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Question 1
Incorrect
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A 59-year-old man is admitted to the Intensive Care Unit from the Coronary Care Ward. He has suffered from an acute myocardial infarction two days earlier. On examination, he is profoundly unwell with a blood pressure of 85/60 mmHg and a pulse rate of 110 bpm. He has crackles throughout his lung fields, with markedly decreased oxygen saturations; he has no audible cardiac murmurs. He is intubated and ventilated, and catheterised.
Investigations:
Investigation Result Normal value
Haemoglobin 121 g/l 135–175 g/l
White cell count (WCC) 5.8 × 109/l 4–11 × 109/l
Platelets 285 × 109/l 150–400 × 109/l
Sodium (Na+) 128 mmol/l 135–145 mmol/l
Potassium (K+) 6.2 mmol/l 3.5–5.0 mmol/l
Creatinine 195 μmol/l 50–120 µmol/l
Troponin T 5.8 ng/ml <0.1 ng/ml
Urine output 30 ml in the past 3 h
ECG – consistent with a myocardial infarction 48 h earlier
Chest X-ray – gross pulmonary oedema
Which of the following fits best with the clinical picture?Your Answer: Nesiritide reduces mortality and improves renal function in this situation
Correct Answer:
Explanation:Treatment Options for Cardiogenic Shock Following Acute Myocardial Infarction
Cardiogenic shock following an acute myocardial infarction is a serious condition that requires prompt and appropriate treatment. One potential treatment option is the use of an intra-aortic balloon pump, which can provide ventricular support without compromising blood pressure. High-dose dopamine may also be used to preserve renal function, but intermediate and high doses can have negative effects on renal blood flow. The chance of death in this situation is high, but with appropriate treatment, it can be reduced to less than 10%. Nesiritide, a synthetic natriuretic peptide, is not recommended as it can worsen renal function and increase mortality. Nitrate therapy should also be avoided as it can further reduce renal perfusion and worsen the patient’s condition. Overall, careful consideration of treatment options is necessary to improve outcomes for patients with cardiogenic shock following an acute myocardial infarction.
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This question is part of the following fields:
- Cardiology
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Question 2
Correct
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An overweight 56-year-old Caucasian male patient attends for the results of a health check arranged by your surgery. He smokes 12 cigarettes a day and is trying to cut down. Alcohol intake is 8 units per week. He tells you that his father underwent a ‘triple bypass’ aged 48 years. His results are as follows: Total cholesterol : HDL ratio 6 HbA1c: 39 mmol/mol Urea and electrolytes: normal Estimated glomerular filtration rate (eGFR): 97 ml/min/1.73m2 Liver function tests: normal Blood pressure (daytime average on 24-h ambulatory monitor): 140/87 Body mass index (BMI): 25 His QRISK2 10-year cardiovascular risk is calculated at 22.7%. In addition to assisting with smoking cessation and providing lifestyle advice, what is the most appropriate means of managing his risk?
Your Answer: Commence atorvastatin 20 mg once a night and start a calcium channel blocker, review after three months
Explanation:This patient has high cholesterol and hypertension, both of which require immediate attention.
Medications:
The patient will start taking atorvastatin 20 mg once a night to address their high cholesterol. After three months, their cholesterol and full lipid profile will be rechecked, and the therapy will be titrated to maintain a total cholesterol of <5. If necessary, the dose may be increased to 40 mg once a night.For hypertension, the patient will start taking a calcium channel blocker as they are over the age of 55. The blood pressure will be monitored regularly, and if it rises above 150/90, additional treatment may be necessary.
Monitoring:
The patient’s cholesterol and full lipid profile will be rechecked after three months of treatment with atorvastatin. The aim is to see a 40% reduction in non-HDL cholesterol. If this is not achieved, a discussion of adherence, lifestyle measures, and the possibility of increasing the dose will take place.The patient’s blood pressure will also be monitored regularly. If it rises above 150/90, additional treatment may be necessary.
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This question is part of the following fields:
- Cardiology
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Question 3
Correct
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You are in pre-assessment clinic and request an electrocardiogram (ECG) on a 58-year-old man attending for a radical prostatectomy.
What are the limits of the normal cardiac axis?Your Answer: -30 to 90 degrees
Explanation:Understanding ECG Analysis: The Normal Cardiac Axis
ECG analysis is a fundamental concept that is essential to understand early on. One of the key components of ECG analysis is the normal cardiac axis, which ranges from −30 to 90 degrees. If the axis is greater than 90 degrees, it implies right axis deviation, while an axis less than −30 degrees indicates left axis deviation.
To determine the axis, leads I, II, and III of the ECG are typically examined. A normal axis is characterized by upgoing waves in all three leads. In contrast, right axis deviation is indicated by a downgoing wave in lead I and an upgoing wave in leads II and III. Left axis deviation is indicated by an upgoing wave in lead I and a downgoing wave in leads II and III.
While −30 to −90 degrees is considered left axis deviation and not a normal axis, −30 to 60 degrees is a normal axis, but it does not cover the full spectrum of a normal axis. Therefore, the correct answer is -30 to 90 degrees. Understanding the normal cardiac axis is crucial for accurate ECG interpretation and diagnosis.
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This question is part of the following fields:
- Cardiology
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Question 4
Correct
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A 65-year-old moderately obese man is brought to the Emergency Department with complaints of severe chest pain and shortness of breath. Upon physical examination, a pericardial tamponade is suspected and confirmed by an electrocardiogram (ECG) showing total electrical alternans and an echocardiogram revealing pericardial effusion. Which jugular vein is typically the most reliable indicator of central venous pressure (CVP)?
Your Answer: Right internal
Explanation:The Best Vein for Measuring Central Venous Pressure
Pericardial tamponade can lead to compression of the heart by the pericardium, resulting in decreased intracardiac diastolic pressure and reduced blood flow to the right atrium. This can cause distension of the jugular veins, making the right internal jugular vein the best vein for measuring central venous pressure (CVP). Unlike the right external vein, which joins the right internal vein at an oblique angle, the right internal vein has a straight continuation with the right brachiocephalic vein and the superior vena cava, making CVP measurement more accurate. On the other hand, the left internal jugular vein makes an oblique union with the left brachiocephalic vein and the external jugular veins, making it a less reliable indicator of CVP. Similarly, the left external vein also joins the left internal vein at an oblique angle, making CVP reading less reliable.
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This question is part of the following fields:
- Cardiology
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Question 5
Correct
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A 63-year-old man presents with increasing shortness of breath on exertion. On examination, bibasilar wet pulmonary crackles are noted with mild bilateral lower limb pitting oedema. His jugular vein is slightly distended. An S4 sound is audible on cardiac auscultation. An electrocardiogram (ECG) shows evidence of left ventricular (LV) hypertrophy. Chest radiography shows bilateral interstitial oedema without cardiomegaly.
Which one of the following findings is most likely to be found in this patient?Your Answer: Impaired LV relaxation – increased LV end-diastolic pressure – normal LV end-systolic volume
Explanation:Understanding the Different Types of Left Ventricular Dysfunction in Heart Failure
Left ventricular (LV) dysfunction can result in heart failure, which is a clinical diagnosis that can be caused by systolic or diastolic dysfunction, or both. Diastolic dysfunction is characterized by impaired LV relaxation, resulting in increased LV end-diastolic pressure but normal LV end-systolic volume. This type of dysfunction can be caused by factors such as LV hypertrophy from poorly controlled hypertension. On the other hand, impaired LV contraction results in systolic dysfunction, which is characterized by LV dilation, increased LV end-systolic and end-diastolic volumes, and increased LV end-diastolic pressure. It is important to differentiate between these types of LV dysfunction in order to properly diagnose and manage heart failure.
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This question is part of the following fields:
- Cardiology
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Question 6
Correct
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A 50-year-old man undergoes a workplace medical and has an ECG performed. What is the electrophysiological basis of the T wave on a typical ECG?
Your Answer: Ventricular repolarisation
Explanation:The T wave on an ECG indicates ventricular repolarisation and is typically positive in all leads except AvR and V1. Abnormal T wave findings may suggest strain, bundle branch block, ischaemia/infarction, hyperkalaemia, Prinzmetal angina, or early STEMI. The P wave represents atrial depolarisation, while atrial repolarisation is hidden by the QRS complex. The PR interval is determined by the duration of conduction delay through the atrioventricular node. Finally, the QRS complex indicates ventricular depolarisation.
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This question is part of the following fields:
- Cardiology
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Question 7
Correct
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A 57-year-old man arrives at the Emergency Department with sudden onset central crushing chest pain. The patient reports feeling pain in his neck and jaw as well. He has no significant medical history, but he does smoke occasionally and consumes up to 60 units of alcohol per week. An ECG is performed, revealing widespread ST elevation indicative of an acute coronary syndrome. At what point do the microscopic changes of acute MI become visible?
Your Answer: 12-24 hours after the infarct
Explanation:The Pathological Progression of Myocardial Infarction: A Timeline of Changes
Myocardial infarction, commonly known as a heart attack, is a serious medical condition that occurs when blood flow to the heart is blocked, leading to tissue damage and potentially life-threatening complications. The pathological progression of myocardial infarction follows a predictable sequence of events, with macroscopic and microscopic changes occurring over time.
Immediately after the infarct occurs, there are usually no visible changes to the myocardium. However, within 3-6 hours, maximal inflammatory changes occur, with the most prominent changes occurring between 24-72 hours. During this time, coagulative necrosis and acute inflammatory responses are visible, with marked infiltration by neutrophils.
