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  • Question 1 - A 67-year old man with a history of cardiovascular disease and COPD visits...

    Incorrect

    • A 67-year old man with a history of cardiovascular disease and COPD visits his GP. During a routine blood test, the GP observes that the patient has mild hyponatraemia. Which medication could have played a role in causing his hyponatraemia?

      Your Answer: Salbutamol

      Correct Answer: Bendroflumethiazide

      Explanation:

      Thiazide diuretics have been linked to the adverse effect of hyponatremia, while caution is advised when using β2-agonists like salbutamol in patients with hypokalemia due to their potential to decrease serum potassium. In cases of hyperkalemia, β2-agonists may be used as a temporary treatment option. Bendroflumethiazide, a thiazide diuretic, can cause electrolyte imbalances such as hypokalemia, hypomagnesemia, and hypochloremic alkalosis. On the other hand, ACE inhibitors like ramipril may lead to hyperkalemia, especially in patients with renal impairment, diabetes mellitus, or those taking potassium-sparing diuretics, potassium supplements, or potassium-containing salts. Atenolol, however, is not directly associated with electrolyte disturbances.

      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
      19.4
      Seconds
  • Question 2 - A 65-year-old man with a history of angina, hypertension, and hypercholesterolaemia has been...

    Correct

    • 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: 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
      3
      Seconds
  • Question 3 - What is the equivalent of cardiac preload? ...

    Incorrect

    • What is the equivalent of cardiac preload?

      Your Answer: Systemic vascular resistance

      Correct Answer: End diastolic volume

      Explanation:

      Preload, also known as end diastolic volume, follows the Frank Starling principle where a slight increase results in an increase in cardiac output. However, if preload is significantly increased, such as exceeding 250ml, it can lead to a decrease in cardiac output.

      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
      8.1
      Seconds
  • Question 4 - Which one of the following nerves is not found in the posterior triangle...

    Correct

    • Which one of the following nerves is not found in the posterior triangle of the neck?

      Your Answer: Ansa cervicalis

      Explanation:

      The anterior triangle of the neck contains the ansa cervicalis.

      The posterior triangle of the neck is an area that is bound by the sternocleidomastoid and trapezius muscles, the occipital bone, and the middle third of the clavicle. Within this triangle, there are various nerves, vessels, muscles, and lymph nodes. The nerves present include the accessory nerve, phrenic nerve, and three trunks of the brachial plexus, as well as branches of the cervical plexus such as the supraclavicular nerve, transverse cervical nerve, great auricular nerve, and lesser occipital nerve. The vessels found in this area are the external jugular vein and subclavian artery. Additionally, there are muscles such as the inferior belly of omohyoid and scalene, as well as lymph nodes including the supraclavicular and occipital nodes.

    • This question is part of the following fields:

      • Cardiovascular System
      290.3
      Seconds
  • Question 5 - A young woman presents with sudden palpitations and difficulty breathing, and her ECG...

    Correct

    • A young woman presents with sudden palpitations and difficulty breathing, and her ECG reveals tachycardia. Which cardiac component typically experiences the most rapid depolarization?

      Your Answer: Sino-atrial node

      Explanation:

      The heart’s conducting system is made up of specialized cardiac muscle cells and fibers that generate and rapidly transmit action potentials. This system is crucial for coordinating the contractions of the heart’s chambers during the cardiac cycle. When this system malfunctions due to conduction blockages or abnormal action potential sources, it can lead to arrhythmias.

      The conducting system has five main components:

      1. The sino-atrial (SAN) node, located in the right atrium, generates electrical signals.
      2. These signals stimulate the atria to contract and travel to the atrio-ventricular (AVN) node in the interatrial septum.
      3. After a delay, the stimulus diverges and is conducted through the left and right bundle of His.
      4. The conduction then passes to the respective Purkinje fibers for each side of the heart.
      5. Finally, the electrical signals reach the endocardium at the apex of the heart and the ventricular epicardium.

      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
      5.8
      Seconds
  • Question 6 - A 68-year-old woman arrives at the emergency department with complaints of shortness of...

    Incorrect

    • A 68-year-old woman arrives at the emergency department with complaints of shortness of breath and palpitations. During the examination, you observe an irregularly irregular pulse. To check for signs of atrial fibrillation, you opt to conduct an ECG. In a healthy individual, where is the SA node located in the heart?

