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Question 1
Correct
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A 65-year-old man arrives at the Emergency Department complaining of central crushing chest pain that spreads to his arm and jaw. Upon examination, his ECG reveals ST elevation in leads II, III, and aVF, with reciprocal changes in I and aVL. Based on this information, which of the following vessels is most likely obstructed?
Your Answer: Right coronary artery
Explanation:Differentiating Myocardial Infarctions Based on ECG Changes
Myocardial infarction (MI) is a serious condition that requires prompt diagnosis and treatment. Electrocardiogram (ECG) changes can help differentiate the location of the MI and guide appropriate management. Here are the ECG changes expected in different types of MI:
Right Coronary Artery (RCA) Infarction: An inferior MI affects the RCA in 80% of cases, with ST elevation in leads II, III, and aVF, and reciprocal changes in leads I and aVL.
Left Circumflex Artery (LCX) Infarction: LCX infarction presents with ST elevation in leads I, aVL, V5, and V6 (lateral leads), and reciprocal changes in the inferior leads II, III, and aVF.
Left Coronary Artery (LCA) Infarction: If the clot is in the LCA before bifurcation, ST changes are expected in leads I, aVL, and V1–V6 (anterolateral leads).
Posterior Descending Artery (PDA) Infarction: PDA infarction gives ECG changes in keeping with a posterior MI, such as ST depression in the anterior leads.
Left Anterior Descending Artery (LAD) Infarction: LAD runs in the anterior of the heart, almost parallel to the septum, and then lateralizes. Therefore, in an LAD infarction, ST changes are expected in leads V1–V6 (anteroseptal leads).
In conclusion, recognizing the ECG changes in different types of MI can help clinicians 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 2
Correct
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Examine the cardiac catheter data provided below for a patient. Which of the following clinical scenarios is most consistent with the given information?
Anatomical site Oxygen saturation (%) Pressure (mmHg) End systolic/End diastolic
Superior vena cava 74 -
Inferior vena cava 72 -
Right atrium 73 5
Right ventricle 74 20/4
Pulmonary artery 74 20/5
Pulmonary capillary wedge pressure - 15
Left ventricle 98 210/15
Aorta 99 125/75Your Answer: A 17-year-old boy who presents after an episode of exercise-induced syncope
Explanation:Left Ventricular Pressure and Cardiac Conditions
Left ventricular pressures that exhibit a sharp decline between the LV and aortic systolic pressures are indicative of hypertrophic cardiomyopathy. This condition is consistent with the catheter data obtained from the patient. However, the data are not consistent with other cardiac conditions such as cyanotic congenital heart disease, post-MI VSD or mitral regurgitation, mitral stenosis, or mitral regurgitation. Although aortic stenosis may also present with a left ventricular outflow obstruction, it is not typically associated with exercise-induced syncope. These findings suggest that the patient’s symptoms are likely due to hypertrophic cardiomyopathy.
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This question is part of the following fields:
- Cardiology
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Question 3
Correct
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A 25-year-old man comes to the Emergency Department complaining of gastroenteritis. He has experienced severe cramps in his left calf and has vomited five times in the last 24 hours. Blood tests reveal hypokalaemia, and an electrocardiogram (ECG) is performed. Which ECG change is most commonly linked to hypokalaemia?
Your Answer: Prominent U waves
Explanation:ECG Changes Associated with Hypo- and Hyperkalaemia
Hypokalaemia, or low levels of potassium in the blood, can cause various changes in an electrocardiogram (ECG). One of the most prominent changes is the appearance of U waves, which follow T waves and usually have the same direction. Hypokalaemia can also cause increased amplitude and width of P waves, prolonged PR interval, T wave flattening and inversion, ST depression, and Q-T prolongation in severe cases.
On the other hand, hyperkalaemia, or high levels of potassium in the blood, can cause peaked T waves, which represent ventricular repolarisation. Hyperkalaemia is also associated with widening of the QRS complex, which can lead to life-threatening ventricular arrhythmias. Flattening of P waves and prolonged PR interval are other ECG changes seen in hyperkalaemia.
It is important to note that some of these ECG changes can overlap between hypo- and hyperkalaemia, such as prolonged PR interval. Therefore, other clinical and laboratory findings should be considered to determine the underlying cause of the ECG changes.
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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 55-year-old woman arrives at the emergency department with a two hour history of central crushing chest pain. She has a history of ischaemic heart disease and poorly controlled diabetes. The ECG shows ST-elevation in V1, V2 and V3, and her serum troponin levels are elevated. What is the most suitable definitive management approach?
Your Answer: Primary percutaneous coronary intervention (PCI)
Explanation:Treatment Options for ST-Elevation Myocardial Infarction (STEMI)
ST-Elevation Myocardial Infarction (STEMI) is a medical emergency that requires immediate intervention. The diagnosis of STEMI is confirmed through cardiac sounding chest pain and evidence of ST-elevation on the ECG. The primary treatment option for STEMI is immediate revascularization through primary percutaneous coronary intervention (PCI) and placement of a cardiac stent.
Therapeutic alteplase, a thrombolytic agent, used to be a common treatment option for STEMI, but it has been largely replaced by primary PCI due to its superior therapeutic outcomes. Aspirin is routinely given in myocardial infarction, and clopidogrel may also be given, although many centers are now using ticagrelor instead.
High-flow oxygen and intravenous morphine may be used for adequate analgesia and resuscitation, but the primary treatment remains primary PCI and revascularization. Routine use of high flow oxygen in non-hypoxic patients with an acute coronary syndrome is no longer advocated.
It is crucial to avoid delaying treatment for STEMI, as it can lead to further deterioration of the patient and increase the risk of cardiac arrhythmia or arrest. Therefore, waiting for troponin results before further management is not an appropriate option. The diagnosis of STEMI can be made through history and ECG findings, and immediate intervention is necessary for optimal outcomes.
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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 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 6
Incorrect
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A 72-year-old man presents to his GP for a routine check-up and is found to have a systolic murmur heard loudest in the aortic region. The murmur increases in intensity with deep inspiration and does not radiate. What is the most probable abnormality in this patient?
Your Answer: Aortic stenosis
Correct Answer: Pulmonary stenosis
Explanation:Systolic Valvular Murmurs
A systolic valvular murmur can be caused by aortic/pulmonary stenosis or mitral/tricuspid regurgitation. It is important to note that the location where the murmur is heard loudest can be misleading. For instance, if it is aortic stenosis, the murmur is expected to radiate to the carotids. However, the significant factor to consider is that the murmur is heard loudest on inspiration. During inspiration, venous return to the heart increases, which exacerbates right-sided murmurs. Conversely, expiration reduces venous return and exacerbates left-sided murmurs. To remember this useful fact, the mnemonic RILE (Right on Inspiration, Left on Expiration) can be used.
If a systolic murmur is enhanced on inspiration, it must be a right-sided murmur, which could be pulmonary stenosis or tricuspid regurgitation. However, in this case, only pulmonary stenosis is an option. systolic valvular murmurs and their characteristics is crucial in making an accurate diagnosis and providing appropriate treatment.
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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 55-year-old woman with type II diabetes is urgently sent to the Emergency Department by her General Practitioner (GP). The patient had seen her GP that morning and reported an episode of chest pain that she had experienced the day before. The GP suspected the pain was due to gastro-oesophageal reflux but had performed an electrocardiogram (ECG) and sent a troponin level to be certain. The ECG was normal, but the troponin level came back that afternoon as raised. The GP advised the patient to go to Accident and Emergency, given the possibility of reduced sensitivity to the symptoms of a myocardial infarction (MI) in this diabetic patient.
