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  • Question 1 - A 55-year-old male patient complains of sudden chest pain and is being evaluated...

    Correct

    • A 55-year-old male patient complains of sudden chest pain and is being evaluated for acute coronary syndrome. Upon fasting, his serum cholesterol level was found to be 7.1 mmol/L (<5.2). What is the best initial course of action for managing this patient?

      Your Answer: Statin therapy

      Explanation:

      Statin Therapy for Hypercholesterolemia in Acute Coronary Syndrome

      Hypercholesterolemia is a common condition in patients with acute coronary syndrome. The initial treatment approach for such patients is statin therapy, which includes drugs like simvastatin, atorvastatin, and rosuvastatin. Statins have been proven to reduce mortality in both primary and secondary prevention studies. The target cholesterol concentration for patients with hypercholesterolemia and acute coronary syndrome is less than 5 mmol/L.

      According to NICE guidance, statins should be used more widely in conjunction with a QRISK2 score to stratify risk. This will help prevent cardiovascular disease and improve patient outcomes. The guidance recommends that statins be used in patients with a 10% or greater risk of developing cardiovascular disease within the next 10 years. By using statins in conjunction with risk stratification, healthcare professionals can provide more targeted and effective treatment for patients with hypercholesterolemia and acute coronary syndrome.

    • This question is part of the following fields:

      • Cardiovascular System
      15.7
      Seconds
  • Question 2 - A 50-year-old man comes to the clinic complaining of gynaecomastia. He is currently...

    Incorrect

    • A 50-year-old man comes to the clinic complaining of gynaecomastia. He is currently undergoing treatment for heart failure and gastro-oesophageal reflux. Which medication that he is taking is the most probable cause of his gynaecomastia?

      Your Answer: Aspirin

      Correct Answer: Spironolactone

      Explanation:

      Medications Associated with Gynaecomastia

      Gynaecomastia, the enlargement of male breast tissue, can be caused by various medications. Spironolactone, ciclosporin, cimetidine, and omeprazole are some of the drugs that have been associated with this condition. Ramipril has also been linked to gynaecomastia, but it is a rare occurrence.

      Aside from these medications, other drugs that can cause gynaecomastia include digoxin, LHRH analogues, cimetidine, and finasteride. It is important to note that not all individuals who take these medications will develop gynaecomastia, and the risk may vary depending on the dosage and duration of treatment.

    • This question is part of the following fields:

      • Cardiovascular System
      8
      Seconds
  • Question 3 - A 65-year-old man presents to the Emergency Department with a 60-minute history of...

    Incorrect

    • A 65-year-old man presents to the Emergency Department with a 60-minute history of central chest pain that extends to his jaw. An ECG reveals an inferior ST-segment elevation myocardial infarction (STEMI). The QRS is positive in leads I and aVL but negative in leads II and aVF. What type of axis deviation is indicated by this finding?

      Your Answer: Right

      Correct Answer: Left

      Explanation:

      To estimate the heart’s axis, one method is the quadrant method, which involves analyzing leads I and aVF. If lead I is positive and lead aVF is negative, this suggests a possible left axis deviation. To confirm left axis deviation, a second method using lead II can be used. If lead II is also negative, then left axis deviation is confirmed. Other types of axis deviation can be determined by analyzing the polarity of leads I and aVF.

      ECG Axis Deviation: Causes of Left and Right Deviation

      Electrocardiogram (ECG) axis deviation refers to the direction of the electrical activity of the heart. A normal axis is between -30 and +90 degrees. Deviation from this range can indicate underlying cardiac or pulmonary conditions.

      Left axis deviation (LAD) can be caused by left anterior hemiblock, left bundle branch block, inferior myocardial infarction, Wolff-Parkinson-White syndrome with a right-sided accessory pathway, hyperkalaemia, congenital heart defects such as ostium primum atrial septal defect (ASD) and tricuspid atresia, and minor LAD in obese individuals.