Between 3-10 days, the infarcted area begins to develop a hyperaemic border, and the process of organisation and repair begins. Granulation tissue replaces dead muscle, and dying neutrophils are replaced by macrophages. Disintegration and phagocytosis of dead myofibres occur during this time.
If a patient survives an acute infarction, the infarct heals through the formation of scar tissue. However, scar tissue does not possess the usual contractile properties of normal cardiac muscle, leading to contractile dysfunction or congestive cardiac failure. The entire process from coagulative necrosis to the formation of well-formed scar tissue takes 6-8 weeks.
In summary, understanding the timeline of changes that occur during myocardial infarction is crucial for early diagnosis and effective treatment. By recognising the macroscopic and microscopic changes that occur over time, healthcare professionals can provide appropriate interventions to improve patient outcomes.
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This question is part of the following fields:
- Cardiology
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Question 8
Correct
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A 55-year-old man was brought to the Emergency Department following a car accident. Upon examination, there are no visible signs of external bleeding, but his blood pressure is 90/40 mmHg and his heart rate is 120 bpm. He presents with distended neck veins and muffled heart sounds.
What is the most probable echocardiogram finding in this case?Your Answer: Pericardial effusion
Explanation:Differential Diagnosis for a Trauma Patient with Beck’s Triad
When a trauma patient presents with hypotension, tachycardia, distended neck veins, and muffled heart sounds, the clinician should suspect pericardial effusion, also known as cardiac tamponade. This condition occurs when fluid accumulates in the pericardial space, compressing the heart and impairing its function. In the context of chest trauma, pericardial effusion is a life-threatening emergency that requires prompt diagnosis and treatment.
Other conditions that may cause similar symptoms but have different underlying mechanisms include mitral regurgitation, pneumothorax, haemothorax, and pleural effusion. Mitral regurgitation refers to the backflow of blood from the left ventricle to the left atrium due to a faulty mitral valve. While it can be detected on an echocardiogram, it is unlikely to cause Beck’s triad as it does not involve fluid accumulation outside the heart.
Pneumothorax is the presence of air in the pleural space, which can cause lung collapse and respiratory distress. A tension pneumothorax, in which air accumulates under pressure and shifts the mediastinum, can also compress the heart and impair its function. However, it would not be visible on an echocardiogram, which focuses on the heart and pericardium.
Haemothorax is the accumulation of blood in the pleural space, usually due to chest trauma or surgery. Like pneumothorax, it can cause respiratory compromise and hypovolemia, but it does not affect the heart directly and would not cause Beck’s triad.
Pleural effusion is a generic term for any fluid accumulation in the pleural space, which can be caused by various conditions such as infection, cancer, or heart failure. While it may cause respiratory symptoms and chest pain, it does not affect the heart’s function and would not cause Beck’s triad or be visible on an echocardiogram.
In summary, a trauma patient with Beck’s triad should be evaluated for pericardial effusion as the most likely cause, but other conditions such as tension pneumothorax or haemothorax should also be considered depending on the clinical context. An echocardiogram can help confirm or rule out pericardial effusion and guide further management.
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This question is part of the following fields:
- Cardiology
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Question 9
Incorrect
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A 68-year-old man presents to the Emergency Department (ED) with chest tightness. The tightness started about a day ago, however today it is worse and associated with shortness of breath and dizziness.
Upon examination, there is a slow rising carotid pulse and systolic murmur which radiates to carotids 3/6. Examination is otherwise unremarkable without calf tenderness. The patient does not have any significant past medical history apart from type II diabetes mellitus and hypertension which are both well controlled.
What is the best diagnostic investigation?Your Answer: D-dimer
Correct Answer: Echocardiogram
Explanation:Diagnostic Investigations for Cardiac Conditions
When a patient presents with signs and symptoms of a cardiac condition, various diagnostic investigations may be performed to determine the underlying cause. In the case of a patient with chest tightness, the first-line investigation is usually an electrocardiogram (ECG) to rule out acute coronary syndrome. However, if the patient is suspected of having aortic stenosis (AS), the best diagnostic investigation is an echocardiogram and Doppler to measure the size of the aortic valve. A normal aortic valve area is more than 2 cm2, while severe AS is defined as less than 1 cm2.
Other diagnostic investigations for cardiac conditions include a coronary angiogram to assess the patency of the coronary arteries and potentially perform an angioplasty to insert a stent if any narrowing is found. Exercise tolerance tests can also be useful in monitoring patients with a cardiac history and heart failure classification. However, a D-dimer test, which is used to diagnose pulmonary embolism, would not be indicated in a patient with suspected AS unless there were additional features suggestive of a pulmonary embolism, such as calf tenderness.
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This question is part of the following fields:
- Cardiology
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Question 10
Correct
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A 62-year-old salesman is found to have a blood pressure (BP) of 141/91 mmHg on a routine medical check. Two months later, his BP was 137/89 mmHg. He leads a physically active life, despite being a heavy smoker. He is not diabetic and his cholesterol levels are low. There is no past medical history of note.
What is the most suitable course of action for managing this patient?Your Answer: Lifestyle advice and reassess every year
Explanation:Hypertension Management and Lifestyle Advice
Managing hypertension requires careful consideration of various factors, including cardiovascular risk, age, and other risk factors. The 2011 NICE guidelines recommend further investigation and assessment for those with a BP of 140/90 mmHg or higher and for those at high risk. Once diagnosed, lifestyle advice and annual reassessment are recommended, with drug therapy considered based on the number of risk factors present.
For patients with cardiovascular risk factors, lifestyle advice and education on reducing cardiovascular risk are crucial. This includes support for smoking cessation, as smoking is a significant risk factor for cardiovascular disease. Patients with high risk, such as the elderly or heavy smokers, should be monitored annually.
While pharmacological treatment may be necessary, thiazide diuretics are no longer used first-line for hypertension management. For patients over 55, calcium channel blockers are recommended as first-line treatment. ACE inhibitors would not be used first-line in patients over 55.
In summary, managing hypertension requires a comprehensive approach that considers various factors, including cardiovascular risk, age, and other risk factors. Lifestyle advice and annual reassessment are crucial for patients with hypertension, with drug therapy considered based on the number of risk factors present.
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This question is part of the following fields:
- Cardiology
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Question 11
Correct
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What is the correct statement regarding the relationship between the electrocardiogram and the cardiac cycle?
Your Answer: The QT interval gives a rough indication of the duration of ventricular systole
Explanation:Understanding the Electrocardiogram: Key Components and Timing
As a junior doctor, interpreting electrocardiograms (ECGs) is a crucial skill. One important aspect to understand is the timing of key components. The QT interval, which measures ventricular depolarization and repolarization, gives an indication of the duration of ventricular systole. However, this measurement is dependent on heart rate and is corrected using Bazett’s formula. The P wave results from atrial depolarization, while the QRS complex is caused by ventricular depolarization. The first heart sound, which coincides with the QRS complex, results from closure of the AV valves as the ventricles contract. The second heart sound, occurring at about the same time as the T wave, is caused by closure of the aortic and pulmonary valves. Understanding the timing of these components is essential for accurate ECG interpretation.
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This question is part of the following fields:
- Cardiology
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Question 12
Incorrect
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A fourth year medical student on a ward round with your team is inquiring about pacemakers.
Which of the following WOULD BE an indication for permanent pacemaker implantation?Your Answer: Type 1 second degree (Mobitz I) AV block
Correct Answer: Third degree AV block (complete heart block)
Explanation:Understanding Indications for Permanent Pacemaker Insertion
A third degree AV block, also known as complete heart block, occurs when the atria and ventricles contract independently of each other. This can lead to syncope, chest pain, or signs of heart failure. Definitive treatment is the insertion of a permanent pacemaker. Other arrhythmias that may require permanent pacing include type 2 second-degree heart block (Mobitz II), sick sinus syndrome, and symptomatic slow atrial fibrillation. Ventricular tachycardia and ventricular fibrillation are not indications for pacing. Type 1 second degree (Mobitz I) AV block is a benign condition that does not require specific treatment. It is important to understand these indications for permanent pacemaker insertion for both exam and clinical purposes.
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This question is part of the following fields:
- Cardiology
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Question 13
Correct
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A 66-year-old patient visits her General Practitioner (GP) with complaints of chest pain and shortness of breath when climbing stairs. She reports no other health issues. During the examination, the GP notes a slow-rising pulse, a blood pressure reading of 130/100 mmHg, and detects a murmur on auscultation.
What is the most probable type of murmur heard in this patient?Your Answer: Ejection systolic murmur (ESM)
Explanation:Common Heart Murmurs and Their Associations
Heart murmurs are abnormal sounds heard during a heartbeat. They can be innocent or pathological, and their characteristics can provide clues to the underlying condition. Here are some common heart murmurs and their associations:
1. Ejection systolic murmur (ESM): This murmur is associated with aortic stenosis and is related to the ventricular outflow tract. It may be innocent in children and high-output states, but pathological causes include aortic stenosis and sclerosis, pulmonary stenosis, and hypertrophic obstructive cardiomyopathy.
2. Mid-diastolic murmur: This murmur is commonly associated with tricuspid or mitral stenosis and starts after the second heart sound and ends before the first heart sound. Rheumatic fever is a common cause of mitral valve stenosis.