Patient Normal range
High-sensitivity troponin T 20 ng/l <14 ng/l
What should be done based on this test result?Your Answer: Repeat troponin level
Explanation:Management of Suspected Myocardial Infarction
Explanation:
When a patient presents with symptoms suggestive of myocardial infarction (MI), a troponin level should be checked. If the level is only slightly raised, it does not confirm a diagnosis of MI, but neither does it rule it out. Therefore, a repeat troponin level should be performed at least 3 hours after the first level and sent as urgent.
In an MI, cardiac enzymes are released from dead myocytes into the blood, causing enzyme levels to rise and eventually fall as they are cleared from blood. If the patient has had an MI, the repeat troponin level should either be further raised or further reduced. If the level remains roughly constant, then an alternative cause should be sought, such as pulmonary embolism, chronic kidney disease, acute kidney injury, pericarditis, heart failure, or sepsis/systemic infection.
Admission to the Coronary Care Unit (CCU) is not warranted yet. Further investigations should be performed to ascertain whether an admission is needed or whether alternative diagnoses should be explored.
Safety-netting and return to the GP should include a repeat troponin level to see if the level is stable (arguing against an MI) or is rising/falling. A repeat electrocardiogram (ECG) should be performed, and a thorough history and examination should be obtained to identify any urgent diagnoses that need to be explored before the patient is discharged.
Thrombolysis carries a risk for bleeding, so it requires a clear indication, which has not yet been obtained. Therefore, it should not be administered without proper evaluation.
The alanine transaminase (ALT) level has been used as a marker of MI in the past, but it has been since superseded as it is not specific for myocardial damage. In fact, it is now used as a component of liver function tests.
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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 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 9
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 10
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 11
Correct
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A 60-year-old man presents with shortness of breath and dizziness. On examination, he has an irregularly irregular pulse.
Which of the following conditions in his past medical history might be the cause of his presentation?Your Answer: Hyperthyroidism
Explanation:Common Endocrine Disorders and their Cardiac Manifestations
Endocrine disorders can have significant effects on the cardiovascular system, including the development of arrhythmias. Atrial fibrillation is a common arrhythmia that can be caused by hyperthyroidism, which should be tested for in patients presenting with this condition. Other signs of thyrotoxicosis include sinus tachycardia, physiological tremor, lid lag, and lid retraction. Graves’ disease, a common cause of hyperthyroidism, can also present with pretibial myxoedema, proptosis, chemosis, and thyroid complex ophthalmoplegia. Mnemonics such as SHIMMERS and ABCD can be used to remember the causes and management of atrial fibrillation.
Cushing syndrome, hyperparathyroidism, and hypothyroidism can also have cardiac manifestations, although they are not typically associated with arrhythmias. Cushing syndrome is not commonly associated with arrhythmias, while hyperparathyroidism can cause hypercalcemia, leading to non-specific symptoms such as aches and pains, dehydration, fatigue, mood disturbance, constipation, and renal stones. Hypothyroidism, on the other hand, may cause bradycardia and can be caused by various factors such as Hashimoto’s thyroiditis, subacute thyroiditis, iodine deficiency, and iatrogenic factors such as post-carbimazole treatment, radio-iodine, thyroidectomy, and certain medications like lithium and amiodarone.
In summary, endocrine disorders can have significant effects on the cardiovascular system, and it is important to be aware of their potential cardiac manifestations, including arrhythmias. Early detection and management of these conditions can help prevent serious complications and improve patient outcomes.
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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 radiologist examining a routine chest X-ray in a 50-year-old man is taken aback by the presence of calcification of a valve orifice located at the upper left sternum at the level of the third costal cartilage.
Which valve is most likely affected?Your Answer: The tricuspid valve
Correct Answer: The pulmonary valve
Explanation:Location and Auscultation of Heart Valves
The heart has four valves that regulate blood flow through its chambers. Each valve has a specific location and can be auscultated to assess its function.
The Pulmonary Valve: Located at the junction of the sternum and left third costal cartilage, the pulmonary valve is best auscultated at the level of the second left intercostal space parasternally.
The Aortic Valve: Positioned posterior to the left side of the sternum at the level of the third intercostal space, the aortic valve is best auscultated in the second right intercostal space parasternally.
The Mitral Valve: Found posteriorly to the left side of the sternum at the level of left fourth costal cartilage, in the fifth intercostal space in mid-clavicular line, the mitral valve can be auscultated to assess its function.
The Valve of the Coronary Sinus: The Thebesian valve of the coronary sinus is an endocardial flap that plays a role in regulating blood flow through the heart.
The Tricuspid Valve: Located behind the lower mid-sternum at the level of the fourth and fifth intercostal spaces, the tricuspid valve is best auscultated over the lower sternum.
Understanding the location and auscultation of heart valves is essential for diagnosing and treating heart conditions.
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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 65-year-old man presents to the Emergency Department with sudden onset epigastric discomfort. He has a significant past medical history of hypercholesterolaemia and type II diabetes mellitus, and he is a heavy smoker. On examination, his pulse is 30 bpm; he is hypotensive and has distended neck veins. The chest is clear to auscultation. Initial blood tests reveal an elevated troponin level, and an electrocardiogram (ECG) shows hyperacute T-waves in leads II, III and aVF.
What is the most likely diagnosis?Your Answer: Right/inferior MI
Explanation:Understanding the Different Types of Myocardial Infarction: A Guide to ECG Changes and Symptoms
Myocardial infarction (MI) can occur in different areas of the heart, depending on which artery is occluded. Right/inferior MIs, which account for up to 40-50% of cases, are caused by occlusion of the RCA or, less commonly, a dominant left circumflex artery. Symptoms include bradycardia, hypotension, and a clear chest on auscultation. Conduction disturbances, particularly type II and III heart blocks, are also common. ECG changes include ST-segment elevation in leads II, III, and aVF, and reciprocal ST-segment depression in aVL (± lead I).
Anterolateral MIs are possible, but less likely to present with bradycardia, hypotension, and a clear chest. An anterior MI, caused by occlusion of the LAD, is associated with tachycardia rather than bradycardia.
Other conditions, such as acute pulmonary edema and pulmonary embolism, may present with similar symptoms but have different ECG changes and additional features. Understanding the ECG changes and symptoms associated with different types of MI can help with accurate diagnosis and appropriate treatment.
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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 42-year-old man presents with central chest pain which is worse unless sitting forward. He says that the pain gets worse when he takes a deep breath in. There is no previous cardiac history and he is a non-smoker. Over the past few days, he has had a fever with cold and flu type symptoms.
On examination, his blood pressure is 130/80 mmHg, and he has an audible pericardial rub.
Investigations:
Investigation Result Normal value
Haemoglobin 135 g/l 135–175 g/l
Erythrocyte sedimentation rate (ESR) 40 mm/h 0–10mm in the 1st hour
White cell count (WCC) 8.5 × 109/l 4–11 × 109/l
Platelets 320 × 109/l 150–400 × 109/l
Creatine kinase (CK) 190 IU/l 23–175 IU/l
Total cholesterol 4.9 mmol/l < 5.2 mmol/l
Electrocardiogram – saddle-shaped ST elevation across all leads.
