00
Correct
00
Incorrect
00 : 00 : 0 00
Session Time
00 : 00
Average Question Time ( Secs)
  • Question 1 - An 68-year-old patient visits the GP complaining of a cough that produces green...

    Incorrect

    • An 68-year-old patient visits the GP complaining of a cough that produces green sputum, fever and shortness of breath. After being treated with antibiotics, her symptoms improve. However, three weeks later, she experiences painful joints, chest pain, fever and an erythema marginatum rash. What is the probable causative organism responsible for the initial infection?

      Your Answer: Staphylococcus aureus

      Correct Answer: Streptococcus pyogenes

      Explanation:

      An immunological reaction is responsible for the development of rheumatic fever.

      Rheumatic fever is a condition that occurs as a result of an immune response to a recent Streptococcus pyogenes infection, typically occurring 2-4 weeks after the initial infection. The pathogenesis of rheumatic fever involves the activation of the innate immune system, leading to antigen presentation to T cells. B and T cells then produce IgG and IgM antibodies, and CD4+ T cells are activated. This immune response is thought to be cross-reactive, mediated by molecular mimicry, where antibodies against M protein cross-react with myosin and the smooth muscle of arteries. This response leads to the clinical features of rheumatic fever, including Aschoff bodies, which are granulomatous nodules found in rheumatic heart fever.

      To diagnose rheumatic fever, evidence of recent streptococcal infection must be present, along with 2 major criteria or 1 major criterion and 2 minor criteria. Major criteria include erythema marginatum, Sydenham’s chorea, polyarthritis, carditis and valvulitis, and subcutaneous nodules. Minor criteria include raised ESR or CRP, pyrexia, arthralgia, and prolonged PR interval.

      Management of rheumatic fever involves antibiotics, typically oral penicillin V, as well as anti-inflammatories such as NSAIDs as first-line treatment. Any complications that develop, such as heart failure, should also be treated. It is important to diagnose and treat rheumatic fever promptly to prevent long-term complications such as rheumatic heart disease.

    • This question is part of the following fields:

      • Cardiovascular System
      12.6
      Seconds
  • Question 2 - A 65-year-old man with heart failure visits his GP complaining of peripheral edema....

    Correct

    • A 65-year-old man with heart failure visits his GP complaining of peripheral edema. Upon examination, he is diagnosed with fluid overload, leading to the release of atrial natriuretic peptide by the atrial myocytes. What is the mechanism of action of atrial natriuretic peptide?

      Your Answer: Antagonist of angiotensin II

      Explanation:

      Angiotensin II is opposed by atrial natriuretic peptide, while B-type natriuretic peptides inhibit the renin-angiotensin-aldosterone system and sympathetic activity. Additionally, aldosterone is antagonized by atrial natriuretic peptide. Renin catalyzes the conversion of angiotensinogen into angiotensin I.

      Atrial natriuretic peptide is a hormone that is primarily secreted by the myocytes of the right atrium and ventricle in response to an increase in blood volume. It is also secreted by the left atrium, although to a lesser extent. This peptide hormone is composed of 28 amino acids and acts through the cGMP pathway. It is broken down by endopeptidases.

      The main actions of atrial natriuretic peptide include promoting the excretion of sodium and lowering blood pressure. It achieves this by antagonizing the actions of angiotensin II and aldosterone. Overall, atrial natriuretic peptide plays an important role in regulating fluid and electrolyte balance in the body.

    • This question is part of the following fields:

      • Cardiovascular System
      9.9
      Seconds
  • Question 3 - A 20-year-old man has a tonsillectomy due to recurrent acute tonsillitis. During recovery,...

    Incorrect

    • A 20-year-old man has a tonsillectomy due to recurrent acute tonsillitis. During recovery, he experiences a postoperative bleeding. Which vessel is the most probable cause of the bleeding?

      Your Answer: Internal jugular vein

      Correct Answer: External palatine vein

      Explanation:

      If the external palatine vein is harmed during tonsillectomy, it can result in reactionary bleeding and is located adjacent to the tonsil.

      Tonsil Anatomy and Tonsillitis

      The tonsils are located in the pharynx and have two surfaces, a medial and lateral surface. They vary in size and are usually supplied by the tonsillar artery and drained by the jugulodigastric and deep cervical nodes. Tonsillitis is a common condition that is usually caused by bacteria, with group A Streptococcus being the most common culprit. It can also be caused by viruses. In some cases, tonsillitis can lead to the development of an abscess, which can distort the uvula. Tonsillectomy is recommended for patients with recurrent acute tonsillitis, suspected malignancy, or enlargement causing sleep apnea. The preferred technique for tonsillectomy is dissection, but it can be complicated by hemorrhage, which is the most common complication. Delayed otalgia may also occur due to irritation of the glossopharyngeal nerve.

