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Question 1
Correct
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A 72-year-old woman presents with worsening abdominal distension and discomfort. During the examination, she exhibits significant dependent edema and an elevated JVP. Cardiac auscultation reveals a pansystolic murmur. The abdomen is distended and tender, with the presence of shifting dullness.
What is the SINGLE most probable diagnosis?Your Answer: Tricuspid regurgitation
Explanation:Tricuspid regurgitation is commonly caused by right ventricular dilatation, often as a result of heart failure. Other factors that can contribute to this condition include right ventricular infarction and cor pulmonale. The clinical signs of right-sided heart failure are frequently observed, such as an elevated jugular venous pressure, peripheral edema, hepatomegaly, and ascites.
The murmur associated with tricuspid regurgitation is a pansystolic murmur that is most audible at the tricuspid area during inspiration. A thrill may also be felt at the left sternal edge. Reverse splitting of the second heart sound can occur due to the early closure of the pulmonary valve. Additionally, a third heart sound may be present due to rapid filling of the right ventricle.
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This question is part of the following fields:
- Cardiology
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Question 2
Correct
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A 32 year old male attends the emergency department due to sharp chest pain that has come on gradually over the past 48 hours. The patient reports he has general muscle aches and feels more fatigued than usual. The patient indicates the pain is retrosternal and worsens with deep inspiration and lying supine. On auscultation of the chest, a rub is audible that resembles the sound of squeaky leather. The rhythm is regular and quiet heart sounds are noted. Observations are shown below:
Blood pressure: 112/68 mmHg
Pulse rate: 92 bpm
Respiratory rate: 18 rpm
Temperature: 37.4ºC
Oxygen saturations: 98% on air
What is the likely diagnosis?Your Answer: Pericarditis
Explanation:Pericardial friction rub is a common finding in pericarditis and is often described as a sound similar to squeaking leather. This patient exhibits symptoms that are consistent with acute pericarditis, including flu-like illness with muscle pain and fatigue, chest pain that worsens when lying down and improves when sitting up or leaning forward, and the presence of a pleural rub. The gradual onset of symptoms rules out conditions like pulmonary embolism or acute myocardial ischemia. It is important to note that while the pericardial rub is often considered part of the classic triad of clinical features, it is only present in about one-third of patients. Additionally, the rub may come and go, so repeated examinations may increase the chances of detecting this sign.
Further Reading:
Pericarditis is an inflammation of the pericardium, which is the protective sac around the heart. It can be acute, lasting less than 6 weeks, and may present with chest pain, cough, dyspnea, flu-like symptoms, and a pericardial rub. The most common causes of pericarditis include viral infections, tuberculosis, bacterial infections, uremia, trauma, and autoimmune diseases. However, in many cases, the cause remains unknown. Diagnosis is based on clinical features, such as chest pain, pericardial friction rub, and electrocardiographic changes. Treatment involves symptom relief with nonsteroidal anti-inflammatory drugs (NSAIDs), and patients should avoid strenuous activity until symptoms improve. Complicated cases may require treatment for the underlying cause, and large pericardial effusions may need urgent drainage. In cases of purulent effusions, antibiotic therapy is necessary, and steroid therapy may be considered for pericarditis related to autoimmune disorders or if NSAIDs alone are ineffective.
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This question is part of the following fields:
- Cardiology
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Question 3
Correct
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You are treating a 68 year old male who has been brought into the resuscitation bay by the ambulance crew. The patient was at home when he suddenly experienced dizziness and difficulty breathing. The ambulance crew presents the patient's ECG to you. You plan on administering atropine to address the patient's bradyarrhythmia.
According to the resuscitation council, what is the maximum recommended total dose of atropine that should be administered?Your Answer: 3mg
Explanation:When treating adults with bradycardia, a maximum of 6 doses of atropine 500 mcg can be administered. Each dose is given intravenously every 3-5 minutes. The total dose should not exceed 3mg.
Further Reading:
Causes of Bradycardia:
– Physiological: Athletes, sleeping
– Cardiac conduction dysfunction: Atrioventricular block, sinus node disease
– Vasovagal & autonomic mediated: Vasovagal episodes, carotid sinus hypersensitivity
– Hypothermia
– Metabolic & electrolyte disturbances: Hypothyroidism, hyperkalaemia, hypermagnesemia
– Drugs: Beta-blockers, calcium channel blockers, digoxin, amiodarone
– Head injury: Cushing’s response
– Infections: Endocarditis
– Other: Sarcoidosis, amyloidosisPresenting symptoms of Bradycardia:
– Presyncope (dizziness, lightheadedness)
– Syncope
– Breathlessness
– Weakness
– Chest pain
– NauseaManagement of Bradycardia:
– Assess and monitor for adverse features (shock, syncope, myocardial ischaemia, heart failure)
– Treat reversible causes of bradycardia
– Pharmacological treatment: Atropine is first-line, adrenaline and isoprenaline are second-line
– Transcutaneous pacing if atropine is ineffective
– Other drugs that may be used: Aminophylline, dopamine, glucagon, glycopyrrolateBradycardia Algorithm:
– Follow the algorithm for management of bradycardia, which includes assessing and monitoring for adverse features, treating reversible causes, and using appropriate medications or pacing as needed.
https://acls-algorithms.com/wp-content/uploads/2020/12/Website-Bradycardia-Algorithm-Diagram.pdf -
This question is part of the following fields:
- Cardiology
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Question 4
Incorrect
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A 35-year-old woman with a history of paroxysmal supraventricular tachycardia is found to have a diagnosis of Lown-Ganong-Levine (LGL) syndrome.
Which of the following statements about LGL syndrome is NOT true?Your Answer: The QRS duration is typically normal
Correct Answer: It is caused by an accessory pathway for conduction
Explanation:Lown-Ganong-Levine (LGL) syndrome is a condition that affects the electrical conducting system of the heart. It is classified as a pre-excitation syndrome, similar to the more well-known Wolff-Parkinson-White (WPW) syndrome. However, unlike WPW syndrome, LGL syndrome does not involve an accessory pathway for conduction. Instead, it is believed that there may be accessory fibers present that bypass all or part of the atrioventricular node.
When looking at an electrocardiogram (ECG) of a patient with LGL syndrome in sinus rhythm, there are several characteristic features to observe. The PR interval, which represents the time it takes for the electrical signal to travel from the atria to the ventricles, is typically shortened and measures less than 120 milliseconds. The QRS duration, which represents the time it takes for the ventricles to contract, is normal. The P wave, which represents the electrical activity of the atria, may be normal or inverted. However, what distinguishes LGL syndrome from other pre-excitation syndromes is the absence of a delta wave, which is a slurring of the initial rise in the QRS complex.
It is important to note that LGL syndrome predisposes individuals to paroxysmal supraventricular tachycardia (SVT), a rapid heart rhythm that originates above the ventricles. However, it does not increase the risk of developing atrial fibrillation or flutter, which are other types of abnormal heart rhythms.