Which of the following diagnoses fits best with this clinical picture?Your Answer: Acute pericarditis
Explanation:Differential Diagnosis of Chest Pain: Acute Pericarditis, Cardiac Tamponade, Myocarditis, Acute Myocardial Infarction, and Unstable Angina
Chest pain can have various causes, and it is important to differentiate between them to provide appropriate treatment. In this case, the clinical history suggests acute pericarditis, which can be caused by viral infections or other factors. Management involves rest and analgesia, with non-steroidals being particularly effective. If there is no improvement, a tapering course of oral prednisolone may be helpful.
Cardiac tamponade is another possible cause of chest pain, which is caused by fluid accumulation in the pericardial space. Patients may present with shortness of breath, hypotension, and muffled heart sounds. Beck’s triad includes a falling blood pressure, a rising JVP, and a small, quiet heart.
Myocarditis can present with signs of heart failure but does not typically cause pain unless there is concurrent pericarditis. Acute myocardial infarction, on the other hand, typically presents with central chest pain that is not affected by inspiration. Unstable angina also causes central chest pain or discomfort at rest, which worsens over time if untreated. However, in this case, the patient has no risk factors for ischaemic heart disease, making it unlikely to be the cause of their symptoms.
In summary, chest pain can have various causes, and it is important to consider the patient’s clinical history and risk factors to 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 15
Correct
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A 42-year-old man presents to the Emergency Department with severe central chest pain that worsens when lying down, is relieved by sitting forward, and radiates to his left shoulder. He has a history of prostate cancer and has recently completed two cycles of radiotherapy. On examination, his blood pressure is 96/52 mmHg (normal <120/80 mmHg), his JVP is elevated, and his pulse is 98 bpm with a decrease in amplitude during inspiration. Heart sounds are faint. The ECG shows low-voltage QRS complexes. What is the most appropriate initial management for this patient?
Your Answer: Urgent pericardiocentesis
Explanation:The patient is experiencing cardiac tamponade, which is caused by fluid in the pericardial sac compressing the heart and reducing ventricular filling. This is likely due to pericarditis caused by recent radiotherapy. Beck’s triad of low blood pressure, raised JVP, and muffled heart sounds are indicative of tamponade. Urgent pericardiocentesis is necessary to aspirate the pericardial fluid, preferably under echocardiographic guidance. A fluid challenge with sodium chloride is not recommended as it may worsen the pericardial fluid. Ibuprofen is not effective in severe cases of pericardial effusion. GTN spray, morphine, clopidogrel, and aspirin are useful in managing myocardial infarction, which is a differential diagnosis to rule out. LMWH is not appropriate for tamponade and may worsen the condition if caused by haemopericardium.
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This question is part of the following fields:
- Cardiology
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Question 16
Incorrect
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Which statement about congenital heart disease is accurate?
Your Answer: Transposition of the great vessels is the most common congenital cyanotic heart disease
Correct Answer: In Down's syndrome with an endocardial cushion defect, irreversible pulmonary hypertension occurs earlier than in children with normal chromosomes
Explanation:Common Congenital Heart Defects and their Characteristics
An endocardial cushion defect, also known as an AVSD, is the most prevalent cardiac malformation in individuals with Down Syndrome. This defect can lead to irreversible pulmonary hypertension, which is known as Eisenmenger’s syndrome. It is unclear why children with Down Syndrome tend to have more severe cardiac disease than unaffected children with the same abnormality.
ASDs, or atrial septal defects, may close on their own, and the likelihood of spontaneous closure is related to the size of the defect. If the defect is between 5-8 mm, there is an 80% chance of closure, but if it is larger than 8 mm, the chance of closure is minimal.
Tetralogy of Fallot, a cyanotic congenital heart disease, typically presents after three months of age. The murmur of VSD, or ventricular septal defect, becomes more pronounced after one month of life. Overall, the characteristics of these common congenital heart defects is crucial for proper diagnosis and treatment.
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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 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 18
Correct
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A 56-year-old man presents to the Emergency Department with crushing substernal chest pain that radiates to the jaw. He has a history of poorly controlled hypertension and uncontrolled type II diabetes mellitus for the past 12 years. An electrocardiogram (ECG) reveals ST elevation, and he is diagnosed with acute myocardial infarction. The patient undergoes percutaneous coronary intervention (PCI) and stenting and is discharged from the hospital. Eight weeks later, he experiences fever, leukocytosis, and chest pain that is relieved by leaning forwards. There is diffuse ST elevation in multiple ECG leads, and a pericardial friction rub is heard on auscultation. What is the most likely cause of the patient's current symptoms?
Your Answer: Dressler’s syndrome
Explanation:Complications of Transmural Myocardial Infarction
Transmural myocardial infarction can lead to various complications, including Dressler’s syndrome and ventricular aneurysm. Dressler’s syndrome typically occurs weeks to months after an infarction and is characterized by acute fibrinous pericarditis, fever, pleuritic chest pain, and leukocytosis. On the other hand, ventricular aneurysm is characterized by a systolic bulge in the precordial area and predisposes to stasis and thrombus formation. Acute fibrinous pericarditis, which manifests a few days after an infarction, is not due to an autoimmune reaction. Reinfarction is unlikely in a patient who has undergone successful treatment for STEMI. Infectious myocarditis, caused by viruses such as Coxsackie B, Epstein-Barr, adenovirus, and echovirus, is not the most likely cause of the patient’s symptoms, given his medical history.
Complications of Transmural Myocardial Infarction
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This question is part of the following fields:
- Cardiology
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Question 19
Correct
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At 15 years of age a boy develops rheumatic fever. Thirty-five years later, he is admitted to hospital with weight loss, palpitations, breathlessness and right ventricular hypertrophy. On examination he is found to have an audible pan systolic murmur.
Which heart valve is most likely to have been affected following rheumatic fever?Your Answer: Mitral
Explanation:Rheumatic Heart Disease and Valve Involvement
Rheumatic heart disease is a condition that results from acute rheumatic fever and causes progressive damage to the heart valves over time. The mitral valve is the most commonly affected valve, with damage patterns varying by age. Younger patients tend to have regurgitation, while those in adolescence have a mix of regurgitation and stenosis, and early adulthood onwards tend to have pure mitral stenosis. Aortic valve involvement can also occur later in life. In this case, the patient is likely experiencing mitral regurgitation, causing palpitations and breathlessness. While the pulmonary valve can be affected, it is rare, and tricuspid involvement is even rarer and only present in advanced stages. Aortic valve involvement can produce similar symptoms, but with different murmurs on examination. When the aortic valve is involved, all leaflets are affected.
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This question is part of the following fields:
- Cardiology
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Question 20
Incorrect
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A 12-year-old girl is diagnosed with rheumatic fever after presenting with a 3-day history of fever and polyarthralgia. The patient’s mother is concerned about any potential lasting damage to the heart.
What is the most common cardiac sequelae of rheumatic fever?Your Answer: Tricuspid regurgitation
Correct Answer: Mitral stenosis
Explanation:Rheumatic Fever and its Effects on Cardiac Valves
Rheumatic fever is a condition caused by group A β-haemolytic streptococcal infection. To diagnose it, the revised Duckett-Jones criteria are used, which require evidence of streptococcal infection and the presence of certain criteria. While all four cardiac valves may be damaged as a result of rheumatic fever, the mitral valve is the most commonly affected, with major criteria including carditis, subcutaneous nodule, migratory polyarthritis, erythema marginatum, and Sydenham’s chorea. Minor criteria include arthralgia, fever, raised CRP or ESR, raised WCC, heart block, and previous rheumatic fever. Mitral stenosis is the most common result of rheumatic fever, but it is becoming less frequently seen in clinical practice. Pulmonary regurgitation, aortic sclerosis, and tricuspid regurgitation are also possible effects, but they are less common than mitral valve damage. Ventricular septal defect is not commonly associated with rheumatic fever.
