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Question 1
Correct
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Examination results for a middle age female post myocardial infarction are as follows:
Sodium = 136 mmol/L
Potassium = 6.2mmol/L
Urea = 5.0 mmol/L
ECG revealed a prolonged QRS complex and tented T waves. What is the most appropriate management?
Your Answer: Calcium gluconate
Explanation:Calcium gluconate is used as a cardio protective agent in people with high blood potassium levels, another alternative being the use of calcium chloride. It is recommended when the potassium levels are high (>6.5 mmol/l) or when the electrocardiogram (ECG) shows changes due to high blood potassium. Though it does not have an effect on potassium levels in the blood, it reduces the excitability of cardiomyocytes, thereby lowering the likelihood of cardiac arrhythmias.
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This question is part of the following fields:
- Cardiovascular System
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Question 2
Incorrect
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A 70-year-old male patient presented with increased difficulty in breathing during the last 4 months. He was diagnosed with mitral stenosis. On examination his BP was 120/80 mmHg and pulse rate was 68 bpm. There were bibasal crepitations on auscultation. He was on bisoprolol, furosemide and ISDN. From the given answers, what is the most likely indication of worsening of his mitral stenosis?
Your Answer: Periods of complete heart block
Correct Answer: Haemoptysis
Explanation:Haemoptysis is a symptom which indicates the worsening of mitral stenosis. It occurs due to the rupture of pulmonary veins or the capillary system due to pulmonary venous hypertension. Elevated serum creatinine is seen in worsening aortic stenosis. Worsening of tricuspid regurgitation causes ascites and a pulsatile liver.
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This question is part of the following fields:
- Cardiovascular System
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Question 3
Incorrect
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Regarding the 3rd heart sound, which one of the following statements is correct?
Your Answer: It is accentuated by expiration
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 4
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:
Correct Answer: Warfarin
Explanation:CHAâ‚‚DSâ‚‚-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 5
Incorrect
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Which of the following is not associated with atrial myxoma?
Your Answer:
Correct Answer: J wave on ECG
Explanation:J waves in an ECG is associated with hypothermia, hypercalcemia, the Brugada syndrome, and idiopathic ventricular fibrillation. The other responses are all associated with atrial myxoma
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This question is part of the following fields:
- Cardiovascular System
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Question 6
Incorrect
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A 60-year-old male patient with hypertension presented with acute onset retrosternal chest pain for 3 hours. On examination his pulse rate was 68 bpm, BP was 100/60 mmHg and JVP was seen 3mm from the sternal notch. Respiratory examination was normal. His ECG showed narrow QRS complexes, ST segment elevation of 2mm in leads II, III and aVF and a complete heart block. What is the most immediate treatment from the following answers?
Your Answer:
Correct Answer: Chewable aspirin 300 mg
Explanation:The diagnosis is inferior ST elevation myocardial infarction. As the right coronary artery supplies the SA and AV nodes and bundle of His, conduction abnormalities are more common with inferior MIs. The most immediate drug management is high dose Aspirin. Definite treatment is urgent cardiac revascularization.
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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 65-year-old male presented with acute ST elevation myocardial infarction and thrombolysis was planned. Which of the following is an absolute contraindication for thrombolysis?
Your Answer:
Correct Answer: Intracerebral Haemorrhage
Explanation:Absolute contraindications for fibrinolytic use in STEMI
Prior intracranial haemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 months -
This question is part of the following fields:
- Cardiovascular System
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Question 8
Incorrect
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Which of the following features of the jugular venous waveform indicates the closure of the tricuspid valve?
Your Answer:
Correct Answer: c wave
Explanation:The a wave indicates atrial contraction. The c wave indicates ventricular contraction and resulting bulging of the tricuspid valve into the right atrium during isovolumetric systole. The v wave indicates venous filling. The x descent indicates the atrium relaxation and the movement of tricuspid valve downward. The y descent indicates the filling of the ventricle after the opening of the tricuspid valve.
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This question is part of the following fields:
- Cardiovascular System
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Question 9
Incorrect
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A 50-year-old male patient presented with acute chest pain and a non ST elevation myocardial infarction (NSTEMI) was diagnosed. He was treated with aspirin 300 mg and 2 puffs of Glyceryl trinitrate (GTN) spray. According to NICE guidelines, which of the following categories of patients should receive clopidogrel?
Your Answer:
Correct Answer: All patients
Explanation:According to NICE guidelines (2013) all people who have had an acute MI treatment should be offered with ACE inhibitor, dual antiplatelet therapy (aspirin plus a second antiplatelet agent), a beta-blocker and a statin.
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This question is part of the following fields:
- Cardiovascular System
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Question 10
Incorrect
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A 50-year-old male patient with schizophrenia complained of chest pain and palpitations. His ECG revealed torsades de pointes ventricular tachycardia. He was on thioridazine for schizophrenia. What is the most appropriate management for his presentation?
Your Answer:
Correct Answer: IV magnesium
Explanation:Thioridazine has a quinidine-like action on the heart and is known to cause cardiac arrhythmias including prolonged PR and QT intervals and widening of QRS complexes. Intravenous magnesium sulphate is regarded as the treatment of choice for this arrhythmia.
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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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A 85-year-old male with a history of hypertension presented with a couple of pre-syncopal episodes. He describes these episodes as him having felt as if he was going to faint and he has had to sit down. There were no precipitating factors, associated chest pain or palpitations. He doesn't have chest pain, shortness of breath on exertion, orthopnoea or paroxysmal nocturnal dyspnoea. On examination he looked well. Blood pressure was 140/80 mmHg and pulse rate was 78 bpm which was irregular. His lungs were clear and heart sounds were normal. ECG showed sinus rhythm with occasional ventricular ectopic beats. Which of the following is an indication for permanent pacemaker implantation?
Your Answer:
Correct Answer: Second-degree block associated with symptoms
Explanation:Indications for permanent pacemaker implantation
-Sinus node dysfunction
-Acquired Atrioventricular(AV) block (Complete third-degree AV block with or without symptoms, Symptomatic second degree AV block, Mobitz type I and II, Exercise-induced second or third degree AV block in the absence of myocardial infarction, Mobitz II with widened QRS complex)
-Chronic bifascicular block
-After acute phase of myocardial infarction
-Neurocardiogenic syncope and hypersensitive carotid sinus syndrome
-Post cardiac transplantation
-Hypertrophic cardiomyopathy
-Pacing to detect and terminate tachycardia
-Cardiac resynchronization therapy in patients with severe systolic heart failure
-Patients with congenital heart disease -
This question is part of the following fields:
- Cardiovascular System
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Question 12
Incorrect
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What is correct statement regarding pulsus alternans?
Your Answer:
Correct Answer: It is found in association with a third heart sound
Explanation:Pulsus alternans is the alternation of one strong and one weak beat without a change in the cycle length. It occurs most commonly in heart failure due to increased resistance to LV ejection, as occurs in hypertension, aortic stenosis, coronary atherosclerosis, and dilated cardiomyopathy. Pulsus alternans is usually associated with an S3 gallop, which is associated with a poor prognosis. It usually disappears with treatment of the heart failure.
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This question is part of the following fields:
- Cardiovascular System
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Question 13
Incorrect
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Of the following options, which is an absolute contraindication to β blockers?
Your Answer:
Correct Answer: Heart block
Explanation:The Joint British Societies’ 2005 guidelines list asthma and heart block as ‘compelling contraindications’ to β blockers – this is because complications can occur which can prove to be fatal. All of the other options listed may be exacerbated by β blockers, and so are only considered to be ‘relative’ contraindications.
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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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An ECG taken on a patient shows dominant R wave in V1. Which of the following cannot be the reason for above ECG change?
Your Answer:
Correct Answer: Primary pulmonary hypertension
Explanation:Dominant R wave in V1 can be a normal variant in children and young adults. Other causes are right ventricular hypertrophy, pulmonary embolus, persistence of left to right shunt, Right Bundle Branch Block (RBBB), posterior myocardial infarction (ST elevation in Leads V7, V8, V9), Wolff-Parkinson-White (WPW) Type A, Incorrect lead placement (e.g. V1 and V3 reversed), dextrocardia, hypertrophic cardiomyopathy and dystrophy (myotonic dystrophy and Duchenne Muscular dystrophy).
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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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Which one of the following responses is the least likely to be associated with primary pulmonary hypertension?
Your Answer:
Correct Answer: Recurrent pulmonary embolism
Explanation:Connective-tissue diseases, liver cirrhosis, exposure to anorexigens and likely other alpha-adrenergic stimulants [e.g., cocaine, amphetamines] and HIV infection are associated with primary pulmonary hypertension. Recurrent pulmonary emboli, chronic lung diseases, left heart diseases are causes for secondary pulmonary hypertension. Pulmonary vascular hypertension after use of fenfluramine is rarely reported.
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This question is part of the following fields:
- Cardiovascular System
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Question 16
Incorrect
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In a patient with cardiomyopathy, which one of the following statements would be aetiologically significant?
Your Answer:
Correct Answer: The presence of diabetes mellitus in a tanned patient
Explanation:Hemochromatosis is a condition that leads to abnormal iron deposition in specific organs. There are two main types: primary (hereditary) and secondary (e.g., transfusion-related). The most common form is hereditary autosomal recessive hemochromatosis type 1, which is caused by an underlying genetic defect that results in partially uninhibited absorption of iron in the small intestine.
Hemochromatosis is mostly asymptomatic but can become symptomatic, usually between the third and fifth decade of life, when poisonous levels of iron have had time to accumulate in the body. Symptoms include fatigue, hyperpigmentation, diabetes mellitus (bronze diabetes), and arthralgia. The deposits may lead to various organ diseases, the most typical being the development of liver cirrhosis, which is accompanied by an increased risk of hepatocellular carcinoma (HCC). Serum ferritin and transferrin saturation levels are typically elevated. Molecular genetic testing or a liver biopsy may be used to confirm the diagnosis. Treatment primarily consists of repeated phlebotomy to reduce iron levels. In addition, dietary changes and drug therapy (chelating agents such as deferoxamine) may be used to influence the amount of iron in the body. -
This question is part of the following fields:
- Cardiovascular System
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Question 17
Incorrect
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A 62-year-old male presented with worsening breathlessness and fatigability. On examination there was bilateral ankle swelling and pulsatile liver. Auscultation revealed a pansystolic murmur best heard at the lower left sternal border. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Tricuspid regurgitation
Explanation:All the clinical features are suggestive of tricuspid regurgitation. The pansystolic murmur of mitral regurgitation is best heard at the apex.
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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 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)Â 9 mmHg Saturation 98 %
Left ventricle 110/80 mmHg Saturation 87 %
Aorta 110/80 mmHg Saturation 76 %
Â
Which the following abnormalities are present in this patient?Your Answer:
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 19
Incorrect
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A 72-year-old male presents to the ER with acute chest pain, fever and sweating. ECG shows an acute MI. Which of the following routes will be the most significant in alleviating the patient's pain?
Your Answer:
Correct Answer: Intravenous
Explanation:The pain of myocardial infarction is usually severe and requires potent opiate analgesia. Intravenous diamorphine 2.5-5 mg (repeated as necessary) is the drug of choice and is not only a powerful analgesic but also has a useful anxiolytic effect.
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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 13-year-old boy presented with difficulty in breathing on exertion. According to his mother who was also present, his exercise tolerance has been gradually worsening for the past weeks. It has reached the point where he is unable to participate in his weekly soccer match. Cardiac catheterization was performed and the results are given below.