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This question is part of the following fields:
- Cardiology
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Question 5
Incorrect
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A 65 year old male is brought to the emergency department following a fall which occurred while the patient was getting out of bed. The patient complains of feeling dizzy as he got out of bed before experiencing tunnel vision and briefly losing consciousness. The patient is certain he only blacked out for a few seconds as the time on the bedside clock had not changed. The patient informs you that he has had several similar episodes over the past few months when getting out of bed, but most of the time he only feels dizzy and doesn't faint. He denies any loss of bladder or bowel control or biting his tongue. An ECG is performed which shows normal sinus rhythm. You note the patient takes the following medication:
Lisinopril 10 mg OD
Fluoxetine 20 mg OD
What is the most likely diagnosis?Your Answer: Paroxysmal atrial fibrillation
Correct Answer: Orthostatic hypotension
Explanation:Orthostatic hypotension is a condition where patients feel lightheaded and may experience tunnel vision when they stand up from a lying down position. These symptoms are often worse in the morning. The patient’s history of recurrent episodes after being in a supine position for a long time strongly suggests orthostatic hypotension. There are no signs of epilepsy, such as deja-vu or jambs vu prodrome, tongue biting, loss of bladder or bowel control, or postictal confusion. The normal ECG and consistent timing of symptoms make postural orthostatic tachycardia syndrome (PAF) less likely. There are no neurological deficits to suggest a transient ischemic attack (TIA). The prodromal symptoms, such as tunnel vision and lightheadedness, align more with orthostatic hypotension rather than vasovagal syncope, which typically occurs after long periods of standing and is characterized by feeling hot and sweaty. Although carotid sinus syndrome could be considered as a differential diagnosis, as the patient’s head turning on getting out of bed may trigger symptoms, it is not one of the options.
Further Reading:
Blackouts, also known as syncope, are defined as a spontaneous transient loss of consciousness with complete recovery. They are most commonly caused by transient inadequate cerebral blood flow, although epileptic seizures can also result in blackouts. There are several different causes of blackouts, including neurally-mediated reflex syncope (such as vasovagal syncope or fainting), orthostatic hypotension (a drop in blood pressure upon standing), cardiovascular abnormalities, and epilepsy.
When evaluating a patient with blackouts, several key investigations should be performed. These include an electrocardiogram (ECG), heart auscultation, neurological examination, vital signs assessment, lying and standing blood pressure measurements, and blood tests such as a full blood count and glucose level. Additional investigations may be necessary depending on the suspected cause, such as ultrasound or CT scans for aortic dissection or other abdominal and thoracic pathology, chest X-ray for heart failure or pneumothorax, and CT pulmonary angiography for pulmonary embolism.
During the assessment, it is important to screen for red flags and signs of any underlying serious life-threatening condition. Red flags for blackouts include ECG abnormalities, clinical signs of heart failure, a heart murmur, blackouts occurring during exertion, a family history of sudden cardiac death at a young age, an inherited cardiac condition, new or unexplained breathlessness, and blackouts in individuals over the age of 65 without a prodrome. These red flags indicate the need for urgent assessment by an appropriate specialist.
There are several serious conditions that may be suggested by certain features. For example, myocardial infarction or ischemia may be indicated by a history of coronary artery disease, preceding chest pain, and ECG signs such as ST elevation or arrhythmia. Pulmonary embolism may be suggested by dizziness, acute shortness of breath, pleuritic chest pain, and risk factors for venous thromboembolism. Aortic dissection may be indicated by chest and back pain, abnormal ECG findings, and signs of cardiac tamponade include low systolic blood pressure, elevated jugular venous pressure, and muffled heart sounds. Other conditions that may cause blackouts include severe hypoglycemia, Addisonian crisis, and electrolyte abnormalities.
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This question is part of the following fields:
- Cardiology
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Question 6
Incorrect
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A 45-year-old man presents with palpitations and is found to have atrial fibrillation. You are requested to evaluate his ECG.
Which of the following statements is correct regarding the ECG findings in atrial fibrillation?Your Answer: The disorganised electrical activity usually originates at the root of the aorta
Correct Answer: Some impulses are filtered out by the AV node
Explanation:The classic ECG features of atrial fibrillation include an irregularly irregular rhythm, the absence of p-waves, an irregular ventricular rate, and the presence of fibrillation waves. This irregular rhythm occurs because the atrial impulses are filtered out by the AV node.
In addition, Ashman beats may be observed in atrial fibrillation. These beats are characterized by wide complex QRS complexes, often with a morphology resembling right bundle branch block. They occur after a short R-R interval that is preceded by a prolonged R-R interval. Fortunately, Ashman beats are generally considered harmless.
The disorganized electrical activity in atrial fibrillation typically originates at the root of the pulmonary veins.
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This question is part of the following fields:
- Cardiology
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Question 7
Correct
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A 45-year-old woman presents with recurrent episodes of central chest pain that radiate to her left arm. She has a history of angina and uses a GTN spray for relief. She reports that the pains have been occurring more frequently in the past few days and have been triggered by less exertion. Currently, she is not experiencing any pain, and her ECG shows normal sinus rhythm with no abnormalities in T wave or ST-segment.
What is the SINGLE most probable diagnosis?Your Answer: Unstable angina
Explanation:Unstable angina is characterized by the presence of one or more of the following symptoms: angina of effort occurring over a few days with increasing frequency, episodes of angina occurring recurrently and predictably without specific provocation, or an unprovoked and prolonged episode of cardiac chest pain. The electrocardiogram (ECG) may appear normal or show T-wave/ST-segment changes, and cardiac enzymes are typically within normal range.
On the other hand, stable angina is defined by central chest pain that is triggered by activities such as exercise and emotional stress. This pain may radiate to the jaw or left arm and is relieved by resting for a few minutes. It is usually brought on by a predictable amount of exertion.
Prinzmetal angina, although rare, is a variant of angina that primarily occurs at rest between midnight and early morning. The attacks can be severe and tend to happen in clusters. This type of angina is caused by coronary artery spasm, and patients may have normal coronary arteries.
Decubitus angina, on the other hand, is angina that occurs when lying down. It often develops as a result of cardiac failure due to an increased volume of blood within the blood vessels, which places additional strain on the heart.
Lastly, Ludwig’s angina is an extremely serious and potentially life-threatening cellulitis that affects the submandibular area. It most commonly arises from an infection in the floor of the mouth, which then spreads to the submandibular space.
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This question is part of the following fields:
- Cardiology
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Question 8
Incorrect
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A 62 year old male arrives at the emergency department complaining of abrupt tearing chest pain that extends to the throat and back. The possibility of aortic dissection is being considered. What is the primary location for dissection?
Your Answer:
Correct Answer: Ascending aorta
Explanation:The primary location for aortic dissection, which is being considered in this case, is the ascending aorta.
Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.
The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.
Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.
Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.
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This question is part of the following fields:
- Cardiology
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Question 9
Incorrect
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You are treating a 68 year old male who has been brought into the resuscitation bay by the ambulance crew. The patient was at home when he suddenly experienced dizziness and difficulty breathing. The ambulance crew presents the patient's ECG to you. You are considering administering atropine to address the patient's bradyarrhythmia. Which of the following statements is accurate regarding the use of atropine?
Your Answer:
Correct Answer: Up to 6 doses of 500 mcg can be given every 3-5 minutes
Explanation:When treating adults with bradycardia, it is recommended to administer a maximum of 6 doses of atropine 500 mcg. These doses can be repeated every 3-5 minutes. The total cumulative dose of atropine should not exceed 3 mg in adults.
Further Reading:
Causes of Bradycardia:
– Physiological: Athletes, sleeping
– Cardiac conduction dysfunction: Atrioventricular block, sinus node disease
– Vasovagal & autonomic mediated: Vasovagal episodes, carotid sinus hypersensitivity
– Hypothermia
– Metabolic & electrolyte disturbances: Hypothyroidism, hyperkalaemia, hypermagnesemia
– Drugs: Beta-blockers, calcium channel blockers, digoxin, amiodarone
– Head injury: Cushing’s response
– Infections: Endocarditis
– Other: Sarcoidosis, amyloidosisPresenting symptoms of Bradycardia:
– Presyncope (dizziness, lightheadedness)
– Syncope
– Breathlessness
– Weakness
– Chest pain
– NauseaManagement of Bradycardia:
– Assess and monitor for adverse features (shock, syncope, myocardial ischaemia, heart failure)
– Treat reversible causes of bradycardia
– Pharmacological treatment: Atropine is first-line, adrenaline and isoprenaline are second-line
– Transcutaneous pacing if atropine is ineffective
– Other drugs that may be used: Aminophylline, dopamine, glucagon, glycopyrrolateBradycardia Algorithm:
– Follow the algorithm for management of bradycardia, which includes assessing and monitoring for adverse features, treating reversible causes, and using appropriate medications or pacing as needed.
https://acls-algorithms.com/wp-content/uploads/2020/12/Website-Bradycardia-Algorithm-Diagram.pdf -
This question is part of the following fields:
- Cardiology
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Question 10
Incorrect
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You are summoned to a cardiac arrest in the resuscitation area of your Emergency Department. The patient is experiencing asystole, and adrenaline is given as part of the cardiac arrest protocol.
Which ONE statement is NOT TRUE regarding the utilization of adrenaline in cardiac arrest?Your Answer:
Correct Answer: In VF arrest it should be given before the 3rd shock
Explanation:Adrenaline should be administered promptly once access to the circulatory system has been established in cases of non-shockable cardiac arrests such as PEA or asystole. The recommended dose is 1 mg, which can be given either as 10 mL of a 1:10,000 solution or as 1 mL of a 1:1000 solution through the intravenous (IV) or intraosseous (IO) routes.
In cases of shockable cardiac arrests like ventricular fibrillation (Vf) or pulseless ventricular tachycardia (pVT), adrenaline should be administered after the third shock has been delivered and chest compressions have been resumed. The same dose of 1 mg can be given using the same concentration options as mentioned earlier.
Subsequently, adrenaline should be administered every 3-5 minutes, alternating with chest compressions, without interrupting the compressions. The alpha-adrenergic effects of adrenaline cause constriction of blood vessels throughout the body, leading to increased pressures in the coronary and cerebral circulation.
The beta-adrenergic effects of adrenaline have positive effects on the heart, increasing its contractility (inotropic) and heart rate (chronotropic), which may also enhance blood flow to the coronary and cerebral arteries. However, it is important to note that these benefits may be counteracted by increased oxygen consumption by the heart, the potential for abnormal heart rhythms, temporary decrease in oxygen levels due to abnormal blood flow in the lungs, impaired microcirculation, and increased dysfunction of the heart after the cardiac arrest.
While there is no evidence supporting the long-term benefits of adrenaline use in cardiac arrest cases, some studies have shown improved short-term survival rates, which justifies its continued use.
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This question is part of the following fields:
- Cardiology
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Question 11
Incorrect
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A 45-year-old male smoker comes in with a severe episode of chest pain that spreads to his left arm and jaw. The pain lasted for about half an hour before being relieved by GTN spray and aspirin. A troponin test is done 12 hours later, which comes back positive. His ECG at the time of presentation reveals widespread ST depression.
What is the MOST LIKELY diagnosis in this case?Your Answer:
Correct Answer: Non-ST-elevation myocardial infarction
Explanation:This patient has developed a non-ST elevation myocardial infarction (NSTEMI). The electrocardiogram (ECG) reveals widespread ST depression, indicating widespread subendocardial ischemia. Additionally, the troponin test results are positive, indicating myocyte necrosis.
The acute coronary syndromes consist of unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI).
Unstable angina is characterized by one or more of the following: angina of effort occurring over a few days with increasing frequency, angina episodes occurring recurrently and predictably without specific provocation, or an unprovoked and prolonged episode of cardiac chest pain. The ECG may show T-wave/ST-segment changes, similar to this case. Cardiac enzymes are typically normal, and the troponin test is negative in unstable angina.
Non-ST elevation myocardial infarction (NSTEMI) typically presents with sustained cardiac chest pain lasting more than 20 minutes. The ECG often shows abnormalities in T-waves or ST-segments. Cardiac enzymes are elevated, and the troponin test is positive.
ST-elevation myocardial infarction (STEMI) usually presents with typical cardiac chest pain suggestive of an acute myocardial infarction. The ECG reveals ST-segment elevation and the development of Q waves. Cardiac enzymes are elevated, and the troponin test is positive.
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This question is part of the following fields:
- Cardiology
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Question 12
Incorrect
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You conduct a cardiovascular examination on a 72-year-old man who complains of difficulty breathing. He informs you that he has a known heart valve issue. During the examination, you observe a faint first heart sound (S1).
What is the most probable cause of this finding?Your Answer:
Correct Answer: Tricuspid regurgitation
Explanation:The first heart sound (S1) is created by vibrations produced when the mitral and tricuspid valves close. It occurs at the end of diastole and the start of ventricular systole, coming before the upstroke of the carotid pulsation.
A sample of the normal heart sounds can be listened to here (courtesy of Littman stethoscopes).