    • This question is part of the following fields:

      • Cardiovascular System
      5.9
      Seconds
  • Question 4 - As a curious fourth-year medical student, you observe the birth of a full-term...

    Incorrect

    • As a curious fourth-year medical student, you observe the birth of a full-term baby delivered vaginally to a mother who has given birth once before. The infant's Apgar score is 9 at 1 minute and 10 at 10 minutes, and the delivery is uncomplicated. However, a postnatal examination reveals that the ductus arteriosus has not closed properly. Can you explain the process by which this structure normally closes?

      Your Answer: Increased oxygen tension which increases the concentration of prostaglandins

      Correct Answer: Decreased prostaglandin concentration

      Explanation:

      The ductus arteriosus, which is a shunt connecting the pulmonary artery with the descending aorta in utero, closes with the first breaths of life. This is due to an increase in pulmonary blood flow, which helps to clear local vasodilating prostaglandins that keep the duct open during fetal development. The opening of the lung alveoli with the first breath of life leads to an increase in oxygen tension in the blood, but this is not the primary mechanism behind the closure of the ductus arteriosus. It is important to note that oxygen tension in the blood increases after birth when the infant breathes in air and no longer receives mixed oxygenated blood via the placenta.

      Understanding Patent Ductus Arteriosus

      Patent ductus arteriosus is a type of congenital heart defect that is generally classified as ‘acyanotic’. However, if left uncorrected, it can eventually result in late cyanosis in the lower extremities, which is termed differential cyanosis. This condition is caused by a connection between the pulmonary trunk and descending aorta. Normally, the ductus arteriosus closes with the first breaths due to increased pulmonary flow, which enhances prostaglandins clearance. However, in some cases, this connection remains open, leading to patent ductus arteriosus.

      This condition is more common in premature babies, those born at high altitude, or those whose mothers had rubella infection in the first trimester. The features of patent ductus arteriosus include a left subclavicular thrill, continuous ‘machinery’ murmur, large volume, bounding, collapsing pulse, wide pulse pressure, and heaving apex beat.

      The management of patent ductus arteriosus involves the use of indomethacin or ibuprofen, which are given to the neonate. These medications inhibit prostaglandin synthesis and close the connection in the majority of cases. If patent ductus arteriosus is associated with another congenital heart defect amenable to surgery, then prostaglandin E1 is useful to keep the duct open until after surgical repair. Understanding patent ductus arteriosus is important for early diagnosis and management of this condition.

    • This question is part of the following fields:

      • Cardiovascular System
      10.3
      Seconds
  • Question 5 - An 80-year-old man arrives at the emergency department with complaints of lightheadedness, fatigue,...

    Incorrect

    • An 80-year-old man arrives at the emergency department with complaints of lightheadedness, fatigue, and shortness of breath during exertion. Upon examination, you observe a pulse rate of 42 beats per minute, mild bibasal crepitations, and bilateral peripheral pitting edema. The patient's ECG reveals a dissociation between the P waves and QRS complexes. Which aspect of the JVP waveform is most likely to be impacted in this individual?

      Your Answer: c wave

      Correct Answer: a wave

      Explanation:

      A complete heart block is indicated by a pulse rate of approximately 40 beats per minute and ECG results. This means that the atria and ventricles are contracting in an unsynchronized manner. When the tricuspid valve is closed and the right atrium contracts, the JVP will experience a significant increase, which is referred to as cannon a waves.

      Understanding the Jugular Venous Pulse

      The jugular venous pulse is a useful tool in assessing right atrial pressure and identifying underlying valvular disease. The waveform of the jugular vein can provide valuable information, such as a non-pulsatile JVP indicating superior vena caval obstruction and Kussmaul’s sign indicating constrictive pericarditis.

      The ‘a’ wave of the jugular venous pulse represents atrial contraction and can be large in conditions such as tricuspid stenosis, pulmonary stenosis, and pulmonary hypertension. However, it may be absent in atrial fibrillation. Cannon ‘a’ waves occur when atrial contractions push against a closed tricuspid valve and are seen in complete heart block, ventricular tachycardia/ectopics, nodal rhythm, and single chamber ventricular pacing.

      The ‘c’ wave represents the closure of the tricuspid valve and is not normally visible. The ‘v’ wave is due to passive filling of blood into the atrium against a closed tricuspid valve and can be giant in tricuspid regurgitation. The ‘x’ descent represents the fall in atrial pressure during ventricular systole, while the ‘y’ descent represents the opening of the tricuspid valve.

      Understanding the jugular venous pulse and its various components can aid in the diagnosis and management of cardiovascular conditions.

    • This question is part of the following fields:

      • Cardiovascular System
      13.8
      Seconds
  • Question 6 - A 67-year-old man is admitted to the hospital with central crushing chest pain...

    Correct

    • A 67-year-old man is admitted to the hospital with central crushing chest pain and undergoes a coronary angiogram. Arterial blockage can result from atherosclerosis, which can cause changes in the endothelium. What is an anticipated change in the endothelium?