      On the other hand, right axis deviation (RAD) can be caused by right ventricular hypertrophy, left posterior hemiblock, lateral myocardial infarction, chronic lung disease leading to cor pulmonale, pulmonary embolism, ostium secundum ASD, Wolff-Parkinson-White syndrome with a left-sided accessory pathway, and minor RAD in tall individuals. It is also normal in infants less than one year old.

      It is important to note that Wolff-Parkinson-White syndrome is a common cause of both LAD and RAD, depending on the location of the accessory pathway. Understanding the causes of ECG axis deviation can aid in the diagnosis and management of underlying conditions.

    • This question is part of the following fields:

      • Cardiovascular System
      8.7
      Seconds
  • Question 4 - You are a doctor working in the intensive care unit. A 35-year-old man...

    Incorrect

    • You are a doctor working in the intensive care unit. A 35-year-old man has been admitted to the ward due to suddenly vomiting large volumes of fresh blood. His blood pressure is 90/60 mmHg and his heart rate is 150bpm. He needs urgent intravenous fluids. Several attempts at intravenous cannulation have been made but to no avail. The on-call anaesthetist suggests performing a great saphenous vein cutdown.

      Where should the anaesthetist make the incision?

      Your Answer: Five centimetres below the inferior margin of the inguinal ligament

      Correct Answer: Anterior to the medial malleolus

      Explanation:

      The long saphenous vein is often used for venous cutdown and passes in front of the medial malleolus. Venous cutdown involves surgically exposing a vein for cannulation.

      On the other hand, the short saphenous vein is situated in front of the lateral malleolus and runs up the back of the thigh to drain into the popliteal vein at the popliteal fossa.

      The long saphenous vein originates from the point where the first dorsal digital vein, which drains the big toe, joins the dorsal venous arch of the foot. It then passes in front of the medial malleolus, ascends the medial aspect of the thigh, and drains into the femoral vein by passing through the saphenous opening.

      The femoral vein becomes the external iliac vein at the inferior margin of the inguinal ligament. It receives blood from the great saphenous and popliteal veins, and a deep vein thrombosis that blocks this vein can be life-threatening.

      During a vascular examination of the lower limb, the dorsalis pedis artery is often palpated. It runs alongside the extensor digitorum longus.

      Lastly, the posterior tibial vein is located at the back of the medial malleolus, together with other structures, within the tarsal tunnel.

      The Anatomy of Saphenous Veins

      The human body has two saphenous veins: the long saphenous vein and the short saphenous vein. The long saphenous vein is often used for bypass surgery or removed as a treatment for varicose veins. It originates at the first digit where the dorsal vein merges with the dorsal venous arch of the foot and runs up the medial side of the leg. At the knee, it runs over the posterior border of the medial epicondyle of the femur bone before passing laterally to lie on the anterior surface of the thigh. It then enters an opening in the fascia lata called the saphenous opening and joins with the femoral vein in the region of the femoral triangle at the saphenofemoral junction. The long saphenous vein has several tributaries, including the medial marginal, superficial epigastric, superficial iliac circumflex, and superficial external pudendal veins.

      On the other hand, the short saphenous vein originates at the fifth digit where the dorsal vein merges with the dorsal venous arch of the foot, which attaches to the great saphenous vein. It passes around the lateral aspect of the foot and runs along the posterior aspect of the leg with the sural nerve. It then passes between the heads of the gastrocnemius muscle and drains into the popliteal vein, approximately at or above the level of the knee joint.

      Understanding the anatomy of saphenous veins is crucial for medical professionals who perform surgeries or treatments involving these veins.

    • This question is part of the following fields:

      • Cardiovascular System
      11.1
      Seconds
  • Question 5 - A 65-year-old farmer arrives at the Emergency department with complaints of intense chest...

    Correct

    • A 65-year-old farmer arrives at the Emergency department with complaints of intense chest pain that spreads to his left arm and causes breathing difficulties. His heart rate is 94 bpm. What ECG changes would you expect to observe based on the probable diagnosis?

      Your Answer: ST elevation in leads II, III, aVF

      Explanation:

      ECG Changes in Myocardial Infarction

      When interpreting an electrocardiogram (ECG) in a patient with suspected myocardial infarction (MI), it is important to consider the specific changes that may be present. In the case of a ST-elevation MI (STEMI), the ECG may show ST elevation in affected leads, such as II, III, and aVF. However, it is possible to have a non-ST elevation MI (NSTEMI) with a normal ECG, or with T wave inversion instead of upright T waves.

