptly to prevent serious health complications.

    • This question is part of the following fields:

      • Cardiology
      8.6
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  • Question 47 - A 56-year-old man presents to the Emergency Department with crushing substernal chest pain...

    Correct

    • A 56-year-old man presents to the Emergency Department with crushing substernal chest pain that radiates to the jaw. He has a history of poorly controlled hypertension and uncontrolled type II diabetes mellitus for the past 12 years. An electrocardiogram (ECG) reveals ST elevation, and he is diagnosed with acute myocardial infarction. The patient undergoes percutaneous coronary intervention (PCI) and stenting and is discharged from the hospital. Eight weeks later, he experiences fever, leukocytosis, and chest pain that is relieved by leaning forwards. There is diffuse ST elevation in multiple ECG leads, and a pericardial friction rub is heard on auscultation. What is the most likely cause of the patient's current symptoms?

      Your Answer: Dressler’s syndrome

      Explanation:

      Complications of Transmural Myocardial Infarction

      Transmural myocardial infarction can lead to various complications, including Dressler’s syndrome and ventricular aneurysm. Dressler’s syndrome typically occurs weeks to months after an infarction and is characterized by acute fibrinous pericarditis, fever, pleuritic chest pain, and leukocytosis. On the other hand, ventricular aneurysm is characterized by a systolic bulge in the precordial area and predisposes to stasis and thrombus formation. Acute fibrinous pericarditis, which manifests a few days after an infarction, is not due to an autoimmune reaction. Reinfarction is unlikely in a patient who has undergone successful treatment for STEMI. Infectious myocarditis, caused by viruses such as Coxsackie B, Epstein-Barr, adenovirus, and echovirus, is not the most likely cause of the patient’s symptoms, given his medical history.

      Complications of Transmural Myocardial Infarction

    • This question is part of the following fields:

      • Cardiology
      16.5
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  • Question 48 - A 62-year-old woman is being evaluated on the medical ward due to increasing...

    Incorrect

    • A 62-year-old woman is being evaluated on the medical ward due to increasing episodes of dyspnoea, mainly on exertion. She has been experiencing fatigue more frequently over the past few months. Upon examination, she exhibits slight wheezing and bilateral pitting ankle oedema. Her medical history includes type I diabetes, rheumatoid arthritis, hypertension, recurrent UTIs, and hypothyroidism. Her current medications consist of insulin, methotrexate, nitrofurantoin, and amlodipine. She has never smoked, drinks two units of alcohol per week, and does not use recreational drugs. Blood tests reveal a haemoglobin level of 152 g/l, a white cell count of 4.7 × 109/l, a sodium level of 142 mmol/l, a potassium level of 4.6 mmol/l, a urea level of 5.4 mmol/l, and a creatinine level of 69 µmol/l. Additionally, her N-terminal pro-B-type natriuretic peptide (NT-proBNP) level is 350 pg/ml, which is higher than the normal value of < 100 pg/ml. What is the most probable diagnosis?

      Your Answer: Left ventricular failure

      Correct Answer: Cor pulmonale

      Explanation:

      Differential Diagnosis: Cor Pulmonale vs. Other Conditions

      Cor pulmonale, or right ventricular failure due to pulmonary heart disease, is the most likely diagnosis for a patient presenting with symptoms such as wheeze, increasing fatigue, and pitting edema. The patient’s history of taking drugs known to cause pulmonary fibrosis, such as methotrexate and nitrofurantoin, supports this diagnosis. Aortic stenosis, asthma, COPD, and left ventricular failure are all possible differential diagnoses, but each has distinguishing factors that make them less likely. Aortic stenosis would not typically present with peripheral edema, while asthma and COPD do not fit with the patient’s lack of risk factors and absence of certain symptoms. Left ventricular failure is also less likely due to the absence of signs such as decreased breath sounds and S3 gallop on heart auscultation. Overall, cor pulmonale is the most likely diagnosis for this patient.

    • This question is part of the following fields:

      • Cardiology
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  • Question 49 - A 61-year-old man experiences persistent, intense chest pain that spreads to his left...

    Incorrect

    • A 61-year-old man experiences persistent, intense chest pain that spreads to his left arm. Despite taking multiple antacid tablets, he finds no relief. He eventually seeks medical attention at the Emergency Department and is diagnosed with a heart attack. He is admitted to the hospital and stabilized before being discharged five days later.
      About three weeks later, the man begins to experience a constant, burning sensation in his chest. He returns to the hospital, where a friction rub is detected during auscultation. Additionally, his heart sounds are muffled.
      What is the most likely cause of this complication, given the man's medical history?

      Your Answer: Bacterial infection

      Correct Answer: Autoimmune phenomenon

      Explanation:

      Understanding Dressler Syndrome

      Dressler syndrome is a condition that occurs several weeks after a myocardial infarction (MI) and results in fibrinous pericarditis with fever and pleuropericardial chest pain. It is believed to be an autoimmune phenomenon, rather than a result of viral, bacterial, or fungal infections. While these types of infections can cause pericarditis, they are less likely in the context of a recent MI. Chlamydial infection, in particular, does not cause pericarditis. Understanding the underlying cause of pericarditis is important for proper diagnosis and treatment of Dressler syndrome.

    • This question is part of the following fields:

      • Cardiology
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  • Question 50 - What do T waves represent on an ECG? ...

    Correct

    • What do T waves represent on an ECG?

      Your Answer: Ventricular repolarisation

      Explanation:

      The Electrical Activity of the Heart and the ECG

      The ECG (electrocardiogram) is a medical test that records the electrical activity of the heart. This activity is responsible for different parts of the ECG. The first part is the atrial depolarisation, which is represented by the P wave. This wave conducts down the bundle of His to the ventricles, causing the ventricular depolarisation. This is shown on the ECG as the QRS complex. Finally, the ventricular repolarisation is represented by the T wave.

      It is important to note that atrial repolarisation is not visible on the ECG. This is because it is of lower amplitude compared to the QRS complex. the different parts of the ECG and their corresponding electrical activity can help medical professionals diagnose and treat various heart conditions.

    • This question is part of the following fields:

      • Cardiology
      7.8
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