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Question 1
Incorrect
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A 55-year-old male with a history of myocardial infarction 4 years ago, was admitted with a history of fever for the past 2 weeks. On investigation, his echocardiography revealed a small vegetation around the mitral valve. His blood culture was positive for Streptococcus viridans. Which of the following is the most appropriate antibiotic therapy?
Your Answer: IV vancomycin + rifampicin + gentamicin
Correct Answer: IV benzylpenicillin
Explanation:According to the American Heart Association (AHA) penicillin-susceptible S viridans, S bovis, and other streptococci (MIC of penicillin of ≤0.1 mcg/mL) should be treated with penicillin G or ceftriaxone or penicillin G + a gentamicin combination or vancomycin (if allergy to penicillin).
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This question is part of the following fields:
- Cardiovascular System
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Question 2
Correct
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A 60-year-old male presented in the OPD with a severe pain in the chest, which radiated to the jaw and his left shoulder. What is your diagnosis?
Your Answer: MI
Explanation:Risk of myocardial infarction is high in patients with diabetes mellitus. High levels of sugar in the blood can damage the arteries and lead to an increased risk of atherosclerosis of the coronary arteries. This is why diabetic patients have an increased risk of Myocardial Infarction.
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This question is part of the following fields:
- Cardiovascular System
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Question 3
Correct
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A 24-year-old male with a history of a cardiac murmur which was not properly followed up, presented with right sided hemiparesis. His blood pressure was 120/70 mmHg. His ECG revealed right bundle branch block with right axis deviation. Which of the following is the most likely cause for this presentation?
Your Answer: Ostium secundum atrial septal defect
Explanation:Ostium secundum atrial septal defects are known to cause stroke due to the passage of emboli from the right sided circulation to the left sided circulation. ECG shows tall, peaked P waves (usually best seen in leads II and V2) and prolongation of the PR interval, rSR pattern in leads V3 R and V1 as well as right axis deviation.
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This question is part of the following fields:
- Cardiovascular System
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Question 4
Incorrect
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A 60-year-old male had an MI one week ago, but has now presented with a pericardial rub and dyspnoea. An ECG was performed and shows ST elevation. A chest x-ray shows loss of margin at the costovertebral angle. Choose the single most likely cause.
Your Answer: Cardiac tamponade
Correct Answer: Dressler's syndrome
Explanation:The pericardial rub indicates pericarditis, which then causes widespread ST elevation. Therefore, the condition is not a new MI but is Dressler’s syndrome.
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This question is part of the following fields:
- Cardiovascular System
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Question 5
Correct
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A 63-year-old heavy smoker complains of pain on exertion in both calves and his buttocks. He has also recently developed erectile dysfunction. On examination, peripheral pulses in both lower limbs including distal and femoral are absent. Where is the single most probable site of obstruction?
Your Answer: Aorto iliac
Explanation:The penis receives its blood supply by the internal pudendal artery, a branch of the internal iliac artery. Erectile dysfunction indicates obstruction at the level of the common iliac arteries or higher.
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This question is part of the following fields:
- Cardiovascular System
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Question 6
Correct
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A 26-year-old male was being investigated further following several hypertensive episodes. There was a marked difference in his systolic blood pressures between the right brachial and the right femoral arteries. Which of the following is most probable diagnosis?
Your Answer: Coarctation of the aorta
Explanation:From the given physical findings (the difference in BP between the radial and femoral arteries), the most probable diagnosis is coarctation of the aorta.
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This question is part of the following fields:
- Cardiovascular System
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Question 7
Incorrect
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A 25-year-old previously well male presented with chest discomfort and difficulty in breathing while running to the bus. Symptoms disappeared after resting. But the symptoms reappeared whilst he was climbing the stairs. On examination he was not dyspnoeic at rest. BP was 110/70 mmHg and pulse rate was 72 bpm. His heart sounds were normal. There was an additional clicking noise in the fourth left intercostal space which is heard with each heartbeat. Which of the following is the most probable cause for his presentation?
Your Answer: Acute pericarditis
Correct Answer: Spontaneous pneumothorax
Explanation:The given history is more compatible with spontaneous pneumothorax. Left-sided pneumothoraxes may be associated with a clicking noise, which is heard with each heart-beat and can sometimes be heard by the patient.