3. Pansystolic murmur: This murmur is associated with mitral regurgitation and is of uniform intensity that starts immediately after S1 and merges with S2. It is also found in tricuspid regurgitation and ventricular septal defects.
4. Early diastolic murmur (EDM): This high-pitched murmur occurs in pulmonary and aortic regurgitation and is caused by blood flowing through a dysfunctional valve back into the ventricle. It may be accentuated by asking the patient to lean forward.
5. Continuous murmur: This murmur is commonly associated with a patent ductus arteriosus (PDA), a connection between the aorta and the pulmonary artery. It causes a continuous murmur, sometimes described as a machinery murmur, heard throughout both systole and diastole.
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This question is part of the following fields:
- Cardiology
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Question 14
Correct
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A 68-year-old man presents with severe epigastric pain and nausea. He reports not having a bowel movement in 3 days, despite normal bowel habits prior to this. The patient has a history of coronary stents placed after a heart attack 10 years ago. He has been asymptomatic since then and takes aspirin for his cardiac condition and NSAIDs for knee arthritis. He has not consumed alcohol in the past 5 years due to a previous episode of acute gastritis.
On examination, there is mild tenderness over the epigastrium but no guarding. Bowel sounds are normal. An erect CXR and abdominal X-ray are unremarkable. Blood gases and routine blood tests (FBC, U&E, LFTs) are normal, with a normal amylase. Upper GI endoscopy reveals gastric erosions.
What is the most important differential diagnosis to consider for this patient?Your Answer: Myocardial infarction
Explanation:Possible Diagnoses for a Patient with Epigastric Pain and History of Cardiac Stents
Introduction:
A patient with a history of cardiac stents presents with epigastric pain. The following are possible diagnoses that should be considered.Myocardial Infarction:
Due to the patient’s history of cardiac stents, ruling out a myocardial infarction (MI) is crucial. An electrocardiogram (ECG) should be performed early to treat any existing cardiac condition without delay.Duodenal Ulcer:
A duodenal ulcer would have likely been visualized on an oesophagogastroduodenoscopy (OGD). However, a normal erect CXR and absence of peritonitis exclude a perforated duodenal ulcer.Acute Gastritis:
Given the patient’s history of aspirin and NSAID use, as well as the gastric erosions visualized on endoscopy, acute gastritis is the most likely diagnosis. However, it is important to first exclude MI as a cause of the patient’s symptoms due to their history of MI and presentation of epigastric pain.Pancreatitis:
Pancreatitis is unlikely, given the normal amylase. However, on occasion, this can be normal in cases depending on the timing of the blood test or whether the pancreas has had previous chronic inflammation.Ischaemic Bowel:
Ischaemic bowel would present with more generalized abdominal pain and metabolic lactic acidosis on blood gas. Therefore, it is less likely to be the cause of the patient’s symptoms. -
This question is part of the following fields:
- Cardiology
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Question 15
Correct
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A final-year medical student is taking a history from a 63-year-old patient as a part of their general practice attachment. The patient informs her that she has a longstanding heart condition, the name of which she cannot remember. The student decides to review an old electrocardiogram (ECG) in her notes, and from it she is able to see that the patient has atrial fibrillation (AF).
Which of the following ECG findings is typically found in AF?Your Answer: Absent P waves
Explanation:Common ECG Findings and Their Significance
Electrocardiogram (ECG) is a diagnostic tool used to evaluate the electrical activity of the heart. It records the heart’s rhythm and detects any abnormalities. Here are some common ECG findings and their significance:
1. Absent P waves: Atrial fibrillation causes an irregular pulse and palpitations. ECG findings include absent P waves and irregular QRS complexes.
2. Long PR interval: A long PR interval indicates heart block. First-degree heart block is a fixed prolonged PR interval.
3. T wave inversion: T wave inversion can occur in fast atrial fibrillation, indicating cardiac ischaemia.
4. Bifid P wave (p mitrale): Bifid P waves are caused by left atrial hypertrophy.
5. ST segment elevation: ST segment elevation typically occurs in myocardial infarction. However, it may also occur in pericarditis and subarachnoid haemorrhage.
Understanding these ECG findings can help healthcare professionals diagnose and treat various cardiac conditions.
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This question is part of the following fields:
- Cardiology
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Question 16
Correct
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A 28-year-old man comes to the clinic complaining of intermittent sharp central chest pains over the past 48 hours. The pain worsens with exertion and when he lies down. He reports no difficulty breathing. The ECG reveals widespread ST elevation.
What is the most probable diagnosis?Your Answer: Pericarditis
Explanation:Distinguishing Pericarditis from Other Cardiac Conditions: A Clinical Overview
Pericarditis is a common cause of widespread ST elevation, characterized by chest pain that is often pleuritic and relieved by sitting forwards. Other symptoms include dry cough, dyspnoea, and flu-like symptoms, with the most important sign being pericardial rub. It can be caused by viral infections, post-MI, tuberculosis, or uraemia.
While pulmonary embolism may cause similar pleuritic pain, it would not result in the same ECG changes as pericarditis. Acute MI causes ST elevation in the affected coronary artery territory, with reciprocal ST depression. Hypertrophic cardiomyopathy presents with syncope or pre-syncope, and ECG changes consistent with left ventricular and septal hypertrophy. Ventricular aneurysm is another cause of ST elevation, but the clinical scenario and patient age align with a diagnosis of acute pericarditis.
In summary, recognizing the unique clinical presentation and ECG changes of pericarditis is crucial in distinguishing it from other cardiac conditions.
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This question is part of the following fields:
- Cardiology
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Question 17
Correct
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A 32-year-old woman presents with dyspnoea on exertion and palpitations. She has an irregularly irregular and tachycardic pulse, and a systolic murmur is heard on auscultation. An ECG reveals atrial fibrillation and right axis deviation, while an echocardiogram shows an atrial septal defect.
What is the process of atrial septum formation?Your Answer: The septum secundum grows down to the right of the septum primum
Explanation:During embryonic development, the septum primum grows down from the roof of the primitive atrium and fuses with the endocardial cushions. It initially has a hole called the ostium primum, which closes as the septum grows downwards. However, a second hole called the ostium secundum develops in the septum primum before fusion can occur. The septum secundum then grows downwards and to the right of the septum primum and ostium secundum. The foramen ovale is a passage through the septum secundum that allows blood to shunt from the right to the left atrium in the fetus, bypassing the pulmonary circulation. This defect closes at birth due to a drop in pressure within the pulmonary circulation after the infant takes a breath. If there is overlap between the foramen ovale and ostium secundum or if the ostium primum fails to close, an atrial septal defect results. This defect does not cause cyanosis because oxygenated blood flows from left to right through the defect.
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This question is part of the following fields:
- Cardiology
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Question 18
Incorrect
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You are assisting in the anaesthesia of an 80-year-old man for a plastics procedure. He is having a large basal cell carcinoma removed from his nose. He has a history of ischaemic heart disease, having had three stents placed 2 years ago. He is otherwise healthy and still able to walk to the shops. His preoperative electrocardiogram (ECG) showed sinus rhythm. During the procedure, his heart rate suddenly increases to 175 bpm with a narrow complex, and you cannot see P waves on the monitor. You are having difficulty obtaining a blood pressure reading but are able to palpate a radial pulse with a systolic pressure of 75 mmHg. The surgeons have been using lidocaine with adrenaline around the surgical site. What is the next best course of action?
Your Answer: Amiodarone 300 mg stat
Correct Answer: 100% O2, synchronised cardioversion, 150-J biphasic shock
Explanation:Treatment Options for a Patient with Narrow-Complex Tachycardia and Low Blood Pressure
When a patient with a history of ischaemic heart disease presents with a narrow-complex tachycardia and low blood pressure, it is likely that they have gone into fast atrial fibrillation. In this case, the first step in resuscitation should be a synchronised direct current (DC) cardioversion with a 150-J biphasic shock. Administering 100% oxygen, a 500 ml Hartmann bolus, and 0.5 mg metaraminol may help increase the patient’s blood pressure, but it does not address the underlying cause of their haemodynamic instability.
Amiodarone 300 mg stat is recommended for patients with narrow-complex tachycardia and haemodynamic instability. However, administering 10 mmol magnesium sulphate is not the first-line treatment for tachycardia unless the patient has torsades de pointes.
Lastly, administering Intralipid® as per guideline for local anaesthetic toxicity is unlikely to be the main source of the patient’s hypotension and does not address their narrow-complex tachycardia. Therefore, it is important to prioritize the synchronised cardioversion and amiodarone administration in this patient’s treatment plan.
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This question is part of the following fields:
- Cardiology
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Question 19
Correct
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A 60-year-old woman received a blood transfusion of 2 units of crossmatched blood 1 hour ago, following acute blood loss. She reports noticing a funny feeling in her chest, like her heart keeps missing a beat. You perform an electrocardiogram (ECG) which shows tall, tented T-waves and flattened P-waves in multiple leads.
