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  • Question 1 - A 45-year-old man undergoes a routine medical exam and his blood pressure is...

    Correct

    • A 45-year-old man undergoes a routine medical exam and his blood pressure is measured at 155/95 mmHg, which is unusual as it has been normal for the past five annual check-ups. What could be the reason for this sudden change?

      Your Answer: An undersized blood pressure cuff

      Explanation:

      Ensuring Accurate Blood Pressure Measurements

      Blood pressure is a crucial physiological measurement in medicine, and it is essential to ensure that the values obtained are accurate. Inaccurate readings can occur due to various reasons, such as using the wrong cuff size, incorrect arm positioning, and unsupported arms. For instance, using a bladder that is too small can lead to an overestimation of blood pressure, while using a bladder that is too large can result in an underestimation of blood pressure. Similarly, lowering the arm below heart level can lead to an overestimation of blood pressure, while elevating the arm above heart level can result in an underestimation of blood pressure.

      It is recommended to measure blood pressure in both arms when considering a diagnosis of hypertension. If there is a difference of more than 20 mmHg between the readings obtained from both arms, the measurements should be repeated. If the difference remains greater than 20 mmHg, subsequent blood pressures should be recorded from the arm with the higher reading. By following these guidelines, healthcare professionals can ensure that accurate blood pressure measurements are obtained, which is crucial for making informed medical decisions.

    • This question is part of the following fields:

      • Cardiovascular System
      4.1
      Seconds
  • Question 2 - A 57-year-old man comes to see his doctor with concerns about his sexual...

    Incorrect

    • A 57-year-old man comes to see his doctor with concerns about his sexual relationship with his new wife. Upon further inquiry, he discloses that he is experiencing difficulty in achieving physical arousal and is experiencing delayed orgasms. He did not report any such issues during his medication review six weeks ago and believes that the recent change in medication may be responsible for this.

      The patient's medical history includes asthma, hypertension, migraine, bilateral hip replacement, and gout.

      Which medication is the most likely cause of his recent prescription change?

      Your Answer: Amlodipine

      Correct Answer: Indapamide

      Explanation:

      Thiazide-like diuretics, including indapamide, can cause sexual dysfunction, which is evident in this patient’s history. Before attempting to manage the issue, it is important to rule out any iatrogenic causes. Ramipril, an ACE-inhibitor, is not associated with sexual dysfunction, while losartan, an angiotensin II receptor blocker, and amlodipine, a dihydropyridine calcium channel blocker, are also not known to cause sexual dysfunction and are used in the management of hypertension.

      Thiazide diuretics are medications that work by blocking the thiazide-sensitive Na+-Cl− symporter, which inhibits sodium reabsorption at the beginning of the distal convoluted tubule (DCT). This results in the loss of potassium as more sodium reaches the collecting ducts. While thiazide diuretics are useful in treating mild heart failure, loop diuretics are more effective in reducing overload. Bendroflumethiazide was previously used to manage hypertension, but recent NICE guidelines recommend other thiazide-like diuretics such as indapamide and chlorthalidone.

      Common side effects of thiazide diuretics include dehydration, postural hypotension, and electrolyte imbalances such as hyponatremia, hypokalemia, and hypercalcemia. Other potential adverse effects include gout, impaired glucose tolerance, and impotence. Rare side effects may include thrombocytopenia, agranulocytosis, photosensitivity rash, and pancreatitis.

      It is worth noting that while thiazide diuretics may cause hypercalcemia, they can also reduce the incidence of renal stones by decreasing urinary calcium excretion. According to current NICE guidelines, the management of hypertension involves the use of thiazide-like diuretics, along with other medications and lifestyle changes, to achieve optimal blood pressure control and reduce the risk of cardiovascular disease.

    • This question is part of the following fields:

      • Cardiovascular System
      11.6
      Seconds
  • Question 3 - A 59-year-old man presents to the emergency department with pleuritic thoracic pain and...

    Incorrect

    • A 59-year-old man presents to the emergency department with pleuritic thoracic pain and fever. His medical history includes an inferior STEMI that occurred 3 weeks ago. During auscultation, a pericardial rub is detected, and his ECG shows diffuse ST segment elevation and PR segment depression. What is the complication of myocardial infarction that the patient is experiencing?