      Your Answer: Reduced nitric oxide bioavailability

      Explanation:

      Fatty infiltration in the subendothelial space is associated with LDL particles, but the endothelium undergoes changes that include reduced nitric oxide bioavailability, proliferation, and pro-inflammatory and pro-oxidant effects.

      Understanding Atherosclerosis and its Complications

      Atherosclerosis is a complex process that occurs over several years. It begins with endothelial dysfunction triggered by factors such as smoking, hypertension, and hyperglycemia. This leads to changes in the endothelium, including inflammation, oxidation, proliferation, and reduced nitric oxide bioavailability. As a result, low-density lipoprotein (LDL) particles infiltrate the subendothelial space, and monocytes migrate from the blood and differentiate into macrophages. These macrophages that phagocytose oxidized LDL, slowly turning into large ‘foam cells’. Smooth muscle proliferation and migration from the tunica media into the intima result in the formation of a fibrous capsule covering the fatty plaque.

      Once a plaque has formed, it can cause several complications. For example, it can form a physical blockage in the lumen of the coronary artery, leading to reduced blood flow and oxygen to the myocardium, resulting in angina. Alternatively, the plaque may rupture, potentially causing a complete occlusion of the coronary artery and resulting in a myocardial infarction. It is essential to understand the process of atherosclerosis and its complications to prevent and manage cardiovascular diseases effectively.

    • This question is part of the following fields:

      • Cardiovascular System
      29.8
      Seconds
  • Question 7 - A newborn with Down's syndrome presents with a murmur at birth. Upon performing...

    Correct

    • A newborn with Down's syndrome presents with a murmur at birth. Upon performing an echocardiogram, what is the most probable congenital cardiac abnormality that will be detected?

      Your Answer: Atrio-ventricular septal defect

      Explanation:

      Congenital Cardiac Anomalies in Down Syndrome

      Down syndrome is a genetic disorder that is characterized by a range of congenital abnormalities. One of the most common abnormalities associated with Down syndrome is duodenal atresia. However, Down syndrome is also frequently associated with congenital cardiac anomalies. The most common cardiac anomaly in Down syndrome is an atrioventricular septal defect (AVSD), followed by ventricular septal defect (VSD), patent ductus arteriosus (PDA), tetralogy of Fallot, and atrial septal defect (ASD). These anomalies can cause a range of symptoms and complications, including heart failure, pulmonary hypertension, and developmental delays. It is important for individuals with Down syndrome to receive regular cardiac evaluations and appropriate medical care to manage these conditions.

    • This question is part of the following fields:

      • Cardiovascular System
      5.4
      Seconds
  • Question 8 - A 67-year-old man presents with crushing central chest pain and flushing. His ECG...

    Incorrect

    • A 67-year-old man presents with crushing central chest pain and flushing. His ECG shows T wave inversion in II, III, and AVF, and his troponin T level is 0.9 ng/ml (normal <0.01). What is the substance that troponin T binds to?

      Your Answer: Myosin

      Correct Answer: Tropomyosin

      Explanation:

      The binding of troponin T to tropomyosin results in the formation of a troponin-tropomyosin complex. The clinical and electrographic characteristics suggest the presence of an inferior myocardial infarction, which is confirmed by the elevated levels of troponin. Troponin T is highly specific to myocardial damage. On the other hand, troponin C binds to calcium ions and is released by damage to both skeletal and cardiac muscle, making it an insensitive marker for myocardial necrosis. Troponin I binds to actin and helps to maintain the troponin-tropomyosin complex in place. It is also specific to myocardial damage. Myosin is the thick component of muscle fibers, and actin slides along myosin to generate muscle contraction. The sarcoplasmic reticulum plays a crucial role in regulating the concentration of calcium ions in the cytoplasm of striated muscle cells.

      Understanding Troponin: The Proteins Involved in Muscle Contraction

      Troponin is a group of three proteins that play a crucial role in the contraction of skeletal and cardiac muscles. These proteins work together to regulate the interaction between actin and myosin, which is essential for muscle contraction. The three subunits of troponin are troponin C, troponin T, and troponin I.

      Troponin C is responsible for binding to calcium ions, which triggers the contraction of muscle fibers. Troponin T binds to tropomyosin, forming a complex that helps regulate the interaction between actin and myosin. Finally, troponin I binds to actin, holding the troponin-tropomyosin complex in place and preventing muscle contraction when it is not needed.

      Understanding the role of troponin is essential for understanding how muscles work and how they can be affected by various diseases and conditions. By regulating the interaction between actin and myosin, troponin plays a critical role in muscle contraction and is a key target for drugs used to treat conditions such as heart failure and skeletal muscle disorders.

    • This question is part of the following fields:

      • Cardiovascular System
      4.3
      Seconds
  • Question 9 - A patient in his late 60s presents with dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea,...