An arterial blood gas (ABG) test shows:
Investigation Result Normal value
Sodium (Na+) 136 mmol/l 135–145 mmol/l
Potassium (K+) 7.1 mmol/l 5–5.0 mmol/l
Chloride (Cl–) 96 mmol/l 95–105 mmol/l
Given the findings, what treatment should be given immediately?Your Answer: Calcium gluconate
Explanation:Treatment Options for Hyperkalaemia: Understanding the Role of Calcium Gluconate, Insulin and Dextrose, Calcium Resonium, Nebulised Salbutamol, and Dexamethasone
Hyperkalaemia is a condition characterized by high levels of potassium in the blood, which can lead to serious complications such as arrhythmias. When a patient presents with hyperkalaemia and ECG changes, the initial treatment is calcium gluconate. This medication stabilizes the myocardial membranes by reducing the excitability of cardiomyocytes. However, it does not reduce potassium levels, so insulin and dextrose are needed to correct the underlying hyperkalaemia. Insulin shifts potassium intracellularly, reducing serum potassium levels by 0.6-1.0 mmol/l every 15 minutes. Nebulised salbutamol can also drive potassium intracellularly, but insulin and dextrose are preferred due to their increased effectiveness and decreased side-effects. Calcium Resonium is a slow-acting treatment that removes potassium from the body by binding it and preventing its absorption in the gastrointestinal tract. While it can help reduce potassium levels in the long term, it is not effective in protecting the patient from arrhythmias acutely. Dexamethasone, a steroid, is not useful in the treatment of hyperkalaemia. Understanding the role of these treatment options is crucial in managing hyperkalaemia and preventing serious complications.
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This question is part of the following fields:
- Cardiology
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Question 20
Correct
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A 72-year-old woman visits her GP for a routine check-up. During the examination, she seems generally healthy but slightly fatigued and experiences some breathlessness at rest. Her pulse is irregularly irregular and measures 72 bpm, while her blood pressure is 126/78 mmHg. Upon further examination, no concerning issues are found. The patient has no significant medical history and is not taking any regular medications.
What is the probable reason for this woman's development of atrial fibrillation (AF)?Your Answer: Lone AF
Explanation:Management of Atrial Fibrillation: The ABCD Approach
Atrial fibrillation (AF) is a common arrhythmia that can be classified as paroxysmal, persistent, or permanent. Treatment options for AF depend on the classification and can be categorized into rate control, rhythm control, and anticoagulation. The ABCD approach is a useful tool for managing AF.
A – Anticoagulation: Patients with AF are at an increased risk for thromboembolic disease, and anticoagulation should be considered in high-risk patients where the benefit outweighs the risk of hemorrhage.
B – Better symptom control: Rate control is aimed at controlling the ventricular response rate to improve symptoms. Rhythm control is aimed at restoring and maintaining sinus rhythm to improve symptoms.
C – Cardiovascular risk factor management: Management of underlying cardiovascular risk factors such as hypertension, diabetes, and hyperlipidemia can help reduce the risk of AF recurrence and complications.
D – Disease management: Management of underlying conditions associated with AF, such as valvular heart disease and heart failure, can help improve AF outcomes.
In summary, the ABCD approach to managing AF involves anticoagulation, better symptom control, cardiovascular risk factor management, and disease management. This approach can help improve outcomes and reduce the risk of complications in patients with AF.
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This question is part of the following fields:
- Cardiology
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Question 21
Correct
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Which congenital cardiac defect is correctly matched with its associated syndrome from the following options?
Your Answer: Turner syndrome and coarctation of the aorta
Explanation:Common Cardiovascular Abnormalities Associated with Genetic Syndromes
Various genetic syndromes are associated with cardiovascular abnormalities. Turner syndrome is linked with coarctation of the aorta, aortic stenosis, bicuspid aortic valve, aortic dilation, and dissection. Marfan syndrome is associated with aortic root dilation, mitral valve prolapse, mitral regurgitation, and aortic dissection. Kartagener syndrome can lead to bicuspid aortic valve, dextrocardia, bronchiectasis, and infertility. However, congenital adrenal hyperplasia is not associated with congenital cardiac conditions. Finally, congenital rubella syndrome is linked with patent ductus arteriosus, atrial septal defect, and pulmonary stenosis.
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This question is part of the following fields:
- Cardiology
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Question 22
Incorrect
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A 70-year-old patient comes to her doctor for a routine check-up. During the examination, her blood pressure is measured in both arms, and the readings are as follows:
Right arm 152/100
Left arm 138/92
What should be the next step in managing this patient's condition?Your Answer: Ask the patient to come back in one week to re-record blood pressure
Correct Answer: Ask the patient to start ambulatory blood pressure monitoring
Explanation:Proper Management of High Blood Pressure Readings
In order to properly manage high blood pressure readings, it is important to follow established guidelines. If a patient displays a blood pressure of over 140/90 in one arm, the patient should have ambulatory blood pressure monitoring (ABPM) in order to confirm the presence or lack of hypertension, in accordance with NICE guidelines.
It is important to note that a diagnosis of hypertension cannot be made from one blood pressure recording. However, if hypertension is confirmed, based upon the patients’ age, amlodipine would be the antihypertensive of choice.
When measuring blood pressure in both arms (as it should clinically be done), the higher of the two readings should be taken. Asking the patient to come back in one week to re-record blood pressure sounds reasonable, but it is not in accordance with the NICE guidelines.
Lastly, it is important to note that considering the patients’ age, ramipril is second line and should not be the first choice for treatment. Proper management of high blood pressure readings is crucial for the overall health and well-being of the patient.
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This question is part of the following fields:
- Cardiology
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Question 23
Correct
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A 30-year-old man presents with syncope, which was preceded by palpitations. He has no past medical history and is generally fit and well. The electrocardiogram (ECG) shows a positive delta wave in V1.
Which of the following is the most likely diagnosis?Your Answer: Wolff–Parkinson–White (WPW) syndrome
Explanation:Differentiating ECG Features of Various Heart Conditions
Wolff-Parkinson-White (WPW) syndrome is a congenital heart condition characterized by an accessory conduction pathway connecting the atria and ventricles. Type A WPW syndrome, identified by a delta wave in V1, can cause supraventricular tachycardia due to the absence of rate-lowering properties in the accessory pathway. Type B WPW syndrome, on the other hand, causes a negative R wave in V1. Radiofrequency ablation is the definitive treatment for WPW syndrome.
Maladie de Roger is a type of ventricular septal defect that does not significantly affect blood flow. Atrioventricular septal defect, another congenital heart disease, can cause ECG features related to blood shunting.
Brugada syndrome, which has three distinct types, does not typically present with a positive delta wave in V1 on ECG. Tetralogy of Fallot, a congenital heart defect, presents earlier with symptoms such as cyanosis and exertional dyspnea.
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This question is part of the following fields:
- Cardiology
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Question 24
Incorrect
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A 55-year-old man presents to the clinic with complaints of chest pain and difficulty breathing. He had been hospitalized four weeks ago for acute coronary syndrome and was discharged on bisoprolol, simvastatin, aspirin, and ramipril. During the examination, a narrow complex tachycardia is observed. What is the absolute contraindication in this scenario?
Your Answer: Digoxin
Correct Answer: Verapamil
Explanation:Verapamil and Beta Blockers: A Dangerous Combination
Verapamil is a type of medication that blocks calcium channels in the heart, leading to a decrease in cardiac output and a slower heart rate. However, it also has negative effects on the heart’s ability to contract, making it a highly negatively inotropic drug. Additionally, it may impair the conduction of electrical signals between the atria and ventricles of the heart.
According to the British National Formulary (BNF), verapamil should not be given to patients who are already taking beta blockers. This is because the combination of these two drugs can lead to dangerously low blood pressure and even asystole, a condition where the heart stops beating altogether.
Therefore, it is important for healthcare professionals to carefully consider a patient’s medication history before prescribing verapamil. If a patient is already taking beta blockers, alternative treatments should be considered to avoid the potentially life-threatening consequences of combining these two drugs.
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This question is part of the following fields:
- Cardiology
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Question 25
Correct
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A 65-year-old man visits his doctor complaining of a persistent cough with yellow sputum, mild breathlessness, and fever for the past three days. He had a heart attack nine months ago and received treatment with a bare metal stent during angioplasty. Due to his penicillin allergy, the doctor prescribed oral clarithromycin 500 mg twice daily for a week to treat his chest infection. However, after five days, the patient returns to the doctor with severe muscle pains in his thighs and shoulders, weakness, lethargy, nausea, and dark urine. Which medication has interacted with clarithromycin to cause these symptoms?
Your Answer: Simvastatin
Explanation:Clarithromycin and its Drug Interactions
Clarithromycin is an antibiotic used to treat various bacterial infections. It is effective against many Gram positive and some Gram negative bacteria that cause community acquired pneumonias, atypical pneumonias, upper respiratory tract infections, and skin infections. Unlike other macrolide antibiotics, clarithromycin is highly stable in acidic environments and has fewer gastric side effects. It is also safe to use in patients with penicillin allergies.
However, clarithromycin can interact with other drugs by inhibiting the hepatic cytochrome P450 enzyme system. This can lead to increased levels of other drugs that are metabolized via this route, such as warfarin, aminophylline, and statin drugs. When taken with statins, clarithromycin can cause muscle breakdown and rhabdomyolysis, which can lead to renal failure. Elderly patients who take both drugs may experience reduced mobility and require prolonged rehabilitation physiotherapy.
To avoid these interactions, it is recommended that patients taking simvastatin or another statin drug discontinue its use during the course of clarithromycin treatment and for one week after. Clarithromycin can also potentially interact with clopidogrel, a drug used to prevent stent thrombosis, by reducing its efficacy. However, clarithromycin does not have any recognized interactions with bisoprolol, lisinopril, or aspirin.