      Your Answer: Another myocardial infarction

      Correct Answer: Dressler syndrome

      Explanation:

      The patient’s symptoms strongly suggest Dressler syndrome, which is an autoimmune-related inflammation of the pericardium that typically occurs 2-6 weeks after a heart attack. This condition is characterized by fever, pleuritic pain, and diffuse ST elevation and PR depression on an electrocardiogram. A pleural friction rub can also be heard during a physical exam.

      While another heart attack is a possibility, the absence of diffuse ST elevation and the presence of a pleural friction rub make this diagnosis less likely.

      A left ventricular aneurysm would present with persistent ST elevation but no chest pain.

      Ventricular free wall rupture typically occurs 1-2 weeks after a heart attack and would present with acute heart failure due to cardiac tamponade, which is characterized by raised jugular venous pressure, pulsus paradoxus, and diminished heart sounds.

      A ventricular septal defect usually occurs within the first week and would present with acute heart failure and a pansystolic murmur.

      Myocardial infarction (MI) can lead to various complications, which can occur immediately, early, or late after the event. Cardiac arrest is the most common cause of death following MI, usually due to ventricular fibrillation. Cardiogenic shock may occur if a large part of the ventricular myocardium is damaged, and it is difficult to treat. Chronic heart failure may result from ventricular myocardium dysfunction, which can be managed with loop diuretics, ACE-inhibitors, and beta-blockers. Tachyarrhythmias, such as ventricular fibrillation and ventricular tachycardia, are common complications. Bradyarrhythmias, such as atrioventricular block, are more common following inferior MI. Pericarditis is common in the first 48 hours after a transmural MI, while Dressler’s syndrome may occur 2-6 weeks later. Left ventricular aneurysm and free wall rupture, ventricular septal defect, and acute mitral regurgitation are other complications that may require urgent medical attention.

    • This question is part of the following fields:

      • Cardiovascular System
      218.1
      Seconds
  • Question 4 - A 78-year-old male patient with AF, who is on appropriate medication for rate...

    Incorrect

    • A 78-year-old male patient with AF, who is on appropriate medication for rate control, is admitted with dig toxicity after receiving antibiotics for a UTI. What ECG finding is most probable?

      Your Answer: ST depression

      Correct Answer: Reverse tick abnormality

      Explanation:

      Dig Toxicity and its Treatment

      Dig Toxicity can occur as a result of taking antibiotics that inhibit enzymes, especially if the prescribing physician does not take this into account. One of the most common signs of dig toxicity is the reverse tick abnormality, which can be detected through an electrocardiogram (ECG).

      To treat dig toxicity, it is important to first address any electrolyte imbalances that may be present. In more severe cases, a monoclonal antibody called digibind may be administered to help alleviate symptoms. Overall, it is important for healthcare providers to be aware of the potential for dig toxicity and to take appropriate measures to prevent and treat it.

    • This question is part of the following fields:

      • Cardiovascular System
      20
      Seconds
  • Question 5 - A 68-year-old man arrives at the emergency department complaining of intense abdominal pain...

    Correct

    • A 68-year-old man arrives at the emergency department complaining of intense abdominal pain that spreads to his back. His medical history shows that he has an abdominal aortic aneurysm. During a FAST scan, it is discovered that the abdominal aorta is widely dilated, with the most significant expansion occurring at the point where it divides into the iliac arteries. What vertebral level corresponds to the location of the most prominent dilation observed in the FAST scan?

      Your Answer: L4

      Explanation:

      The abdominal aorta divides into two branches at the level of the fourth lumbar vertebrae. At the level of T12, the coeliac trunk arises, while at L1, the superior mesenteric artery branches off. The testicular artery and renal artery originate at L2, and at L3, the inferior mesenteric artery is formed.

      The aorta is a major blood vessel that carries oxygenated blood from the heart to the rest of the body. At different levels along the aorta, there are branches that supply blood to specific organs and regions. These branches include the coeliac trunk at the level of T12, which supplies blood to the stomach, liver, and spleen. The left renal artery, at the level of L1, supplies blood to the left kidney. The testicular or ovarian arteries, at the level of L2, supply blood to the reproductive organs. The inferior mesenteric artery, at the level of L3, supplies blood to the lower part of the large intestine. Finally, at the level of L4, the abdominal aorta bifurcates, or splits into two branches, which supply blood to the legs and pelvis.