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This question is part of the following fields:
- Cardiovascular System
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Question 8
Incorrect
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A 48-year-old man presents with severe retrosternal pain, which was present for the past 40 minutes. ECG shows ST elevation and blood tests reveal high troponin levels. He has already been given oxygen, GTN and morphine. What is the next most appropriate step?
Your Answer: Anticoagulant & heparin
Correct Answer: Percutaneous angiography
Explanation:The patient is experiencing an acute myocardial infarction and percutaneous angiography is the next most appropriate step in management. Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is a nonsurgical technique for treating obstructive coronary artery disease, including unstable angina, acute myocardial infarction (MI), and multivessel coronary artery disease (CAD).
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This question is part of the following fields:
- Cardiovascular System
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Question 9
Correct
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The conductive system of the heart anatomically includes the:
Your Answer: Atrioventricular node
Explanation:The cardiac conduction system is a collection of nodes and specialised cells including the:
Sinoatrial node
Atrioventricular node
Atrioventricular bundle (bundle of His)
Purkinje fibres -
This question is part of the following fields:
- Cardiovascular System
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Question 10
Incorrect
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The ECG of a 48-year-old man shows broad complex tachycardia with a HR of 154 bpm 2 days after an MI. His BP is 90/60 mmHg and he is complaining of palpitations and dyspnoea. What is the most appropriate management?
Your Answer: IV amiodarone
Correct Answer: DC Shock
Explanation:Dysrhythmias are the most frequent MI complication. The patient seems to have a post MI atrial fibrillation which is treated, in an emergency context, with DC shock.
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This question is part of the following fields:
- Cardiovascular System
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Question 11
Incorrect
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Which of the following is not an indication for an implantable cardiac defibrillator?
Your Answer: Previous myocardial infarction with non-sustained VT on 24 hr monitoring
Correct Answer: Wolff-Parkinson White syndrome
Explanation:Class I indications (i.e., the benefit greatly outweighs the risk, and the treatment should be administered): -Structural heart disease, sustained VT
-Syncope of undetermined origin, inducible VT or VF at electrophysiologic study (EPS)
-Left ventricular ejection fraction (LVEF) ≤35% due to prior MI, at least 40 days post-MI, NYHA class II or III
-LVEF ≤35%, NYHA class II or III
-LVEF ≤30% due to prior MI, at least 40 days post-MI
-LVEF ≤40% due to prior MI, inducible VT or VF at EPSClass IIa indications (i.e., the benefit outweighs the risk and it is reasonable to administer the treatment):
-Unexplained syncope, significant LV dysfunction, nonischaemic cardiomyopathy
-Sustained VT, normal or near-normal ventricular function
-Hypertrophic cardiomyopathy with 1 or more major risk factors
-Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) with 1 or more risk factors for sudden cardiac death (SCD)
-Long QT syndrome, syncope or VT while receiving beta-blockers
-Nonhospitalized patients awaiting heart transplant
-Brugada syndrome, syncope or VT
-Catecholaminergic polymorphic VT, syncope or VT while receiving beta-blockers
-Cardiac sarcoidosis, giant cell myocarditis, or Chagas disease -
This question is part of the following fields:
- Cardiovascular System
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Question 12
Incorrect
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A 42-year-old previously well woman presented with acute severe central chest pain for the past 2 hours. She has a family history of premature coronary artery disease. Her husband passed away recently due to prostate cancer. On examination her blood pressure was 130/80 mmHg and pulse rate was 80 bpm. Her ECG showed ST segment elevation and her troponin was slightly elevated. Emergency angiogram revealed slight wall irregularities with no luminal obstruction. Cardiovascular MR showed an apical ballooning of the myocardium resembling an octopus pot. Which of the following is the most likely cause for the ST segment elevation?
