-
Question 1
Correct
-
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: 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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 2
Correct
-
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: 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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 3
Correct
-
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: 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
-
-
Question 4
Correct
-
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: 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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 5
Incorrect
-
Which of the following is not an indication for an implantable cardiac defibrillator?
Your Answer: Previous myocardial infarction with non-sustained VT on 24 hr monitoring
Correct Answer: Wolff-Parkinson White syndrome
Explanation:Class I indications (i.e., the benefit greatly outweighs the risk, and the treatment should be administered): -Structural heart disease, sustained VT
-Syncope of undetermined origin, inducible VT or VF at electrophysiologic study (EPS)
-Left ventricular ejection fraction (LVEF) ≤35% due to prior MI, at least 40 days post-MI, NYHA class II or III
-LVEF ≤35%, NYHA class II or III
-LVEF ≤30% due to prior MI, at least 40 days post-MI
-LVEF ≤40% due to prior MI, inducible VT or VF at EPSClass IIa indications (i.e., the benefit outweighs the risk and it is reasonable to administer the treatment):
-Unexplained syncope, significant LV dysfunction, nonischaemic cardiomyopathy
-Sustained VT, normal or near-normal ventricular function
-Hypertrophic cardiomyopathy with 1 or more major risk factors
-Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) with 1 or more risk factors for sudden cardiac death (SCD)
-Long QT syndrome, syncope or VT while receiving beta-blockers
-Nonhospitalized patients awaiting heart transplant
-Brugada syndrome, syncope or VT
-Catecholaminergic polymorphic VT, syncope or VT while receiving beta-blockers
-Cardiac sarcoidosis, giant cell myocarditis, or Chagas disease -
This question is part of the following fields:
- Cardiovascular System
-
-
Question 6
Correct
-
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: 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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 7
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: Electrocardiogram
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 8
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 9
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
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 10
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 11
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 12
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).
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 13
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 14
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 15
Incorrect
-
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
-
Right atrium
71
6
Right ventricle
72
-
Pulmonary artery
86
53/13
PCWP
-
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 16
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 17
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 18
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 19
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 20
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 21
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 22
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 23
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 24
Incorrect
-
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
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 25
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 26
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 27
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 28
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
-
-
Question 29
Incorrect
-
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.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 30
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
-
This question is part of the following fields:
- Cardiovascular System
-
SESSION STATS - PERFORMANCE PER SPECIALTY