    • This question is part of the following fields:

      • Cardiovascular System
      6.5
      Seconds
  • Question 6 - Mrs. Green is a 64-year-old woman with colon cancer. She is undergoing adjuvant...

    Incorrect

    • Mrs. Green is a 64-year-old woman with colon cancer. She is undergoing adjuvant chemotherapy, however in the past six months has suffered four deep vein thrombosis (DVT) events, despite being optimally anticoagulated with the maximum dose of dabigatran. On one occasion she suffered a DVT during treatment with dalteparin (a low molecular weight heparin). She has been admitted with symptoms of another DVT.

      What is the recommended treatment for her current DVT?

      Your Answer: Prescribe Thrombo-Embolic Deterrent (TED) stockings

      Correct Answer: Insert an inferior vena caval filter

      Explanation:

      For patients with recurrent venous thromboembolic disease, an inferior vena cava filter may be considered. This is particularly relevant for patients with cancer who have experienced multiple DVTs despite being fully anticoagulated. Before considering an inferior vena cava filter, alternative treatments such as increasing the target INR to 3-4 for long-term high-intensity oral anticoagulant therapy or switching to LMWH should be considered. This recommendation is in line with NICE guidelines on the diagnosis, management, and thrombophilia testing of venous thromboembolic diseases. Prescribing apixaban, increasing the dose of dabigatran off-license, or prescribing Thrombo-Embolic Deterrent (TED) stockings are not appropriate solutions for this patient. Similarly, initiating end-of-life drugs and preparing the family is not indicated based on the clinical description provided.

      Management of Pulmonary Embolism

      Pulmonary embolism (PE) is a serious condition that requires prompt management. The National Institute for Health and Care Excellence (NICE) updated their guidelines on the management of venous thromboembolism (VTE) in 2020, with some key changes. One of the significant changes is the recommendation to use direct oral anticoagulants (DOACs) as the first-line treatment for most people with VTE, including those with active cancer. Another change is the increasing use of outpatient treatment for low-risk PE patients, determined by a validated risk stratification tool.

      Anticoagulant therapy is the cornerstone of VTE management. The guidelines recommend using apixaban or rivaroxaban as the first-line treatment for PE, followed by LMWH, dabigatran, edoxaban, or a vitamin K antagonist (VKA) if necessary. For patients with active cancer, DOACs are now recommended instead of LMWH. The length of anticoagulation depends on whether the VTE was provoked or unprovoked, with treatment typically lasting for at least three months. Patients with unprovoked VTE may continue treatment for up to six months, depending on their risk of recurrence and bleeding.

      In cases of haemodynamic instability, thrombolysis is recommended as the first-line treatment for massive PE with circulatory failure. Other invasive approaches may also be considered where appropriate facilities exist. Patients who have repeat pulmonary embolisms, despite adequate anticoagulation, may be considered for inferior vena cava (IVC) filters. However, the evidence base for IVC filter use is weak, and further studies are needed.

    • This question is part of the following fields:

      • Cardiovascular System
      20.1
      Seconds
  • Question 7 - A 52-year-old man comes to the emergency department complaining of severe crushing chest...

    Correct

    • A 52-year-old man comes to the emergency department complaining of severe crushing chest pain that spreads to his left arm and jaw. He also feels nauseous. Upon conducting an ECG, you observe ST-segment elevation in several chest leads and diagnose him with ST-elevation MI. From which vessel do the coronary vessels arise?

      Your Answer: Ascending aorta

      Explanation:

      The left and right coronary arteries originate from the left and right aortic sinuses, respectively. The left aortic sinus is located on the left side of the ascending aorta, while the right aortic sinus is situated at the back.

      The coronary sinus is a venous vessel formed by the confluence of four coronary veins. It receives venous blood from the great, middle, small, and posterior cardiac veins and empties into the right atrium.

      The descending aorta is a continuation of the aortic arch and runs through the chest and abdomen before dividing into the left and right common iliac arteries. It has several branches along its path.