Anatomical site
Oxygen saturation (%)
Pressure (mmHg)
Superior vena cava
73
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Right atrium
71
6
Right ventricle
72
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Pulmonary artery
86
53/13
PCWP
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15
Left ventricle
97
111/10
Aorta
96
128/61
Which of the following is the diagnosis?Your Answer:
Correct Answer: Patent ductus arteriosus
Explanation:The oxygen saturation in the pulmonary artery is higher than that of the right ventricle. The pressure of the pulmonary artery and of the PCWP are also high. So patent ductus arteriosus is highly suggestive.
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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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A 25-year-old girl's ECG revealed a normal PR interval and QRS while the QT is prolonged. History reveals she has been having frequent fainting attacks since childhood. What is the cause of these syncopal attacks?
Your Answer:
Correct Answer: Torsade de pointes
Explanation:Patients with a long QT wave syndrome are prone to recurrent syncope if they have Torsade’s de pointes since it degenerates into fibrillation of the ventricles.
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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 72-year-old male with a history of type II diabetes mellitus and hypertension for 15 years, presented with gradual onset difficulty in breathing on exertion and bilateral ankle swelling for the past 3 months. On examination he had mild ankle oedema. His JVP was not elevated. His heart sounds were normal but he had bibasal crepitations on auscultation. Which of the following clinical signs has the greatest sensitivity in detecting heart failure in this patient?
Your Answer:
Correct Answer: Third heart sound
Explanation:The presence of a third heart sound is the most sensitive indicator of heart failure. All of the other signs can be found in heart failure with varying degrees.
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This question is part of the following fields:
- Cardiovascular System
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Question 23
Incorrect
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A 62 year-old patient with a history of a stroke, presented with chest pain and exertional dyspnoea. ECG revealed atrial fibrillation and on chest X-ray there was straightening of the left heart border. The most likely diagnosis will be?
Your Answer:
Correct Answer: Rheumatic mitral valve stenosis
Explanation:Symptoms of exertional dyspnoea, atrial fibrillation and radiological evidence of straightening of the left heart border favours the diagnosis of rheumatoid mitral valve stenosis.
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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 30-year-old male, who is the brother of a patient with hypertrophic cardiomyopathy has come for the screening. Which of the following is the most appropriate method of screening?
Your Answer:
Correct Answer: Echocardiography
Explanation:12-lead electrocardiography and transthoracic echocardiography are recommended as a screening method for family members of patients with HCM.
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This question is part of the following fields:
- Cardiovascular System
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Question 25
Incorrect
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A 30-year-old male patient presented with palpitations that occur randomly at rest. There have however been episodes of fast palpitations and dizziness on exertion. On examination there was a systolic murmur at the apex as well as a prominent apex beat and the chest was clear. Which of the following is LEAST likely to suggest a diagnosis of hypertrophic cardiomyopathy?
Your Answer:
Correct Answer: A history of hypertension for 10 years
Explanation:Hypertrophic cardiomyopathy is an autosomal dominant condition. Patients present with sudden cardiac death, dyspnoea, syncope and presyncope, angina, palpitations, orthopnoea and paroxysmal nocturnal dyspnoea, Congestive heart failure and dizziness. Physical findings include double or triple apical impulse, prominent a wave in the JVP, an ejection systolic crescendo-decrescendo murmur and a holosystolic murmur at the apex and axilla of mitral regurgitation.
ECG shows ST-T wave abnormalities and LVH, axis deviation (right or left), conduction abnormalities (P-R prolongation, bundle-branch block), sinus bradycardia with ectopic atrial rhythm, atrial enlargement, abnormal and prominent Q wave in the anterior precordial and lateral limb leads.
2D echocardiography shows abnormal systolic anterior leaflet motion of the mitral valve, LVH, left atrial enlargement, small ventricular chamber size, septal hypertrophy with septal-to-free wall ratio greater than 1.4:1, mitral valve prolapse and mitral regurgitation, decreased midaortic flow, partial systolic closure of the aortic valve in midsystole -
This question is part of the following fields:
- Cardiovascular System
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Question 26
Incorrect
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A 85-year-old previously well man was found to have a BP of 155/90 mmHg. His average reading from the monitoring of his ambulatory BP was 147/92 mmHg. His calculated 10 year cardiovascular risk was 15%. Which of the following is the most appropriate management of this patient?
Your Answer:
Correct Answer: Give lifestyle advice and repeat blood pressure in 6 months
Explanation:According to different guidelines for patients above 80 years, the targeted systolic blood pressure varies from 140-150 mmHg. As this patient’s BP is within that range, he can be kept under observation.
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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 32-year-old primigravida in her 37th week of pregnancy was admitted for the management of pre-eclampsia. Her blood pressure was 180/110 mmHg and urine protein was +++. Magnesium sulphate was started. Which of the following are important parameters that should be monitored during the administration of magnesium sulphate?
Your Answer:
Correct Answer: Reflexes + respiratory rate
Explanation:The clinical effect and toxicity of MgSO4 can be linked to its concentration in plasma. A concentration of 1.8 to 3.0 mmol/L has been suggested for treatment of eclamptic convulsions. Maternal toxicity is rare when MgSO4 is carefully administered and monitored. The first warning of impending toxicity in the mother is loss of the patellar reflex at plasma concentrations between 3.5 and 5 mmol/L. Respiratory paralysis occurs at 5 to 6.5 mmol/L. Cardiac conduction is altered at greater than 7.5 mmol/L, and cardiac arrest can be expected when concentrations of magnesium exceed 12.5 mmol/L. Careful attention to the monitoring guidelines can prevent toxicity. Deep tendon reflexes, respiratory rate, urine output and serum concentrations are the most commonly monitored parameters.
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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 75-year-old male with rheumatoid arthritis underwent a colectomy 2 days ago for colon cancer. He was put on a prophylactic dose of low molecular weight heparin postoperatively as well as prednisolone. Now he complains of central chest pain and his ECG revealed an acute ST elevation myocardial infarction. He was given aspirin and oxygen as the initial treatment. Which of the following is the most appropriate management for this patient?
Your Answer:
Correct Answer: IV diamorphine + arrange percutaneous coronary intervention
Explanation:There is a high risk of bleeding due to recent surgery and heparin. So thrombolysis is not an option. The most appropriate management is percutaneous coronary intervention.
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This question is part of the following fields:
- Cardiovascular System
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Question 29
Incorrect
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Patients on digoxin therapy are required to receive an initially higher dose of the drug, in order to amplify the effect of the treatment. Which of the following makes this requirement necessary?
Your Answer:
Correct Answer: Half-life
Explanation:A loading dose is required for drugs that are eliminated from the body in a slow, progressive manner. Half-life is the indicator showing if a drug has a fast, intermediate or slow elimination rate.
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This question is part of the following fields:
- Cardiovascular System
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Question 30
Incorrect
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The ECG of a 29-year-old female shows an irregular rhythm with a HR of 154 bpm. She presented complaining of heart palpitations and hot flashes for the past 4 days. What is the most likely treatment?
Your Answer:
Correct Answer: Beta blockers
Explanation:At 29 years old, the most probable cause of this arrhythmia is thyrotoxicosis. β blockers relieve symptoms such as tachycardia, tremor, and anxiety in thyrotoxic patients. β blockade should be used as the primary treatment only in patients with thyrotoxicosis due to thyroiditis.
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This question is part of the following fields:
- Cardiovascular System
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Question 31
Incorrect
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A 60-year-old male patient with NSTEMI was started on low dose aspirin as secondary prevention. Which of the following, describe the action of aspirin as an antiplatelet agent?
Your Answer:
Correct Answer: Inhibits the production of thromboxane A2
Explanation:The antithrombotic action of aspirin is due to inhibition of platelet function by acetylation of the platelet cyclooxygenase (COX) at the functionally important amino acid serine529. This prevents the access of the substrate (arachidonic aid) to the catalytic site of the enzyme at tyrosine385 and results in an irreversible inhibition of platelet-dependent thromboxane formation.
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This question is part of the following fields:
- Cardiovascular System
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Question 32
Incorrect
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A 65-year-old male with a history of smoking and alcohol was admitted with an ST elevation myocardial infarction. He was obese and lives a sedentary lifestyle. What is the non-pharmacological intervention which will be most helpful to reduce future ischaemic events?
Your Answer:
Correct Answer: Stopping smoking
Explanation:Stopping smoking is the single most effective non-pharmacological intervention which will reduce future ischaemic events. But the rest of the responses are also important interventions with regards to reducing future ischaemic events.
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This question is part of the following fields:
- Cardiovascular System
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Question 33
Incorrect
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The conductive system of the heart anatomically includes the:
Your Answer:
Correct 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 34
Incorrect
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A 70-year-old female was brought in by the paramedics after she collapsed whilst shopping. She has a tachycardia of 150 bpm and her BP is 100/60 mmHg. Her ECG showed a broad complex tachycardia. Which of the following is more suggestive of a ventricular tachycardia (VT) over a supraventricular tachycardia (SVT) with aberrant conduction?
Your Answer:
Correct Answer: Atrioventricular dissociation
Explanation:To differentiate VT from SVT with aberrant conduction the following electrocardiographic features should be looked for:
Evidence of preceding atrial activity for SVT. Oesophageal leads are helpful if P waves are hidden in the QRS complex.
QRS duration more than 140 ms for VT.
QRS morphology: Features of QRS morphology that favour SVT are RBBB or triphasic patterns like rSR in V1 and qRS in V6. Monophasic pattern like R or qR in V1 and rS or QS in V6 or multiple morphology QRS complexes favour VT.
AV dissociation for VT. -
This question is part of the following fields:
- Cardiovascular System
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Question 35
Incorrect
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A 56-year-old man injected his usual insulin dose and went to the washroom to wash his hands before going to dinner. His wife found him unconscious in the washroom a few minutes later. Which of the following investigations needs to be done?
Your Answer:
Correct Answer: Random capillary glucose
Explanation:The state of this patient is most likely a diabetic coma caused by hypoglycaemic shock. A random capillary glucose check can confirm the glucose level and whether prompt IM glucagon should be given.
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This question is part of the following fields:
- Cardiovascular System
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Question 36
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:
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 37
Incorrect
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A 72-year-old male presented to the Emergency Department with a broad complex tachycardia. Which of the following features is more suggestive that this has resulted because of a supraventricular tachycardia (SVT) rather than a ventricular tachycardia (VT)?
Your Answer:
Correct Answer: Absence of QRS concordance in chest leads on ECG
Explanation:To differentiate ventricular tachycardia (VT) from supraventricular tachycardia (SVT) with aberrant conduction the following electrocardiographic features should be looked for:
Evidence of preceding atrial activity for SVT. Oesophageal leads are helpful if P waves are hidden in the QRS complex.
QRS duration more than 140 ms for VT.
QRS morphology: Features of QRS morphology that favour SVT are RBBB or triphasic patterns like rSR in V1 and qRS in V6. Monophasic pattern like R or qR in V1 and rS or QS in V6 or multiple morphology QRS complexes favour VT.
AV dissociation for VT. -
This question is part of the following fields:
- Cardiovascular System
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Question 38
Incorrect
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A 30-year-old primigravida in her 23rd week of pregnancy presented with palpitations. Her ECG showed supraventricular tachycardia (SVT). 15 minutes after admission the SVT spontaneously reverted to sinus rhythm. She had two episodes of SVT later which were associated with palpitations. Which of the following is the most appropriate treatment for this presentation?