      Other ECG changes that may be indicative of cardiac issues include a prolonged PR interval, which could suggest heart block, and ST depression, which may reflect ischemia. Additionally, tall P waves may be seen in hyperkalemia.

      It is important to note that a patient may have an MI without displaying any ECG changes at all. In these cases, checking cardiac markers such as troponin T can help confirm the diagnosis. Overall, the various ECG changes that may be present in MI can aid in prompt and accurate diagnosis and treatment.

    • This question is part of the following fields:

      • Cardiovascular System
      7.8
      Seconds
  • Question 6 - A 39-year-old male arrives at the emergency department complaining of palpitations and is...

    Correct

    • A 39-year-old male arrives at the emergency department complaining of palpitations and is diagnosed with monomorphic ventricular tachycardia. What electrolyte is responsible for maintaining the resting potential of ventricular myocytes?

      Your Answer: Potassium

      Explanation:

      The resting potential of cardiac myocytes is maintained by potassium, while depolarization is initiated by a sudden influx of sodium ions and repolarization is caused by the outflow of potassium. The extended duration of a cardiac action potential, in contrast to skeletal muscle, is due to a gradual influx of calcium.

      Understanding the Cardiac Action Potential and Conduction Velocity

      The cardiac action potential is a series of electrical events that occur in the heart during each heartbeat. It is responsible for the contraction of the heart muscle and the pumping of blood throughout the body. The action potential is divided into five phases, each with a specific mechanism. The first phase is rapid depolarization, which is caused by the influx of sodium ions. The second phase is early repolarization, which is caused by the efflux of potassium ions. The third phase is the plateau phase, which is caused by the slow influx of calcium ions. The fourth phase is final repolarization, which is caused by the efflux of potassium ions. The final phase is the restoration of ionic concentrations, which is achieved by the Na+/K+ ATPase pump.

      Conduction velocity is the speed at which the electrical signal travels through the heart. The speed varies depending on the location of the signal. Atrial conduction spreads along ordinary atrial myocardial fibers at a speed of 1 m/sec. AV node conduction is much slower, at 0.05 m/sec. Ventricular conduction is the fastest in the heart, achieved by the large diameter of the Purkinje fibers, which can achieve velocities of 2-4 m/sec. This allows for a rapid and coordinated contraction of the ventricles, which is essential for the proper functioning of the heart. Understanding the cardiac action potential and conduction velocity is crucial for diagnosing and treating heart conditions.

    • This question is part of the following fields:

      • Cardiovascular System
      9.2
      Seconds
  • Question 7 - A 65-year-old man with a history of hypertension, diabetes and high cholesterol arrives...

    Correct

    • A 65-year-old man with a history of hypertension, diabetes and high cholesterol arrives at the hospital complaining of severe chest pain that spreads to his jaw. He has vomited twice and feels lightheaded.

      An electrocardiogram (ECG) reveals widespread ST elevation with reciprocal ST-segment depression. A troponin T serum level is obtained and confirms an elevated reading.

      What is the target of this cardiac biomarker?

      Your Answer: Tropomyosin

      Explanation:

      The troponin-tropomyosin complex is formed when troponin T binds to tropomyosin. In cases of ST-elevation myocardial infarction (STEMI), elevated levels of troponin T in the bloodstream can confirm the presence of cardiac tissue damage. This biomarker plays a role in regulating muscle contraction by binding to tropomyosin. However, troponin I, not troponin T, binds to actin to hold the troponin-tropomyosin complex in place. While troponin T is released in cases of cardiac cell damage, it is considered less sensitive and specific than troponin I in diagnosing myocardial infarction.

      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
      6.6
      Seconds
  • Question 8 - A 49-year-old man named Mr. Johnson visits his GP surgery to review his...