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This question is part of the following fields:
- Cardiology
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Question 21
Incorrect
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A 61-year-old man comes to his General Practitioner complaining of increasing exertional dyspnoea accompanied by bilateral peripheral oedema. He reports feeling extremely fatigued lately. During the physical examination, his lungs are clear, but he has ascites. On auscultation of his heart sounds, you detect a holosystolic murmur with a high pitch at the left sternal edge, extending to the right sternal edge. What is the probable reason for this patient's symptoms?
Your Answer: Aortic stenosis
Correct Answer: Tricuspid regurgitation
Explanation:Differentiating Heart Murmurs and Symptoms
Tricuspid regurgitation is characterized by signs of right heart failure, such as dyspnea and peripheral edema, and a classical murmur. The backflow of blood to the right atrium leads to right heart dilation, weakness, and eventually failure, resulting in ascites and poor ejection fraction causing edema.
Mitral regurgitation has a similar murmur to tricuspid regurgitation but is heard best at the apex.
Aortic regurgitation is identified by an early diastolic decrescendo murmur at the left sternal edge.
Aortic stenosis does not typically result in ascites, and its murmur is ejection systolic.
Pulmonary stenosis is characterized by a mid-systolic crescendo-decrescendo murmur best heard over the pulmonary post and not a holosystolic murmur at the left sternal edge.
Understanding Heart Murmurs and Symptoms
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This question is part of the following fields:
- Cardiology
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Question 22
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 23
Correct
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A 72-year-old man is brought by ambulance to Accident and Emergency. He presents with central crushing chest pain and has ST-segment elevation present on an electrocardiogram (ECG). You are at a District General Hospital without access to percutaneous coronary intervention (PCI), and you will not be able to transfer the patient across for PCI in time.
Which of the following is an absolute contraindication to thrombolysis?Your Answer: Brain neoplasm
Explanation:Relative and Absolute Contraindications to Thrombolysis
Thrombolysis is a treatment option for patients with ongoing cardiac ischemia and presentation within 12 hours of onset of pain. However, it is important to consider both relative and absolute contraindications before administering thrombolysis.
Cerebral neoplasm is the only absolute contraindication, while advanced liver disease, severe hypertension (not meeting absolute contraindication values), active peptic ulceration, and pregnancy or recent delivery are all relative contraindications.
Primary PCI is the preferred treatment option if available, but thrombolysis can be used as an alternative if necessary. The benefit of thrombolysis decreases over time, and a target time of less than 30 minutes from admission is recommended. Thrombolysis should not be given if the onset of pain is more than 24 hours after presentation.
It is important to carefully consider contraindications before administering thrombolysis to ensure patient safety and optimal treatment outcomes.
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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 70-year-old man with a history of hyperlipidaemia, hypertension and angina arrives at the Emergency Department with severe chest pain that radiates down his left arm. He is sweating heavily and the pain does not subside with rest or sublingual nitroglycerin. An electrocardiogram (ECG) reveals ST segment elevation in leads II, III and avF.
What is the leading cause of death within the first hour after the onset of symptoms in this patient?Your Answer: Emboli from a left ventricular thrombus
Correct Answer: Arrhythmia
Explanation:After experiencing an inferior-wall MI, the most common cause of death within the first hour is a lethal arrhythmia, such as ventricular fibrillation. This can be caused by various factors, including ischaemia, toxic metabolites, or autonomic stimulation. If ventricular fibrillation occurs within the first 48 hours, it may be due to transient causes and not affect long-term prognosis. However, if it occurs after 48 hours, it is usually indicative of permanent dysfunction and associated with a worse long-term prognosis. Other complications that may occur after an acute MI include emboli from a left ventricular thrombus, cardiac tamponade, ruptured papillary muscle, and pericarditis. These complications typically occur at different time frames after the acute MI and present with different symptoms.
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This question is part of the following fields:
- Cardiology
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Question 25
Incorrect
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A 68-year-old woman presents to the hospital with complaints of shortness of breath, extreme weakness, and epigastric pain that started 30 minutes ago while she was using the restroom. She is still experiencing these symptoms and is sweating profusely. Her heart rate is 150 bpm, and her blood pressure is 180/110 mmHg. An ECG is ordered, which shows elevated ST segments in consecutive leads and Q waves. What is the most probable cause of this woman's condition?
Your Answer: Coronary artery stenosis
Correct Answer: Completely occlusive thrombus
Explanation:Causes of Chest Pain: Understanding Myocardial Infarction and Other Conditions
Chest pain can be a symptom of various conditions, including myocardial infarction, coronary artery stenosis, coronary vasospasm, partially occlusive thrombus, and pulmonary embolism. Understanding the differences between these conditions is crucial for accurate diagnosis and treatment.
Myocardial Infarction
Myocardial infarction, or heart attack, is a serious condition that occurs when a completely occlusive thrombus blocks blood flow to the heart. Women are more likely to experience atypical symptoms such as shortness of breath, weakness, and fatigue, rather than the typical substernal chest pain. However, heart rate, blood pressure, and ECG changes indicate a myocardial infarction.
Coronary Artery Stenosis
Coronary artery stenosis causes stable angina, which subsides with rest. It is characterized by a narrowing of the coronary arteries that supply blood to the heart.
Coronary Vasospasm
Coronary vasospasm is the cause of Prinzmetal’s angina, which presents as intermittent chest pain at rest. It is caused by the sudden constriction of the coronary arteries.
Partially Occlusive Thrombus
A partially occlusive thrombus may present similarly to a completely occlusive thrombus, but it does not usually cause an elevation in the ST segment.
Pulmonary Embolism
A pulmonary embolism is an occlusion of circulation in the lungs and presents as severe shortness of breath. However, it does not typically cause the specific ECG changes seen in myocardial infarction.
Understanding the differences between these conditions can help healthcare professionals accurately diagnose and treat chest pain.
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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 patient in their 60s with idiopathic pericarditis becomes increasingly unwell, with hypotension, jugular venous distention and muffled heart sounds on auscultation. Echocardiogram confirms a pericardial effusion.
At which of the following sites does this effusion occur?Your Answer: Between the visceral pericardium and the parietal pericardium
Explanation:Understanding the Site of Pericardial Effusion
Pericardial effusion is a condition where excess fluid accumulates in the pericardial cavity, causing compression of the heart. To understand the site of pericardial effusion, it is important to know the layers of the pericardium.
The pericardium has three layers: the fibrous pericardium, the parietal pericardium, and the visceral pericardium. The pericardial fluid is located in between the visceral and parietal pericardium, which is the site where a pericardial effusion occurs.
It is important to note that pericardial effusion does not occur between the parietal pericardium and the fibrous pericardium, the visceral pericardium and the myocardium, the fibrous pericardium and the mediastinal pleura, or the fibrous pericardium and the central tendon of the diaphragm.
In summary, pericardial effusion occurs at the site where pericardial fluid is normally produced – between the parietal and visceral layers of the serous pericardium. Understanding the site of pericardial effusion is crucial in diagnosing and treating this condition.
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This question is part of the following fields:
- Cardiology
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Question 27
Correct
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A 16-year-old boy is discovered following a street brawl with a stab wound on the left side of his chest to the 5th intercostal space, mid-clavicular line. He has muffled heart sounds, distended neck veins, and a systolic blood pressure of 70 mmHg. What is the most accurate description of his condition?