Your Answer:
Correct Answer: Verapamil
Explanation:Both long-acting calcium channel blockers and beta blockers improve symptoms of patients with SVT. Verapamil does not have adverse maternal or fetal side effects which would suggest that the use of verapamil in the treatment of supraventricular arrhythmias in pregnancy is safe and effective. Beta blockers are associated with intrauterine fetal growth restriction.
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This question is part of the following fields:
- Cardiovascular System
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Question 39
Incorrect
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A 18-year-old male was screened for hypertrophic cardiomyopathy (HOCM) as his brother had the same condition. What is the echocardiographic finding that is related to the highest risk of sudden cardiac death?
Your Answer:
Correct Answer: Significant thickening of the interventricular septum
Explanation:There are five prognostic factors which indicate poor prognosis in HOCM:
-family history of HOCM-related sudden cardiac death
-unexplained recent syncope
-large left ventricular wall thickness (MLVWT > 30 mm)
-multiple bursts of nsVT on ambulatory electrocardiography
-hypotensive or attenuated blood pressure response to exercise -
This question is part of the following fields:
- Cardiovascular System
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Question 40
Incorrect
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A 42-year-old man presented with palpitations and shortness of breath on exertion. On examination his lungs were clear and heart sounds were normal. There was a left sided parasternal heave. His electrocardiogram (ECG) revealed atrial fibrillation with right axis deviation. Echocardiography showed dilated right heart chambers. Left and right heart catheterisation study revealed the following
Inferior vena cava Oxygen saturations 63 %
Superior vena cava Oxygen saturations 59 %
Right atrium Oxygen saturations 77 %
Right ventricle Oxygen saturations 78 %
Pulmonary artery Oxygen saturations 82 %
Arterial saturation Oxygen saturations 98 %
What is the most likely diagnosis from the following answers?Your Answer:
Correct Answer: Atrial septal defect
Explanation:Right ventricular volume overload is indicated by a parasternal heave and right axis deviation. Oxygen saturation in right atrium is higher than oxygen saturation of the inferior and superior vena cavae. So the most probable diagnosis is atrial septal defect.
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This question is part of the following fields:
- Cardiovascular System
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Question 41
Incorrect
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Which of the following is not associated with right axis deviation?
Your Answer:
Correct Answer: Wolf-Parkinson-White syndrome with right-sided accessory pathway
Explanation:Causes for right axis deviation:
-Right ventricular hypertrophy and Left posterior fascicular block
-Lateral myocardial infarction.
-Acute or chronic lung diseases: Pulmonary embolism, pulmonary hypertension, chronic obstructive pulmonary disease (COPD), cor pulmonale.
-Congenital heart disease (e.g., dextrocardia, secundum atrial septal defect).
-Wolff-Parkinson-White syndrome.
-Ventricular ectopic rhythms (e.g., ventricular tachycardia). -
This question is part of the following fields:
- Cardiovascular System
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Question 42
Incorrect
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Which of the following characteristics does the jugular venous waveform have in tricuspid regurgitation?
Your Answer:
Correct Answer: Large V waves
Explanation:The jugular venous pulsation has a biphasic waveform.
– The a wave corresponds to right atrial contraction and ends synchronously with the carotid artery pulse. The peak of the ‘a’ wave demarcates the end of atrial systole.
– The c wave corresponds to right ventricular contraction causing the tricuspid valve to bulge towards the right atrium during RV isovolumetric contraction.
– The x’ descent follows the ‘c’ wave and occurs as a result of the right ventricle pulling the tricuspid valve downward during ventricular systole (ventricular ejection/atrial relaxation). (As stroke volume is ejected, the ventricle takes up less space in the pericardium, allowing relaxed atrium to enlarge). The x’ (x prime) descent can be used as a measure of right ventricle contractility.
– The x descent follows the ‘a’ wave and corresponds to atrial relaxation and rapid atrial filling due to low pressure.
– The v wave corresponds to venous filling when the tricuspid valve is closed and venous pressure increases from venous return – this occurs during and following the carotid pulse.
– The y descent corresponds to the rapid emptying of the atrium into the ventricle following the opening of the tricuspid valve. -
This question is part of the following fields:
- Cardiovascular System
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Question 43
Incorrect
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A 12-year-old boy has a history of fever for one week (39C), with no other symptoms leading up to the fever. He recently had a surgical extraction of one of his incisors two weeks before consultation. On examination of CVS, a mid-systolic click followed by a late systolic murmur is heard. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Infection
Explanation:Tooth extraction or any surgical procedure may introduce bacteria into the blood stream. The most commonly involved organisms include Staphylococcus aureus and Streptococcus viridans. Once in the blood, these organisms have a very high tendency of attaching to the walls of the heart and causing inflammation known as endocarditis.
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This question is part of the following fields:
- Cardiovascular System
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Question 44
Incorrect
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A 60-year-old female with a recent history of MI, complained of exertional dyspnoea. On examination there was a third heart sound. ECG showed ST elevations in leads V1 to V4. Which of the following is the most probable reason for this presentation?
Your Answer:
Correct Answer: Left ventricular aneurysm
Explanation:Electrocardiography is characterized by ST elevation that persists several weeks after an acute MI. The features of heart failure (exertional dyspnoea and third or fourth heart sound) favours the diagnosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 45
Incorrect
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A 60-year-old male smoker and a known hypertensive presented with central chest pain radiating to the back. On examination he was tachycardic and hypotensive. His ECG showed inferior ST elevation and his transoesophageal echocardiogram showed a double lumen in the ascending aorta. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Dissecting aortic aneurysm
Explanation:The classic history in this high risk patient is suggestive of a dissecting aortic aneurysm. His transoesophageal echocardiogram confirms the diagnosis. ST elevation in ECG is probably due to the extension of the dissection of the aorta which results in compromised coronary blood supply.
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This question is part of the following fields:
- Cardiovascular System
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Question 46
Incorrect
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Which of the following describes the reason for the decline of the use of beta blockers as antihypertensives in last few years?
Your Answer:
Correct Answer: Less likely to prevent stroke + potential impairment of glucose tolerance
Explanation:According to the latest research, beta blockers are associated with higher incidence of fatal and non-fatal strokes, all cardiovascular events, and cardiovascular mortality. New-onset diabetes also associates with beta blockers.
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This question is part of the following fields:
- Cardiovascular System
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Question 47
Incorrect
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A 70-year-old man underwent temporary transvenous pacing. While in the coronary care unit he developed presyncope. His pulse rate was 30 bpm. His ECG showed pacing spikes which were not related to QRS complexes. What is the most appropriate action that can be taken?
Your Answer:
Correct Answer: Increase the pacing voltage to a maximum
Explanation:Pacemaker spikes on the ECG indicate that pacemaker is functioning. The most probable cause for this presentation is the change of the position of the tip of the pacing wire. Increasing the voltage will solve the problem. If it works, repositioning of the pacing wire should be done.
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This question is part of the following fields:
- Cardiovascular System
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Question 48
Incorrect
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Concerning myosin, which of the following statements is true?
Your Answer:
Correct Answer: Myosin heavy chain mutations are associated with development of familial hypertrophic cardiomyopathy
Explanation:Myosin is a protein found in contractile tissues. It is described in two groups: conventional myosin, which is arranged in pairs of light chains against pairs of heavy chain myosin. Unconventional myosin that is not arranged in filaments, preforms many functions in a wide range of cells, such as in organelle transport and in endocytosis. Myosin contains Adenosine triphosphate (ATP) and contains actin binding sites to preform its function. Other types of mutations in myosin can be seen besides the heavy chain mutation cardiomyopathy and they include: Carney’s complex , Usher syndrome and non-syndromic deafness
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This question is part of the following fields:
- Cardiovascular System
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Question 49
Incorrect
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A 60-year-old patient with hypertension attended his regular clinic. His compliance was poor. His blood pressure was 180/100 mmHg. His pulse rate was 85 bpm which was irregularly irregular. On examination there was bibasal crepitation. No murmurs were heard. What is the most likely cause for these findings?
Your Answer:
Correct Answer: Left ventricular hypertrophy
Explanation:Left ventricular hypertrophy due to long standing hypertension is the most probable cause. The irregularly irregular pulse was suggestive of atrial fibrillation, which is due to diastolic dysfunction. Poor ventricular filling causes pulmonary congestion which manifests as bibasal crepitations.
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This question is part of the following fields:
- Cardiovascular System
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Question 50
Incorrect
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A 65-year-old woman was referred due to a pulse rate of 40 bpm. Which of the following answers is associated with the least risk of asystole?
Your Answer:
Correct Answer: Complete heart block with a narrow complex QRS
Explanation:From the given answers, complete heart block with a narrow complex QRS complex is associated with the least risk of asystole. Transvenous pacing is indicated by the other given responses.
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This question is part of the following fields:
- Cardiovascular System
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Question 51
Incorrect
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Which of the following is the site where B-type natriuretic peptide is mainly secreted?
Your Answer:
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 52
Incorrect
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In which condition are β-blockers not recommended as the first line of therapy?
Your Answer:
Correct Answer: Hypertension
Explanation:For patients with hypertension, ACE inhibitors, diuretics, or calcium-channel blockers are given as first-line pharmacological agents. Patients with angina, chronic heart failure, myocardial infarction, and permanent atrial fibrillation with rapid ventricular rate, are given β-blockers as first-line therapy. In these cases, increased cardiac activity can not be met by the amount of blood being supplied to the heart. Giving β-blockers will reduce the workload of the heart and slow down the cardiac activity.
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This question is part of the following fields:
- Cardiovascular System
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Question 53
Incorrect
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From the following responses, what is the commonest cardiovascular abnormality associated with Marfan's syndrome of an adult?
Your Answer:
Correct Answer: Aortic root dilatation
Explanation:The main cardiovascular manifestations associated with Marfan’s syndrome are aortic dilatation and mitral valve prolapse.
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This question is part of the following fields:
- Cardiovascular System
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Question 54
Incorrect
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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:
Correct 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 55
Incorrect
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A 20-year-old male presented after an episode where he had collapsed. This was the second time he has collapsed during the past 3 weeks. His father passed away at the age of 40 due to sudden cardiac death. Echocardiography showed evidence of hypertrophic cardiomyopathy. His 24 hr ECG revealed several short runs of nonsustained ventricular tachycardia (VT). Which of the following is the most appropriate management for this patient?
Your Answer:
Correct Answer: Implantable cardiovertor defibrillator
Explanation:This patient has a high risk of sudden cardiac death due to a strong family history and non sustained VT. So the most appropriate management is implantable cardiovertor defibrillator.
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This question is part of the following fields:
- Cardiovascular System
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Question 56
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:
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 57
Incorrect
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Wolff-Parkinson-White syndrome is not linked with which of the following?
Your Answer:
Correct Answer: Ventricular tachycardia in the absence of drug therapy
Explanation:Ventricular tachycardia is not linked with Wolff-Parkinson-White syndrome. The other options are linked to WPW syndrome.
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This question is part of the following fields:
- Cardiovascular System
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Question 58
Incorrect
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A 80-year-old male patient with ischaemic heart disease, hypertension and dyslipidemia presented with productive cough, fever with chills and loss of appetite for 4 days. On examination he was unwell and febrile with a temperature of 38.3. His blood pressure was 130/80 mmHg and pulse rate was 140 bpm. Respiratory rate was 18 breaths per minute. On auscultation there were crepitations over the left lower zone of his chest. His abdomen was soft and nontender. ECG showed an irregular narrow complex tachycardia. Which of the following is the most appropriate acute management to treat his tachycardia?