      The pulmonary veins transport oxygenated blood from the lungs to the left atrium and do not have any branches.

      The pulmonary artery carries deoxygenated blood from the right ventricle to the lungs. It splits into the left and right pulmonary arteries, which travel to the left and right lungs, respectively.

      The patient in the previous question has exhibited symptoms indicative of acute coronary syndrome, and the ECG results confirm an ST-elevation myocardial infarction.

      The walls of each cardiac chamber are made up of the epicardium, myocardium, and endocardium. The heart and roots of the great vessels are related anteriorly to the sternum and the left ribs. The coronary sinus receives blood from the cardiac veins, and the aortic sinus gives rise to the right and left coronary arteries. The left ventricle has a thicker wall and more numerous trabeculae carnae than the right ventricle. The heart is innervated by autonomic nerve fibers from the cardiac plexus, and the parasympathetic supply comes from the vagus nerves. The heart has four valves: the mitral, aortic, pulmonary, and tricuspid valves.

    • This question is part of the following fields:

      • Cardiovascular System
      16.2
      Seconds
  • Question 8 - A 63-year-old man visits the clinic with complaints of palpitations and constipation that...

    Incorrect

    • A 63-year-old man visits the clinic with complaints of palpitations and constipation that has been bothering him for the past 5 days. He reports passing gas but feels uneasy. The patient has a history of hypertension, and you recently prescribed bendroflumethiazide to manage it. To check for signs of hypokalaemia, you conduct an ECG. What is an ECG indication of hypokalaemia?

      Your Answer: ST-segment elevation

      Correct Answer: Prolonged PR interval

      Explanation:

      Hypokalaemia can be identified through a prolonged PR interval on an ECG. However, this same ECG sign may also be present in cases of hyperkalaemia. Additional ECG signs of hypokalaemia include small or absent P waves, tall tented T waves, and broad bizarre QRS complexes. On the other hand, hyperkalaemia can be identified through ECG signs such as long PR intervals, a sine wave pattern, and tall tented T waves, as well as broad bizarre QRS complexes.

      Hypokalaemia, a condition characterized by low levels of potassium in the blood, can be detected through ECG features. These include the presence of U waves, small or absent T waves (which may occasionally be inverted), a prolonged PR interval, ST depression, and a long QT interval. The ECG image provided shows typical U waves and a borderline PR interval. To remember these features, one user suggests the following rhyme: In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT.

    • This question is part of the following fields:

      • Cardiovascular System
      21.4
      Seconds
  • Question 9 - Which ions are responsible for the plateau phase of the cardiac action potential...

    Correct

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

      Your 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
      2.2
      Seconds
  • Question 10 - A 32-year-old woman arrives at the emergency department with a sudden and severe...

    Incorrect

    • A 32-year-old woman arrives at the emergency department with a sudden and severe headache, describing it as the worst she has ever experienced. She has a medical history of hypertension and polycystic kidney disease (PKD). The emergency physician diagnoses a subarachnoid hemorrhage, which is a common complication of her PKD.

      What is the gold standard investigation for intracranial vascular disease?

      Your Answer: Non-contrast CT of the head

      Correct Answer: Cerebral angiography

      Explanation:

      The gold standard investigation for intracranial vascular disease is cerebral angiography, which can diagnose intracranial aneurysms and other vascular diseases by visualizing arteries and veins using contrast dye injected into the bloodstream. This technique can also create 3-D reconstructed images that allow for a comprehensive view of the cerebral vessels and accompanying pathology from all angles.

      Individuals with PKD are at an increased risk of cerebral aneurysms, which can lead to subarachnoid hemorrhages.

      Flow-Sensitive MRI (FS MRI) is a useful tool that combines functional MRI with images of cerebrospinal fluid (CSF) flow. It can aid in planning the surgical removal of skull base tumors, spinal cord tumors, or tumors causing hydrocephalus.

      While contrast and non-contrast CT scans are commonly used as the first line of investigation for intracranial lesions, they are not the gold standard and are superseded by cerebral angiography.