    Incorrect

    • A patient in his late 60s presents with dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, fatigue, cyanosis. A diagnosis of acute heart failure is made. He is started on diuretics, ACE inhibitors, beta-blockers but shows minimal improvement with medications.

      What should be considered if he continues to fail to improve?

      Your Answer: High-flow oxygen

      Correct Answer: Continuous positive airway pressure

      Explanation:

      If a patient with acute heart failure does not show improvement with appropriate medication, CPAP should be considered as a viable treatment option.

      Heart failure requires acute management, with recommended treatments including IV loop diuretics such as furosemide or bumetanide. Oxygen may also be given in accordance with British Thoracic Society guidelines to maintain oxygen saturations between 94-98%. Vasodilators such as nitrates should not be routinely given to all patients, but may be considered for those with concomitant myocardial ischaemia, severe hypertension, or regurgitant aortic or mitral valve disease. However, hypotension is a major side-effect and contraindication.

      For patients with respiratory failure, CPAP may be used. In cases of hypotension or cardiogenic shock, treatment can be challenging as loop diuretics and nitrates may exacerbate hypotension. Inotropic agents like dobutamine may be considered for patients with severe left ventricular dysfunction and potentially reversible cardiogenic shock. Vasopressor agents like norepinephrine are typically only used if there is insufficient response to inotropes and evidence of end-organ hypoperfusion. Mechanical circulatory assistance such as intra-aortic balloon counterpulsation or ventricular assist devices may also be used.

      While opiates were previously used routinely to reduce dyspnoea/distress in patients, NICE now advises against routine use due to studies suggesting increased morbidity in patients given opiates. Regular medication for heart failure such as beta-blockers and ACE-inhibitors should be continued, with beta-blockers only stopped if the patient has a heart rate less than 50 beats per minute, second or third degree atrioventricular block, or shock.

    • This question is part of the following fields:

      • Cardiovascular System
      10.8
      Seconds
  • Question 10 - A 70-year-old male presents to the Emergency Department with a 3-hour history of...

    Incorrect

    • A 70-year-old male presents to the Emergency Department with a 3-hour history of tearing chest pain. He has a past medical history of poorly controlled hypertension. His observations show:

      Respiratory rate of 20 breaths/min
      Pulse of 95 beats/min
      Temperature of 37.3ºC
      Blood pressure of 176/148 mmHg
      Oxygen saturations of 97% on room air

      Auscultation of the heart identifies a diastolic murmur, heard loudest over the 2nd intercostal space, right sternal border.

      What CT angiography findings would be expected in this patient's likely diagnosis?

      Your Answer: Ballooning of the aortic arch

      Correct Answer: False lumen of the ascending aorta

      Explanation:

      A false lumen in the descending aorta is a significant indication of aortic dissection on CT angiography. This condition is characterized by tearing chest pain, hypertension, and aortic regurgitation, which can be detected through a diastolic murmur over the 2nd intercostal space, right sternal border. The false lumen is formed due to a tear in the tunica intima of the aortic wall, which fills with a large volume of blood and is easily visible on angiographic CT.

      Ballooning of the aortic arch is an incorrect answer as it refers to an aneurysm, which is a condition where the artery walls weaken and abnormally bulge out or widen. Aneurysms are prone to rupture and can have varying effects depending on their location.

      Blurring of the posterior wall of the descending aorta is also an incorrect answer as it is a sign of a retroperitoneal, contained rupture of an aortic aneurysm. This condition may present with hypovolemic shock, hypotension, tachycardia, and tachypnea, leading to collapse.

      Total occlusion of the left anterior descending artery is another incorrect answer as it would likely result in ST-elevation myocardial infarction (STEMI). Although chest pain is a symptom of both conditions, the nature of the pain and investigation findings make aortic dissection more likely. It is important to note that coronary arteries can only be viewed through coronary angiography, which involves injecting contrast directly into the coronary arteries using a catheter, and not through CT angiography.

      Aortic dissection is classified according to the location of the tear in the aorta. The Stanford classification divides it into type A, which affects the ascending aorta in two-thirds of cases, and type B, which affects the descending aorta distal to the left subclavian origin in one-third of cases. The DeBakey classification divides it into type I, which originates in the ascending aorta and propagates to at least the aortic arch and possibly beyond it distally, type II, which originates in and is confined to the ascending aorta, and type III, which originates in the descending aorta and rarely extends proximally but will extend distally.

      To diagnose aortic dissection, a chest x-ray may show a widened mediastinum, but CT angiography of the chest, abdomen, and pelvis is the investigation of choice. However, the choice of investigations should take into account the patient’s clinical stability, as they may present acutely and be unstable. Transoesophageal echocardiography (TOE) is more suitable for unstable patients who are too risky to take to the CT scanner.