Your Answer: Beck’s triad
Explanation:Medical Triads and Laws
There are several medical triads and laws that are used to diagnose certain conditions. One of these is Beck’s triad, which consists of muffled or distant heart sounds, low systolic blood pressure, and distended neck veins. This triad is associated with cardiac tamponade.
Another law is Courvoisier’s law, which states that if a patient has a palpable gallbladder that is non-tender and is associated with painless jaundice, the cause is unlikely to be gallstones.
Meigs syndrome is a triad of ascites, pleural effusion, and a benign ovarian tumor.
Cushing’s syndrome is a set of signs and symptoms that occur due to prolonged use of corticosteroids, including hypertension and central obesity. However, this is not relevant to the patient in the question as there is no information about steroid use and the blood pressure is low.
Finally, Charcot’s triad is used in ascending cholangitis and consists of right upper quadrant pain, jaundice, and fever.
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This question is part of the following fields:
- Cardiology
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Question 28
Correct
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A 30-year-old woman visits her GP to discuss contraception options, specifically the combined oral contraceptive pill. She has no medical history, is a non-smoker, and reports no symptoms of ill-health. During her check-up, her GP measures her blood pressure and finds it to be 168/96 mmHg, which is consistent on repeat testing and in both arms. Upon examination, her BMI is 24 kg/m2, her pulse is 70 bpm, femoral pulses are palpable, and there is an audible renal bruit. Urinalysis is normal, and blood tests reveal no abnormalities in full blood count, urea, creatinine, electrolytes, or thyroid function. What is the most conclusive test to determine the underlying cause of her hypertension?
Your Answer: Magnetic resonance imaging with gadolinium contrast of renal arteries
Explanation:Diagnostic Tests for Secondary Hypertension: Assessing the Causes
Secondary hypertension is a condition where high blood pressure is caused by an underlying medical condition. To diagnose the cause of secondary hypertension, various diagnostic tests are available. Here are some of the tests that can be done:
Magnetic Resonance Imaging with Gadolinium Contrast of Renal Arteries
This test is used to diagnose renal artery stenosis, which is the most common cause of secondary hypertension in young people, especially young women. It is done when a renal bruit is detected. Fibromuscular dysplasia, a vascular disorder that affects the renal arteries, is one of the most common causes of renal artery stenosis in young adults, particularly women.Echocardiogram
While an echocardiogram can assess for end-organ damage resulting from hypertension, it cannot provide the actual cause of hypertension. Coarctation of the aorta is unlikely if there is no blood pressure differential between arms.24-Hour Urine Cortisol
This test is done to diagnose Cushing syndrome, which is unlikely in this case. The most common cause of Cushing syndrome is exogenous steroid use, which the patient does not have. In addition, the patient has a normal BMI and does not have a cushingoid appearance on examination.Plasma Metanephrines
This test is done to diagnose phaeochromocytoma, which is unlikely in this case. The patient does not have symptoms suggestive of it, such as sweating, headache, palpitations, and syncope. Phaeochromocytoma is also a rare tumour, causing less than 1% of cases of secondary hypertension.Renal Ultrasound
This test is a less accurate method for assessing the renal arteries. Renal parenchymal disease is unlikely in this case as urinalysis, urea, and creatinine are normal.Diagnostic Tests for Secondary Hypertension: Assessing the Causes
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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 50-year-old man with hypertension and type II diabetes mellitus presented to the Emergency Department with diaphoresis, severe central chest pain, and breathlessness. An ECG showed ST elevation in leads II, III, and aVF. Where is the probable location of the responsible arterial stenosis?
Your Answer: Right coronary artery
Explanation:Coronary Arteries and Their Associated Leads
The heart is supplied with blood by the coronary arteries. Each artery supplies a specific area of the heart and can be identified by the leads on an electrocardiogram (ECG).
The right coronary artery supplies the inferior part of the left ventricle, interventricular septum, and right ventricle. The circumflex artery predominantly supplies the left free wall of the left ventricle and would be picked up by leads I, aVL, and V5–6. The left anterior descending artery supplies the septum, apex, and anterior wall of the left ventricle and would be picked up by leads V1–4.
Proximal aortic stenosis is very rare and would cause problems of perfusion in distal organs before reducing enough blood supply to the heart to cause a myocardial infarction. The left main stem splits into both the circumflex and left anterior descending arteries. Acute occlusion at this location would be catastrophic and a person is unlikely to survive to hospital. It would be picked up by leads V1–6, I, and aVL.
Understanding the specific areas of the heart supplied by each coronary artery and their associated leads on an ECG can aid in the diagnosis and treatment of cardiac conditions.
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This question is part of the following fields:
- Cardiology
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Question 30
Correct
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A 63-year-old man experiences a myocardial infarction (MI) that results in necrosis of the anterior papillary muscle of the right ventricle, leading to valve prolapse. Which structure is most likely responsible for the prolapse?
Your Answer: Anterior and posterior cusps of the tricuspid valve
Explanation:Cusps and Papillary Muscles of the Heart Valves
The heart valves play a crucial role in regulating blood flow through the heart. The tricuspid and mitral valves are located between the atria and ventricles of the heart. These valves have cusps, which are flaps of tissue that open and close to allow blood to flow in one direction. The papillary muscles, located in the ventricles, attach to the cusps of the valves and help to control their movement.
Tricuspid Valve:
The tricuspid valve has three cusps: anterior, posterior, and septal. The anterior and posterior cusps are attached to the anterior and posterior papillary muscles, respectively. The septal cusp is attached to the septal papillary muscle.Mitral Valve:
The mitral valve has two cusps: anterior and posterior. These cusps are not attached to papillary muscles directly, but rather to chordae tendineae, which are thin tendons that connect the cusps to the papillary muscles.Understanding the anatomy of the heart valves and their associated papillary muscles is important for diagnosing and treating heart conditions such as valve prolapse or regurgitation.
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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 65-year-old retiree visits his GP as he is becoming increasingly breathless and tired whilst walking. He has always enjoyed walking and usually walks 3 times a week. Over the past year he has noted that he can no longer manage the same distance that he used to be able to without getting breathless and needing to stop. He wonders if this is a normal part of ageing or if there could be an underlying medical problem.
Which of the following are consistent with normal ageing with respect to the cardiovascular system?Your Answer: Reduced VO2 max
Explanation:Ageing and Cardiovascular Health: Understanding the Normal and Abnormal Changes
As we age, our organs may still function normally at rest, but they may struggle to respond adequately to stressors such as exercise or illness. One of the key indicators of cardiovascular health is VO2 max, which measures the maximum rate of oxygen consumption during exercise. In normal ageing, VO2 max may decrease along with muscle strength, making intense exertion more difficult. However, significantly reduced VO2 max, left ventricular ejection fraction (LVEF), or stroke volume are not consistent with normal ageing. Additionally, hypotension or hypertension are not typical changes associated with ageing. Understanding these normal and abnormal changes can help us better monitor and manage our cardiovascular health as we age.
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This question is part of the following fields:
- Cardiology
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Question 32
Incorrect
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A 58-year-old Caucasian man with type II diabetes is seen for annual review. His blood pressure is 174/99 mmHg, and his 24-hour urine collection reveals moderately increased albuminuria (microalbuminuria). Blood results show Na+ 140 mmol/l, K+ 4.0 mmol/l, urea 4.2 mmol/l and creatinine 75 ÎĽmol/l.