      Understanding Cerebral Blood Flow and Angiography

      Cerebral blood flow is regulated by the central nervous system, which can adjust its own blood supply. Various factors can affect cerebral pressure, including CNS metabolism, trauma, pressure, and systemic carbon dioxide levels. The most potent mediator is PaCO2, while acidosis and hypoxemia can also increase cerebral blood flow to a lesser degree. In patients with head injuries, increased intracranial pressure can impair blood flow. The Monro-Kelly Doctrine governs intracerebral pressure, which considers the brain as a closed box, and changes in pressure are offset by the loss of cerebrospinal fluid. However, when this is no longer possible, intracranial pressure rises.

      Cerebral angiography is an invasive test that involves injecting contrast media into the carotid artery using a catheter. Radiographs are taken as the dye works its way through the cerebral circulation. This test can be used to identify bleeding aneurysms, vasospasm, and arteriovenous malformations, as well as differentiate embolism from large artery thrombosis. Understanding cerebral blood flow and angiography is crucial in diagnosing and treating various neurological conditions.

    • This question is part of the following fields:

      • Cardiovascular System
      28.5
      Seconds
  • Question 11 - A 78-year-old woman with a history of heart failure visits the clinic complaining...

    Correct

    • A 78-year-old woman with a history of heart failure visits the clinic complaining of constipation that has lasted for 5 days. Upon further inquiry, she mentions feeling weaker than usual this week and experiencing regular muscle cramps. During the examination, you observe reduced tone and hyporeflexia in both her upper and lower limbs. You suspect that her symptoms may be caused by hypokalaemia, which could be related to the diuretics she takes to manage her heart failure. Which of the following diuretics is known to be associated with hypokalaemia?

      Your Answer: Furosemide

      Explanation:

      Hypokalaemia is a potential side effect of loop diuretics such as furosemide. In contrast, potassium-sparing diuretics like spironolactone, triamterene, eplerenone, and amiloride are more likely to cause hyperkalaemia. The patient in the scenario is experiencing symptoms suggestive of hypokalaemia, including muscle weakness, cramps, and constipation. Hypokalaemia can also cause fatigue, myalgia, hyporeflexia, and in rare cases, paralysis.

      Loop Diuretics: Mechanism of Action and Clinical Applications

      Loop diuretics, such as furosemide and bumetanide, are medications that inhibit the Na-K-Cl cotransporter (NKCC) in the thick ascending limb of the loop of Henle. By doing so, they reduce the absorption of NaCl, resulting in increased urine output. Loop diuretics act on NKCC2, which is more prevalent in the kidneys. These medications work on the apical membrane and must first be filtered into the tubules by the glomerulus before they can have an effect. Patients with poor renal function may require higher doses to ensure sufficient concentration in the tubules.

      Loop diuretics are commonly used in the treatment of heart failure, both acutely (usually intravenously) and chronically (usually orally). They are also indicated for resistant hypertension, particularly in patients with renal impairment. However, loop diuretics can cause adverse effects such as hypotension, hyponatremia, hypokalemia, hypomagnesemia, hypochloremic alkalosis, ototoxicity, hypocalcemia, renal impairment, hyperglycemia (less common than with thiazides), and gout. Therefore, careful monitoring of electrolyte levels and renal function is necessary when using loop diuretics.

    • This question is part of the following fields:

      • Cardiovascular System
      17.5
      Seconds
  • Question 12 - One of the elderly patients at your general practice was recently hospitalized and...

    Incorrect

    • One of the elderly patients at your general practice was recently hospitalized and diagnosed with myeloma. It was discovered that they have severe chronic kidney disease. The patient comes in for an update on their condition. After reviewing their medications, you realize they are taking ramipril for hypertension, which is contraindicated in renal failure. What is the most accurate description of the effect of ACE inhibitors on glomerular filtration pressure?

      Your Answer: Vasoconstriction of the afferent arteriole

      Correct Answer: Vasodilation of the efferent arteriole

      Explanation:

      The efferent arteriole experiences vasodilation as a result of ACE inhibitors and ARBs, which inhibit the production of angiotensin II and block its receptors. This leads to a decrease in glomerular filtration pressure and rate, particularly in individuals with renal artery stenosis. On the other hand, the afferent arteriole remains dilated due to the presence of prostaglandins. NSAIDs, which inhibit COX-1 and COX-2, can cause vasoconstriction of the afferent arteriole and a subsequent decrease in glomerular filtration pressure. In healthy individuals, the afferent arteriole remains dilated while the efferent arteriole remains constricted to maintain a balanced glomerular pressure. The patient in the scenario has been diagnosed with myeloma, a disease that arises from the malignant transformation of B-cells and is characterized by bone infiltration, hypercalcaemia, anaemia, and renal impairment.