      The management of type A aortic dissection is surgical, but blood pressure should be controlled to a target systolic of 100-120 mmHg while awaiting intervention. On the other hand, type B aortic dissection is managed conservatively with bed rest and IV labetalol to reduce blood pressure and prevent progression. Complications of a backward tear include aortic incompetence/regurgitation and MI, while complications of a forward tear include unequal arm pulses and BP, stroke, and renal failure. Endovascular repair of type B aortic dissection may have a role in the future.

    • This question is part of the following fields:

      • Cardiovascular System
      34.5
      Seconds
  • Question 11 - A 55-year-old man with a recent diagnosis of essential hypertension and prescribed ramipril...

    Incorrect

    • A 55-year-old man with a recent diagnosis of essential hypertension and prescribed ramipril has returned for a follow-up appointment after 6 weeks. He has a medical history of osteoarthritis and benign prostate hypertrophy. Despite being compliant with his medication, his blood pressure reading is 145/90 mmHg, which is higher than his previous readings at home. What could be the reason for his inadequate blood pressure control despite medical treatment?

      Your Answer: Alcohol

      Correct Answer: Ibuprofen

      Explanation:

      The patient with osteoarthritis is likely taking NSAIDs, which can diminish the effectiveness of ACE inhibitors in controlling hypertension. Additionally, NSAIDs can worsen the hyperkalemic effects of ACE inhibitors, contributing to the patient’s uncontrolled blood pressure. It is important to note that alcohol can also exacerbate the hypotensive effects of ACE inhibitors. Nitrates, on the other hand, are useful in managing hypertension.

      Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.

      While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.

      Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.

      The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.

    • This question is part of the following fields:

      • Cardiovascular System
      23.7
      Seconds
  • Question 12 - A 72-year-old woman visits her physician for a regular examination. The physician observes...

    Incorrect

    • A 72-year-old woman visits her physician for a regular examination. The physician observes an elevation in pulse pressure, which is attributed to a decline in aortic compliance due to age-related alterations. What is an additional factor that can lead to an increase in pulse pressure?

      Your Answer: Decreased blood volume

      Correct Answer: Increased stroke volume

      Explanation:

      Stroke volume has a direct impact on pulse pressure, with an increase in stroke volume leading to an increase in pulse pressure. However, conditions such as aortic stenosis and heart failure can decrease stroke volume and therefore lower pulse pressure. Additionally, a decrease in blood volume can also reduce preload and subsequently lower pulse pressure.

      Cardiovascular physiology involves the study of the functions and processes of the heart and blood vessels. One important measure of heart function is the left ventricular ejection fraction, which is calculated by dividing the stroke volume (the amount of blood pumped out of the left ventricle with each heartbeat) by the end diastolic LV volume (the amount of blood in the left ventricle at the end of diastole) and multiplying by 100%. Another key measure is cardiac output, which is the amount of blood pumped by the heart per minute and is calculated by multiplying stroke volume by heart rate.

      Pulse pressure is another important measure of cardiovascular function, which is the difference between systolic pressure (the highest pressure in the arteries during a heartbeat) and diastolic pressure (the lowest pressure in the arteries between heartbeats). Factors that can increase pulse pressure include a less compliant aorta (which can occur with age) and increased stroke volume.

      Finally, systemic vascular resistance is a measure of the resistance to blood flow in the systemic circulation and is calculated by dividing mean arterial pressure (the average pressure in the arteries during a heartbeat) by cardiac output. Understanding these measures of cardiovascular function is important for diagnosing and treating cardiovascular diseases.

    • This question is part of the following fields:

      • Cardiovascular System
      12.4
      Seconds
  • Question 13 - A 40-year-old man undergoes a routine health check and his ECG reveals a...

    Correct

    • A 40-year-old man undergoes a routine health check and his ECG reveals a prolonged QT segment. He has no medical history and is not taking any medication. His father and grandfather both died from sudden cardiac arrest in their early 30s.

      What arrhythmias are most likely to occur as a result of this ECG abnormality?

      Your Answer: Torsades de pointes

      Explanation:

      Torsades de pointes is the most common consequence of Long QT syndrome, which can also result in polymorphic ventricular tachycardia.

      Long QT syndrome (LQTS) is a genetic condition that causes a delay in the ventricles’ repolarization. This delay can lead to ventricular tachycardia/torsade de pointes, which can cause sudden death or collapse. The most common types of LQTS are LQT1 and LQT2, which are caused by defects in the alpha subunit of the slow delayed rectifier potassium channel. A normal corrected QT interval is less than 430 ms in males and 450 ms in females.

      There are various causes of a prolonged QT interval, including congenital factors, drugs, and other conditions. Congenital factors include Jervell-Lange-Nielsen syndrome and Romano-Ward syndrome. Drugs that can cause a prolonged QT interval include amiodarone, sotalol, tricyclic antidepressants, and selective serotonin reuptake inhibitors. Other factors that can cause a prolonged QT interval include electrolyte imbalances, acute myocardial infarction, myocarditis, hypothermia, and subarachnoid hemorrhage.