Your Answer: Coronary artery disease
Correct Answer: Takotsubo cardiomyopathy
Explanation:Causes for ST segment elevation other than myocardial infarction
Natural variants
-Early repolarization
-Left ventricular hypertrophy and hypertrophic cardiomyopathy
-Left bundle branch block
Artefacts
-Leads mispositioning
-Electrical cardioversion
Cardiovascular diseases
-Pericarditis/ Myocarditis
-Aortic dissection
-Prinzmetal’s angina
-Takotsubo Cardiomyopathy
-Brugada Syndrome and arrhythmogenic right ventricular cardiomyopathy/dysplasia
Pulmonary diseases
-Pulmonary thromboembolism
-Pneumothorax
-Atelectasis and pulmonary metastases
Gastrointestinal diseases
-Acute pancreatitis
-Acute cholecystitis
Other conditions
-Hyperkalaemia
-Drug induced ST segment elevation (e.g. – clozapine)
-Haemorrhagic cerebrovascular diseaseCoronary artery disease and myocardial infarction can be excluded with a negative angiogram and a slightly elevated troponin. Hypertrophic cardiomyopathy can be excluded with cardiovascular MR findings. Left ventricular aneurysm usually occurs following a myocardial infarction, but there is no positive history for that. The characteristic findings on cardiovascular MR confirms the diagnosis of Takotsubo cardiomyopathy.
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This question is part of the following fields:
- Cardiovascular System
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Question 13
Correct
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A 75-year-old female smoker who is diabetic and hypertensive, presents to the emergency which acute chest pain and worsening condition. She is obese and has recently been immobile due to a hip pain. The doctor fails to resuscitate her and she is pronounced dead. What do you think caused her death?
Your Answer: Pulmonary embolism
Explanation:Pulmonary embolism (PE) is the obstruction of one or more pulmonary arteries by solid, liquid, or gaseous masses. In most cases, the embolism is caused by blood thrombi, which arise from the deep vein system in the legs or pelvis (deep vein thrombosis) and embolize to the lungs via the inferior vena cava.
Risk factors include: immobility, inherited hypercoagulability disorders, being overweight or obese, smoking cigarettes, taking birth control pills (oral contraceptives) or hormone replacement therapy, having diseases such as stroke, paralysis, chronic heart disease, or high blood pressure, pregnancy, and recent surgery.
The clinical presentation is variable and, depending on the extent of vessel obstruction, can range from asymptomatic to cardiogenic shock. Symptoms are often nonspecific, including chest pain, coughing, dyspnoea, and tachycardia.
The diagnosis of PE is based primarily on the clinical findings and is confirmed by detection of an embolism in contrast CT pulmonary angiography (CTA). Arterial blood gas analysis typically shows evidence of respiratory alkalosis with low partial oxygen pressure, low partial carbon dioxide pressure, and elevated pH. Another commonly performed test is the measurement of D-dimer levels, which can rule out PE if negative.
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This question is part of the following fields:
- Cardiovascular System
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Question 14
Incorrect
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A 72-year-old male was admitted with acute right leg pain at rest. On examination, the right leg was white and peripheral pulses were not palpable. He gives a history of intermittent claudication for the past two years. What is the most probable cause for this presentation?
Your Answer: Prolonged immobility
Correct Answer: Atrial fibrillation
Explanation:This presentation is compatible with acute limb ischemia, which is a surgical emergency. Thromboembolism following atrial fibrillation is the most probable cause for this presentation as there is no history of prolonged immobilization or other associated risk factors in this male patient.
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This question is part of the following fields:
- Cardiovascular System
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Question 15
Incorrect
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Regarding the 3rd heart sound, which one of the following statements is correct?
Your Answer: Is lost in AF
Correct Answer: It may be a normal finding in women up to the age of 50
Explanation:The 3rd heart sound corresponds to early diastolic filling in ventricular relaxation after the closure of the aortic valve. Associated conditions include cardiac failure, constrictive pericarditis and atrial myxomas. It is low pitched and accentuated by inspiration. The 3rd heart sound may arise from ventricular relaxation and it can be seen as a normal finding among children, young adults and women till 50 years of age.
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This question is part of the following fields:
- Cardiovascular System
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Question 16
Correct
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A 25-year-old male presented with acute severe central chest pain which radiated backwards between his scapulae. He didn't have difficulty in breathing and the pain wasn't exacerbated by deep inspiration or a change in position. His father had died due to a heart disease when he was small. He also has a cardiac murmur which was never properly investigated. On examination he was tachycardic with a BP of 165/60 mmHg. There was a diastolic murmur at lower left sternal border which is best heard with the patient sitting forward. Which of the following is the most probable cause for his chest pain?