A loud S1 can be associated with the following conditions:
– Increased transvalvular gradient (e.g. mitral stenosis, tricuspid stenosis)
– Increased force of ventricular contraction (e.g. tachycardia, hyperdynamic states like fever and thyrotoxicosis)
– Shortened PR interval (e.g. Wolff-Parkinson-White syndrome)
– Mitral valve prolapse
– Thin individualsA soft S1 can be associated with the following conditions:
– Inappropriate apposition of the AV valves (e.g. mitral regurgitation, tricuspid regurgitation)
– Prolonged PR interval (e.g. heart block, digoxin toxicity)
– Decreased force of ventricular contraction (e.g. myocarditis, myocardial infarction)
– Increased distance from the heart (e.g. obesity, emphysema, pericardial effusion)A split S1 can be associated with the following conditions:
– Right bundle branch block
– LV pacing
– Ebstein anomaly -
This question is part of the following fields:
- Cardiology
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Question 13
Incorrect
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You are called to a cardiac arrest in a child in the Emergency Department. Which SINGLE statement regarding resuscitation in children is true?
Your Answer:
Correct Answer: The ratio of chest compressions to ventilations is 15:2
Explanation:The ratio of chest compressions to ventilations is 15:2. This ratio has not been proven through experiments, but it has been validated through mathematical studies. When performing chest compressions on a child, it is recommended to make them at least 1/3 of the depth of the child’s chest. Additionally, the optimal compression rate is between 100 and 120 compressions per minute.
To protect the airway of an unconscious child, the oropharyngeal (Guedel) airway is the best option. However, it should not be used on awake patients as there is a risk of vomiting and aspiration.
In children, asystole is the most common arrest rhythm. This occurs when the young heart responds to prolonged hypoxia and acidosis by progressively slowing down, eventually resulting in asystole. -
This question is part of the following fields:
- Cardiology
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Question 14
Incorrect
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A 32 year old with a documented peanut allergy is currently receiving treatment for an anaphylactic reaction. What are the most likely cardiovascular manifestations that you would observe in a patient experiencing an episode of anaphylaxis?
Your Answer:
Correct Answer: Hypotension and tachycardia
Explanation:Anaphylaxis, also known as anaphylactic shock, is characterized by certain symptoms similar to other types of shock. These symptoms include low blood pressure (hypotension), rapid heart rate (tachycardia), irregular heart rhythm (arrhythmia), changes in the electrocardiogram (ECG) indicating reduced blood flow to the heart (myocardial ischemia), such as ST elevation, and in severe cases, cardiac arrest.
Further Reading:
Anaphylaxis is a severe and life-threatening hypersensitivity reaction that can have sudden onset and progression. It is characterized by skin or mucosal changes and can lead to life-threatening airway, breathing, or circulatory problems. Anaphylaxis can be allergic or non-allergic in nature.
In allergic anaphylaxis, there is an immediate hypersensitivity reaction where an antigen stimulates the production of IgE antibodies. These antibodies bind to mast cells and basophils. Upon re-exposure to the antigen, the IgE-covered cells release histamine and other inflammatory mediators, causing smooth muscle contraction and vasodilation.
Non-allergic anaphylaxis occurs when mast cells degrade due to a non-immune mediator. The clinical outcome is the same as in allergic anaphylaxis.
The management of anaphylaxis is the same regardless of the cause. Adrenaline is the most important drug and should be administered as soon as possible. The recommended doses for adrenaline vary based on age. Other treatments include high flow oxygen and an IV fluid challenge. Corticosteroids and chlorpheniramine are no longer recommended, while non-sedating antihistamines may be considered as third-line treatment after initial stabilization of airway, breathing, and circulation.
Common causes of anaphylaxis include food (such as nuts, which is the most common cause in children), drugs, and venom (such as wasp stings). Sometimes it can be challenging to determine if a patient had a true episode of anaphylaxis. In such cases, serum tryptase levels may be measured, as they remain elevated for up to 12 hours following an acute episode of anaphylaxis.
The Resuscitation Council (UK) provides guidelines for the management of anaphylaxis, including a visual algorithm that outlines the recommended steps for treatment.
https://www.resus.org.uk/sites/default/files/2021-05/Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf -
This question is part of the following fields:
- Cardiology
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Question 15
Incorrect
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A 48 year old female presents to the emergency department complaining of palpitations. She reports experiencing brief episodes of palpitations over the past week, which typically resolve on their own after 5-10 minutes. However, today's episode has been ongoing for 30 minutes. The patient denies any chest pain or shortness of breath. The patient's vital signs are as follows:
Blood pressure: 110/70 mmHg
Pulse: 120 bpm
Respiration rate: 17 bpm
Temperature: 36.5ºC
Oxygen saturations: 97% on room air
An electrocardiogram (ECG) is performed and reveals atrial fibrillation. What is the most appropriate initial management for this patient?Your Answer:
Correct Answer: Administer 50 mg atenolol
Explanation:When managing newly diagnosed atrial fibrillation, a rate control strategy is often used. In this approach, beta blockers are typically the first line of treatment. However, sotalol is not recommended, and instead, other beta blockers like atenolol, acebutolol, metoprolol, nadolol, oxprenolol, and propranolol are preferred. Among these options, atenolol is commonly chosen in NHS trusts due to its cost-effectiveness.
For patients with signs of hemodynamic instability or adverse features, rhythm control (cardioversion) may be considered if they present within 48 hours of likely onset. However, in the case of this patient, their symptoms started a week ago, and there are no indications of hemodynamic instability or adverse features.
Digoxin monotherapy is typically reserved for individuals who have limited physical activity or are unable to take other first-line rate control medications due to other health conditions or contraindications.
Further Reading:
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting around 5% of patients over the age of 70-75 years and 10% of patients aged 80-85 years. While AF can cause palpitations and inefficient cardiac function, the most important aspect of managing patients with AF is reducing the increased risk of stroke.
AF can be classified as first detected episode, paroxysmal, persistent, or permanent. First detected episode refers to the initial occurrence of AF, regardless of symptoms or duration. Paroxysmal AF occurs when a patient has 2 or more self-terminating episodes lasting less than 7 days. Persistent AF refers to episodes lasting more than 7 days that do not self-terminate. Permanent AF is continuous atrial fibrillation that cannot be cardioverted or if attempts to do so are deemed inappropriate. The treatment goals for permanent AF are rate control and anticoagulation if appropriate.
Symptoms of AF include palpitations, dyspnea, and chest pain. The most common sign is an irregularly irregular pulse. An electrocardiogram (ECG) is essential for diagnosing AF, as other conditions can also cause an irregular pulse.
Managing patients with AF involves two key parts: rate/rhythm control and reducing stroke risk. Rate control involves slowing down the irregular pulse to avoid negative effects on cardiac function. This is typically achieved using beta-blockers or rate-limiting calcium channel blockers. If one drug is not effective, combination therapy may be used. Rhythm control aims to restore and maintain normal sinus rhythm through pharmacological or electrical cardioversion. However, the majority of patients are managed with a rate control strategy.
Reducing stroke risk in patients with AF is crucial. Risk stratifying tools, such as the CHA2DS2-VASc score, are used to determine the most appropriate anticoagulation strategy. Anticoagulation is recommended for patients with a score of 2 or more. Clinicians can choose between warfarin and novel oral anticoagulants (NOACs) for anticoagulation.