      LQTS may be detected on a routine ECG or through family screening. Long QT1 is usually associated with exertional syncope, while Long QT2 is often associated with syncope following emotional stress, exercise, or auditory stimuli. Long QT3 events often occur at night or at rest and can lead to sudden cardiac death.

      Management of LQTS involves avoiding drugs that prolong the QT interval and other precipitants if appropriate. Beta-blockers are often used, and implantable cardioverter defibrillators may be necessary in high-risk cases. It is important to note that sotalol may exacerbate LQTS.

    • This question is part of the following fields:

      • Cardiovascular System
      9.2
      Seconds
  • Question 14 - A 30-year-old female patient complains of chest pain that is mainly located behind...

    Incorrect

    • A 30-year-old female patient complains of chest pain that is mainly located behind her sternum but radiates to both shoulders. The pain worsens when she breathes deeply or exercises. She has never smoked, drinks a bottle of wine per week, and had a flu-like illness about ten days ago. During examination, her temperature is 38°C, heart rate is 80 bpm, blood pressure is 118/76 mmHg, and respiratory rate is 16. A high pitched rub is audible during systole, and when asked to take a deep breath, she reports more pain on inspiration. The ECG shows ST elevation in both anterior and inferior leads. What is the most probable diagnosis?

      Your Answer: Pulmonary embolism

      Correct Answer: Pericarditis

      Explanation:

      Common Heart Conditions

      Pericarditis is a heart condition that is often triggered by a heart attack or viral infections like Coxsackie B. Patients with pericarditis usually have a history of flu-like symptoms. One of the most common symptoms of pericarditis is widespread ST elevation on the ECG, which is characterized by upward concavity.

      Alcoholic cardiomyopathy is another heart condition that can cause heart failure. Patients with this condition may experience symptoms like shortness of breath, fatigue, and swelling in the legs and ankles.

      Angina is a type of chest pain that can be stable or unstable depending on whether it occurs at rest or during physical activity. Stable angina is usually triggered by physical exertion, while unstable angina can occur even when a person is at rest.

    • This question is part of the following fields:

      • Cardiovascular System
      21.6
      Seconds
  • Question 15 - A 64-year-old woman is being monitored in the nurse-led heart failure clinic. She...

    Correct

    • A 64-year-old woman is being monitored in the nurse-led heart failure clinic. She has left-sided heart failure and her recent echo revealed a reduced ejection fraction. She complains of nocturnal breathlessness and needing multiple pillows to sleep.

      She is prescribed bisoprolol and another medication with the explanation that it will help decrease mortality.

      What is the probable medication she has been prescribed?

      Your Answer: Ramipril

      Explanation:

      In the treatment of heart failure, medications are used to improve the heart’s ability to pump blood effectively. Beta blockers, such as bisoprolol, are commonly prescribed to slow the heart rate and improve filling. The first-line drugs for heart failure are beta blockers and ACE inhibitors. Therefore, the patient in question will be prescribed an ACE inhibitor, such as ramipril, as the second drug. Ramipril works by reducing venous resistance, making it easier for the heart to pump blood out, and lowering arterial pressures, which increases the heart’s pre-load.

      Carvedilol is not the correct choice for this patient. Although it can be used in heart failure, the patient is already taking a beta blocker, and adding another drug from the same class could cause symptomatic bradycardia or hypotension.

      Digoxin is not the appropriate choice either. While it can be used in heart failure, it should only be initiated by a specialist.

      Sacubitril-valsartan is also not the right choice for this patient. Although it is becoming more commonly used in heart failure patients, it should only be prescribed by a specialist after first and second-line treatment options have been exhausted.

      Chronic heart failure can be managed through drug treatment, according to updated guidelines issued by NICE in 2018. While loop diuretics are useful in managing fluid overload, they do not reduce mortality in the long term. The first-line treatment for all patients is a combination of an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Aldosterone antagonists are recommended as second-line treatment, but potassium levels should be monitored as both ACE inhibitors and aldosterone antagonists can cause hyperkalaemia. Third-line treatment should be initiated by a specialist and may include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, and cardiac resynchronisation therapy. Other treatments include annual influenzae and one-off pneumococcal vaccines. Those with asplenia, splenic dysfunction, or chronic kidney disease may require a booster every 5 years.

    • This question is part of the following fields:

      • Cardiovascular System
      21.5
      Seconds
  • Question 16 - Which ions are responsible for the plateau phase of the cardiac action potential...

    Incorrect

    • Which ions are responsible for the plateau phase of the cardiac action potential in stage 2?