      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
      11
      Seconds
  • Question 13 - 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: Streptococcus pneumoniae

      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
      5.3
      Seconds
  • Question 14 - A 50-year-old man with a history of rate-controlled atrial fibrillation (AF) presents with...

    Incorrect

    • A 50-year-old man with a history of rate-controlled atrial fibrillation (AF) presents with chest pain, palpitations, and dizziness. The patient has a past medical history of a transient ischemic episode and is taking warfarin to prevent further ischemic episodes. He also has a history of gout, low back pain, depression, and polymyalgia rheumatica.

      Upon immediate ECG, the patient is found to have an irregularly irregular rhythm consistent with fast AF. You decide to perform electrical cardioversion and prescribe a course of amiodarone to prevent recurrence.

      What drug interaction should you be cautious of in this patient?

      Your Answer: Naproxen and amiodarone

      Correct Answer: Warfarin and amiodarone

      Explanation:

      The metabolism of warfarin is reduced by amiodarone, which can increase the risk of bleeding. However, there are no known interactions between amiodarone and naproxen, paracetamol, codeine, or allopurinol. It should be noted that the patient in question is not diabetic and therefore should not be taking metformin.

      Amiodarone is a medication used to treat various types of abnormal heart rhythms. It works by blocking potassium channels, which prolongs the action potential and helps to regulate the heartbeat. However, it also has other effects, such as blocking sodium channels. Amiodarone has a very long half-life, which means that loading doses are often necessary. It should ideally be given into central veins to avoid thrombophlebitis. Amiodarone can cause proarrhythmic effects due to lengthening of the QT interval and can interact with other drugs commonly used at the same time. Long-term use of amiodarone can lead to various adverse effects, including thyroid dysfunction, corneal deposits, pulmonary fibrosis/pneumonitis, liver fibrosis/hepatitis, peripheral neuropathy, myopathy, photosensitivity, a ‘slate-grey’ appearance, thrombophlebitis, injection site reactions, and bradycardia. Patients taking amiodarone should be monitored regularly with tests such as TFT, LFT, U&E, and CXR.

    • This question is part of the following fields:

      • Cardiovascular System
      18.4
      Seconds
  • Question 15 - 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
      13.1
      Seconds
  • Question 16 - A 25-year-old is suffering from tonsillitis and experiencing significant pain. Which nerve is...

    Correct

    • A 25-year-old is suffering from tonsillitis and experiencing significant pain. Which nerve is responsible for providing sensory innervation to the tonsillar fossa?

      Your Answer: Glossopharyngeal nerve

      Explanation:

      The tonsillar fossa is primarily innervated by the glossopharyngeal nerve, with a smaller contribution from the lesser palatine nerve. As a result, patients may experience ear pain (otalgia) after undergoing a tonsillectomy.

      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
      4.2
      Seconds
  • Question 17 - A 29-year-old woman has presented herself for review at an antenatal clinic upon...

    Correct

    • A 29-year-old woman has presented herself for review at an antenatal clinic upon discovering her pregnancy.

      Your Answer: Warfarin

      Explanation:

      Understanding Warfarin: Mechanism of Action, Indications, Monitoring, Factors, and Side-Effects

      Warfarin is an oral anticoagulant that has been widely used for many years to manage venous thromboembolism and reduce stroke risk in patients with atrial fibrillation. However, it has been largely replaced by direct oral anticoagulants (DOACs) due to their ease of use and lack of need for monitoring. Warfarin works by inhibiting epoxide reductase, which prevents the reduction of vitamin K to its active hydroquinone form. This, in turn, affects the carboxylation of clotting factor II, VII, IX, and X, as well as protein C.