Your Answer:
Correct Answer: Antibiotics
Explanation:The most likely diagnosis is acute atrial fibrillation (AF) precipitated by acute pneumonia. History of fever, cough and the auscultation findings support it. So the most appropriate management is treating the pneumonia with antibiotics. Treating the underlying cause will reduce the heart rate. Other responses are helpful in the management of chronic AF.
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This question is part of the following fields:
- Cardiovascular System
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Question 59
Incorrect
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A 45-year-old male was discharged recently after treatment of bleeding peptic ulcers. 3 days after discharge he was readmitted complaining of acute severe chest pain for the past 1 hour. His ECG showed an acute ST elevation myocardial infarction. His FBC, blood urea, serum electrolytes and serum creatinine were within normal ranges. Faecal occult blood was negative. Which of the following is the most appropriate management for this patient?
Your Answer:
Correct Answer: Primary angioplasty
Explanation:The patient has a recent history of bleeding peptic ulcer disease, which is an absolute contraindication for thrombolysis. So he should be offered primary angioplasty.
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This question is part of the following fields:
- Cardiovascular System
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Question 60
Incorrect
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A 25-year-old male presented with an episode of syncope. His examination findings were normal. He gave a history of sudden cardiac death of a close relative. His ECG showed incomplete right bundle-branch block and ST-segment elevations in the anterior precordial leads. What is the most probable diagnosis?
Your Answer:
Correct Answer: Brugada syndrome
Explanation:Brugada syndrome is an autosomal dominant disorder characterized by sudden cardiac death. The positive family history and characteristic ECG findings are in favour of Brugada syndrome. Usually the physical findings are normal.
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This question is part of the following fields:
- Cardiovascular System
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Question 61
Incorrect
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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:
Correct 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 62
Incorrect
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A 80-year-old male with hypertension presented with his second episode of atrial fibrillation. He was warfarinised and discharged. Later he was reviewed and found to be in sinus rhythm. Which of the following is the most appropriate next step?
Your Answer:
Correct Answer: Continue lifelong warfarin
Explanation:CHAâ‚‚DSâ‚‚-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
A score of 2 or more is considered as high risk and anticoagulation is indicated. This patient’s score is 3, so he needs life long warfarin to prevent stroke. -
This question is part of the following fields:
- Cardiovascular System
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Question 63
Incorrect
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A 40-year-old female presented with palmar xanthomas and tuberoeruptive xanthomas on her elbows and knees. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Type III hyperlipoproteinaemia
Explanation:Palmar xanthomas and tuberoeruptive xanthomas are found in type III hyperlipoproteinemia (dysbetalipoproteinemia,broad-beta disease, remnant removal disease)
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This question is part of the following fields:
- Cardiovascular System
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Question 64
Incorrect
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A 30-year-old male was brought in with a history of a stab injury to left chest. He was complaining of chest pain. On examination he was tachycardic, hypotensive and had an elevated JVP, pulsus paradoxus and muffled heart sounds. Respiratory examination was unremarkable. Which of the following is most probable diagnosis?
Your Answer:
Correct Answer: Cardiac tamponade
Explanation:Becks triad (hypotension, elevated systemic venous pressure, often with jugular venous distention and muffled heart sounds) is a characteristic collection of clinical findings found in cardiac tamponade. Pulsus paradoxus is also associated with it. The history and clinical findings in this scenario are compatible with the diagnosis of cardica tamponade. The normal respiratory examination excludes tension pneumothorax.
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This question is part of the following fields:
- Cardiovascular System
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Question 65
Incorrect
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Which type of myocardial infarction has the worst prognosis?
Your Answer:
Correct Answer: Anterior wall MI complicated with continuing left ventricular failure and an exercise tolerance of 3 METS on a predischarge exercise test
Explanation:Exercise tolerance of 3 METS on a predischarge exercise test is the most important indicator of a poor post-MI prognosis. Other similar features that predispose the individual to a poor prognosis are resuscitation from a secondary ventricular tachyarrhythmia after the fist 24h and poor left ventricular function on echo.
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This question is part of the following fields:
- Cardiovascular System
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Question 66
Incorrect
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A 60-year-old man presented with difficulty in breathing. On examination he was severely dyspnoeic and tachycardic. What is the clinical sign that would favour the diagnosis of cardiac tamponade over constrictive pericarditis?
Your Answer:
Correct Answer: Pulsus paradoxus
Explanation:Pulsus paradoxus is defined as the exaggerated fall in systolic blood pressure during inspiration by greater than 10 mmHg. Cardiac tamponade is the classic cause of pulsus paradoxus. Kussmaul’s sign (a rise in the jugular venous pressure on inspiration) is mostly seen in constrictive pericarditis. Hypotension, muffled heart sounds and raised JVP can be seen in both conditions.
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This question is part of the following fields:
- Cardiovascular System
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Question 67
Incorrect
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A 28-year-old male was screened for hypertrophic cardiomyopathy (HOCM). His father has passed away recently at the age of 48 and found to have HOCM during post mortem examination. On examination of this patient his BP was 142/84 mmHg and pulse rate was 68 bpm which was regular. There was a mid systolic murmur and a double apex beat. Echocardiography showed a septal wall thickness of 3.3 cm. What is the factor most closely linked to his 20 year risk of sudden cardiac death?
Your Answer:
Correct Answer: Septal wall thickness of 3.3 cm
Explanation:There are five prognostic factors which indicate poor prognosis in HOCM:
-family history of HOCM-related sudden cardiac death
-unexplained recent syncope
-large left ventricular wall thickness (MLVWT > 30 mm)
-multiple bursts of nsVT on ambulatory electrocardiography
-hypotensive or attenuated blood pressure response to exercise -
This question is part of the following fields:
- Cardiovascular System
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Question 68
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:
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 69
Incorrect
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A 65-year-old male patient presented with acute severe central chest pain for one hour. His ECG confirmed the diagnosis of acute ST elevation myocardial infarction and he was treated with thrombolysis. Two days later he developed sudden onset breathlessness and became unwell. On examination he had bibasal crepitation and a systolic murmur at the apex which radiated to the axilla. Which of the following is the most likely cause for this presentation?
Your Answer:
Correct Answer: Ruptured papillary muscle
Explanation:The most likely cause for acute breathlessness is due to papillary muscle rupture which causes mitral regurgitation.
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This question is part of the following fields:
- Cardiovascular System
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Question 70
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:
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 71
Incorrect
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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:
Correct 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 72
Incorrect
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A 65-year-old gentleman presented with 2 weeks history of exertional dyspnoea, orthopnoea and chest pain. Past history revealed that a few years ago, he had been treated with antibiotics for complaints of fever, joint pains and chest pain. The most likely diagnosis will be?
Your Answer:
Correct Answer: Mitral valve stenosis
Explanation:The commonest symptom of mitral valve stenosis is dyspnoea, and it is one of the most common clinical findings which can be seen in rheumatic fever.
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This question is part of the following fields:
- Cardiovascular System
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Question 73
Incorrect
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A 60-year-old male presented with ventricular tachycardia which was successfully cardioverted. To check whether he had prolonged QT interval, which of the following is the most appropriate method to measure the QT interval in ECG?
Your Answer:
Correct Answer: Time between the start of the Q wave and the end of the T wave
Explanation:The QT interval is the time from the start of the Q wave to the end of the T wave. It represents the time taken for ventricular depolarisation and repolarisation. The QT interval should be measured in either lead II or V5-6.
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This question is part of the following fields:
- Cardiovascular System
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Question 74
Incorrect
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A young alcoholic male patient presented at hospital with complaints of tachycardia and palpitations for the past few hours. During examination, his blood pressure and ECG were normal. What would be the next step in management of this patient?
Your Answer:
Correct Answer: Reassure and life Style modification
Explanation:Normal blood pressure and ECG rule out any pathological cause of the complaints described in this scenario. These symptoms are most probably due to anxiety or effects of alcohol intake. Lifestyle modification will be the best management plan along with reassurance to calm the patient.
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This question is part of the following fields:
- Cardiovascular System
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Question 75
Incorrect
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A 60-year-old previously well male patient was admitted with acute severe central chest pain associated with excessive sweating and nausea for the past 45 minutes. On examination he was found to have xanthelasma. His blood pressure was 170/100 mmHg and pulse rate was 104 bpm. His ECG showed ST elevation more than 2mm in leads II, III and aVF. His troponin T was 120 ng/ml. His FBC and renal functions were normal. He was given aspirin, clopidogrel, morphine and IV 5 mg of atenolol. Which of the following is the most appropriate next step?
Your Answer:
Correct Answer: Immediate referral to cardiologist for primary angioplasty
Explanation:The diagnosis is acute inferior ST elevation myocardial infarction so the most appropriate management is primary angioplasty.
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This question is part of the following fields:
- Cardiovascular System
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Question 76
Incorrect
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A 50-year-old male with a history of type II diabetes mellitus and hypertension presented with exertional dyspnoea and chest pain for 2 weeks. On examination his blood pressure was 145/80 mmHg. On auscultation reversed splitting of the second heart sound and bibasal crepitations were detected. What would be the most likely finding on his ECG?
Your Answer:
Correct Answer: Left bundle branch block
Explanation:When closure of the pulmonary valve occurs before the aortic valve, reversed splitting occurs. The causes of reversed splitting are aortic stenosis, hypertrophic cardiomyopathy, left bundle branch block (LBBB), and a ventricular pacemaker.
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This question is part of the following fields:
- Cardiovascular System
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Question 77
Incorrect
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A 65-year-old previously well man was referred due to an abnormal heart sound which was detected during a medical check up. On examination he looked well. His blood pressure was 120/70 mmHg and pulse rate was 68 bpm which was regular. His jugular venous pressure was not elevated and he didn't have ankle oedema. He had an early diastolic murmur, best heard at the left sternal edge, which was more clear in expiration when the patient leant forward. His lungs were clear. His FBC, Urea and electrolytes, LFTs and lipid profile were normal. His ECG showed sinus rhythm. His chest X-ray was normal. Echocardiography showed mild to moderate aortic regurgitation with normal left ventricular size and normal function.
Which of the following is the most appropriate way of managing this patient?Your Answer:
Correct Answer: Start him on an angiotensin-converting enzyme (ACE) inhibitor
Explanation:Although this patient’s left ventricular function is normal at the time of examination, there is chance of deterioration of it due to aortic regurgitation. It is found that ACE inhibitors slow the development of left ventricular dysfunction. So this patient should be started on an ACE inhibitor.
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This question is part of the following fields:
- Cardiovascular System
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Question 78
Incorrect
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A 34-year-old male presented with exertional dyspnoea and chest pain for the past 2 weeks. On examination there was a mid-systolic murmur which is best heard at the apex and double apical impulse. His ECG showed left ventricular hypertrophy (LVH). What is the risk factor which would be most indicative of the potential for sudden death in this patient?
Your Answer:
Correct Answer: Degree of left ventricular hypertrophy
Explanation:The history is suggestive of hypertrophic obstructive cardiac myopathy. The degree of left ventricular hypertrophy is strongly associated with sudden cardiac death.
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This question is part of the following fields:
- Cardiovascular System
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Question 79
Incorrect
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A 60-year-old female presented after an acute overdose of amiodarone. Her blood pressure was 110/70 mmHg and pulse rate was 35 bpm. She was given 500 mcg of atropine but there was no response. Which of the following is the most appropriate next step?
Your Answer:
Correct Answer: Isoprenaline
Explanation:Permanent pacing is not indicated as the bradycardia is reversible. Temporary pacing is the definite treatment. Isoprenaline can be used until temporary pacing is available.