      Your Answer: Atrioventricular septum

      Correct Answer: Right atrium

      Explanation:

      The SA node is situated at the junction of the superior vena cava and the right atrium, and is responsible for initiating cardiac impulses in a healthy heart. The AV node, located in the atrioventricular septum, regulates the spread of excitation from the atria to the ventricles. The patient’s symptoms of palpitations and shortness of breath, along with an irregularly irregular pulse, strongly indicate atrial fibrillation. ECG findings consistent with atrial fibrillation include an irregularly irregular rhythm and the absence of P waves.

      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
      11.9
      Seconds
  • Question 7 - A 35-year-old man visits his GP complaining of feeling increasingly unwell for the...

    Incorrect

    • A 35-year-old man visits his GP complaining of feeling increasingly unwell for the past few weeks. He reports experiencing heavy night sweats, fatigue, and shortness of breath. Upon further questioning, he reveals a history of intravenous drug use for many years and has been using methadone exclusively for the last 2 months. During the physical examination, the GP observes splinter haemorrhages. What is the probable causative organism?

      Your Answer: Candida albicans

      Correct Answer: Staphylococcus aureus

      Explanation:

      The patient is exhibiting symptoms that are indicative of infective endocarditis and has a past of using intravenous drugs. Infective endocarditis can be caused by various factors, but in developed countries, S. aureus is the most prevalent cause. This is especially true for individuals who use intravenous drugs, as in this case.

      Aetiology of Infective Endocarditis

      Infective endocarditis is a condition that affects patients with previously normal valves, rheumatic valve disease, prosthetic valves, congenital heart defects, intravenous drug users, and those who have recently undergone piercings. The strongest risk factor for developing infective endocarditis is a previous episode of the condition. The mitral valve is the most commonly affected valve.

      The most common cause of infective endocarditis is Staphylococcus aureus, particularly in acute presentations and intravenous drug users. Historically, Streptococcus viridans was the most common cause, but this is no longer the case except in developing countries. Coagulase-negative Staphylococci such as Staphylococcus epidermidis are commonly found in indwelling lines and are the most common cause of endocarditis in patients following prosthetic valve surgery. Streptococcus bovis is associated with colorectal cancer, with the subtype Streptococcus gallolyticus being most linked to the condition.

      Culture negative causes of infective endocarditis include prior antibiotic therapy, Coxiella burnetii, Bartonella, Brucella, and HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella). It is important to note that systemic lupus erythematosus and malignancy, specifically marantic endocarditis, can also cause non-infective endocarditis.

    • This question is part of the following fields:

      • Cardiovascular System
      6.7
      Seconds
  • Question 8 - A 57-year-old man presents to the emergency department with acute, severe shortness of...

    Correct

    • A 57-year-old man presents to the emergency department with acute, severe shortness of breath.

      During the clinical examination, an elevated JVP is noted, and bilateral basal crackles are heard on auscultation. An S3 gallop is also heard on auscultation of his heart.

      The physician places him on high flow oxygen and positions him upright. You are asked to review the patient's medication chart and discontinue any medications that may be contraindicated in his current condition.

      Which medication should you discontinue?

      Your Answer: Nicorandil

      Explanation:

      Nicorandil is a medication that is commonly used to treat angina. It works by activating potassium channels, which leads to vasodilation. This process is achieved through the activation of guanylyl cyclase, which results in an increase in cGMP. However, there are some adverse effects associated with the use of nicorandil, including headaches, flushing, and the development of ulcers on the skin, mucous membranes, and eyes. Additionally, gastrointestinal ulcers, including anal ulceration, may also occur. It is important to note that nicorandil should not be used in patients with left ventricular failure.

    • This question is part of the following fields:

      • Cardiovascular System
      17.3
      Seconds
  • Question 9 - An 80-year-old man presents to the emergency department with complaints of chest pain,...

    Correct

    • An 80-year-old man presents to the emergency department with complaints of chest pain, dizziness, and palpitations. He has a medical history of mitral stenosis and denies any alcohol or smoking habits. Upon conducting an ECG, it is observed that lead I shows positively directed sawtooth deflections, while leads II, III, and aVF show negatively directed sawtooth deflections. What pathology does this finding suggest?