In summary, while clarithromycin is an effective antibiotic, it is important to be aware of its potential drug interactions, particularly with statin drugs and clopidogrel. Patients should always inform their healthcare provider of all medications they are taking to avoid any adverse effects.
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This question is part of the following fields:
- Cardiology
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Question 26
Correct
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A 7-year-old girl comes to the clinic complaining of headaches, particularly during times of stress or physical activity. She has no significant medical history. During her neurological exam, no abnormalities are found. However, a systolic murmur is heard along the length of her left sternal edge and spine. Her chest is clear and her blood pressure is 156/88 mmHg in her left arm and 104/68 mmHg in her left leg. An ECG reveals sinus rhythm with evidence of left ventricular hypertrophy. What is the most likely diagnosis?
Your Answer: Coarctation of the aorta
Explanation:Coarctation of the Aorta and its Interventions
Coarctation of the aorta is a condition where the aorta narrows, usually distal to the left subclavian artery. This can cause an asymptomatic difference in upper and lower body blood pressures and can lead to left ventricular hypertrophy. The severity of the restriction varies, with severe cases presenting early with cardiac failure, while less severe cases can go undiagnosed into later childhood.
Interventions for coarctation of the aorta include stenting, excision and graft placement, and using the left subclavian artery to bypass the coarctation. An atrial septal defect and hypertrophic occlusive cardiomyopathy would not cause a blood pressure difference between the upper and lower body. Stress headaches and a flow murmur are not appropriate diagnoses for a child with hypertension, which should be thoroughly investigated for an underlying cause.
In contrast, transposition of the great arteries is a major cyanotic cardiac abnormality that presents in infancy. It is important to diagnose and treat coarctation of the aorta to prevent complications such as left ventricular hypertrophy and cardiac failure.
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This question is part of the following fields:
- Cardiology
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Question 27
Correct
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What do T waves represent on an ECG?
Your Answer: Ventricular repolarisation
Explanation:The Electrical Activity of the Heart and the ECG
The ECG (electrocardiogram) is a medical test that records the electrical activity of the heart. This activity is responsible for different parts of the ECG. The first part is the atrial depolarisation, which is represented by the P wave. This wave conducts down the bundle of His to the ventricles, causing the ventricular depolarisation. This is shown on the ECG as the QRS complex. Finally, the ventricular repolarisation is represented by the T wave.
It is important to note that atrial repolarisation is not visible on the ECG. This is because it is of lower amplitude compared to the QRS complex. the different parts of the ECG and their corresponding electrical activity can help medical professionals diagnose and treat various heart conditions.
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This question is part of the following fields:
- Cardiology
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Question 28
Incorrect
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A 56-year-old man presents with non-specific chest pain lasting 6 hours. His ECG shows no significant changes, and cardiac enzymes are normal. As the pain becomes sharper and localizes to the left side of his chest over the next 48 hours, he reports that it worsens when lying down and taking deep breaths. The diagnosis is pericarditis.
What can be said about the pericardium in this case?Your Answer: The visceral layer of the serous pericardium derives from the embryonic endoderm
Correct Answer: The transverse sinus of the pericardium can be found behind the major vessels emerging from the ventricles, but in front of the superior vena cava
Explanation:Pericardium Layers and Sinuses: Understanding the Anatomy of the Heart’s Protective Membrane
The pericardium is a protective membrane that surrounds the heart. It consists of two layers: the fibrous pericardium and the serous pericardium. The fibrous pericardium adheres to the heart muscle and is derived from the somatopleuric mesoderm of the body cavity. The visceral layer of the serous pericardium, also known as the epicardium, adheres to the heart muscle and is derived from the splanchnopleuric mesoderm of the body cavity.
The pericardium also contains two sinuses: the transverse sinus and the oblique sinus. The transverse sinus can be found behind the major vessels emerging from the ventricles, but in front of the superior vena cava. The oblique sinus is the other pericardial sinus.
It is important to understand the anatomy of the pericardium in order to properly diagnose and treat conditions that affect the heart.
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This question is part of the following fields:
- Cardiology
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Question 29
Correct
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A 25-year-old woman attends a new patient health check at the General Practice surgery she has recently joined. She mentions she occasionally gets episodes of palpitations and light-headedness and has done so for several years. Her pulse is currently regular, with a rate of 70 bpm, and her blood pressure is 110/76 mmHg. A full blood count is sent, which comes back as normal. The general practitioner requests an electrocardiogram (ECG), which shows a widened QRS complex with a slurred upstroke and a shortened PR interval.
Which of the following is the most likely diagnosis?Your Answer: Wolff–Parkinson–White syndrome
Explanation:Common Cardiac Conditions and Their ECG Findings
Wolff-Parkinson-White syndrome is a condition that affects young people and is characterized by episodes of syncope and palpitations. It is caused by an accessory pathway from the atria to the ventricles that bypasses the normal atrioventricular node. The ECG shows a slurred upstroke to the QRS complex, known as a delta wave, which reflects ventricular pre-excitation. Re-entry circuits can form, leading to tachyarrhythmias and an increased risk of ventricular fibrillation.
Hypertrophic cardiomyopathy is an inherited condition that presents in young adulthood and is the most common cause of sudden cardiac death in the young. Symptoms include syncope, dyspnea, palpitations, and abnormal ECG findings, which may include conduction abnormalities, arrhythmias, left ventricular hypertrophy, and ST or T wave changes.
First-degree heart block is characterized by a prolonged PR interval and may be caused by medication, electrolyte imbalances, or post-myocardial infarction. It may also be a normal variant in young, healthy individuals.
Ebstein’s anomaly typically presents in childhood and young adulthood with fatigue, palpitations, cyanosis, and breathlessness on exertion. The ECG shows right bundle branch block and signs of atrial enlargement, such as tall, broad P waves.
Mobitz type II atrioventricular block is a type of second-degree heart block that is characterized by a stable PR interval with some non-conducted beats. It often progresses to complete heart block. Mobitz type I (Wenckebach) block, on the other hand, is characterized by a progressively lengthening PR interval, followed by a non-conducted beat and a reset of the PR interval back to a shorter value.
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This question is part of the following fields:
- Cardiology
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Question 30
Incorrect
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A 25-year-old man presents to the Emergency Department with severe vomiting and diarrhoea that has lasted for four days. He has been unable to keep down any fluids and is dehydrated, so he is started on an intravenous infusion. Upon investigation, his potassium level is found to be 2.6 mmol/L (3.5-4.9). What ECG abnormality would you anticipate?
Your Answer: Shortened P-R interval
Correct Answer: S-T segment depression
Explanation:Hypokalaemia and Hyperkalaemia
Hypokalaemia is a condition characterized by low levels of potassium in the blood. This can be caused by excess loss of potassium from the gastrointestinal or renal tract, decreased oral intake of potassium, alkalosis, or insulin excess. Additionally, hypokalaemia can be seen if blood is taken from an arm in which IV fluid is being run. The characteristic ECG changes associated with hypokalaemia include S-T segment depression, U-waves, inverted T waves, and prolonged P-R interval.
On the other hand, hyperkalaemia is a condition characterized by high levels of potassium in the blood. This can be caused by kidney failure, medications, or other medical conditions. The changes that may be seen with hyperkalaemia include tall, tented T-waves, wide QRS complexes, and small P waves.
It is important to understand the causes and symptoms of both hypokalaemia and hyperkalaemia in order to properly diagnose and treat these conditions. Regular monitoring of potassium levels and ECG changes can help in the management of these conditions.
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This question is part of the following fields:
- Cardiology
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Question 31
Correct
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A 51-year-old man passed away from a massive middle cerebral artery stroke. He had no previous medical issues. Upon autopsy, it was discovered that his heart weighed 400 g and had normal valves and coronary arteries. The atria and ventricles were not enlarged. The right ventricular walls were normal, while the left ventricular wall was uniformly hypertrophied to 20-mm thickness. What is the probable reason for these autopsy results?
Your Answer: Essential hypertension
Explanation:Differentiating Cardiac Conditions: Causes and Risks
Cardiac conditions can have varying causes and risks, making it important to differentiate between them. Essential hypertension, for example, is characterized by uniform left ventricular hypertrophy and is a major risk factor for stroke. On the other hand, atrial fibrillation is a common cause of stroke but does not cause left ventricular hypertrophy and is rarer with normal atrial size. Hypertrophic obstructive cardiomyopathy, which is more common in men and often has a familial tendency, typically causes asymmetric hypertrophy of the septum and apex and can lead to arrhythmogenic or unexplained sudden cardiac death. Dilated cardiomyopathies, such as idiopathic dilated cardiomyopathy, often have no clear precipitant but cause a dilated left ventricular size, increasing the risk for a mural thrombus and an embolic risk. Finally, tuberculous pericarditis is difficult to diagnose due to non-specific features such as cough, dyspnoea, sweats, and weight loss, with typical constrictive pericarditis findings being very late features with fluid overload and severe dyspnoea. Understanding the causes and risks associated with these cardiac conditions can aid in their proper diagnosis and management.
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This question is part of the following fields:
- Cardiology
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Question 32
Correct
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An 82-year-old woman presents to her general practitioner with increasing shortness of breath on exertion and swelling of her ankles and lower legs. During examination, she appears alert and oriented, but has significant erythema of her malar area. Her cardiovascular system shows an irregular heart rate of 92-104 beats per minute with low volume, and a blood pressure of 145/90 mmHg lying and standing. Her jugular venous pressure is raised with a single waveform, and her apex beat is undisplaced and forceful in character. There is a soft mid-diastolic murmur heard during heart sounds 1 + 2. Bibasal crackles are present in her chest, and she has pitting peripheral edema to the mid-calf. Based on these findings, what is the most likely cause of her collapse?