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This question is part of the following fields:
- Cardiovascular System
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Question 80
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:
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 81
Incorrect
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A 28-year-old primigravida in her 24th week of pregnancy presented with a history of fast and regular palpitations. There is no history of collapse. On examination she was well, pulse rate was 102 bpm, which was regular and her blood pressure was 110/70 mmHg. Her JVP was not elevated. Heart sounds were normal. ECG showed sinus tachycardia. Which of the following can be expected due to the physiological changes which occur during pregnancy?
Your Answer:
Correct Answer: Tachycardia
Explanation:The cardiovascular alterations which occur during pregnancy are for the optimal growth and development of the foetus and help to protect the mother from the risks of delivery, such as haemorrhage. The changes are characterized by an increased vascular volume, cardiac output, and heart rate, with a marked fall in vascular resistance and reduction in blood pressure.
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This question is part of the following fields:
- Cardiovascular System
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Question 82
Incorrect
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A 52-year-old female who was a smoker, with a history of asymptomatic atrial septal defect (ASD) presented with difficulty in breathing on exertion and ankle oedema for the past 2 weeks. She has defaulted on her follow up for ASD. On examination she was cyanosed and clubbing was noted. Her pulse rate was 92 and blood pressure was 100/60 mmHg. Echocardiography revealed a dilated right ventricle of the heart. The right ventricular pressure was 90 mmHg. Significant tricuspid and pulmonary regurgitation were also noted. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Eisenmenger's syndrome
Explanation:According to echocardiography findings pulmonary pressure is closer to systemic blood pressure and it is evidence of pulmonary hypertension. Because of the reversal of shunt due to pulmonary hypertension, cyanosis and clubbing have developed. So the most probable diagnosis is Eisenmenger’s syndrome.
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This question is part of the following fields:
- Cardiovascular System
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Question 83
Incorrect
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A 45-year-old male is suffering from bronchial carcinoma. This is causing obstruction of the superior vena cava. Which of the following is the most suitable palliative treatment option in this case?
Your Answer:
Correct Answer: Radiotherapy
Explanation:Bronchial carcinoma causes obstruction of the superior vena cava through its mass effect. From the options listed in this case, radiotherapy is the most suitable treatment option.
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This question is part of the following fields:
- Cardiovascular System
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Question 84
Incorrect
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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:
Correct 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 85
Incorrect
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Which of the following is not an indication for an implantable cardiac defibrillator?
Your Answer:
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 86
Incorrect
-
A 60-year-old man with previous history of myocardial infarction and hypertension presented with severe retrosternal chest pain for the past 2 hours. During initial management he collapsed and pulseless ventricular tachycardia was detected. The external defibrillator arrived in 3 minutes. From the following answers, what is the most appropriate immediate management of this patient whilst waiting for the defibrillator?
Your Answer:
Correct Answer:
Explanation:Immediate Management of Pulseless Ventricular Tachycardia:
- Continuous Chest Compressions:
- Continuous chest compressions should be started immediately to maintain circulation while the defibrillator is being prepared. High-quality chest compressions are crucial and should not be delayed.
- Defibrillation:
- Once the defibrillator arrives, defibrillation should be performed as soon as possible. For pulseless ventricular tachycardia, delivering a shock is critical to attempt to restore a normal heart rhythm.
Other options:
He should be given a precordial thump: This is not recommended as a primary action when a defibrillator is available or arriving imminently.
A ventilation to compression ratio of 30:2 should be commenced: While ventilation is important, continuous chest compressions take precedence in the initial phase. The ratio of 30:2 is used during CPR when ventilations are also being provided, typically when two rescuers are present.
Await arrival of defibrillator, then deliver shock: Waiting passively without performing chest compressions is not appropriate.
Intravenous adrenaline should be given: Adrenaline is part of the advanced life support protocol, but the first immediate action should be chest compressions followed by defibrillation.
- Continuous Chest Compressions:
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This question is part of the following fields:
- Cardiovascular System
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Question 87
Incorrect
-
A 60-year-old female presented with difficulty in breathing. What is the clinical sign that will indicate the presence of established pulmonary hypertension?
Your Answer:
Correct Answer: Raised jugular venous pressure
Explanation:A prominent A wave is observed in the jugular venous pulse and this indicates the presence of established pulmonary hypertension. In addition the pulmonic component of the second heart sound (P2) may be increased and the P2 may demonstrate fixed or paradoxical splitting. The signs of right ventricular failure include a high-pitched systolic murmur of tricuspid regurgitation, hepatomegaly, a pulsatile liver, ascites, and peripheral oedema.
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This question is part of the following fields:
- Cardiovascular System
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Question 88
Incorrect
-
A 60-year-old patient was admitted to the surgery department for elective herniorrhaphy. Due to a problem in his history, his operation was postponed. Which of the following is the most likely cause for this postponement?
Your Answer:
Correct Answer: MI 2 months ago
Explanation:After an MI, elective surgeries are recommended to be delayed for at least 6 months. This will help the patient become physically fit for the stress of surgery. Any surgery before this can carry a significant increased risk of mortality.
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This question is part of the following fields:
- Cardiovascular System
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Question 89
Incorrect
-
A 65-year-male patient was started on warfarin for chronic atrial fibrillation (AF). Which of the following clotting factors is not affected by warfarin?
Your Answer:
Correct Answer: Factor XII
Explanation:Carboxylation of factor II, VII, IX, X and protein C is affected by warfarin. Factor XII is not affected.
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This question is part of the following fields:
- Cardiovascular System
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Question 90
Incorrect
-
An 82-year-old patient presents to the clinic complaining of palpitations. ECG reveals waves with saw-tooth pattern, QRS complex of 80ms duration, a ventricular rate of 150/min and a regular R-R interval. Which of the following is most likely responsible for these findings?
Your Answer:
Correct Answer: Atrial flutter
Explanation:Atrial flutter is a common supraventricular tachyarrhythmia that is usually caused by a single macroreentrant rhythm within the atria, associated with a sawtooth appearance on the ECG. In stable patients the treatment includes rate control and rhythm control, however in unstable patients, a synchronized cardioversion is required.
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This question is part of the following fields:
- Cardiovascular System
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Question 91
Incorrect
-
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:
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 92
Incorrect
-
A female patient presents with pain upon inspiration and dyspnoea. She had a myocardial infarction four days ago. What is the most probable diagnosis?
Your Answer:
Correct Answer: Pericarditis
Explanation:Although viral infection is the most common identifiable cause of acute pericarditis, the condition may be associated with many diseases. Non-viral causes of pericarditis include bacterial infection, MI, chest trauma, and neoplasm. Post-MI pericarditis may develop two to four days after an acute infarction and results from a reaction between the pericardium and the damaged adjacent myocardium. Dressler’s syndrome is a post-MI phenomenon in which pericarditis develops weeks to months after an acute infarction; this syndrome is thought to reflect a late autoimmune reaction mediated by antibodies to circulating myocardial antigens.
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This question is part of the following fields:
- Cardiovascular System
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Question 93
Incorrect
-
A 28-year-old male was admitted with palpitations and chest discomfort for the past 1 hour. On examination his pulse rate was 200 bpm and blood pressure was 80/50 mmHg. His ECG revealed narrow complex tachycardia with a heart rate of 200 bpm. Which of the following is the most appropriate management of this patient?
Your Answer:
Correct Answer: Synchronised DC synchronised cardioversion
Explanation:Narrow complex tachycardia with hypotension is a medical emergency. Immediate synchronized cardioversion is the ideal management.
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This question is part of the following fields:
- Cardiovascular System
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Question 94
Incorrect
-
A 44-year-old man complains of unceasing chest pain which is aggravated by inspiration four weeks after his MI. His temperature is 37.5C and ESR is 45mm/h. What is the single most likely explanation for the abnormal investigations
Your Answer:
Correct Answer: Dressler syndrome
Explanation:Dressler syndrome signs and symptoms include pericarditis, low-grade fever, and pleuritic chest pain. It commonly occurs two to five weeks following the initial event or for as long as three months.
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This question is part of the following fields:
- Cardiovascular System
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Question 95
Incorrect
-
An old man presented with headache and weakness of the left half of the body. His CT scan showed an intracranial bleed (ICB). All of the following factors can lead to ICB except?
Your Answer:
Correct Answer: Moderate alcohol use
Explanation:Moderate alcohol intake has no association with intracranial bleeding (ICB), rather some authors suggested that it is protective. Patients with a previous history of DVT, mitral valve prolapse or those using cocaine are at an increased risk of developing an ICB.
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This question is part of the following fields:
- Cardiovascular System
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Question 96
Incorrect
-
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:
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 97
Incorrect
-
A 30-year-old male with Down's Syndrome was found to have a systolic murmur during routine clinical examination. Which of the following is the most common cardiac defect associated with Down's Syndrome which will explain this finding?
Your Answer:
Correct Answer: Endocardial cushion defect
Explanation:Atrioventricular septal defect (AVSD) also known as endocardial cushion defect is the most common cardiac abnormality in Down’s Syndrome.
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This question is part of the following fields:
- Cardiovascular System
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Question 98
Incorrect
-
A 25-year-old previously well female, in her 10th week of pregnancy presented with a left sided painful calf swelling. An ultrasound scan revealed deep venous thrombosis (DVT) of her left leg. Which of the following is the most appropriate management of this patient?
Your Answer:
Correct Answer: Initiate and then continue treatment with heparin until delivery
Explanation:Warfarin is contraindicated during pregnancy due to its teratogenic effects. She should be given heparin throughout her pregnancy. It can be converted to warfarin if necessary after the delivery.
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This question is part of the following fields:
- Cardiovascular System
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Question 99
Incorrect
-
A 57-year-old female arrives at the emergency due to chest pain, shortness of breath and palpitations. ECG is done which shows a supraventricular tachycardia with a heart rate of 220/min. carotid massage fails to bring the heart rate down. How would you manage this patient?
Your Answer:
Correct Answer: DC shock
Explanation:Synchronized electrical cardioversion may also be used to treat stable ventricular tachycardia (VT) that does not respond to a trial of intravenous medications. Unstable patients with SVT and a pulse are always treated with synchronized cardioversion. The appropriate voltage for cardioverting SVT is 50-100 J. This is what AHA recommends and also SVT converts quite readily with 50-100 J.
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This question is part of the following fields:
- Cardiovascular System
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Question 100
Incorrect
-
A 59-year-old man experienced an acute chest pain, which lasted for 45 mins whilst he was driving. The pain was located centrally and was accompanied by cold sweats and difficulty in speaking. History reveals he is a T1DM patient who's been on antihypertensive medication for 13 years. What is the most likely diagnosis?
Your Answer:
Correct Answer: Myocardial infarction
Explanation:The patient is diabetic and at major risk for an MI. The duration and location of the pain, the cold sweats and the difficulty in speaking suggest an MI. Pericarditis pain worsens upon inspiration or in a supine position. Patients usually lean forward to relieve the pain. (antalgic position). Pneumothorax pain is pleuritic in regards to location. Pulmonary embolism is accompanied by dyspnoea and pleuritic pain. Costochondritis pain is localized at the costochondral junction and it worsens with movements of the chest such as coughing or sneezing.
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This question is part of the following fields:
- Cardiovascular System
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Question 101
Incorrect
-
A 54-year-old patient presented with a dry cough after starting treatment for hypertension. He was prescribed ramipril 2.5mg and the dry cough started after that, which disturbed his sleep. His blood pressure was normal. Which of the following is the most appropriate management?
Your Answer:
Correct Answer: Stop the ramipril and prescribe candesartan
Explanation:ACE inhibitors are known to cause a dry cough and they should be stopped, to settle the cough. The next drug of choice is an angiotensin receptor blocker such as candesartan.