Before starting anticoagulation, the patient’s bleeding risk should be assessed using tools like the HAS-BLED score or the ORBIT tool. These tools evaluate factors such as hypertension, abnormal renal or liver function, history of bleeding, age, and use of drugs that predispose to bleeding.
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This question is part of the following fields:
- Cardiology
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Question 16
Incorrect
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You are requested to evaluate a teenager who is in resus with a supraventricular tachycardia. The patient is stable hemodynamically but has already received 3 doses of IV adenosine and vagal maneuvers. However, there has been no improvement in their condition.
Based on the current APLS guidelines, what would be the most suitable next course of action in managing this patient?Your Answer:
Correct Answer: Give IV amiodarone 5-10 mg/kg
Explanation:Supraventricular tachycardia (SVT) is the most common arrhythmia that occurs in children and infants, causing cardiovascular instability. According to the current APLS guidelines, if a patient with SVT shows no signs of shock and remains stable, initial attempts should be made to use vagal maneuvers. If these maneuvers are unsuccessful, the following steps are recommended:
– Administer an initial dose of 100 mcg/kg of adenosine.
– After two minutes, if the child is still in stable SVT, administer another dose of 200 mcg/kg of adenosine.
– After an additional two minutes, if the child remains in stable SVT, administer another dose of 300 mcg/kg of adenosine.If these measures do not resolve the SVT, the guidelines suggest considering the following options:
– Administer adenosine at a dose of 400-500 mcg/kg.
– Perform a synchronous DC shock.
– Administer amiodarone.When using amiodarone, the initial dose should be 5-10 mg/kg given over a period of 20 minutes to 2 hours. This should be followed by a continuous infusion of 300 mcg/kg/hour, with adjustments made based on the response, increasing by 1.5 mg/kg/hour. The total infusion rate should not exceed 1.2 g in a 24-hour period.
If defibrillation is necessary for the treatment of SVT in children, it should be performed as a DC synchronous shock at a dosage of 1-2 J/kg.
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This question is part of the following fields:
- Cardiology
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Question 17
Incorrect
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A 42 year old male comes to the emergency department with a sudden onset of 'tearing' pain in the middle of his chest that extends to the center of his back. The patient is tall and has a slender physique. Additionally, you observe that the patient has elongated arms and fingers. During the chest examination, you notice a prominent protrusion of the sternum (pectus carinatum). What is the probable underlying cause of this patient's chest pain?
Your Answer:
Correct Answer: Aortic dissection
Explanation:Marfan’s syndrome is a condition that greatly increases the risk of aortic dissection. This patient exhibits several characteristics commonly seen in individuals with Marfan syndrome, such as tall stature, low BMI, and pectoral abnormalities like pectus carinatum and excavatum. Additionally, their long limbs and fingers are also indicative of Marfan’s syndrome. It is important to note that aortic dissection tends to occur at a much younger age in individuals with Marfan syndrome compared to those without connective tissue diseases. The median age for type A dissection in Marfan’s patients is 36.7 years, while for type B dissection it is 40 years. In contrast, individuals without Marfan’s syndrome typically experience dissection at the ages of 63 and 62 years for type A and type B dissections, respectively.
Further Reading:
Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.
The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.
Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.
Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.
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This question is part of the following fields:
- Cardiology
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Question 18
Incorrect
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A 25-year-old woman comes in with a complaint of palpitations that occur during her regular jogging routine. Her mother passed away at a young age from an unknown cause. During the examination, her pulse feels irregular and there is a presence of a double apical impulse. A systolic murmur can be heard at the left sternal edge that spreads throughout the praecordium.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Hypertrophic obstructive cardiomyopathy (HOCM)
Explanation:Hypertrophic obstructive cardiomyopathy (HOCM) is a primary heart disease characterized by the enlargement of the myocardium in the left and right ventricles. It is the most common reason for sudden cardiac death in young individuals and athletes. HOCM can be inherited in an autosomal dominant manner, and a family history of unexplained sudden death is often present.
Symptoms that may be experienced in HOCM include palpitations, breathlessness, chest pain, and syncope. Clinical signs that can be observed in HOCM include a jerky pulse character, a double apical impulse (where both atrial and ventricular contractions can be felt), a thrill at the left sternal edge, and an ejection systolic murmur at the left sternal edge that radiates throughout the praecordium. Additionally, a 4th heart sound may be present due to blood hitting a stiff and enlarged left ventricle during atrial systole.
On the other hand, Brugada syndrome is another cause of sudden cardiac death, but patients with this condition are typically asymptomatic and have a normal clinical examination.
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This question is part of the following fields:
- Cardiology
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Question 19
Incorrect
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A 72 year old male patient has arrived at the emergency department after injuring himself in a fall. Upon reviewing the patient's medical history, you discover that he was diagnosed with mitral stenosis last year. You advise the medical students to assess the patient for indications of this condition.
What is a typical symptom observed in individuals with mitral stenosis?Your Answer:
Correct Answer: Malar flush
Explanation:One of the clinical features of mitral stenosis is malar flush, which refers to a reddening or flushing of the cheeks. Other clinical features include a mid-late diastolic murmur that is best heard during expiration, a loud S1 heart sound with an opening snap, a low volume pulse, atrial fibrillation, and signs of pulmonary edema such as crepitations or the presence of white or pink frothy sputum.
Further Reading:
Mitral Stenosis:
– Causes: Rheumatic fever, Mucopolysaccharidoses, Carcinoid, Endocardial fibroelastosis
– Features: Mid-late diastolic murmur, loud S1, opening snap, low volume pulse, malar flush, atrial fibrillation, signs of pulmonary edema, tapping apex beat
– Features of severe mitral stenosis: Length of murmur increases, opening snap becomes closer to S2
– Investigation findings: CXR may show left atrial enlargement, echocardiography may show reduced cross-sectional area of the mitral valveMitral Regurgitation:
– Causes: Mitral valve prolapse, Myxomatous degeneration, Ischemic heart disease, Rheumatic fever, Connective tissue disorders, Endocarditis, Dilated cardiomyopathy
– Features: pansystolic murmur radiating to left axilla, soft S1, S3, laterally displaced apex beat with heave
– Signs of acute MR: Decompensated congestive heart failure symptoms
– Signs of chronic MR: Leg edema, fatigue, arrhythmia (atrial fibrillation)
– Investigation findings: Doppler echocardiography to detect regurgitant flow and pulmonary hypertension, ECG may show signs of LA enlargement and LV hypertrophy, CXR may show LA and LV enlargement in chronic MR and pulmonary edema in acute MR. -
This question is part of the following fields:
- Cardiology
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Question 20
Incorrect
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You evaluate a 45-year-old Asian man with a heart murmur. During auscultation, you observe a loud first heart sound and a mid-diastolic murmur at the apex. Upon examination, you observe that he has plum-red discoloration of his cheeks.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Mitral stenosis
Explanation:The clinical symptoms of mitral stenosis include shortness of breath, which tends to worsen during exercise and when lying flat. Tiredness, palpitations, ankle swelling, cough, and haemoptysis are also common symptoms. Chest discomfort is rarely reported.