Which of the following medications would be the most appropriate to use first line to treat the hypertension?Your Answer: Amlodipine
Correct Answer: Ramipril
Explanation:First-line treatment for hypertension in diabetic patients: Ramipril
Ramipril is the first-line treatment for hypertension in diabetic patients due to its ability to reduce proteinuria in diabetic nephropathy, in addition to its antihypertensive effect. Calcium channel blockers, such as amlodipine, may be preferred for pregnant women or patients with hypertension but no significant proteinuria. Bendroflumethiazide may be introduced if first-line therapy is ineffective, while atenolol can be used in difficult-to-treat hypertension where dual therapy is ineffective. Furosemide is usually avoided in type II diabetes due to its potential to interfere with blood glucose levels.
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This question is part of the following fields:
- Cardiology
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Question 33
Correct
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A 48-year-old man presents to the Emergency Department with chest tightness. His blood pressure is 200/105 mmHg and heart rate is 70 bpm. His femoral pulses cannot be felt. Echocardiography reveals cardiomegaly and a left-ventricular ejection fraction of 34%. The patient also has a N-terminal pro-brain natriuretic peptide (NT-proBNP) of 25,000 pg/mL. As a result of the patient’s hypertension and high levels of NT-proBNP, he undergoes coronary angiography to exclude cardiac ischaemia. There is no evidence of myocardial ischaemia, but there are significant arterial findings.
Which of the following is most likely to be seen on coronary angiography of this patient?Your Answer: Stenotic arteries
Explanation:Differentiating Arterial Conditions: Understanding the Symptoms and Causes
When it comes to arterial conditions, it is important to understand the symptoms and causes in order to make an accurate diagnosis. Here, we will explore several potential conditions and how they may present in a patient.
Stenotic Arteries:
Coarctation of the aorta is a potential condition to consider in younger adults with poorly controlled hypertension. Symptoms may include weak or absent femoral pulses, heart failure, and left-ventricular hypertrophy. Angiography may reveal stenosis in the middle and proximal segments of the left anterior descending artery, as well as in the left circumflex artery.Thickened Arteries:
Atherosclerosis, or the build-up of plaque in the arteries, is a risk factor for heart attacks and stroke. However, it is unlikely to explain persistently high blood pressure or an absent femoral pulse.Aortic Aneurysm:
While chronic high blood pressure can increase the risk of an aortic aneurysm, sudden, intense chest or back pain is a more common symptom. Additionally, a patient with an aneurysm would likely have low blood pressure and an elevated heart rate, which is inconsistent with the vitals seen in this presentation.Calcified Arteries:
Calcification of arteries is caused by elevated lipid content and increases with age. While it can increase the risk of heart attack and stroke, it would not explain the absence of a femoral pulse or extremely high blood pressure.Patent Foramen Ovale:
This condition, which predisposes patients to paradoxical emboli, is typically diagnosed on an echocardiogram and is unlikely to cause hypertension. It should be considered in patients who have had a stroke before the age of 50.In summary, understanding the symptoms and causes of arterial conditions is crucial for accurate diagnosis and treatment.
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This question is part of the following fields:
- Cardiology
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Question 34
Correct
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During a routine GP check-up, a 33-year-old woman is found to have a mid-diastolic rumbling murmur accompanied by a loud first heart sound. What valvular abnormality is likely causing this?
Your Answer: Mitral stenosis
Explanation:Valvular Murmurs
Valvular murmurs are a common topic in medical exams, and it is crucial to have a good of them. The easiest way to approach them is by classifying them into systolic and diastolic murmurs. If the arterial valves, such as the aortic or pulmonary valves, are narrowed, ventricular contraction will cause turbulent flow, resulting in a systolic murmur. On the other hand, if these valves are incompetent, blood will leak back through the valve during diastole, causing a diastolic murmur.
Similarly, the atrioventricular valves, such as the mitral and tricuspid valves, can be thought of in the same way. If these valves are leaky, blood will be forced back into the atria during systole, causing a systolic murmur. If they are narrowed, blood will not flow freely from the atria to the ventricles during diastole, causing a diastolic murmur.
Therefore, a diastolic murmur indicates either aortic/pulmonary regurgitation or mitral/tricuspid stenosis. The loud first heart sound is due to increased force in closing the mitral or tricuspid valve, which suggests stenosis. the different types of valvular murmurs and their causes is essential for medical professionals to diagnose and treat patients accurately.
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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 60-year-old man is seen at cardiology outpatients 6 weeks after an anterior myocardial infarction. His wife complains that she cannot sleep at night due to his constant coughing and throat clearing.
Which medication is likely causing these symptoms?Your Answer: Perindopril
Explanation:Common Side-Effects of Cardiovascular Medications
Cardiovascular medications are commonly prescribed to manage various heart conditions. However, they can also cause side-effects that can affect a patient’s quality of life. Here are some common side-effects of popular cardiovascular medications:
Perindopril: This medication can cause a dry, persistent cough, as well as hyperkalaemia, fatigue, dizziness, and hypotension.
Amiodarone: Side-effects of this medication include dizziness, visual disturbance, unco-ordination, tremors, paraesthesia, deranged liver function tests (LFTs), deranged thyroid function tests (TFTs), and lung fibrosis.
Atenolol: β-blockers like atenolol can cause fatigue, Raynaud’s phenomenon, bronchospasm, change in bowel habit, and sexual dysfunction.
Atorvastatin: Statins like atorvastatin can cause myopathy/myositis, derangement of glucose control, and deranged LFTs.
Candesartan: Angiotensin receptor blockers like candesartan can cause dizziness, headache, hyperkalaemia, and first-dose orthostatic hypotension. They are often prescribed to patients who are intolerant of ACE inhibitors due to dry cough.
In conclusion, patients taking cardiovascular medications should be aware of these potential side-effects and report any concerns to their healthcare provider.
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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 previously healthy 58-year-old man collapsed while playing with his grandchildren. Although he quickly regained consciousness and became fully alert, his family called an ambulance. The emergency medical team found no abnormalities on the electrocardiogram. Physical examination was unremarkable. However, the patient was admitted to the Coronary Care Unit of the local hospital. During the evening, the patient was noted to have a fast rhythm with a wide complex on his monitor, followed by hypotension and loss of consciousness.
After electrical cardioversion with 200 watt-seconds of direct current, which one of the following may possible therapy include?Your Answer: Amiodarone
Explanation:The patient in the scenario is experiencing a fast rhythm with wide complexes, which is likely ventricular tachycardia (VT). As the patient is unstable, electrical cardioversion was attempted first, as recommended by the Resuscitation Council Guideline. If cardioversion fails and the patient remains unstable, intravenous amiodarone can be used as a loading dose of 300 mg over 10-20 minutes, followed by an infusion of 900 mg/24 hours. Amiodarone is a class III anti-arrhythmic agent that prolongs the repolarization phase of the cardiac action potential by blocking potassium efflux. Side-effects associated with amiodarone include deranged thyroid and liver function tests, nausea, vomiting, bradycardia, interstitial lung disease, jaundice, and sleep disorders.
Epinephrine is used in the treatment of acute anaphylaxis and cardiopulmonary resuscitation. It acts on adrenergic receptors, causing bronchodilation and vasoconstriction. Side-effects associated with epinephrine include palpitations, arrhythmias, headache, tremor, and hypertension.