      Your Answer: Sodium in, calcium in

      Correct Answer: Calcium in, potassium out

      Explanation:

      The Phases of Cardiac Action Potential

      The cardiac action potential is a complex process that involves four distinct phases. The first phase, known as phase 0 or the depolarisation phase, is initiated by the opening of fast Na channels, which allows an influx of Na ions into the cell. This influx of positively charged ions creates a positive current that rapidly depolarises the cell membrane.

      In the second phase, known as phase 1 or initial repolarisation, the fast Na channels close, causing a brief period of repolarisation. This is followed by phase 2 or the plateau phase, which is characterised by the opening of K and Ca channels. The influx of calcium ions into the cell is balanced by the efflux of potassium ions, resulting in a net neutral current.

      The final phase, phase 3 or repolarisation, is initiated by the closure of Ca channels, which causes a net negative current as K+ ions continue to leave the cell. It is important to note that the inward movement of sodium alone would not result in a plateau, as it represents a positive current. The normal action of the sodium-potassium pump involves the inward movement of potassium combined with the outward movement of sodium.

    • This question is part of the following fields:

      • Cardiovascular System
      9.5
      Seconds
  • Question 17 - A 32-year-old woman who is 34 weeks pregnant with her first baby is...

    Correct

    • A 32-year-old woman who is 34 weeks pregnant with her first baby is worried about the possibility of her child having a congenital heart defect. She was born with patent ductus arteriosus (PDA) herself and wants to know what treatment options are available for this condition.

      What treatment will you recommend if her baby is diagnosed with PDA?

      Your Answer: The baby receives indomethacin as a neonate

      Explanation:

      The preferred treatment for patent ductus arteriosus (PDA) in neonates is indomethacin or ibuprofen, administered after birth. While PDA is more common in premature infants, a family history of heart defects can increase the risk. Diagnosis typically occurs during postnatal baby checks, often due to the presence of a murmur or symptoms of heart failure. Doing nothing is not a recommended approach, as spontaneous closure is rare. Surgery may be necessary if medical management is unsuccessful. Prostaglandin E1 is not the best answer, as it is typically used in cases where PDA is associated with another congenital heart defect. Indomethacin or ibuprofen are not given to the mother during the antenatal period.

      Understanding Patent Ductus Arteriosus

      Patent ductus arteriosus is a type of congenital heart defect that is generally classified as ‘acyanotic’. However, if left uncorrected, it can eventually result in late cyanosis in the lower extremities, which is termed differential cyanosis. This condition is caused by a connection between the pulmonary trunk and descending aorta. Normally, the ductus arteriosus closes with the first breaths due to increased pulmonary flow, which enhances prostaglandins clearance. However, in some cases, this connection remains open, leading to patent ductus arteriosus.

      This condition is more common in premature babies, those born at high altitude, or those whose mothers had rubella infection in the first trimester. The features of patent ductus arteriosus include a left subclavicular thrill, continuous ‘machinery’ murmur, large volume, bounding, collapsing pulse, wide pulse pressure, and heaving apex beat.

      The management of patent ductus arteriosus involves the use of indomethacin or ibuprofen, which are given to the neonate. These medications inhibit prostaglandin synthesis and close the connection in the majority of cases. If patent ductus arteriosus is associated with another congenital heart defect amenable to surgery, then prostaglandin E1 is useful to keep the duct open until after surgical repair. Understanding patent ductus arteriosus is important for early diagnosis and management of this condition.

    • This question is part of the following fields:

      • Cardiovascular System
      6.6
      Seconds
  • Question 18 - A 75-year-old male presents to his GP with a four week history of...

    Correct

    • A 75-year-old male presents to his GP with a four week history of shortness of breath when he walks for approximately two minutes on level ground. There is also an associated central chest pain which resolves when he rests. The pain is localised and does not radiate.

      On examination, there were obvious signs of ankle and sacral pitting oedema. A left ventricular heave was palpated but the apex beat was not displaced. A systolic murmur was heard best at the second intercostal space just right of the sternum. This murmur also radiated to the carotid arteries.

      Which investigation is most likely to confirm the underlying cause of his symptoms?

      Your Answer: Echocardiogram

      Explanation:

      Diagnosis of Valvular Heart Disease

      Echocardiography is the most sensitive and specific way to diagnose valvular heart disease (VHD). It involves observing the valvular leaflets and degree of calcified stenosis of the aortic valve, as well as calculating cardiac output and ejection fraction for prognostic information. Chest x-ray may reveal a calcified aortic valve and left ventricular hypertrophy, while bilateral ankle edema is a minor sign for congestive heart failure. To assess the severity of heart failure, an x-ray, ECG, and BNP should be performed, but echocardiogram remains the most reliable diagnostic tool for VHD.

      A myocardial infarction is unlikely in this patient due to her age and the duration of symptoms. Instead, her angina-type pain is likely due to her underlying aortic valve disease. An angiogram of the coronary arteries alone cannot diagnose valvular defects. Cardiac enzymes such as troponin I and T are markers for myocardial necrosis and will not aid in the diagnosis of VHD. While ECG should be performed in a patient presenting with these symptoms, it alone is insufficient to diagnose VHD. The ECG may show left axis deviation due to left ventricular hypertrophy.