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This question is part of the following fields:
- Cardiovascular System
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Question 102
Incorrect
-
A 55-year-old man presented with retrosternal chest pain associated with excessive sweating and vomiting. On examination his BP was 100/60 mmHg and pulse rate was 72 bpm. Bibasal crepitations were auscultated. His ECG showed ST elevation in V1 to V4 and ST depression in leads II, III and aVF. Which of the following would be the finding during angioplasty?
Your Answer:
Correct Answer: Complete occlusion of the left anterior descending artery
Explanation:The ECG findings are suggestive of anterior myocardial infarction and the most likely artery affected is the left anterior descending artery. Occlusion of the right coronary artery will be shown by ST elevation in lead II, III, aVF and occlusion of the circumflex artery will show changes in leads I, aVL, V5 and V6. To have ST elevation, there should be complete occlusion of the artery.
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This question is part of the following fields:
- Cardiovascular System
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Question 103
Incorrect
-
In which of the following options does reversed splitting of the second heart sound occur?
Your Answer:
Correct Answer: Left bundle branch block (LBBB)
Explanation:Reversed splitting of the second heart sound occurs with reversal of the normal A2, P2 pattern – A2 may, therefore, be delayed, as with severe AS and LBBB. P2 may be early, as in Wolff-Parkinson-White Type B and persistent ductus arteriosus. Atrial septal defects show wide fixed splitting. Also, RBBB has wide (not fixed) splitting.
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This question is part of the following fields:
- Cardiovascular System
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Question 104
Incorrect
-
A 80-year-old male was found on the floor. His blood pressure was 100/60 mmHg. His core temperature was 31ºC. His FBC and serum electrolytes were within normal limits. Which of the following would be found in his ECG?
Your Answer:
Correct Answer: Long QT interval
Explanation:Hypothermia is defined as a core body temperature of < 35 °C.
Hypothermia may produce the following ECG changes:
-Bradyarrhythmia
-Osborne Waves (= J waves)
-Prolonged PR, QRS and QT intervals
-Shivering artefact
-Ventricular ectopics
-Cardiac arrest due to VT, VF or asystole -
This question is part of the following fields:
- Cardiovascular System
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Question 105
Incorrect
-
A 45-year-old male complains of angina pain. Which of the following features on exercise testing would have the strongest predictive value for ischaemic heart disease?
Your Answer:
Correct Answer: Decline in systolic BP by 20 mmHg in stage 1 of the Bruce protocol
Explanation:The classic criteria for visual interpretation of positive stress test findings include the following:J point (the junction of the point of onset of the ST-T wave; it is normally at or near the isoelectric baseline of the ECG), ST80 (the point that is 80 msec from the J point), depression of 0.1 mV (1 mm) or more and ST-segment slope within the range of ± 1 mV/sec in 3 consecutive beats
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This question is part of the following fields:
- Cardiovascular System
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Question 106
Incorrect
-
An echocardiogram of a 50-year-old male patient showed an infarct in the anterolateral aspect of the left side of the heart and apex. An angiogram was then done. Obstruction of which of the following arteries is the cause of this myocardial infarction?
Your Answer:
Correct Answer: Left anterior descending artery
Explanation:The left coronary artery is responsible for supplying the entire left side of the heart, however, it divides into the left anterior descending artery which supplies the apex of the heart and the interventricular septum, and the left circumflex artery which supplies the posterolateral part of the left ventricle and a portion of the papillary muscle. The infarction is noted at the apex of the heart and the interventricular septum, therefore, the obstruction has occurred in the left anterior descending artery.
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This question is part of the following fields:
- Cardiovascular System
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Question 107
Incorrect
-
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:
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 108
Incorrect
-
A 50-year-old male patient was started on amiodarone. Prior to commencement, his blood urea and electrolytes were checked. What is the reason for doing this investigation before starting amiodarone?
Your Answer:
Correct Answer: To detect hypokalaemia
Explanation:Any antiarrhythmic drugs can potentially cause arrhythmias. Before starting amiodarone, any electrolyte imbalance including hypokalaemia, hypomagnesemia, or hypocalcaemia should be corrected to prevent any arrhythmias.
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This question is part of the following fields:
- Cardiovascular System
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Question 109
Incorrect
-
A 65-year-old male patient admitted with myocardial infarction received thrombolysis, which lead to full resolution of the ST elevations on his ECG. He was on aspirin, clopidogrel, atorvastatin and enalapril. The next day he complained of pain in his legs and there was a diffuse petechial rash over his lower legs, especially in the feet. All his peripheral pulses were palpable. His FBC revealed neutrophilia with eosinophilia. His IgE antibodies were 3 kU/L (<2). What is the most likely reason for this presentation?
Your Answer:
Correct Answer: Cholesterol emboli
Explanation:He has a consequence of atherosclerotic disease (MI). The most probable diagnosis is cutaneous cholesterol emboli as it is more common after anticoagulation or thrombolytics, the skin involvement, eosinophilia and raised IgE. It is more common above 60 yrs. of age.
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This question is part of the following fields:
- Cardiovascular System
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Question 110
Incorrect
-
Bicuspid aortic valve is in association with which of the following.
Your Answer:
Correct Answer: Coarctation of the aorta
Explanation:Bicuspid aortic valve is the most common congenital cardiovascular anomaly, occurring in 1-2% of the population. Coarctation and bicuspid aortic valve occur more frequently in males with a prevalence of approximately 4:1. A high prevalence of these same cardiovascular lesions is also found in women with Turner’s syndrome.
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This question is part of the following fields:
- Cardiovascular System
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Question 111
Incorrect
-
A 13-year-old girl is brought by her mother to the A&E with breathlessness, fatigue and palpitations. Anamnesis does not reveal any syncope or chest pain in the past. on the other hand, these symptoms were present intermittently for a year. Clinical examination reveals a pan-systolic murmur associated with giant V waves in the jugular venous pulse. Chest auscultation and resting ECG are normal. 24 hour ECG tape shows a short burst of supraventricular tachycardia. What is the most probable diagnosis?
Your Answer:
Correct Answer: Ebstein's anomaly
Explanation:Ebstein’s anomaly is characterised by apical displacement and adherence of the septal and posterior leaflets of the tricuspid valve to the underlying myocardium, thereby displacing the functional tricuspid orifice apically and dividing the right ventricle into two portions. The main haemodynamic abnormality leading to symptoms is tricuspid valve incompetence. The clinical spectrum is broad; patients may be asymptomatic or experience right-sided heart failure, cyanosis, arrhythmias and sudden cardiac death (SCD). Many Ebstein’s anomaly patients have an interatrial communication (secundum atrial septal defect (ASD II) or patent foramen ovale). Other structural anomalies may also be present, including a bicuspid aortic valve (BAV), ventricular septal defect (VSD), and pulmonary stenosis. The morphology of the tricuspid valve in Ebstein anomaly, and consequently the clinical presentation, is highly variable. The tricuspid valve leaflets demonstrate variable degrees of failed delamination (separation of the valve tissue from the myocardium) with fibrous attachments to the right ventricular endocardium.
The displacement of annular attachments of septal and posterior (inferior) leaflets into the right ventricle toward the apex and right ventricular outflow tract is the hallmark finding of Ebstein anomaly. -
This question is part of the following fields:
- Cardiovascular System
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Question 112
Incorrect
-
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:
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 113
Incorrect
-
During the peri-infarct period, which of these drug classes have been shown to have the greatest favourable benefit?
Your Answer:
Correct Answer: Beta blockers
Explanation:Statins and ACE inhibitors are beneficial initially for the first 24 hours but not proven to have a benefit in the post infarct period. Statins have plaque stabilising functions when activated early following infarction. In contrast, when started immediately, beta blockers are the most beneficial. Nitrates have not been proven beneficial for survival and some calcium channel blockers actually increased the mortality rate.
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This question is part of the following fields:
- Cardiovascular System
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Question 114
Incorrect
-
A 60-year-old man presented with severe central chest pain for the last 2 hours. He was on insulin for diabetes mellitus and he was dependent on haemodialysis because of end stage renal failure. He had undergone haemodialysis 48 hours prior to this presentation. His ECG showed an acute inferior myocardial infarction. Despite thrombolysis and other appropriate treatment, he continued to have chest pain after 6 hours from the initial presentation. His blood pressure was 88/54 mmHg and he had bibasal crepitations. His investigation results are given below.
Serum sodium 140 mmol/l (137-144)
Serum potassium 6.6 mmol/l (3.5-4.9)
Serum urea 50 mmol/l (2.5-7.5)
Serum creatinine 940 μmol/l (60-110)
Haemoglobin 10.2g/dl (13.0-18.0)
Troponin T >24 g/l (<0.04)
Left ventricular ejection fraction was 20%
What is the most appropriate management for this patient?Your Answer:
Correct Answer: Coronary angiography and rescue PCI
Explanation:According to the history the patient has cardiogenic shock and pulmonary oedema. On-going ischaemia is indicated by persisting symptoms. So the most appropriate management is coronary angiography and rescue PCI. There are no indications for blood transfusion at this moment and it will aggravate the pulmonary oedema. Haemodialysis, beta blockers and furosemide cannot be given due to low blood pressure.
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This question is part of the following fields:
- Cardiovascular System
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Question 115
Incorrect
-
A 60-year-old male with no past medical history presented to Casualty with acute chest pain. ST elevation myocardial infarction (STEMI) is diagnosed following an ECG on arrival. He was subsequently successfully thrombolysed. Which of the following combinations of drugs is the most suitable combination for him to be taking 4 weeks after his STEMI?
Your Answer:
Correct Answer: ACE inhibitor + beta-blocker + statin + aspirin + clopidogrel
Explanation:According to NICE guidelines (2013) all people who have had an acute MI, treatment should be offered with ACE inhibitor, dual antiplatelet therapy (aspirin plus a second antiplatelet agent), beta-blocker and a statin.
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This question is part of the following fields:
- Cardiovascular System
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Question 116
Incorrect
-
A 55-year-old female with a history of hypertension presented with severe central chest pain for the past one hour, associated with sweating and vomiting. Her ECG showed ST elevation myocardial infarction, evident in leads V2-V4. Which of the following is an absolute contraindication for thrombolysis?
Your Answer:
Correct Answer: Intracranial neoplasm
Explanation:Absolute contraindications for fibrinolytic use in STEMI
Prior intracranial haemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 months -
This question is part of the following fields:
- Cardiovascular System
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Question 117
Incorrect
-
A 44-year-old man presents suffering from retrosternal chest pain that started 2 hours ago and radiates to the throat. Which investigation would you immediately perform?
Your Answer:
Correct Answer: Troponin levels
Explanation:The patient’s age and symptoms are indicating a myocardial infarction. Although, the cause of the pain could also be related to the digestive system, a possible myocardial infarction should be excluded or, if present, managed immediately. Troponins are used to establish the diagnosis. Levels of troponin can become elevated in the blood within 3 or 4 hours after heart injury and may remain elevated for 10 to 14 days.
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This question is part of the following fields:
- Cardiovascular System
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Question 118
Incorrect
-
A 30-year-old male presented with exercise related syncope and dyspnoea for 2 weeks. His father passed away at the age of 40, due to sudden cardiac death. His ECG showed left ventricular hypertrophy with widespread T wave inversions. Which of the following is the most appropriate next investigation to confirm the diagnosis?