Intravenous propranolol is a non-selective β-adrenergic receptor blocker that has limited use in treating arrhythmias and thyrotoxic crisis. It is contraindicated in patients with severe hypotension, asthma, COPD, bradycardia, sick sinus rhythm, atrioventricular block, and cardiogenic shock. Side-effects associated with propranolol include insomnia, nightmares, nausea, diarrhea, bronchospasm, exacerbation of Raynaud’s, bradycardia, hypotension, and heart block.
Digoxin, a cardiac glycoside extracted from the plant genus Digitalis, can be used in the treatment of supraventricular arrhythmias and heart failure. However, it is of no use in this scenario as the patient is experiencing a broad complex tachycardia. Digoxin has a narrow therapeutic window, and even small changes in dosing can lead to toxicity. Side-effects associated with digoxin include nausea, vomiting, diarrhea, bradycardia, dizziness, yellow vision, and eosinophilia.
Diltiazem, a non-dihydropyridine calcium channel blocker, is normally used for hypertension and prophylaxis and treatment of ang
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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 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 38
Incorrect
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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 contraction – increased LV end-diastolic pressure – increased LV end-systolic volume
Correct 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 39
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 40
Incorrect
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A newborn baby is found to have a heart murmur that is later identified as Ebstein's anomaly. Is it possible that a medication taken by the mother during pregnancy could have played a role in causing this congenital heart defect?
Your Answer: Phenytoin
Correct Answer: Lithium
Explanation:Lithium Exposure During Pregnancy Linked to Ebstein’s Anomaly
Exposure to lithium during pregnancy has been found to be linked to the development of Ebstein’s anomaly in newborns. Ebstein’s anomaly is a rare congenital heart defect that affects the tricuspid valve, which separates the right atrium and right ventricle of the heart. This condition can cause a range of symptoms, including shortness of breath, fatigue, and heart palpitations.
Studies have shown that women who take lithium during pregnancy are at an increased risk of having a child with Ebstein’s anomaly. Lithium is commonly used to treat bipolar disorder, and while it can be an effective treatment, it is important for women who are pregnant or planning to become pregnant to discuss the risks and benefits of taking lithium with their healthcare provider.
It is important for healthcare providers to be aware of the potential risks associated with lithium use during pregnancy and to closely monitor pregnant women who are taking this medication. Early detection and treatment of Ebstein’s anomaly can improve outcomes for affected infants.
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This question is part of the following fields:
- Cardiology
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Question 41
Incorrect
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A 56-year-old patient presents for an annual review. He has no significant past medical history. He is a smoker and has a family history of ischaemic heart disease: body mass index (BMI) 27.4, blood pressure (BP) 178/62 mmHg, fasting serum cholesterol 7.9 mmol/l (normal value < 5.17 mmol/l), triglycerides 2.2 mmol/l (normal value < 1.7 mmol/l), fasting glucose 5.8 mmol/l (normal value 3.9–5.6 mmol/l).
Which of the following would be the most appropriate treatment for his cholesterol?Your Answer: Dietary advice and repeat in six months
Correct Answer: Start atorvastatin
Explanation:Treatment Options for Primary Prevention of Cardiovascular Disease
The primary prevention of cardiovascular disease (CVD) involves identifying and managing risk factors such as high cholesterol, smoking, hypertension, and family history of heart disease. The National Institute for Health and Care Excellence (NICE) provides guidelines for the treatment of these risk factors.
Start Atorvastatin: NICE recommends offering atorvastatin 20 mg to people with a 10% or greater 10-year risk of developing CVD. Atorvastatin is preferred over simvastatin due to its superior efficacy and side-effect profile.
Reassure and Repeat in One Year: NICE advises using the QRISK2 risk assessment tool to assess CVD risk and starting treatment if the risk is >10%.
Dietary Advice and Repeat in Six Months: Dietary advice should be offered to all patients, including reducing saturated fat intake, increasing mono-unsaturated fat intake, choosing wholegrain varieties of starchy food, reducing sugar intake, eating fruits and vegetables, fish, nuts, seeds, and legumes.
Start Bezafibrate: NICE advises against routinely offering fibrates for the prevention of CVD to people being treated for primary prevention.
Start Ezetimibe: Ezetimibe is not a first-line treatment for hyperlipidaemia, but people with primary hypercholesterolaemia should be considered for ezetimibe treatment.
Overall, a combination of lifestyle changes and medication can effectively manage cardiovascular risk factors and prevent the development of CVD.
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This question is part of the following fields:
- Cardiology
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Question 42
Correct
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You are urgently requested to assess a 23-year-old male who has presented to the Emergency department after confessing to consuming 14 units of alcohol and taking 2 ecstasy tablets tonight. He is alert and oriented but is experiencing palpitations. He denies any chest pain or difficulty breathing.
The patient's vital signs are as follows: heart rate of 180 beats per minute, regular rhythm, blood pressure of 115/80 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 99% on room air. An electrocardiogram (ECG) is performed and reveals an atrioventricular nodal re-entry tachycardia (SVT).
What would be your first course of action in terms of treatment?Your Answer: Vagal manoeuvres
Explanation:SVT is a type of arrhythmia that occurs above the ventricles and is commonly seen in patients in their 20s with alcohol and drug use as precipitating factors. Early evaluation of ABC is important, and vagal manoeuvres are recommended as the first line of treatment. Adenosine is the drug of choice if vagal manoeuvres fail, and DC cardioversion is required if signs of decompensation are present. Amiodarone is not a first-line treatment for regular narrow complex SVT.
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This question is part of the following fields:
- Cardiology
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Question 43
Correct
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A 55-year-old man is experiencing chest pain and shortness of breath three weeks after a myocardial infarction that was treated with percutaneous coronary intervention (PCI) for a proximal left anterior descending artery occlusion. On examination, he has a loud friction rub over the praecordium, bilateral pleural effusions on chest x-ray, and ST elevation on ECG. What is the most probable diagnosis?
Your Answer: Dressler's syndrome
Explanation:Dressler’s Syndrome
Dressler’s syndrome is a type of pericarditis that typically develops between two to six weeks after a person has experienced an anterior myocardial infarction or undergone heart surgery. This condition is believed to be caused by an autoimmune response to myocardial antigens. In simpler terms, the body’s immune system mistakenly attacks the heart tissue, leading to inflammation of the pericardium, which is the sac that surrounds the heart.
The symptoms of Dressler’s syndrome can vary from person to person, but they often include chest pain, fever, fatigue, and shortness of breath. In some cases, patients may also experience a cough, abdominal pain, or joint pain. Treatment for this condition typically involves the use of nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and manage pain. In severe cases, corticosteroids may be prescribed to help suppress the immune system.
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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 16-year-old boy is discovered following a street brawl where he was stabbed. He has a stab wound on the left side of his chest, specifically the fifth intercostal space, mid-clavicular line. His blood pressure (BP) is 70 mmHg systolic, his heart sounds are muffled, and his jugular veins are distended, with a prominent x descent and an absent y descent.
What is the most appropriate way to characterize the boy's condition?Your Answer: Beck’s triad
Explanation:Cardiac Terminology: Beck’s Triad, Takotsubo Cardiomyopathy, Virchow’s Triad, Cushing Syndrome, and Kussmaul’s Sign
Beck’s Triad: A combination of muffled or distant heart sounds, low systolic blood pressure, and distended neck veins. This triad is associated with cardiac tamponade.
Takotsubo Cardiomyopathy: A non-ischaemic cardiomyopathy triggered by emotional stress, resulting in sudden weakening or dysfunction of a portion of the myocardium. It is also known as broken heart syndrome.