The clinical signs of mitral stenosis can include a malar flush, an irregular pulse if atrial fibrillation is present, a tapping apex beat that can be felt as the first heart sound, and a left parasternal heave if there is pulmonary hypertension. The first heart sound is often loud, and a mid-diastolic murmur can be heard.
The mid-diastolic murmur of mitral stenosis is a rumbling sound that is best heard at the apex, in the left lateral position during expiration, using the bell of the stethoscope.
Mitral stenosis is typically caused by rheumatic heart disease, and it is more common in females, with about two-thirds of patients being female.
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This question is part of the following fields:
- Cardiology
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Question 21
Incorrect
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A 60-year-old man presents with worsening symptoms of shortness of breath. You examine his cardiovascular system and discover a slow-rising, low-volume pulse. His apex beat is sustained, and you can auscultate an ejection systolic murmur that is loudest in the aortic area that radiates to the carotids.
What is the SINGLE most likely diagnosis?Your Answer:
Correct Answer: Aortic stenosis
Explanation:Aortic stenosis is a common condition where the valve in the heart becomes narrowed due to the progressive calcification that occurs with age. This typically occurs around the age of 70. Other causes of aortic stenosis include calcification of a congenital bicuspid aortic valve and rheumatic fever.
The symptoms of aortic stenosis can vary but commonly include difficulty breathing during physical activity, fainting, dizziness, chest pain (angina), and in severe cases, sudden death. However, it is also possible for aortic stenosis to be asymptomatic, meaning that there are no noticeable symptoms.
When examining a patient with aortic stenosis, there are several signs that may be present. These include a slow-rising and low-volume pulse, a narrow pulse pressure, a sustained apex beat, a thrill (a vibrating sensation) in the area of the aorta, and an ejection click if the valve is pliable. Additionally, there is typically an ejection systolic murmur, which is a specific type of heart murmur, that can be heard loudest in the aortic area (located at the right sternal edge, 2nd intercostal space) and may radiate to the carotid arteries.
It is important to differentiate aortic stenosis from aortic sclerosis, which is a degeneration of the aortic valve but does not cause obstruction of the left ventricular outflow tract. Aortic sclerosis can be distinguished by the presence of a normal pulse character and the absence of radiation of the murmur.
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This question is part of the following fields:
- Cardiology
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Question 22
Incorrect
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A 72-year-old woman with a history of type II diabetes and hypertension presents with central chest discomfort. Her ECG showed ST depression in the inferior leads, but her discomfort subsides, and ECG returns to normal after receiving GTN spray and IV morphine. She was also given 300 mg of aspirin in the ambulance en route to the hospital. Her vital signs are as follows: SaO2 99% on room air, HR 89 bpm, and BP 139/82 mmHg. A troponin test has been scheduled and she is scheduled for an urgent coronary angiography.
Which of the following medications should you also consider administering to this patient?Your Answer:
Correct Answer: Unfractionated heparin
Explanation:This patient is likely experiencing an acute coronary syndrome, possibly a non-ST-elevation myocardial infarction (NSTEMI) or unstable angina. The troponin test will help confirm the diagnosis. The patient’s ECG showed ST depression in the inferior leads, but this normalized after treatment with GTN and morphine, ruling out a ST-elevation myocardial infarction (STEMI).
Immediate pain relief should be provided. GTN (sublingual or buccal) can be used, but intravenous opioids like morphine should be considered, especially if a heart attack is suspected.
Aspirin should be given to all patients with unstable angina or NSTEMI as soon as possible and continued indefinitely, unless there are contraindications like bleeding risk or aspirin hypersensitivity. A loading dose of 300 mg should be administered right after presentation.
Fondaparinux should be given to patients without a high bleeding risk, unless coronary angiography is planned within 24 hours of admission. Unfractionated heparin can be an alternative to fondaparinux for patients who will undergo coronary angiography within 24 hours. For patients with significant renal impairment, unfractionated heparin can also be considered, with dose adjustment based on clotting function monitoring.
Routine administration of oxygen is no longer recommended, but oxygen saturation should be monitored using pulse oximetry as soon as possible, preferably before hospital admission. Supplemental oxygen should only be offered to individuals with oxygen saturation (SpO2) below 94% who are not at risk of hypercapnic respiratory failure, aiming for a SpO2 of 94-98%. For individuals with chronic obstructive pulmonary disease at risk of hypercapnic respiratory failure, a target SpO2 of 88-92% should be achieved until blood gas analysis is available.
Bivalirudin, a specific and reversible direct thrombin inhibitor (DTI), is recommended by NICE as a possible treatment for adults with STEMI undergoing percutaneous coronary intervention.
For more information, refer to the NICE guidelines on the assessment and diagnosis of chest pain of recent onset.
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This question is part of the following fields:
- Cardiology
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Question 23
Incorrect
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A 70 year old male visits the emergency department with a complaint of increasing shortness of breath. You observe that the patient had moderate aortic regurgitation on an echocardiogram conducted 12 months ago.
What is a characteristic symptom of aortic regurgitation (AR)?Your Answer:
Correct Answer: Water hammer pulse
Explanation:A collapsing pulse, also known as a water hammer pulse, is a common clinical feature associated with aortic regurgitation (AR). In AR, the pulse rises rapidly and forcefully before quickly collapsing. This pulsation pattern may also be referred to as Watson’s water hammer pulse or Corrigan’s pulse. Heart sounds in AR are typically quiet, and the second heart sound (S2) may even be absent if the valve fails to fully close. A characteristic early to mid diastolic murmur is often present. Other typical features of AR include a wide pulse pressure, a mid-diastolic Austin-Flint murmur in severe cases, a soft S1 and S2 (with S2 potentially being absent), a hyperdynamic apical pulse, and signs of heart failure such as lung creases, raised jugular venous pressure (JVP), and tachypnea.
Further Reading:
Valvular heart disease refers to conditions that affect the valves of the heart. In the case of aortic valve disease, there are two main conditions: aortic regurgitation and aortic stenosis.
Aortic regurgitation is characterized by an early diastolic murmur, a collapsing pulse (also known as a water hammer pulse), and a wide pulse pressure. In severe cases, there may be a mid-diastolic Austin-Flint murmur due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams. The first and second heart sounds (S1 and S2) may be soft, and S2 may even be absent. Additionally, there may be a hyperdynamic apical pulse. Causes of aortic regurgitation include rheumatic fever, infective endocarditis, connective tissue diseases like rheumatoid arthritis and systemic lupus erythematosus, and a bicuspid aortic valve. Aortic root diseases such as aortic dissection, spondyloarthropathies like ankylosing spondylitis, hypertension, syphilis, and genetic conditions like Marfan’s syndrome and Ehler-Danlos syndrome can also lead to aortic regurgitation.