Your Answer: Mitral stenosis
Explanation:Distinguishing Mitral Stenosis from Other Valvular Diseases: Exam Findings
Mitral stenosis is a condition that presents with symptoms of left and right ventricular failure, atrial fibrillation, and its complications. When examining a patient suspected of having mitral stenosis, there are several significant signs to look out for. These include a low-volume pulse, atrial fibrillation, normal pulse pressure and blood pressure, loss of ‘a’ waves and large v waves in the jugular venous pressure, an undisplaced, discrete/forceful apex beat, and a mid-diastolic murmur heard best with the bell at the apex. Additionally, patients with mitral stenosis often have signs of right ventricular dilation and secondary tricuspid regurgitation.
It is important to distinguish mitral stenosis from other valvular diseases, such as mixed mitral and aortic valve disease, aortic stenosis, aortic regurgitation, and mitral regurgitation. The examination findings for these conditions differ from those of mitral stenosis. For example, mixed mitral and aortic valve disease would not present with the same signs as mitral stenosis. Aortic stenosis presents with symptoms of left ventricular failure, angina, and an ejection systolic murmur radiating to the carotids. Aortic regurgitation causes an early diastolic murmur and a collapsing pulse on examination. Finally, mitral regurgitation causes a pan-systolic murmur radiating to the axilla. By understanding the unique examination findings for each valvular disease, healthcare professionals can accurately diagnose and treat their patients.
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This question is part of the following fields:
- Cardiology
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Question 33
Incorrect
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An 82-year-old woman is brought to the Emergency Department after experiencing a sudden loss of consciousness while grocery shopping. Upon examination, she is fully alert and appears to be in good health.
Her vital signs are normal, with a CBG of 5.8 mmol/l. However, her cardiovascular system shows an irregular, low volume heart rate of 90-110 beats per minute, and her blood pressure is 145/120 mmHg while lying down and standing up. Her JVP is raised by 5 cm, and her apex beat is displaced to the mid-axillary line, with diffuse heart sounds. A loud pansystolic murmur is heard at the apex, radiating to the axilla and at the lower left sternal edge, along with a mid-diastolic rumble best heard at the apex. There are occasional bibasal crackles in her chest, which clear up with coughing. Additionally, she has mild peripheral edema up to the mid-calf.
Based on these clinical findings, what is the most likely cause of her collapse?Your Answer: Mitral stenosis
Correct Answer: Mixed mitral valve disease
Explanation:This patient exhibits features of mixed mitral valve disease, which can be challenging to diagnose due to contradictory signs. She has a mid-diastolic rumble, low-volume pulse, and atrial fibrillation, indicating mitral stenosis. However, she also has a displaced apex beat and a pan-systolic murmur, indicating mitral regurgitation. Mixed aortic valve disease is also common in these patients. Aortic stenosis and mixed aortic valve disease are unlikely diagnoses based on the clinical findings, while mitral stenosis and mitral regurgitation alone do not fully explain the examination results.
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This question is part of the following fields:
- Cardiology
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Question 34
Correct
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A 70-year-old man experiences an acute myocardial infarction and subsequently develops a bundle branch block. Which coronary artery is the most probable culprit?
Your Answer: Left anterior descending artery
Explanation:Coronary Artery Branches and Their Functions
The heart is supplied with blood by the coronary arteries, which branch off the aorta. These arteries are responsible for delivering oxygen and nutrients to the heart muscle. Here are some of the main branches of the coronary arteries and their functions:
1. Left Anterior Descending Artery: This artery supplies the front and left side of the heart, including the interventricular septum. It is one of the most important arteries in the heart.
2. Acute Marginal Branch of the Right Coronary Artery: This branch supplies the right ventricle of the heart.
3. Circumflex Branch of the Left Coronary Artery: This artery supplies the left atrium, left ventricle, and the sinoatrial node in some people.
4. Obtuse Marginal Branch of the Circumflex Artery: This branch supplies the left ventricle.
5. Atrioventricular Nodal Branch of the Right Coronary Artery: This branch supplies the atrioventricular node. Blockage of this branch can result in heart block.
Understanding the functions of these coronary artery branches is crucial for diagnosing and treating heart conditions.
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This question is part of the following fields:
- Cardiology
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Question 35
Correct
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A 28-year-old male presents with a blood pressure reading of 170/100 mmHg. Upon examination, he exhibits a prominent aortic ejection click and murmurs are heard over the ribs anteriorly and over the back. Additionally, he reports experiencing mild claudication with exertion and has feeble pulses in his lower extremities. What is the most probable diagnosis?
Your Answer: Coarctation of the aorta
Explanation:Coarctation of the Aorta: Symptoms and Diagnosis
Coarctation of the aorta is a condition that can present with various symptoms. These may include headaches, nosebleeds, cold extremities, and claudication. However, hypertension is the most typical symptom. A mid-systolic murmur may also be present over the anterior part of the chest, back, spinous process, and a continuous murmur may also be heard.
One important radiographic finding in coarctation of the aorta is notching of the ribs. This is due to erosion by collaterals. It is important to diagnose coarctation of the aorta early on, as it can lead to serious complications such as heart failure, stroke, and aortic rupture.
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This question is part of the following fields:
- Cardiology
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Question 36
Correct
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A 70-year-old male presents with abdominal pain.
He has a past medical history of stroke and myocardial infarction. During examination, there was noticeable distension of the abdomen and the stools were maroon in color. The lactate level was found to be 5 mmol/L, which is above the normal range of <2.2 mmol/L.
What is the most probable diagnosis for this patient?Your Answer: Acute mesenteric ischaemia
Explanation:Acute Mesenteric Ischaemia
Acute mesenteric ischaemia is a condition that occurs when there is a disruption in blood flow to the small intestine or right colon. This can be caused by arterial or venous disease, with arterial disease further classified as non-occlusive or occlusive. The classic triad of symptoms associated with acute mesenteric ischaemia includes gastrointestinal emptying, abdominal pain, and underlying cardiac disease.
The hallmark symptom of mesenteric ischaemia is severe abdominal pain, which may be accompanied by other symptoms such as nausea, vomiting, abdominal distention, ileus, peritonitis, blood in the stool, and shock. Advanced ischaemia is characterized by the presence of these symptoms.
There are several risk factors associated with acute mesenteric ischaemia, including congestive heart failure, cardiac arrhythmias (especially atrial fibrillation), recent myocardial infarction, atherosclerosis, hypercoagulable states, and hypovolaemia. It is important to be aware of these risk factors and to seek medical attention promptly if any symptoms of acute mesenteric ischaemia are present.
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This question is part of the following fields:
- Cardiology
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Question 37
Correct
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A 65-year-old insurance broker with mitral stenosis is seen in the Cardiology Clinic. He reports increasing shortness of breath on exertion and general fatigue over the past six months. Additionally, he notes swelling in his feet and ankles at the end of the day. What is the first-line intervention for symptomatic mitral stenosis with a mobile undistorted mitral valve and no left atrial thrombus or mitral regurgitation?
Your Answer: Balloon valvuloplasty
Explanation:Treatment Options for Mitral Valve Disease
Mitral valve disease can be managed through various treatment options depending on the severity and type of the condition. Balloon valvuloplasty is the preferred option for symptomatic patients with mitral stenosis, while mitral valve repair is the preferred surgical management for mitral regurgitation. Aortic valve replacement is an option if the aortic valve is faulty. Mitral valve replacement with a metallic valve requires high levels of anticoagulation, and therefore repair is preferred if possible. The Blalock–Taussig shunt is a surgical method for palliation of cyanotic congenital heart disease. Mitral valve repair may be considered in patients with mitral stenosis if the valve anatomy is unsuitable for balloon valvuloplasty. However, if the patient has severe symptomatic mitral stenosis with signs of heart failure, mitral valve replacement would be the first line of treatment.
Treatment Options for Mitral Valve Disease
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This question is part of the following fields:
- Cardiology
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Question 38
Incorrect
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A 30-year-old woman with rheumatic fever has ongoing shortness of breath following her infection. You suspect she may have mitral stenosis.
What is the most suitable surface anatomical landmark to listen for this murmur?Your Answer: Fourth intercostal space, left of the sternum
Correct Answer: At the apex beat
Explanation:Surface Locations for Cardiac Auscultation
Cardiac auscultation is a crucial part of a physical examination to assess the heart’s function. The surface locations for cardiac auscultation are essential to identify the specific valve sounds. Here are the surface locations for cardiac auscultation:
1. Apex Beat: The mitral valve is best heard over the palpated apex beat. If it cannot be felt, then it should be assumed to be in the fifth intercostal space, mid-clavicular line.
2. Fifth Intercostal Space, Mid-Axillary Line: This location is too lateral to hear a mitral valve lesion in a non-dilated ventricle.
3. Second Intercostal Space, Left of the Sternum: The pulmonary valve is located in the second intercostal space, left of the sternum.
4. Fourth Intercostal Space, Left of the Sternum: The tricuspid valve is located in the fourth intercostal space, left of the sternum.
5. Xiphisternum: The xiphisternum is not used as a marker for cardiac auscultation, though it is used to guide echocardiography for certain standard views.