Your Answer: Aortic dissection
Explanation:The most probable diagnosis is Marfan’s syndrome because of a family history of cardiac death and heart murmurs. A characteristic feature is pain which radiates to the back. A wide pulse pressure and a diastolic heart murmur is suggestive of aortic dissection.
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This question is part of the following fields:
- Cardiovascular System
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Question 17
Incorrect
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A 32-year-old previously well primigravida in her 16th week of pregnancy came to the antenatal clinic for a routine review. Her blood pressure was 152/90 mmHg. On her last clinic visit 4 weeks ago her blood pressure was 148/86 mmHg. She was put on ambulatory blood pressure monitoring and her mean blood pressure was 148/88 mmHg. Her urine examination was negative for protein. Which of the following is the most likely diagnosis?
Your Answer: Pregnancy-induced hypertension
Correct Answer: Pre-existing hypertension
Explanation:Pre-eclampsia is excluded from negative proteinuria. White coat hypertension is excluded with ambulatory blood pressure monitoring. Pregnancy induced hypertension develops after 20 weeks of gestation. So the most likely answer is pre-existing hypertension. She should be investigated for a secondary cause for hypertension.
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This question is part of the following fields:
- Cardiovascular System
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Question 18
Incorrect
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A 71-year-old female presents with a pansystolic murmur. History reveals a myocardial infarction which manifested three days ago. What is the most likely cause of the murmur?
Your Answer: Atrial Septal Defect
Correct Answer: Rupture of papillary muscle
Explanation:A pan-systolic murmur is the result of mitral regurgitation. Mitral regurgitation in this case is most probably due to post-MI rupture of the papillary muscle of the mitral valve.
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This question is part of the following fields:
- Cardiovascular System
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Question 19
Incorrect
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A 54-year-old man presents to the physician complaining of chest pain and fever. He underwent hemicolectomy a few days back. Echocardiography is done which shows a systolic murmur. Which other investigation would be required?
Your Answer: CT
Correct Answer: Blood culture
Explanation:Infective endocarditis (IE) is an infectious inflammation of the endocardium that affects the heart valves. The condition is a result of bacteraemia, which is most commonly caused by dental procedures, surgery, distant primary infections, and nonsterile injections. IE clinically presents with either an acute or subacute course. Acute disease is usually caused by Staphylococcus aureus and causes rapid endocardium destruction. Subacute progression is most commonly caused by viridans streptococci species and generally affects individuals with pre-existing damage to the heart valves, structural heart defects, or the presence of prosthetic valves. Clinical features include constitutional symptoms (fatigue, fever/chills, malaise) in combination with signs of pathological cardiac changes (e.g., new or changed heart murmur, heart failure signs) and possibly manifestations of subsequent damage to other organs (e.g., glomerulonephritis, septic embolic stroke). Diagnosis is made based on the Duke criteria, whose main features include positive blood cultures and evidence of endocardial involvement in echocardiography. Initial treatment of IE consists of empiric IV antibiotic therapy, which is then adapted to blood culture results and continued for four to six weeks. Prophylaxis is only administered in specific circumstances, e.g., in patients with pre-existing heart conditions undergoing dental or surgical procedures. If left untreated, infective endocarditis can be fatal within a few weeks.
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This question is part of the following fields:
- Cardiovascular System
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Question 20
Incorrect
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A 9-year-old boy with central cyanosis underwent cardiac catheterization. His study results were given below
Right atrium 7 mmHg Saturation 60 %
Right ventricle 110/6 mmHg Saturation 55 %
Pulmonary artery 20/5 mmHg Saturation 55 %
Left atrium (mean) 9 mmHg Saturation 98 %
Left ventricle 110/80 mmHg Saturation 87 %
Aorta 110/80 mmHg Saturation 76 %
Which the following abnormalities are present in this patient?Your Answer: Ventricular septal defect
Correct Answer: Pulmonary stenosis
Explanation:The overall diagnosis is Fallot’s tetralogy. Ventricular septal defect with left to right shunt is indicated by drop of oxygen saturation from left atrium to left ventricle. Pulmonary stenosis is indicated by the pressure difference between the pulmonary artery and the right atrium. There is oxygen saturation drop from the left ventricle to the aorta which can be due to the overriding aorta.