Aortic stenosis, on the other hand, is characterized by a narrow pulse pressure, a slow rising pulse, and a delayed ESM (ejection systolic murmur). The second heart sound (S2) may be soft or absent, and there may be an S4 (atrial gallop) that occurs just before S1. A thrill may also be felt. The duration of the murmur is an important factor in determining the severity of aortic stenosis. Causes of aortic stenosis include degenerative calcification (most common in older patients), a bicuspid aortic valve (most common in younger patients), William’s syndrome (supravalvular aortic stenosis), post-rheumatic disease, and subvalvular conditions like hypertrophic obstructive cardiomyopathy (HOCM).
Management of aortic valve disease depends on the severity of symptoms. Asymptomatic patients are generally observed, while symptomatic patients may require valve replacement. Surgery may also be considered for asymptomatic patients with a valvular gradient greater than 40 mmHg and features such as left ventricular systolic dysfunction. Balloon valvuloplasty is limited to patients with critical aortic stenosis who are not fit for valve replacement.
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This question is part of the following fields:
- Cardiology
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Question 24
Incorrect
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A 37 year old female presents to the emergency department complaining of shortness of breath and chest pain in the center of her chest. Upon further questioning, the patient reveals that she experienced muscle pain, gastrointestinal issues, a mild fever, and fatigue for approximately three days about a week ago. She informs you that she is typically in good health and regularly runs 5-10km two to three times per week. The patient has no significant medical history, does not take any medications on a regular basis, has never smoked, and does not consume alcohol. Given the patient's symptoms, you suspect the possibility of myocarditis. Which of the following sets of blood test results would be expected in a patient with myocarditis?
Your Answer:
Correct Answer: creatine kinase: elevated, troponin I: elevated, BNP: elevated
Explanation:In cases of myocarditis, levels of cardiac muscle enzymes (CK-MB, Troponin I, and Troponin T) and B-type natriuretic peptide (BNP) are usually elevated. It is important to note that CK-MB is a subtype of CK, so an increase in CK-MB will also result in an increase in total CK levels. This poses a challenge in differentiating myocarditis from coronary artery disease in the emergency department. Typically, a definitive diagnosis is not made until the patient undergoes additional tests such as angiography and possibly endomyocardial biopsy (EMB).
Further Reading:
Myocarditis is inflammation of the myocardium, the middle layer of the heart wall, that is not caused by a blockage in the coronary arteries. It can be caused by various factors, including infections (such as viruses, bacteria, parasites, and fungi), immune reactions, toxins, physical injury, and certain medications or vaccines. Coxsackie virus is the most common cause of myocarditis in Europe and the USA, while globally, Trypanosoma cruzi, which causes Chagas disease, is the most common cause.
The symptoms of myocarditis can vary widely and often resemble those of heart failure or coronary heart disease. Common symptoms include chest pain, palpitations, breathlessness, fatigue, and swelling. The clinical presentation can also be influenced by the underlying cause of the inflammation. Diagnosis of myocarditis is challenging as there is no specific clinical presentation, and the gold standard test, endomyocardial biopsy, is not readily available in emergency departments.
Various tests can be performed to aid in the diagnosis of myocarditis, including electrocardiogram (ECG), chest X-ray, cardiac enzymes (such as troponin or CK-MB), brain natriuretic peptide (BNP) levels, and echocardiogram. These tests may show non-specific abnormalities, such as ST-segment and T-wave abnormalities on ECG, bilateral pulmonary infiltrates on chest X-ray, elevated cardiac enzymes and BNP levels, and left ventricular motion abnormalities on echocardiogram.
Management of myocarditis is primarily supportive, focusing on treating cardiac failure and addressing the underlying cause. Supportive care and conventional heart failure therapy, such as ACE inhibitors or angiotensin II receptor blockers, vasodilators, beta-blockers, and diuretics, may be used to improve cardiac function and reduce symptoms. Treatment of the underlying cause, such as antiparasitic agents for Chagas disease or antibiotics for bacterial infections, may also be necessary. In severe cases leading to cardiogenic shock, more aggressive treatment with invasive monitoring, inotropes, vasopressors, and potentially heart transplantation may be required.
In summary, myocarditis is inflammation of the myocardium that can be caused by various factors. It presents with a wide range of symptoms and can be challenging to diagnose. Management involves supportive care, treatment of cardiac failure, and addressing the underlying cause. Severe cases may require more aggressive treatment and potentially heart transplantation.
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This question is part of the following fields:
- Cardiology
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Question 25
Incorrect
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A 32-year-old woman is brought to the Emergency Department by ambulance due to 'severe palpitations.' Her heart rate is 180 bpm, and her rhythm strip is suggestive of supraventricular tachycardia. You plan to administer adenosine.
Which of the following is NOT a contraindication to the use of adenosine?Your Answer:
Correct Answer: History of heart transplant
Explanation:Adenosine is a type of purine nucleoside that is primarily utilized in the diagnosis and treatment of paroxysmal supraventricular tachycardia. Its main mechanism of action involves stimulating A1-adenosine receptors and opening acetylcholine-sensitive potassium channels. This leads to hyperpolarization of the cell membrane in the atrioventricular (AV) node and slows down conduction in the AV node by inhibiting calcium channels.
When administering adenosine, it is given rapidly through an intravenous bolus, followed by a saline flush. The initial dose for adults is 6 mg, and if necessary, additional doses of 12 mg or 18 mg can be given at 1-2 minute intervals until the desired effect is observed. It is important to note that the latest ALS guidelines recommend 18 mg for the third dose, while the BNF/NICE guidelines suggest 12 mg.
One of the advantages of adenosine is its very short half-life, which is less than 10 seconds. This means that its effects are rapid, typically occurring within 10 seconds. However, the duration of action is also short, lasting only 10-20 seconds. Due to its short half-life, any side effects experienced are usually brief. These side effects may include a sense of impending doom, facial flushing, dyspnea, chest discomfort, and a metallic taste.
There are certain contraindications to the use of adenosine. These include 2nd or 3rd degree AV block, sick sinus syndrome, long QT syndrome, severe hypotension, decompensated heart failure, chronic obstructive lung disease, and asthma. It is important to exercise caution when administering adenosine to patients with a heart transplant, as they are particularly sensitive to its effects. In these cases, a reduced initial dose of 3 mg is recommended, followed by 6 mg and then 12 mg.
It is worth noting that the effects of adenosine can be potentiated by dipyridamole, a medication commonly used in combination with adenosine. Therefore, the dose of adenosine should be adjusted and reduced in patients who are also taking dipyridamole.