Your Answer:
Correct Answer: Transthoracic echo
Explanation:The most likely diagnosis is hypertrophic obstructive cardiomyopathy which is suggestive by the history, positive family history and ECG findings. Two-dimensional echocardiography is diagnostic for hypertrophic cardiomyopathy. In general, a summary of echocardiography findings includes abnormal systolic anterior leaflet motion of the mitral valve, LV hypertrophy, left atrial enlargement, small ventricular chamber size, septal hypertrophy with septal-to-free wall ratio greater than 1.4:1, mitral valve prolapse and mitral regurgitation, decreased midaortic flow, and partial systolic closure of the aortic valve in midsystole.
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This question is part of the following fields:
- Cardiovascular System
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Question 119
Incorrect
-
Which of the following statements describe the mechanism of fibrates most accurately?
Your Answer:
Correct Answer: Increased lipoprotein lipase activity via PPAR-alpha
Explanation:The main mechanism of fibrate drugs is activation of gene transcription factors known as PPARs, particularly PPAR-?, which regulate the expression of genes that control lipoprotein metabolism. There are several consequences of PPAR-? activation, which reduce circulating LDL cholesterol and triglycerides and increase HDL cholesterol.
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This question is part of the following fields:
- Cardiovascular System
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Question 120
Incorrect
-
The phonocardiogram of a 40-year-old male patient showed a normal S1 but an abnormal S2. S2 was fixed and widely split. Out of the following, which condition do you think this patient most likely suffering from?
Your Answer:
Correct Answer: Secundum atrial septal defect
Explanation:The second heart sound (S2) corresponds to the closing of the semilunar valves, first the aortic and then the pulmonary valve. The gap between the closure of these two valves is normally insignificant and is heard as a single heart sound. In certain pathological conditions, this gap increases when there is a delay in right ventricular emptying, but in cases other than an atrial septal defect, the sound is not fixed. In an atrial septal defect, the right ventricle continuously receives blood, causing a delay and a fixed and split S2.
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This question is part of the following fields:
- Cardiovascular System
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Question 121
Incorrect
-
A 50-year-old smoker with a history of hypertension presented with acute severe chest pain and acute myocardial infarction was diagnosed. Which of the following is a contraindication for thrombolysis?
Your Answer:
Correct Answer: History of likely ischaemic stroke within the past month
Explanation:Absolute contraindications for fibrinolytic use in STEMI
Prior intracranial haemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 months -
This question is part of the following fields:
- Cardiovascular System
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Question 122
Incorrect
-
A 62-year-old obese female presented with dilated veins over the lateral aspect of her right ankle. Which of the following is most responsible for her presentation?
Your Answer:
Correct Answer: Short saphenous vein
Explanation:Varicose veins (venous insufficiency syndrome) are dilated, tortuous veins due to reverse venous flow. All the given veins can be affected from this condition. As the patient has varicose veins over lateral aspect of ankle, the short saphenous vein is affected. The great or long saphenous vein travels along the medial aspect of the ankle
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This question is part of the following fields:
- Cardiovascular System
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Question 123
Incorrect
-
Which of the following is the mechanism of action of bivalirudin in acute coronary syndrome?
Your Answer:
Correct Answer: Reversible direct thrombin inhibitor
Explanation:Bivalirudin is a competitive, direct thrombin inhibitor. It inhibits both free and clot-bound thrombin and thrombin-induced platelet aggregation. Thrombin enables fibrinogen conversion to fibrin during the coagulation cascade. So inhibition of fibrinogen conversion to fibrin inhibits thrombus development.
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This question is part of the following fields:
- Cardiovascular System
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Question 124
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:
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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Question 125
Incorrect
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A 42-year-old male patient who was on enalapril for hypertension presented with generalized body weakness. Investigations revealed hyperkalaemia. Which of the following can be expected in his ECG?
Your Answer:
Correct Answer: Tall, tented T waves
Explanation:In hyperkalaemia the ECG will show tall, tented T waves as well as small P waves and widened QRS complexes.Â
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This question is part of the following fields:
- Cardiovascular System
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Question 126
Incorrect
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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:
Correct 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 127
Incorrect
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A 72-year-old man presents to the emergency department with dyspnoea and low exercise tolerance. He's known to have a history of ischemic heart disease on medication. Which drug most probably caused his presenting complaint?
Your Answer:
Correct Answer: Diclofenac Sodium
Explanation:Diclofenac sodium is a non-selective reversible and competitive inhibitor of cyclooxygenase (COX), subsequently blocking the conversion of arachidonic acid into prostaglandin precursors. This leads to an inhibition of the formation of prostaglandins that are involved in pain, inflammation and fever. Clinical trials of several COX-2 selective and non-selective NSAIDs of up to three years duration have shown an increased risk of serious cardiovascular (CV) thrombotic events, including myocardial infarction (MI), and stroke, which can be fatal.
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This question is part of the following fields:
- Cardiovascular System
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Question 128
Incorrect
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A 50-year-old male presented with episodes of collapse during the last month. Each episode persisted for about 2-3 minutes. They were self-limiting and associated with twitching of the limbs. There was no associated tonic-clonic movements, tongue biting, urinary or faecal incontinence. On examination he had reversed splitting of S2 and an ejection systolic murmur at the right sternal border. His electrocardiogram (ECG) showed left ventricular hypertrophy with strain pattern. CXR showed an area of calcification over the cardiac silhouette. Which of the following is the most probable diagnosis of this patient?
Your Answer:
Correct Answer: Aortic stenosis
Explanation:The classic triad of symptoms in patients with aortic stenosis is chest pain, heart failure and syncope. Pulsus parvus et tardus, pulsus alternans, hyperdynamic left ventricle, reversed splitting of the S2, prominent S4 and systolic murmur are some of the common findings of aortic stenosis. A calcified aortic valve is found in almost all adults with hemodynamically significant aortic stenosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 129
Incorrect
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A 1-month-old boy was brought to the ED by his mother because he has been irritable and feeding poorly for the last 24 hours. His CXR shows cardiomegaly but with clear lung fields while his ECG shows a regular narrow complex tachycardia with difficulty identifying the P wave. The boy is conscious but has cold extremities. What is the most appropriate next step?
Your Answer:
Correct Answer: Synchronized DC cardio-version
Explanation:The most possible diagnosis is SVT. The boy is suffering from hemodynamic instability, as indicated by his cold extremities. DC cardioversion is the treatment of choice.
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This question is part of the following fields:
- Cardiovascular System
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Question 130
Incorrect
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Which of the following indicates the opening of tricuspid valve in jugular venous waveform?
Your Answer:
Correct Answer: y descent
Explanation:The a wave indicates atrial contraction. The c wave indicates ventricular contraction and the resulting bulging of tricuspid valve into the right atrium during isovolumetric systole. The v wave indicates venous filling. The x descent indicates the atrium relaxation and the movement of the tricuspid valve downward. The y descent indicates the filling of the ventricle after tricuspid opening.
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This question is part of the following fields:
- Cardiovascular System
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Question 131
Incorrect
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A 50-year-old male presented with acute severe central chest pain and acute ST elevation myocardial infarction was diagnosed. He was treated with streptokinase. 2 days later he was sweating excessively and he was found to be hypotensive. Which of the following cannot be considered as a reason for this presentation?
Your Answer:
Correct Answer: Hypotensive effect of streptokinase
Explanation:Hypotensive effect of streptokinase occurs during the streptokinase infusion which is usually transient. Acute mitral regurgitation due to rupture of papillary muscles, ventricular septal defects and reinfarctions (left or right) are known to cause hypotension after 24 hrs. Pulmonary embolism is less likely but cannot be excluded.
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This question is part of the following fields:
- Cardiovascular System
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Question 132
Incorrect
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Which of the following is suggestive of co-existence of mitral regurgitation and mitral stenosis?
Your Answer:
Correct Answer: Displaced apex beat
Explanation:Apex beat displacement is caused by mitral regurgitation and because it is not found in mitral stenosis, it is suggestive of mixed mitral disease. The other given responses occur in mitral stenosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 133
Incorrect
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An 8-year-old boy is presented with arthritis, cough and non-blanching purpura. His coagulation profile is normal. His CBC: Hb 11.8 TLC 7.2*10^9 Plt 286*10^9. What is the most likely diagnosis?
Your Answer:
Correct Answer: Henoch-Schönlein Purpura (HSP)
Explanation:The best answer is Henoch-Schönlein Purpura (HSP). This patient has a characteristic rash and the labs are consistent with this diagnosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 134
Incorrect
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A previously well 33-year-old female was admitted with a history of recurrent episodes of palpitations. She didn't have chest pain. She frequently drank plenty of coffee and alcohol. Her blood pressure was 120/80 mmHg and pulse rate was 200 bpm which was regular. There was no sign of heart failure. Her ECG revealed narrow complex tachycardia. She was given 3mg of IV adenosine but there was no response. Which of the following is the most appropriate management if she doesn't respond to 6mg of IV adenosine?
Your Answer:
Correct Answer: IV 12mg adenosine
Explanation:Vagal manoeuvres can be tried first. If not responding to these then adenosine can be trialled. If 3mg of adenosine has no effect, then give adenosine 6 mg rapid IV push. If patient does not convert, give adenosine 12 mg rapid IV push. Can repeat 12 mg dose of adenosine once if there is no response. If no response, diltiazem or beta-blockers can be given as alternatives.
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This question is part of the following fields:
- Cardiovascular System
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Question 135
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:
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 136
Incorrect
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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:
Correct 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 137
Incorrect
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A 65-year-old man was seen at autopsy. He had swollen legs and signs of a transudate fluid at his liver. Before passing away, he was treated for bronchitis and TB. What is the most probable cause of the transudate?
Your Answer:
Correct Answer: Cardiac failure
Explanation:The patient most probably experienced congestive hepatopathy and leg oedema due to right sided cardiac failure.
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This question is part of the following fields:
- Cardiovascular System
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Question 138
Incorrect
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A 69-year-old male, who is a hypertensive and a smoker presented with sudden onset central chest pain radiating to his back. Examination revealed a pulsatile mass in the abdomen. Which of the following is the most appropriate next step?
Your Answer:
Correct Answer: USG
Explanation:The history is suggestive of ruptured Abdominal Aortic Aneurysm (AAA). Characteristic pain, pulsatile abdominal mass and risk factors such as age>60, hypertension and smoking support the diagnosis. Ultrasonography is the standard imaging tool for AAA. It can also detect free peritoneal blood.
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This question is part of the following fields:
- Cardiovascular System
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Question 139
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:
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 140
Incorrect
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A 30-year-old man presents with hypertension and decreased serum potassium levels. Which hormone should be tested in addition in order to establish the diagnosis?
Your Answer:
Correct Answer: Aldosterone
Explanation:High blood pressure and a low level of potassium in the blood indicates hyperaldosteronism. Therefore, aldosterone should be tested immediately to establish the diagnosis. Hyperaldosteronism, is a medical condition wherein too much aldosterone is produced by the adrenal glands, which can lead to lowered levels of potassium in the blood (hypokalaemia) and increased hydrogen ion excretion (alkalosis).
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This question is part of the following fields:
- Cardiovascular System
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Question 141
Incorrect
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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:
Correct 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 142
Incorrect
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A 60-year-old male patient with a history of heavy smoking was admitted complaining of acute severe central chest pain for the past one hour. His blood pressure was 150/90 mmHg and pulse rate was 88 bpm. His peripheral oxygen saturation was 93%. ECG showed ST elevation > 2 mm in lead II, III and aVF. He was given loading doses of aspirin, clopidogrel and atorvastatin and face mask oxygen was given. Which one of the following investigations should be done and then depending on result, definitive treatment can be initiated?