    Incorrect

    • A 49-year-old man named Mr. Johnson visits his GP surgery to review his blood pressure as he has been diagnosed with type II diabetes mellitus. His blood pressure is 150/112 mmHg and his heart rate is 82 bpm. Mr. Johnson smokes 20 cigarettes a day, drinks three pints of beer most nights, and has a diet high in saturated fat. He drives to work, even though his office is only one mile away from his house. He appears anxious and worried about having a heart attack soon. What would be your first step in treating his hypertension?

      Your Answer: Prescribe lisinopril

      Correct Answer: Lifestyle advice and review

      Explanation:

      Importance of Confirming Persistent High Blood Pressure

      While reducing high blood pressure is crucial, it is important to confirm that it is persistent and not just a one-time occurrence. Anxiety or other factors could artificially elevate blood pressure readings. Therefore, it is necessary to conduct multiple tests to confirm the diagnosis. Additionally, lifestyle changes such as exercise, healthy eating, and stress reduction can help lower blood pressure and improve overall health. Prescribing medication should only be done when necessary, as it can lead to side effects, drug interactions, and poor adherence. It is important to consider the risks and benefits before prescribing medication and to prioritize non-pharmacological interventions whenever possible. For more information, refer to the NICE guidelines on hypertension.

    • This question is part of the following fields:

      • Cardiovascular System
      19.2
      Seconds
  • Question 9 - 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
      5.8
      Seconds
  • Question 10 - An 85-year-old woman arrives at the emergency department with complaints of palpitations and...

    Correct

    • An 85-year-old woman arrives at the emergency department with complaints of palpitations and difficulty breathing. During the examination, you observe an irregularly irregular pulse. After conducting an ECG, you discover the absence of P waves and a ventricular rate of 94 beats per minute. What specific part of the heart prevents a rapid atrial rate from transmitting to the ventricles?

      Your Answer: Atrioventricular node

      Explanation:

      The correct answer is the atrioventricular (AV) node, which is located within the atrioventricular septum near the septal cusp of the tricuspid valve. It regulates the spread of excitation from the atria to the ventricles.

      The sinoatrial (SA) node is situated in the right atrium, at the top of the crista terminalis where the right atrium meets the superior vena cava. It is where cardiac impulses originate in a healthy heart.

      The bundle of His is a group of specialized cardiac myocytes that transmit the electrical impulse from the AV node to the ventricles.

      The Purkinje fibers are a collection of fibers that distribute the cardiac impulse throughout the muscular ventricular walls.

      The bundle of Kent is not present in a healthy heart. It refers to the accessory pathway between the atria and ventricles that exists in Wolff-Parkinson-White (WPW) syndrome. This additional conduction pathway allows for fast conduction of impulses between the atria and ventricles, without the additional control of the AV node. This results in a type of supraventricular tachycardia known as an atrioventricular re-entrant tachycardia.

      The patient in the above question has presented with palpitations and shortness of breath. An irregularly irregular pulse is highly indicative of atrial fibrillation (AF). ECG signs of atrial fibrillation include an irregularly irregular rhythm and absent P waves. In AF, the impulses from the fibrillating heart are typically prevented from reaching the ventricles by the AV node.

      The heart has four chambers and generates pressures of 0-25 mmHg on the right side and 0-120 mmHg on the left. The cardiac output is the product of heart rate and stroke volume, typically 5-6L per minute. The cardiac impulse is generated in the sino atrial node and conveyed to the ventricles via the atrioventricular node. Parasympathetic and sympathetic fibers project to the heart via the vagus and release acetylcholine and noradrenaline, respectively. The cardiac cycle includes mid diastole, late diastole, early systole, late systole, and early diastole. Preload is the end diastolic volume and afterload is the aortic pressure. Laplace’s law explains the rise in ventricular pressure during the ejection phase and why a dilated diseased heart will have impaired systolic function. Starling’s law states that an increase in end-diastolic volume will produce a larger stroke volume up to a point beyond which stroke volume will fall. Baroreceptor reflexes and atrial stretch receptors are involved in regulating cardiac output.

    • This question is part of the following fields:

      • Cardiovascular System
      6.1
      Seconds

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Cardiovascular System (5/10) 50%
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