    • This question is part of the following fields:

      • Cardiovascular System
      81.4
      Seconds
  • Question 19 - A 65-year-old man with a history of angina, hypertension, and hypercholesterolaemia has been...

    Incorrect

    • A 65-year-old man with a history of angina, hypertension, and hypercholesterolaemia has been discharged from the hospital after experiencing a non-ST-elevation myocardial infarction (NSTEMI). He was already taking aspirin, atorvastatin, bisoprolol, and ramipril before his NSTEMI. As part of his post-discharge instructions, he has been advised to take ticagrelor for the next 12 months. What is the mechanism of action of this newly prescribed medication?

      Your Answer: Direct thrombin inhibitor

      Correct Answer: P2Y12 receptor antagonist

      Explanation:

      Ticagrelor functions similarly to clopidogrel by hindering the binding of ADP to platelet receptors. It is prescribed to prevent atherothrombotic events in individuals with acute coronary syndrome (ACS) and is typically administered in conjunction with aspirin. Additionally, it is a specific and reversible inhibitor.

      ADP receptor inhibitors, such as clopidogrel, prasugrel, ticagrelor, and ticlopidine, work by inhibiting the P2Y12 receptor, which leads to sustained platelet aggregation and stabilization of the platelet plaque. Clinical trials have shown that prasugrel and ticagrelor are more effective than clopidogrel in reducing short- and long-term ischemic events in high-risk patients with acute coronary syndrome or undergoing percutaneous coronary intervention. However, ticagrelor may cause dyspnea due to impaired clearance of adenosine, and there are drug interactions and contraindications to consider for each medication. NICE guidelines recommend dual antiplatelet treatment with aspirin and ticagrelor for 12 months as a secondary prevention strategy for ACS.

    • This question is part of the following fields:

      • Cardiovascular System
      11.9
      Seconds
  • Question 20 - A 36-year-old male comes to his GP complaining of chest pain that has...

    Correct

    • A 36-year-old male comes to his GP complaining of chest pain that has been present for a week. The pain worsens when he breathes in and is relieved when he sits forward. He also has a non-productive cough. He recently had a viral infection. An ECG was performed and showed global saddle-shaped ST elevation.

      Your Answer: Acute pericarditis

      Explanation:

      Chest pain that is relieved by sitting or leaning forward is often a symptom of acute pericarditis. This condition is commonly caused by a viral infection and may also present with flu-like symptoms, non-productive cough, and dyspnea. ECG changes may show a saddle-shaped ST elevation.

      Cardiac tamponade, on the other hand, is characterized by Beck’s triad, which includes hypotension, raised JVP, and muffled heart sounds. Dyspnea and tachycardia may also be present.

      A myocardial infarction is unlikely if the chest pain has been present for a week, as it typically presents more acutely and with constant chest pain regardless of body positioning. ECG changes would also occur in specific territories rather than globally.

      A pneumothorax presents with sudden onset dyspnea, pleuritic chest pain, tachypnea, and sweating. No ECG changes would be observed.

      A pulmonary embolism typically presents with acute onset tachypnea, fever, tachycardia, and crackles. Signs of deep vein thrombosis may also be present.

      Acute Pericarditis: Causes, Features, Investigations, and Management

      Acute pericarditis is a possible diagnosis for patients presenting with chest pain. The condition is characterized by chest pain, which may be pleuritic and relieved by sitting forwards. Other symptoms include non-productive cough, dyspnoea, and flu-like symptoms. Tachypnoea and tachycardia may also be present, along with a pericardial rub.

      The causes of acute pericarditis include viral infections, tuberculosis, uraemia, trauma, post-myocardial infarction, Dressler’s syndrome, connective tissue disease, hypothyroidism, and malignancy.

      Investigations for acute pericarditis include ECG changes, which are often global/widespread, as opposed to the ‘territories’ seen in ischaemic events. The ECG may show ‘saddle-shaped’ ST elevation and PR depression, which is the most specific ECG marker for pericarditis. All patients with suspected acute pericarditis should have transthoracic echocardiography.

      Management of acute pericarditis involves treating the underlying cause. A combination of NSAIDs and colchicine is now generally used as first-line treatment for patients with acute idiopathic or viral pericarditis.

      In summary, acute pericarditis is a possible diagnosis for patients presenting with chest pain. The condition is characterized by chest pain, which may be pleuritic and relieved by sitting forwards, along with other symptoms. The causes of acute pericarditis are varied, and investigations include ECG changes and transthoracic echocardiography. Management involves treating the underlying cause and using a combination of NSAIDs and colchicine as first-line treatment.

    • This question is part of the following fields:

      • Cardiovascular System
      4
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiovascular System (8/20) 40%
Passmed