Knowing the surface locations for cardiac auscultation is crucial to identify the specific valve sounds and assess the heart’s function accurately.
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This question is part of the following fields:
- Cardiology
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Question 39
Incorrect
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A young marine biologist was snorkelling among giant stingrays when the tail (barb) of one of the stingrays suddenly pierced his chest. The tip of the barb pierced the right ventricle and the man instinctively removed it in the water. When he was brought onto the boat, there was absence of heart sounds, reduced cardiac output and engorged jugular veins.
What was the most likely diagnosis for the young marine biologist who was snorkelling among giant stingrays and had the tail (barb) of one of the stingrays pierce his chest, causing the tip of the barb to pierce the right ventricle? Upon being brought onto the boat, the young man exhibited absence of heart sounds, reduced cardiac output and engorged jugular veins.Your Answer: Haemothorax
Correct Answer: Cardiac tamponade
Explanation:Differential diagnosis of a patient with chest trauma
When evaluating a patient with chest trauma, it is important to consider various potential diagnoses based on the clinical presentation and mechanism of injury. Here are some possible explanations for different symptoms:
– Cardiac tamponade: If a projectile penetrates the fibrous pericardium, blood can accumulate in the pericardial cavity and compress the heart, leading to decreased cardiac output and potential death.
– Deep vein thrombosis: This condition involves the formation of a blood clot in a deep vein, often in the leg. However, it does not typically cause the symptoms described in this case.
– Stroke: A stroke occurs when blood flow to the brain is disrupted, usually due to a blockage or rupture of an artery. This is not likely to be the cause of the patient’s symptoms.
– Pulmonary embolism: If a clot from a deep vein thrombosis travels to the lungs and obstructs blood flow, it can cause sudden death. However, given the history of trauma, other possibilities should be considered first.
– Haemothorax: This refers to the accumulation of blood in the pleural cavity around a lung. While it can cause respiratory distress and chest pain, it does not typically affect jugular veins or heart sounds. -
This question is part of the following fields:
- Cardiology
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Question 40
Correct
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An 82-year-old man has been experiencing increasing shortness of breath, tiredness, intermittent chest pain and leg swelling for the past 6 months. He recently underwent an echocardiogram as an outpatient which revealed evidence of heart failure. As the FY1 on the Medical Assessment Unit, you have been tasked with taking the patient's medical history. He has a history of hypertension and gout and is currently taking diltiazem (calcium-channel blocker) 60 mg po bd, furosemide (diuretic) 20 mg po od, Spironolactone 25mg od, allopurinol 100 mg po od, paracetamol 1 g po qds prn, and lisinopril 20 mg po od. Considering his likely diagnosis of heart failure, which medication should be discontinued?
Your Answer: Diltiazem
Explanation:Medications for Heart Failure: Understanding their Effects
Heart failure is a complex condition that requires careful management, including the use of various medications. In this context, it is important to understand the effects of each drug and how they can impact the patient’s health. Here is a brief overview of some commonly used medications for heart failure and their effects:
Diltiazem: This calcium-channel blocker can be used to treat angina and hypertension. However, it is advisable to stop calcium-channel blockers in patients with heart disease, as they can reduce the contractility of the heart, exacerbating the condition.
Spironolactone: This drug can help alleviate leg swelling by reducing water retention. It is also one of the three drugs in heart failure that have been shown to reduce mortality, along with ACE inhibitors and b-blockers.
Allopurinol: This medication is used in the prevention of gout long term and has no detrimental effect on the heart.
Paracetamol: This drug does not have an effect on the heart.
Lisinopril: This ACE inhibitor is used in the treatment of hypertension and the prophylactic treatment of angina. Stopping this medication is likely to worsen heart failure. Like spironolactone and b-blockers, ACE inhibitors have been shown to reduce mortality in heart failure, although the mechanisms behind this effect are not fully understood.
In summary, understanding the effects of medications for heart failure is crucial for optimizing patient care and improving outcomes. Healthcare providers should carefully consider each drug’s benefits and risks and tailor treatment to the individual patient’s needs.
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This question is part of the following fields:
- Cardiology
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Question 41
Incorrect
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Various cardiac diseases necessitate the use of pacemakers to maintain regular heartbeats and sustain the patient's life. The following are three types of pacemakers, labeled 1-3: AAI, VVI, and DDD. Can you correctly match each pacemaker to the condition it is typically used to treat?
Your Answer: AAI – ventricular systolic dysfunction; VVI – atrial fibrillation (AF); DDD – long QT syndrome
Correct Answer: AAI – sinus node dysfunction; VVI – AF; DDD – second-degree heart block
Explanation:Understanding Pacemaker Coding and Indications
Pacemakers are electronic devices that are implanted in the chest to regulate the heartbeat. They are used to treat a variety of heart conditions, including sinus node dysfunction, atrial fibrillation (AF), and heart block. Pacemakers are coded based on the chambers they pace, sense, and respond to, as well as their ability to modulate heart rate and provide multisite pacing.
AAI pacemakers are used to pace the atria in patients with sinus node dysfunction and intact AV conduction. VVI pacemakers are used in patients with chronic atrial impairment, such as AF. DDD pacemakers are used to pace both the atria and ventricles in patients with second-degree heart block.
It is important to note that AAI pacemakers would not be effective in treating ventricular systolic dysfunction, and DDD pacemakers cannot be used in the treatment of long QT syndrome. However, pacemakers can be used in long QT syndrome if clinically necessary, and DDD pacing may be appropriate for some patients with first-degree heart block.
In summary, understanding pacemaker coding and indications is crucial for selecting the appropriate device for each patient’s unique heart condition.
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This question is part of the following fields:
- Cardiology
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Question 42
Correct
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A 57-year-old man arrives at the Emergency Department with sudden onset central crushing chest pain. The patient reports feeling pain in his neck and jaw as well. He has no significant medical history, but he does smoke socially and consumes up to 60 units of alcohol per week. An ECG is performed, revealing widespread ST elevation indicative of an acute coronary syndrome.
What is the earliest point at which the microscopic changes of acute MI become apparent?Your Answer: 12-24 hours after the infarct
Explanation:The Pathological Progression of Myocardial Infarction: A Timeline of Changes
Myocardial infarction, commonly known as a heart attack, is a serious medical condition that occurs when blood flow to the heart is blocked, leading to tissue damage and potentially life-threatening complications. The pathological progression of myocardial infarction follows a predictable sequence of events, with macroscopic and microscopic changes occurring over time.
Immediately after the infarct occurs, there are usually no visible changes to the myocardium. However, within 3-6 hours, maximal inflammatory changes occur, with the most prominent changes occurring between 24-72 hours. During this time, coagulative necrosis and acute inflammatory responses are visible, with marked infiltration by neutrophils.
Between 3-10 days, the infarcted area begins to develop a hyperaemic border, and the process of organisation and repair begins. Granulation tissue replaces dead muscle, and dying neutrophils are replaced by macrophages. Disintegration and phagocytosis of dead myofibres occur during this time.
If a patient survives an acute infarction, the infarct heals through the formation of scar tissue. However, scar tissue does not possess the usual contractile properties of normal cardiac muscle, leading to contractile dysfunction or congestive cardiac failure. The entire process from coagulative necrosis to the formation of well-formed scar tissue takes 6-8 weeks.
In summary, understanding the timeline of changes that occur during myocardial infarction is crucial for early diagnosis and effective treatment. By recognising the macroscopic and microscopic changes that occur over time, healthcare professionals can provide appropriate interventions to improve patient outcomes.
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This question is part of the following fields:
- Cardiology
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Question 43
Incorrect
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A 60-year-old man with hypertension and hypercholesterolaemia experienced severe central chest pain lasting one hour. His electrocardiogram (ECG) in the ambulance reveals anterolateral ST segment elevation. Although his symptoms stabilized with medical treatment in the ambulance, he suddenly passed away while en route to the hospital.
What is the probable reason for his deterioration and death?Your Answer: Myocardial wall rupture
Correct Answer: Ventricular arrhythmia
Explanation:Complications of Myocardial Infarction
Myocardial infarction (MI) is a serious medical condition that can lead to various complications. Among these complications, ventricular arrhythmia is the most common cause of death. Malignant ventricular arrhythmias require immediate direct current (DC) electrical therapy to terminate the arrhythmias. Mural thrombosis, although it may cause systemic emboli, is not a common cause of death. Myocardial wall rupture and muscular rupture typically occur 4-7 days post-infarction, while papillary muscle rupture is also a possibility. Pulmonary edema, which can be life-threatening, is accompanied by symptoms of breathlessness and orthopnea. However, it can be treated effectively with oxygen, positive pressure therapy, and vasodilators.
Understanding the Complications of Myocardial Infarction
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This question is part of the following fields:
- Cardiology
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Question 44
Correct
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A 57-year-old male with a known history of rheumatic fever and frequent episodes of pulmonary oedema is diagnosed with pulmonary hypertension. During examination, an irregularly irregular pulse was noted and auscultation revealed a loud first heart sound and a rumbling mid-diastolic murmur. What is the most probable cause of this patient's pulmonary hypertension?
Your Answer: Mitral stenosis
Explanation:Cardiac Valve Disorders: Mitral Stenosis, Mitral Regurgitation, Aortic Regurgitation, Pulmonary Stenosis, and Primary Pulmonary Hypertension
Cardiac valve disorders are conditions that affect the proper functioning of the heart valves. Among these disorders are mitral stenosis, mitral regurgitation, aortic regurgitation, pulmonary stenosis, and primary pulmonary hypertension.