      Your Answer: Atrial flutter

      Explanation:

      Atrial flutter is identified by a sawtooth pattern on the ECG and is a type of supraventricular tachycardia. It occurs when electrical activity from the sinoatrial node reenters the atria instead of being conducted to the ventricles. Valvular heart disease is a risk factor, and atrial flutter is managed similarly to atrial fibrillation.

      Left bundle branch block causes a delayed contraction of the left ventricle and is identified by a W pattern in V1 and an M pattern in V6 on an ECG. It does not produce a sawtooth pattern on the ECG.

      Ventricular fibrillation is characterized by chaotic electrical conduction in the ventricles, resulting in a lack of normal ventricular contraction. It can cause cardiac arrest and requires advanced life support management.

      Wolff-Parkinson-White syndrome is caused by an accessory pathway between the atria and the ventricles and is identified by a slurred upstroke at the beginning of the QRS complex, known as a delta wave. It can present with symptoms such as palpitations, shortness of breath, and syncope.

      Atrial flutter is a type of supraventricular tachycardia that is characterized by a series of rapid atrial depolarization waves. This condition can be identified through ECG findings, which show a sawtooth appearance. The underlying atrial rate is typically around 300 beats per minute, which can affect the ventricular or heart rate depending on the degree of AV block. For instance, if there is a 2:1 block, the ventricular rate will be 150 beats per minute. Flutter waves may also be visible following carotid sinus massage or adenosine.

      Managing atrial flutter is similar to managing atrial fibrillation, although medication may be less effective. However, atrial flutter is more sensitive to cardioversion, so lower energy levels may be used. For most patients, radiofrequency ablation of the tricuspid valve isthmus is curative.

    • This question is part of the following fields:

      • Cardiovascular System
      13.7
      Seconds
  • Question 10 - A newborn male delivered at 38 weeks gestation presents with severe cyanosis within...

    Incorrect

    • A newborn male delivered at 38 weeks gestation presents with severe cyanosis within the first hour of life. He experiences worsening respiratory distress and is unable to feed properly. The infant is immediately transferred to the neonatal intensive care unit for supportive care. The mother did not receive any prenatal care and the baby was delivered via an uncomplicated spontaneous vaginal delivery.

      During physical examination, the neonate appears lethargic and cyanotic. His vital signs are as follows: respiratory rate 60/min, oxygen saturation 82% (on 65% oxygen), heart rate 155/min, blood pressure 98/68 mmHg. Cardiac auscultation reveals a loud S2 heart sound.

      A chest x-ray shows an 'eggs on a string' appearance of the cardiac silhouette. An electrocardiogram (ECG) indicates right ventricular dominance. Further diagnostic testing with echocardiography confirms a congenital heart defect.

      What is the most likely embryological pathology underlying this neonate's congenital heart defect?

      Your Answer: Absent tricuspid valve and hypoplastic right ventricle

      Correct Answer: Failure of the aorticopulmonary septum to spiral

      Explanation:

      Transposition of great vessels is caused by the failure of the aorticopulmonary septum to spiral during early life, resulting in a cyanotic heart disease. The classic X-ray description and clinical findings support this diagnosis. Other cyanotic heart defects, such as tricuspid atresia and Tetralogy of Fallot, have different clinical features and X-ray findings. Non-cyanotic heart defects, such as atrial septal defect, have a defect in the interatrial septum. Aortic coarctation is characterized by a narrowing near the insertion of ductus arteriosus.

      Understanding Transposition of the Great Arteries

      Transposition of the great arteries (TGA) is a type of congenital heart disease that results in cyanosis. This condition occurs when the aorticopulmonary septum fails to spiral during septation, causing the aorta to leave the right ventricle and the pulmonary trunk to leave the left ventricle. Infants born to diabetic mothers are at a higher risk of developing TGA.

      The clinical features of TGA include cyanosis, tachypnea, a loud single S2, and a prominent right ventricular impulse. Chest x-rays may show an egg-on-side appearance. To manage TGA, prostaglandins can be used to maintain the ductus arteriosus. However, surgical correction is the definitive treatment for this condition.

    • This question is part of the following fields:

      • Cardiovascular System
      10.7
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiovascular System (5/10) 50%
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