Your Answer:
Correct Answer: None
Explanation:The history and ECG findings are adequate to begin cardiac revascularization of this patient. There is no need for cardiac markers to confirm the diagnosis. Further delay in starting definite treatment is not recommended.
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This question is part of the following fields:
- Cardiovascular System
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Question 143
Incorrect
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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:
Correct 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 144
Incorrect
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A 44-year-old female is admitted to the emergency with dyspnoea, syncope, fever and arthropathy. She was recently diagnosed with pulmonary emboli. Cardiovascular examination reveals an early diastolic sound with a mid diastolic rumble. The JVP is found to be elevated and there are prominent a waves. Which of the following would be the most likely cause of her symptoms?
Your Answer:
Correct Answer: Atrial myxoma
Explanation:Cardiac myxomas are the most common type of primary tumour of the heart. They are usually benign and arise from primary connective tissue. Most cardiac myxomas arise sporadically; however, 10% are hereditary (following an autosomal dominant pattern). Even though they may develop in any chamber of the heart, most (+-75 %) cardiac myxomas arise in the left atrium, usually from the interatrial septum, while the rest occur in the right atrium (ventricular myxomas are rare). Clinical features are primarily caused by obstruction of the blood flow through the heart and include dyspnoea on exertion, palpitations, syncope, weight loss, or even sudden death. Rarely, life-threatening conditions (e.g., stroke) may result from an embolization from the myxoma. Typical examination findings include abnormal heart sounds, such as a rumbling diastolic murmur over the apex or a characteristic tumour plop.
The diagnosis is not easily established clinically because of the nonspecific nature of symptoms. Echocardiography is the diagnostic procedure of choice. Surgical resection of the tumour is the curative treatment of choice. The prognosis is usually favourable, but tumours can recur after inadequate resection. -
This question is part of the following fields:
- Cardiovascular System
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Question 145
Incorrect
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A 57-year-old female presented to the cardiology centre with a history of chest tightness for a few hours, accompanied by pain radiating to the left side of the shoulder and neck. ECG was normal. What is the next best investigation for this patient?
Your Answer:
Correct 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 146
Incorrect
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A 32-year-old male who was on methadone has suddenly collapsed while running and was found dead. What is the most likely cause for his death?
Your Answer:
Correct Answer: Prolonged QT
Explanation:Methadone and cocaine can cause QT prolongation through the direct effects on the resting membrane potential. Methadone can increase QT dispersion in addition to QT interval. Methadone inhibits the Human Ether-a-go-go Related Gene (hERG) and causes QTc prolongation and development of Torsades de point. Brugada-like syndrome is another condition found in methadone users which predisposes the users to life-threatening ventricular tachycardia and sudden cardiac death.
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This question is part of the following fields:
- Cardiovascular System
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Question 147
Incorrect
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A 42-year-old female presented with pain in her calves during walking which settled after resting. On examination there were orange colour deposits in the her palmar creases. Her fasting lipid profile showed a total cholesterol of 9.2 mmol/l (<5) and triglycerides of 7.0 mmol/l (<2). Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Type III hyperlipidaemia
Explanation:Palmar xanthomas are found in type III hyperlipoproteinemia. Her total cholesterol level and triglyceride level support the diagnosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 148
Incorrect
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A 54-year-old female presents with shortness of breath that has been going on for the last 10 months. Physical examination shows that she has an irregularly irregular pulse and a loud P2 with fixed splitting accompanied by a systolic ejection murmur in the 2nd left intercostal space. Which of the following would be the most likely diagnosis?
Your Answer:
Correct Answer: Atrial septal defect (ASD)
Explanation:Atrial septal defect (ASD) is one of the more commonly recognized congenital cardiac anomalies presenting in adulthood. ASD is characterized by a defect in the interatrial septum allowing pulmonary venous return from the left atrium to pass directly to the right atrium. Depending on the size of the defect, size of the shunt, and associated anomalies, this can result in a spectrum of disease ranging from no significant cardiac sequelae to right-sided volume overload, pulmonary arterial hypertension, and even atrial arrhythmias.
With the routine use of echocardiography, the detection and, therefore, the incidence of ASD is increased compared to earlier incidence studies using catheterization, surgery, or autopsy for diagnosis. The subtle physical examination findings and often minimal symptoms during the first 2-3 decades of life contribute to a delay in diagnosis until adulthood, the majority (more than 70%) of which is detected by the fifth decade of life.
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This question is part of the following fields:
- Cardiovascular System
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Question 149
Incorrect
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A 68-year-old male with history of poorly controlled hypertension was admitted with shortness of breath on exertion, orthopnoea for three months. He was diagnosed with congestive cardiac failure and was started on digoxin 62.5 μg daily, furosemide 80 mg daily and amiloride 10 mg daily. On admission his lab results showed that his serum urea was 6 mmol/L and serum creatinine was 115 μmol/L. One month later he came for a follow up consultation. On examination he had bilateral ankle oedema. His blood pressure was 138/90 mmHg and pulse rate was 92 bpm. His JVP was not elevated. His apex beat was displaced laterally and he had a few bibasal crepitations on auscultation. There were no cardiac murmurs. His investigation results revealed the following:
Serum sodium 143 mmol/L (137-144)
Serum potassium 3.5 mmol/L (3.5-4.9)
Serum urea 8 mmol/L (2.5-7.5)
Serum creatinine 140 μmol/L (60-110)
Serum digoxin 0.7 ng/mL (1.0-2.0)
CXR showed cardiomegaly and a calcified aorta. ECG showed left ventricular hypertrophy.
Which of the following is the most appropriate next step in the management of this patient?Your Answer:
Correct Answer: Add an ACE inhibitor to the current regimen
Explanation:From the given history the patient has NYHA grade III heart failure. He can be safely started on an ACE inhibitor as his serum potassium was towards the lower limit. As there an impairment of renal function, his urea, creatinine and serum electrolytes should be closely monitored after commencing an ACE inhibitor. Adding atenolol will not have any clinical benefit. Increasing the digoxin dose is not needed as the patient is in sinus rhythm. Increasing furosemide will only have symptomatic relief.
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This question is part of the following fields:
- Cardiovascular System
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Question 150
Incorrect
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A 75-year-old female has developed recurrent breathlessness after having a mitral valve replacement 13 years ago. Her husband has also noticed a prominent pulsation in her neck. She has also complained of ankle swelling and pain in the abdomen. Choose the most probable diagnosis from the list of options.
Your Answer:
Correct Answer: Tricuspid regurgitation
Explanation:Multiple symptoms point towards tricuspid regurgitation: recurrent breathlessness (if the cause if LV dysfunction); a prominent pulsation in her neck (giant V waves); pain in the abdomen (pain in liver upon exertion); and ankle swelling.
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This question is part of the following fields:
- Cardiovascular System
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Question 151
Incorrect
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A 35-year-old previously well male gives a history of on-and-off retrosternal heaviness during exertion, relieved by resting. Pain lasts about 20-25 minutes. What is the clinical diagnosis of this presentation?
Your Answer:
Correct Answer: Stable angina
Explanation:The history is suggestive of stable angina because of it’s duration, aggravating and relieving factors. Patients get retrosternal pain or discomfort which sometimes radiates to jaw or left axilla during a period of increased myocardial demand. Pain relieves during resting when myocardial demand meets supply.
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This question is part of the following fields:
- Cardiovascular System
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Question 152
Incorrect
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A 60-year-old male has complained of a recent onset of postural syncope, impotence, diarrhoea, and profuse sweating. He also has diabetes. In this patient, what is the most likely cause of syncope?
Your Answer:
Correct Answer: Autonomic neuropathy
Explanation:Due to the symptoms, a diabetic autonomic neuropathy should be a suspect as a cause for the syncope. Unless associated with atrial fibrillation, mitral regurgitation is not usually expected to cause syncope. PAF can sometimes present with palpitations and a feeling of light-headedness followed by syncope, but is not always the case.
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This question is part of the following fields:
- Cardiovascular System
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Question 153
Incorrect
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A 50-year-old patient was admitted to the hospital for elective herniorrhaphy. Which of the following options will lead to a postponement of his operation?
Your Answer:
Correct Answer: Myocardial infarction two months ago
Explanation:Patients with a recent cerebrovascular incident (less than 60 days) are at very high risk of cardiac complications when under general anaesthesia. Complications like MI, heart failure and even death. Elective surgery should be postponed till stabilization of the cardiac condition is achieved.
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This question is part of the following fields:
- Cardiovascular System
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Question 154
Incorrect
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A 45-year-old smoker presented with sudden onset of chest pain radiating to his left arm, with associated sweating. ECG showed ST elevation in leads I, aVL and V1-V4. The most likely diagnosis would be?
Your Answer:
Correct Answer: Anterior MI
Explanation:An anterior wall myocardial infarction is characterised by ST elevation in leads I, aVL and V1-V5.
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This question is part of the following fields:
- Cardiovascular System
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Question 155
Incorrect
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A 59-year-old man complains of weakness in his right lower and upper limb since 3 for a few hours. He is has been taking Digoxin for 2 years. What is the most definitive investigation for this condition?
Your Answer:
Correct Answer: Angiography
Explanation:Digoxin is a cardiac glycoside, having positive inotropic effects on the heart. It increases the strength of contractility of the heart, increasing the heart rate, but lowering blood pressure. This patient developed weakness in his limbs most likely caused by extremely low blood pressure that could be due to diseased blood vessels reacting to the side-effects of digoxin, therefore an angiography would be the best investigation.
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This question is part of the following fields:
- Cardiovascular System
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Question 156
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:
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 157
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:
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 158
Incorrect
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A 54-year-old heavy smoker presented with acute chest pain for 3 hrs which associated with excessive sweating and vomiting. His past medical history was unremarkable but his father has passed away due to a heart attack at the age of 50. Examination findings were normal and ECG was also normal. He was pain free after 12 hours from admission. What is the most appropriate investigation that can be done at this moment?
Your Answer:
Correct Answer: Troponin T
Explanation:The positive family history and the smoking make him an ideal candidate for a myocardial infarction. The chest pain is also a suggestive symptom. So troponin is needed to rule out MI.
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This question is part of the following fields:
- Cardiovascular System
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Question 159
Incorrect
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A 8-year-old girl with suspected patent foramen ovale, presented with her parents for the confirmation of the diagnosis. Which of the following is the best investigation to confirm the diagnosis?
Your Answer:
Correct Answer: Transoesophageal Echocardiography
Explanation:A 3-dimensional transoesophageal echocardiography (3D TEE) provides direct visualization of the entire PFO anatomy and surrounding structures. It allows more accurate diagnosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 160
Incorrect
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A 35-year-old female with systemic lupus erythematosus (SLE) was brought to Casualty, complaining of chest pain and worsening difficulty in breathing for the past 36 hrs. On examination she was tachypnoeic, her BP was 85/65 mmHg and peripheral oxygen saturation was 98% on air. Her cardiac examination was normal but her jugular venous pressure was elevated. She didn't have ankle oedema. Her ECG showed sinus tachycardia and her CXR showed clear lung fields with a slightly enlarged heart. Which of the following is the most appropriate next step?
Your Answer:
Correct Answer: Urgent transthoracic echocardiogram
Explanation:Acute breathlessness in SLE can be due to a pericardial effusion or a pulmonary embolism. Normal peripheral oxygen saturation and normal ECG, make the diagnosis of pulmonary embolism less likely. To exclude pericardial effusion, an urgent transthoracic echocardiogram is needed.
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This question is part of the following fields:
- Cardiovascular System
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SESSION STATS - PERFORMANCE PER SPECIALTY