Mitral stenosis is a narrowing of the mitral valve, usually caused by rheumatic fever. Symptoms include palpitations, dyspnea, and hemoptysis. Diagnosis is aided by electrocardiogram, chest X-ray, and echocardiography. Management may be medical or surgical.
Mitral regurgitation is a systolic murmur that presents with a sustained apex beat displaced to the left and a left parasternal heave. On auscultation, there will be a soft S1, a loud S2, and a pansystolic murmur heard at the apex radiating to the left axilla.
Aortic regurgitation presents with a collapsing pulse with a wide pulse pressure. On palpation of the precordium, there will be a sustained and displaced apex beat with a soft S2 and an early diastolic murmur at the left sternal edge.
Pulmonary stenosis is associated with a normal pulse, with an ejection systolic murmur radiating to the lung fields. There may be a palpable thrill over the pulmonary area.
Primary pulmonary hypertension most commonly presents with progressive weakness and shortness of breath. There is evidence of an underlying cardiac disease, meaning the underlying pulmonary hypertension is more likely to be secondary to another disease process.
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This question is part of the following fields:
- Cardiology
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Question 45
Correct
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A 35-year-old woman presents to her Accident and Emergency with visual loss. She has known persistently uncontrolled hypertension, previously managed in the community. Blood tests are performed as follows:
Investigation Patient Normal value
Sodium (Na+) 148 mmol/l 135–145 mmol/l
Potassium (K+) 2.7 mmol/l 3.5–5.0 mmol/l
Creatinine 75 μmol/l 50–120 µmol/
Chloride (Cl–) 100 mEq/l 96–106 mEq/l
What is the next most appropriate investigation?Your Answer: Aldosterone-to-renin ratio
Explanation:Investigating Hypertension in a Young Patient: The Importance of Aldosterone-to-Renin Ratio
Hypertension in a young patient with hypernatraemia and hypokalaemia can be caused by renal artery stenosis or an aldosterone-secreting adrenal adenoma. To determine the cause, measuring aldosterone levels alone is not enough. Both renin and aldosterone levels should be measured, and the aldosterone-to-renin ratio should be evaluated. If hyperaldosteronism is confirmed, CT or MRI of the adrenal glands is done to locate the cause. If both are normal, adrenal vein sampling may be performed. MR angiogram of renal arteries is not a first-line investigation. Similarly, CT angiogram of renal arteries should not be the first choice. 24-hour urine metanephrine levels are not useful in this scenario. The electrolyte abnormalities point towards elevated aldosterone levels, not towards a phaeochromocytoma.
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This question is part of the following fields:
- Cardiology
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Question 46
Incorrect
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A 56-year-old, 80 kg woman arrives at the Emergency Department complaining of chest pain that began 5 hours ago. She has no known allergies and is not taking any regular medications. Her electrocardiogram shows T-wave inversion in lateral leads but no ST changes, and her serum troponin level is significantly elevated. What is the appropriate combination of drugs to administer immediately?
Your Answer: Aspirin 300 mg, clopidogrel 75 mg, fondaparinux 2.5 mg
Correct Answer: Aspirin 300 mg, prasugrel 60 mg, fondaparinux 2.5 mg
Explanation:For patients with different combinations of medications, the appropriate treatment plan may vary. In general, aspirin should be given as soon as possible and other medications may be added depending on the patient’s condition and the likelihood of undergoing certain procedures. For example, if angiography is not planned within 24 hours of admission, a loading dose of aspirin and prasugrel with fondaparinux may be given. If PCI is planned, unfractionated heparin may be considered. The specific dosages and medications may differ based on the patient’s individual needs and risk factors.
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This question is part of the following fields:
- Cardiology
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Question 47
Incorrect
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A 51-year-old woman with a history of hypothyroidism experiences a collapse during her yoga class. She has been reporting occasional chest pains and difficulty breathing during exercise in the past few weeks. During her physical examination, an ejection systolic murmur is detected at the right upper sternal edge, and her second heart sound is faint. Additionally, she has a slow-rising pulse. What is the most probable cause of her symptoms?
Your Answer: Aortic valve regurgitation
Correct Answer: Bicuspid aortic valve
Explanation:Differentiating Aortic and Mitral Valve Disorders
When evaluating a patient with a heart murmur, it is important to consider the characteristics of the murmur and associated symptoms to determine the underlying valve disorder. In a patient under 70 years old, a slow-rising and weak pulse with a history of collapse is indicative of critical stenosis caused by a bicuspid aortic valve. On the other hand, calcific aortic stenosis is more common in patients over 70 years old and presents differently. Aortic valve regurgitation is characterized by a murmur heard during early diastole and a collapsing pulse, but it is less likely to cause syncope. Mitral valve regurgitation causes a pan-systolic murmur at the apex with a laterally displaced apex beat, but it may present with congestive heart failure rather than syncope or angina. Mitral valve prolapse may cause a mid-systolic click, but a pan-systolic murmur at the apex may be present if there is coexisting mitral regurgitation. By understanding the unique features of each valve disorder, clinicians can make an accurate diagnosis and provide appropriate treatment.
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This question is part of the following fields:
- Cardiology
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Question 48
Incorrect
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A 48-year-old woman comes to you for consultation after being seen two days ago for a fall. She has a medical history of type 2 diabetes mellitus, bilateral knee replacements, chronic hypotension, and heart failure, which limits her mobility. Her weight is 120 kg. During her previous visit, her ECG showed that she had AF with a heart rate of 180 bpm. She was prescribed bisoprolol and advised to undergo a 48-hour ECG monitoring. Upon her return, it was discovered that she has non-paroxysmal AF.
What is the most appropriate course of action?Your Answer: Send her for urgent electrical cardioversion
Correct Answer: Start her on digoxin
Explanation:Treatment Options for Atrial Fibrillation in a Patient with Heart Failure
When treating a patient with atrial fibrillation (AF) and heart failure, the aim should be rate control. While bisoprolol is a good choice, it may not be suitable for a patient with chronic low blood pressure. In this case, digoxin would be the treatment of choice. Anticoagulation with a NOAC or warfarin is also necessary. Cardioversion with amiodarone should not be the first line of treatment due to the patient’s heart failure. Increasing the dose of bisoprolol may not be the best option either. Amlodipine is not effective for rate control in AF, and calcium-channel blockers should not be used in heart failure. Electrical cardioversion is not appropriate for this patient. Overall, the treatment plan should be tailored to the patient’s individual needs and medical history.
Managing Atrial Fibrillation and Heart Failure: Treatment Options
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This question is part of the following fields:
- Cardiology
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Question 49
Incorrect
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A 68-year-old man presents to the Cardiology Clinic with worsening central crushing chest pain that only occurs during physical activity and never at rest. He is currently taking bisoprolol 20 mg per day, ramipril, omeprazole, glyceryl trinitrate (GTN), and atorvastatin. What is the most suitable course of action?
Your Answer: Immediate angiogram
Correct Answer: Commence isosorbide mononitrate and arrange an outpatient angiogram
Explanation:Management of Stable Angina: Adding Isosorbide Mononitrate and Arranging Outpatient Angiogram
For a patient with stable angina who is already taking appropriate first-line medications such as bisoprolol and GTN, the next step in management would be to add a long-acting nitrate like isosorbide mononitrate. This medication provides longer-term vasodilation compared to GTN, which is only used when required. This can potentially reduce the frequency of angina symptoms.
An outpatient angiogram should also be arranged for the patient. While stable angina does not require an urgent angiogram, performing one on a non-urgent basis can provide more definitive management options like stenting if necessary.
Increasing the dose of ramipril or statin is not necessary unless there is evidence of worsening hypertension or high cholesterol levels, respectively. Overall, the management of stable angina should be tailored to the individual patient’s needs and risk factors.
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This question is part of the following fields:
- Cardiology
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Question 50
Correct
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An 82-year-old man presents with increasing shortness of breath, tiredness, intermittent chest pain and leg swelling for the last 6 months. His past medical history includes hypertension, gout and a previous myocardial infarction 5 years ago. His current medications are as follows:
diltiazem 60 mg orally (po) twice daily (bd)
spironolactone 100 mg po once daily (od)
allopurinol 100 mg po od
paracetamol 1 g po four times daily (qds) as required (prn)
lisinopril 20 mg po od.
Given this man’s likely diagnosis, which of the above medications should be stopped?Your Answer: Diltiazem
Explanation:Medications for Heart Failure: Uses and Contraindications
Diltiazem is a calcium channel blocker that can treat angina and hypertension, but it should be stopped in patients with chronic heart disease and heart failure due to its negative inotropic effects.
Spironolactone can alleviate leg swelling and is one of the three drugs that have been shown to reduce mortality in heart failure, along with ACE inhibitors and β-blockers.
Allopurinol is safe to use in heart failure patients as it is used for the prevention of gout and has no detrimental effect on the heart.
Paracetamol does not affect the heart and is safe to use in heart failure patients.
Lisinopril is an ACE inhibitor used to treat hypertension and angina, and stopping it can worsen heart failure. It is also one of the three drugs that have been shown to reduce mortality in heart failure. The mechanism by which ACE inhibitors reduce mortality is not fully understood.
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This question is part of the following fields:
- Cardiology
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