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This question is part of the following fields:
- Cardiology
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Question 26
Incorrect
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A 68 year old male presents to the emergency department with central heavy chest pain that began 10 hours ago while the patient was sitting down watching television. The patient has previously refused treatment for high cholesterol and stage 1 hypertension. Physical examination reveals a mildly elevated blood pressure of 156/94 mmHg, but is otherwise unremarkable. The ECG shows ST depression and T wave inversion in leads V1-V3. Initial troponin results are negative, and a second high sensitivity troponin assay performed 3 hours later also returns negative. What is the most likely diagnosis?
Your Answer:
Correct Answer: Unstable angina
Explanation:Distinguishing between unstable angina and other acute coronary syndromes can be done by looking at normal troponin results. If serial troponin tests come back negative, it can rule out a diagnosis of myocardial infarction. Unstable angina is characterized by myocardial ischemia occurring at rest or with minimal exertion, without any acute damage or death of heart muscle cells. The patient in question shows ECG and biochemical features that align with this definition. Vincent’s angina, on the other hand, refers to an infection in the throat accompanied by ulcerative gingivitis.
Further Reading:
Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).
The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.
There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.
The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.
The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.
The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.
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This question is part of the following fields:
- Cardiology
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Question 27
Incorrect
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A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations. She informs you that she was recently diagnosed with Wolff-Parkinson-White syndrome. You proceed to perform an ECG.
Which ONE statement about the ECG findings in Wolff-Parkinson-White (WPW) syndrome is accurate?Your Answer:
Correct Answer: Type A WPW can resemble right bundle branch block
Explanation:Wolff-Parkinson-White (WPW) syndrome is a condition that affects the electrical system of the heart. It occurs when there is an abnormal pathway, known as the bundle of Kent, between the atria and the ventricles. This pathway can cause premature contractions of the ventricles, leading to a type of rapid heartbeat called atrioventricular re-entrant tachycardia (AVRT).
In a normal heart rhythm, the electrical signals travel through the bundle of Kent and stimulate the ventricles. However, in WPW syndrome, these signals can cause the ventricles to contract prematurely. This can be seen on an electrocardiogram (ECG) as a shortened PR interval, a slurring of the initial rise in the QRS complex (known as a delta wave), and a widening of the QRS complex.
There are two distinct types of WPW syndrome that can be identified on an ECG. Type A is characterized by predominantly positive delta waves and QRS complexes in the praecordial leads, with a dominant R wave in V1. This can sometimes be mistaken for right bundle branch block (RBBB). Type B, on the other hand, shows predominantly negative delta waves and QRS complexes in leads V1 and V2, and positive in the other praecordial leads, resembling left bundle branch block (LBBB).
Overall, WPW syndrome is a condition that affects the electrical conduction system of the heart, leading to abnormal heart rhythms. It can be identified on an ECG by specific features such as shortened PR interval, delta waves, and widened QRS complex.
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This question is part of the following fields:
- Cardiology
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Question 28
Incorrect
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You evaluate a 75-year-old woman with chronic heart failure.
Which specific beta-blocker is approved for the treatment of chronic heart failure?Your Answer:
Correct Answer: Nebivolol
Explanation:Currently, there are three beta-blockers that have been approved for the treatment of chronic heart failure. These medications include bisoprolol, carvedilol, and nebivolol.
Chronic HF is a common clinical syndrome resulting from coronary artery disease (CAD), HTN, valvular heart disease, and/or primary cardiomyopathy. There is now conclusive evidence that β-blockers, when added to ACE inhibitors, substantially reduce mortality, decrease sudden death, and improve symptoms in patients with HF. Despite the overwhelming evidence and guidelines that mandate the use of β-blockers in all HF patients without contraindications, many patients do not receive this treatment.
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This question is part of the following fields:
- Cardiology
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Question 29
Incorrect
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A 28-year-old woman presents after experiencing a syncopal episode earlier in the day. She fainted while jogging on the treadmill at her local gym. She regained consciousness quickly and currently feels completely fine. Upon examination, she has a slim physique, normal heart sounds without any additional sounds or murmurs, clear lungs, and a soft abdomen. She is originally from Thailand and mentions that her mother passed away suddenly in her 30s.
Her ECG reveals:
- Right bundle branch block pattern
- Downward-sloping 'coved' ST elevation in leads V1-V3
- Widespread upward-sloping ST depression in other leads
What is the SINGLE most likely diagnosis?Your Answer:
Correct Answer: Brugada syndrome
Explanation:Brugada syndrome is a genetic disorder that is passed down from one generation to another in an autosomal dominant manner. It is characterized by abnormal findings on an electrocardiogram (ECG) and can lead to sudden cardiac death. The cause of death in individuals with Brugada syndrome is typically ventricular fibrillation, which occurs as a result of specific defects in ion channels that are determined by our genes. Interestingly, this syndrome is more commonly observed in South East Asia and is actually the leading cause of sudden unexplained cardiac death in Thailand.
One of the key features seen on an ECG that is consistent with Type 1 Brugada syndrome is a pattern known as right bundle branch block. Additionally, there is a distinct downward sloping coved ST elevation observed in leads V1-V3. These specific ECG findings help to identify individuals who may be at risk for developing Brugada syndrome and experiencing its potentially fatal consequences.
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This question is part of the following fields:
- Cardiology
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Question 30
Incorrect
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A 55 year old female presents to the emergency department 3 hours after experiencing severe central chest pain that radiates to the back while gardening. The patient describes the pain as tearing and states it is the worst pain she has ever felt. You note a past medical history of poorly controlled hypertension. The patient's vital signs are as follows:
Blood pressure 182/98 mmHg
Pulse rate 94 bpm
Respiration rate 22 rpm
Oxygen saturation 97% on room air
Temperature 37.3ºC
An ECG is performed which shows normal sinus rhythm. Chest X-ray reveals a widened mediastinum and an abnormal aortic contour.
What is the most appropriate initial treatment for this patient?Your Answer:
Correct Answer: Intravenous labetalol
Explanation:The most appropriate initial treatment for this patient would be intravenous labetalol. Labetalol is a non-selective beta blocker with alpha-blocking properties. It is the preferred initial treatment for aortic dissection because it helps to reduce blood pressure and heart rate, which can help to decrease the shear forces acting on the aortic wall and prevent further dissection. Intravenous administration of labetalol allows for rapid and effective control of blood pressure.
Other treatment options, such as intravenous magnesium sulphate, intravenous verapamil, GTN sublingual spray, and oral nifedipine, are not appropriate for the management of aortic dissection. Magnesium sulphate is used for the treatment of certain arrhythmias and pre-eclampsia, but it does not address the underlying issue of aortic dissection. Verapamil and nifedipine are calcium channel blockers that can lower blood pressure, but they can also cause reflex tachycardia, which can worsen the condition. GTN sublingual spray is used for the treatment of angina, but it does not address the underlying issue of aortic dissection.
Further Reading:
Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.
The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.
Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.
Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.
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This question is part of the following fields:
- Cardiology
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