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This question is part of the following fields:
- Cardiovascular System
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Question 21
Incorrect
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Which of the following is the site where B-type natriuretic peptide is mainly secreted?
Your Answer: Juxtaglomerular cells
Correct Answer: Ventricular myocardium
Explanation:B-type natriuretic peptide (BNP) is secreted mainly from the left ventricle and it is secreted as a response to stretching caused by increased ventricular blood volume.
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This question is part of the following fields:
- Cardiovascular System
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Question 22
Incorrect
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A 25-year-old female presented with a history of sudden collapse. She had been playing netball and had suddenly collapsed. This collapse had been accompanied by a brief period of loss of consciousness. She experienced palpitations for a brief period prior to losing consciousness. On examination her BP was 120/70 mmHg and pulse rate was 72 bpm, which was regular. The rest of the examination was also normal.
She had similar experience of collapse, about two years ago. She was well except for these two incidents and she has not been on any medication. All the investigations done at the first presentation (2 years ago), including FBC, ECG and echocardiography were normal. Her ECG done at this presentation revealed QT prolongation of 0.50 s. FBC, CXR and other investigations were normal. Which of the following is the best way of managing this patient?Your Answer: Electrophysiological studies
Correct Answer: Start on a beta-blocker
Explanation:Beta-blockers are drugs of choice for patients with LQTS. The protective effect of beta-blockers is related to their adrenergic blockade, which diminishes the risk of cardiac arrhythmias. They may also reduce the QT interval in some patients.
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This question is part of the following fields:
- Cardiovascular System
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Question 23
Correct
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A 2-day-old girl is admitted by her mother because she gets cyanotic upon feeding and she wouldn't stop crying. The doctors suspect a congenital heart disease. What is the most probable aetiology?
Your Answer: Transposition of the great arteries
Explanation:Transposition of the great arteries results in a significant hypoxemic status that is observed clinically by central cyanosis. The bluish discoloration of the skin and mucous membranes is therefore the basic pattern of clinical presentation in transposition. Its onset and severity depend on anatomical and functional variants that influence the degree of mixing between the two circulations. Limited intercirculatory mixing, usually present if the ventricular septum is intact or the atrial septal defect is restrictive, is related to progressive and profound central cyanosis evident within the first hours of life. Tachypnoea, tachycardia, diaphoresis, poor weight gain, a gallop rhythm, and eventually hepatomegaly can be then detected later on during infancy. Heart murmurs associated with left outflow tract obstruction, due to a persistent arterial duct or a septal defect may be heard, but they are not a constant finding.
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This question is part of the following fields:
- Cardiovascular System
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Question 24
Incorrect
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A 41-year-old male was involved in a fight and received a stab wound in the left 4th intercostal space. He was transferred to ER immediately with a BP 80/40 and HR 125. On examination, his neck veins are dilated and his heart sounds are faint. His trachea is central. What is the SINGLE most likely diagnosis?
Your Answer: Tension pneumothorax
Correct Answer: Cardiac tamponade
Explanation:The cardinal symptom of the cardiac tamponade is a shocked patient with tachycardia and congested neck veins.
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This question is part of the following fields:
- Cardiovascular System
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Question 25
Correct
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A 57-year-old female presented to the cardiology centre with a history of chest tightness accompanied by pain radiating to the left side of the neck and left shoulder. The pain started 3 hours ago. ECG was normal. What is the next best investigation for this patient?
Your Answer: Cardiac enzymes
Explanation:This patient’s symptoms of angina radiating to the neck and shoulders gives a strong suspicion of MI. Cardiac enzymes such as troponins are highly specific and sensitive for a heart attack.
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This question is part of the following fields:
- Cardiovascular System
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Question 26
Incorrect
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A 60-year-old man with atrial fibrillation (AF) who is on warfarin and is awaiting tooth extraction. Recent INR was 2.7 and his target INR was 2.0-3.0. Which of the following is the most appropriate management?