Virchow’s Triad: A triad that includes hypercoagulability, endothelial/vessel wall injury, and stasis. These factors contribute to a risk of thrombosis.
Cushing Syndrome: A condition caused by prolonged use of corticosteroids, resulting in signs and symptoms such as hypertension and central obesity. However, low blood pressure is not a typical symptom.
Kussmaul’s Sign: A paradoxical rise in jugular venous pressure on inspiration due to impaired filling of the right ventricle. This sign is commonly associated with constrictive pericarditis or restrictive cardiomyopathy. In cardiac tamponade, the jugular veins have a prominent x descent and an absent y descent, whereas in constrictive pericarditis, there will be a prominent x and y descent.
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This question is part of the following fields:
- Cardiology
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Question 45
Incorrect
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A 45-year-old man visits his GP for a routine check-up. He reports feeling well today but has a history of chronic respiratory tract infections and lung issues. He is immunocompetent.
During the examination, his temperature and blood pressure are normal. His heart rate is regular and his breathing is effortless. The GP detects a diastolic murmur with a snap that is most audible at the right fifth intercostal space in the mid-clavicular line.
What is the most probable diagnosis?Your Answer: Idiopathic pulmonary hypertension
Correct Answer: Primary ciliary dyskinesia
Explanation:Possible Diagnosis for a Patient with Chronic Respiratory Infections and a Heart Murmur
Primary Ciliary Dyskinesia: A Congenital Syndrome of Ciliary Dysfunction
The patient described in the case likely has primary ciliary dyskinesia, also known as Kartagener’s syndrome, which is a congenital syndrome of ciliary dysfunction. This disorder affects the proper beating of Ciliary, leading to the accumulation of infectious material within the respiratory tree and abnormal cell migration during development, resulting in situs inversus. Additionally, abnormal Ciliary can lead to non-motile sperm and infertility.
Other Possible Diagnoses
Although the GP noticed a diastolic murmur suggestive of mitral stenosis, the patient does not have symptoms of congestive heart failure. Asthma could be associated with chronic lung and respiratory tract infections, but it would not explain the heart murmur. Squamous cell lung cancer is less likely in a man who is 40 years old with a normal respiratory examination and would not explain the heart murmur. Idiopathic pulmonary hypertension usually causes progressive breathlessness, a dry cough, and fine inspiratory crepitations on examination, rather than the picture here.
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This question is part of the following fields:
- Cardiology
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Question 46
Correct
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A 65-year-old woman with ischaemic heart disease presents with sudden onset palpitations. She has no other complaints. On examination, a regular tachycardia is present. Her blood pressure is 150/90 mmHg. Chest is clear. ECG reveals a regular tachycardia with a QRS width of 80 ms and a rate of 149 beats per min in a sawtooth pattern.
What is the diagnosis?Your Answer: Atrial flutter
Explanation:Common Cardiac Arrhythmias: Types and Characteristics
Cardiac arrhythmias are abnormal heart rhythms that can cause serious health complications. Here are some common types of cardiac arrhythmias and their characteristics:
1. Atrial Flutter: A type of supraventricular tachycardia that is characterized by a sawtooth pattern on the ECG. It is caused by a premature electrical impulse in the atrium and can degenerate into atrial fibrillation. Treatment involves rate or rhythm control, and electrical cardioversion is more effective than in atrial fibrillation.
2. Fast Atrial Fibrillation: Another type of supraventricular tachycardia that presents as an irregularly irregular tachycardia.
3. Ventricular Tachycardia: A common arrhythmia in cardiopaths that is characterized by a wide-complex tachycardia on ECG.
4. Mobitz Type II: A form of second-degree heart block that is characterized by intermittent non-conducted P waves on ECG without progressive prolongation of the QRS interval.
5. Brugada Syndrome: A rare electrophysiological condition that causes sudden death in young adults. ECG findings usually show ST elevation in leads V1 to V3 with a right bundle branch block.
It is important to identify and treat cardiac arrhythmias promptly to prevent serious health complications.
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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 patient comes to your general practice with deteriorating shortness of breath and ankle swelling. You have been treating them for a few years for their congestive cardiac failure, which has been gradually worsening. Currently, the patient is at ease when resting, but standing up and walking a few steps cause their symptoms to appear. According to the New York Heart Association (NYHA) classification, what stage of heart failure are they in?
Your Answer: IV
Correct Answer: III
Explanation:Understanding NYHA Classification for Heart Failure Patients
The NYHA classification system is used to assess the severity of heart failure symptoms in patients. Class I indicates no limitation of physical activity, while class IV indicates severe limitations and symptoms even at rest. This patient falls under class III, with marked limitation of physical activity but no symptoms at rest. It is important for healthcare professionals to understand and use this classification system to properly manage and treat heart failure patients.
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This question is part of the following fields:
- Cardiology
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Question 48
Correct
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A 49-year-old woman presents to the Cardiology clinic with a heart murmur. During the physical exam, the patient exhibits a collapsing pulse. Upon auscultation, a 2/5 early diastolic murmur is heard at the lower left sternal edge, which is more pronounced during expiration.
What is the most probable clinical sign that will be observed?Your Answer: Corrigan’s sign
Explanation:Cardiac Signs and Their Associated Conditions
Corrigan’s Sign: This sign is characterized by an abrupt distension and collapse of the carotid arteries, indicating aortic incompetence. It is often seen in patients with a collapsing pulse and an early diastolic murmur, which are suggestive of aortic regurgitation. A wide pulse pressure may also be found.
Malar Flush: Mitral stenosis is associated with malar flush, a mid-diastolic murmur, loudest at the apex when the patient is in the left lateral position, and a tapping apex. A small-volume pulse is also typical.
Tapping Apex: A tapping apex is a classical sign of mitral stenosis.
Pulsatile Hepatomegaly: Severe tricuspid regurgitation can cause reverse blood flow to the liver during systole, resulting in pulsatile hepatomegaly.
Clubbing: Clubbing is more commonly seen in lung pathology and is unlikely to present in aortic regurgitation. It is seen in congenital cyanotic heart disease.
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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 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: Primary pulmonary hypertension
Correct 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 50
Incorrect
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A 57-year-old male with a history of hypertension for six years presents to the Emergency department with complaints of severe chest pain that radiates to his back, which he describes as tearing in nature. He is currently experiencing tachycardia and hypertension, with a blood pressure reading of 185/95 mmHg. A soft early diastolic murmur is also noted. The ECG shows ST elevation of 2 mm in the inferior leads, and a small left-sided pleural effusion is visible on chest x-ray. Based on the patient's clinical history, what is the initial diagnosis that needs to be ruled out?
Your Answer: Inferior myocardial infarction
Correct Answer: Aortic dissection
Explanation:Aortic Dissection in a Hypertensive Patient
This patient is experiencing an aortic dissection, which is a serious medical condition. The patient’s hypertension is a contributing factor, and the pain they are experiencing is typical for this condition. One of the key features of aortic dissection is radiation of pain to the back. Upon examination, the patient also exhibits hypertension, aortic regurgitation, and pleural effusion, which are all consistent with this diagnosis. The ECG changes in the inferior lead are likely due to the aortic dissection compromising the right coronary artery. To properly diagnose and treat this patient, it is crucial to thoroughly evaluate their peripheral pulses and urgently perform imaging of the aorta. Proper and timely medical intervention is necessary to prevent further complications and ensure the best possible outcome for the patient.
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This question is part of the following fields:
- Cardiology
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