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Question 1
Correct
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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: 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 2
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: Bisoprolol
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 3
Correct
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A 30-year-old male presented with palpitations for 1 week. The palpitations were intermittent and lasted a few hours per day. Which of the following is the most appropriate management?
Your Answer: 24 hr ECG
Explanation:Palpitations can be due to many reasons. As palpitations are not constant in this case, a 24 hr ECG is important to isolate these episodes and find any cardiac cause. Drugs depend on the cause for the palpitations.
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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 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: Dressler's syndrome
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 5
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 6
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 7
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 8
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 9
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 10
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 11
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 12
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 13
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 14
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 15
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 16
Incorrect
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A 48-year-old male presented with exertional angina for 2 weeks. He has no significant past medical history or cardiac risk factors except a total cholesterol of 5.8 mmol/L. He has been already started on aspirin. Which of the following is the most suitable drug combination for him?
Your Answer:
Correct Answer: B-blocker and statin
Explanation:Beta blockers and calcium channel blockers have proven prognostic benefits. Nitrates don’t have any proven prognostic benefits. A statin is indicated for a patient with angina and cholesterol level of 5.5 to 8.5 to prevent risk of myocardial infarction. So the preferred combination from the given answers is beta blocker + statin.
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This question is part of the following fields:
- Cardiovascular System
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Question 17
Incorrect
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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 18
Incorrect
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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 19
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 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 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 22
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 23
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 24
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 25
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 26
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 27
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 28
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 29
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 30
Incorrect
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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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SESSION STATS - PERFORMANCE PER SPECIALTY