Your Answer: Check INR 72 hours before procedure, proceed if INR < 2.5
Correct Answer:
Explanation:The latest reserches say that simple tooth extraction in patients on warfarin treatment can be performed safely without high risk of bleeding, providing that the INR is equal to or less than 3.5 on the day of extraction. A close follow-up and monitoring of patients taking warfarin is mandatory after dental extraction.
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This question is part of the following fields:
- Cardiovascular System
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Question 27
Incorrect
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A 72-year-old female patient with a history of atrial fibrillation was admitted with recurrent episodes of syncopal attacks. Her ECG showed torsade de pointes. What is the drug which does not cause the above presentation?
Your Answer: Amiodarone
Correct Answer: Omeprazole
Explanation:Drugs causing torsades de pointes are Amiodarone, Chlorpromazine, Clarithromycin, Disopyramide, Dofetilide, Erythromycin, Haloperidol, Methadone, Procainamide, Quinidine, Sotalol, Levofloxacin, Moxifloxacin, Nilotinib, Ondansetron, Ranolazine, Sunitinib, Ziprasidone, Amitriptyline, Ciprofloxacin, Imipramine, Chlorthalidone, Dasatinib, Hydrochlorothiazide, Furosemide.
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This question is part of the following fields:
- Cardiovascular System
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Question 28
Incorrect
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A non-cyanosed 1-year-old female patient has a continuous murmur which is loudest at the left sternal edge. What pulse abnormality is most associated with patent ductus arteriosus if that's her suspected diagnosis?
Your Answer: Pulsus alternans
Correct Answer: Collapsing pulse
Explanation:DIAGNOSIS:
A consensus definition for hemodynamically significant PDA is lacking. The diagnosis is often suspected clinically, when an infant demonstrates signs of excessive shunting from the arterial to pulmonary circulation. Continuous or a systolic murmur; note, a silent PDA may also occur when the ductus shunt is large enough that nonturbulent flow fails to generate a detectible murmur.
A low diastolic blood pressure (due to runoff into the ductus during diastole, more frequent in the most premature infants).
A wide pulse pressure (due to ductus runoff or steal)Hypotension (especially in the most premature infants)
Bounding pulses
Increased serum creatinine concentration or oliguria
Hepatomegaly -
This question is part of the following fields:
- Cardiovascular System
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Question 29
Incorrect
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A 65-year-old man with hypertension presented with sudden onset right arm weakness which resolved after 10 hrs. He has had 2 similar episodes during the last 6 weeks. On examination his blood pressure was 140/80 mmHg and pulse rate was 88 bpm. His ECG showed atrial fibrillation and the CT scan of his brain was normal. Which of the following is the most appropriate management for this patient?
Your Answer: Aspirin
Correct Answer: Warfarin
Explanation:CHA₂DS₂-VASc score is used for atrial fibrillation stroke risk calculation.
Congestive heart failure – 1 point
Hypertension – 1 point
Age >75 years – 2 points
Diabetes mellitus – 1 point
Stroke/Transient Ischemic Attack/Thromboembolic event – 2 points
Vascular disease (prior MI, PAD, or aortic plaque) – 1 point
Age 65 to 74 years – 1 point
Sex category (i.e., female sex) – 1 point
Score of 2 or more is considered as high risk and anticoagulation is indicated. This patient’s score is 4, so he needs life-long warfarin to prevent a stroke. -
This question is part of the following fields:
- Cardiovascular System
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Question 30
Incorrect
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A 28-year-old primigravida in her 24th week of pregnancy came for the routine follow up. She was asymptomatic at the time of examination. Her blood pressure was 152/92 mmHg and pulse rate was 90 bpm. Her blood pressure at the booking visit had been 132/80 mmHg. Her other examination findings were normal. Which of the following is the best method to use to treat her?
Your Answer: Moxonidine
Correct Answer: Labetalol
Explanation:Methyldopa is the drug of first choice for the control of mild to moderate hypertension in pregnancy. Labetalol is also considered as a first line drug for hypertension in pregnancy. Calcium channel blockers and hydralazine are considered as second line drugs. Beta-blockers (except labetalol), angiotensin receptor blockers, angiotensin-converting enzyme inhibitors and thiazides are not recommended.
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This question is part of the following fields:
- Cardiovascular System
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SESSION STATS - PERFORMANCE PER SPECIALTY