      Warfarin is indicated for patients with mechanical heart valves, with the target INR depending on the valve type and location. Mitral valves generally require a higher INR than aortic valves. It is also used as a second-line treatment after DOACs for venous thromboembolism and atrial fibrillation, with target INRs of 2.5 and 3.5 for recurrent cases. Patients taking warfarin are monitored using the INR, which may take several days to achieve a stable level. Loading regimes and computer software are often used to adjust the dose.

      Factors that may potentiate warfarin include liver disease, P450 enzyme inhibitors, cranberry juice, drugs that displace warfarin from plasma albumin, and NSAIDs that inhibit platelet function. Warfarin may cause side-effects such as haemorrhage, teratogenic effects, skin necrosis, temporary procoagulant state, thrombosis, and purple toes.

      In summary, understanding the mechanism of action, indications, monitoring, factors, and side-effects of warfarin is crucial for its safe and effective use in patients. While it has been largely replaced by DOACs, warfarin remains an important treatment option for certain patients.

    • This question is part of the following fields:

      • Cardiovascular System
      14
      Seconds
  • Question 18 - 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
      3.8
      Seconds
  • Question 19 - A 55-year-old female is referred to the cardiologist by her GP due to...

    Incorrect

    • A 55-year-old female is referred to the cardiologist by her GP due to experiencing postural dyspnoea and leg oedema for a few months. The cardiologist conducts an echocardiogram and finds out that her left ventricular ejection fraction is 34%. Based on her clinical presentation, she is diagnosed with congestive cardiac failure.

      To alleviate her symptoms and improve her long-term prognosis, the patient is prescribed several medications. However, she visits the GP after two weeks, complaining of a dry, tickling cough that she attributes to one of her new medications.

      Which medication is most likely causing this new symptom in the patient?

      Your Answer: Spironolactone (aldosterone blocker)

      Correct Answer: Ramipril (ACE inhibitor)

      Explanation:

      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
      13.5
      Seconds
  • Question 20 - A 40-year-old woman visits her GP complaining of muscle cramps, fatigue, and tingling...

    Incorrect

    • A 40-year-old woman visits her GP complaining of muscle cramps, fatigue, and tingling in her fingers and toes for the past two weeks. Upon conducting a blood test, the doctor discovers low levels of serum calcium and parathyroid hormone. The patient is new to the clinic and seems a bit confused, possibly due to hypocalcemia, and is unable to provide a complete medical history. However, she mentions that she was recently hospitalized. What is the most probable cause of her hypoparathyroidism?

      Your Answer: Chronic kidney disease

      Correct Answer: Thyroidectomy

      Explanation:

      Due to their location behind the thyroid gland, the parathyroid glands are at risk of damage during a thyroidectomy, leading to iatrogenic hypoparathyroidism. This condition is characterized by low levels of both parathyroid hormone and calcium, indicating that the parathyroid glands are not responding to the hypocalcemia. The patient’s confusion and prolonged hospital stay are likely related to the surgery.

      Hypocalcemia can also be caused by chronic kidney disease, which triggers an increase in parathyroid hormone production in an attempt to raise calcium levels, resulting in hyperparathyroidism. Additionally, a deficiency in vitamin D, which is activated by the kidneys and aids in calcium absorption in the terminal ileum, can also lead to hyperparathyroidism.

      While a parathyroid adenoma is a common occurrence, it is more likely to cause hyperparathyroidism than hypoparathyroidism, which is a relatively rare side effect of thyroidectomy.

      Anatomy and Development of the Parathyroid Glands

      The parathyroid glands are four small glands located posterior to the thyroid gland within the pretracheal fascia. They develop from the third and fourth pharyngeal pouches, with those derived from the fourth pouch located more superiorly and associated with the thyroid gland, while those from the third pouch lie more inferiorly and may become associated with the thymus.

      The blood supply to the parathyroid glands is derived from the inferior and superior thyroid arteries, with a rich anastomosis between the two vessels. Venous drainage is into the thyroid veins. The parathyroid glands are surrounded by various structures, with the common carotid laterally, the recurrent laryngeal nerve and trachea medially, and the thyroid anteriorly. Understanding the anatomy and development of the parathyroid glands is important for their proper identification and preservation during surgical procedures.

    • This question is part of the following fields:

      • Cardiovascular System
      13.1
      Seconds

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