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www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital20122
CardiologyQ001:A60yearmanwhoistype2diabeticisadmittedwithchestpain.HisECGsshowinferiorST elevation of 1 mm in 2 leads. He is thrombolysed with steptokinase. His BMmeasurementis15,andhasmissedhisgliclazidedosetoday.Whatisthebestmanagement?
A.ContinuewithgliclazideB.PRNactrapidtokeeptheBMscontrolledC.IvslidingscaleinsulinD.CommencemetforminE.IgnoretheBMsandfocusonhiscardiacside
Answer:c)ivslidingscaleinsulin.TheDIGAMI study compared "conventional"antidiabetic therapy to intensive insulintherapyconsistingofacuteinsulininfusionduringtheearlyhoursofMIandthricedailysubcutaneousinsulininjectionfortheremainderofthehospitalstayandaminimumof3monthsthereafter.Forpatientswithinsulinandbetterglycaemiccontrol,mortalityofpatientsweredecreasedatoneyear.
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital20123
CardiologyQ002:A 55 year old patient presentedwith breathlessness and ankle oedema. The bloodpressureis135/80mmHg.Onexamination,herJVPriseswithinspiration.Shehasasoftsystolicmurmurandathirdheartsound.BloodtestsrevealaHb10.5g/dl,WCC7.5x10^9/l,Platelets150x10^9/l,sodium136mmol/l,potassium3.5mmol/l,creatinine140mol/l,urea6mol/l.ECGshowspoorRwaveprogression.Anechocardiogramshowsnopericardialeffusion,theventriclesarestiffandsystolicfunctionismildlyimpaired.Whichofthefollowingisthelikelydiagnosis?
A.RestrictivecardiomyopathyB.DilatedcardiomyopathyC.ConstrictivepericarditisD.IschaemiccardiomyopathyE.Pulmonaryembolus
Answer:a)restrictivecardiomyopathy.Inthisscenario,thesymptomscanbecausedbyanyformofcardiomyopathy.TheriseinJVPwithinspirationsuggestseitherconstrictiveorrestrictivecardiomyopathy.Echocardiography show ing no pericardial effusion and stiffness suggests restrictiverather than constrictive cardiomyopathy. The transmitral dopplers on the echomayshowE/Awavereversalandhighvelocitieswhichmaysuggestrestrictivepicture.This may be due to infiltration due to haemochromatosis, endomyocardial fibrosis,sarcoidosis,myeloma,lymphomaorconnectivetissuedisease.
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital20124
CardiologyQ003:A40yearoldpatienthadamitralvalvereplacement formitralstenosis1monthago.Shepresentswithfevers,lethargyandrigor.HerbloodtestsrevealHb9.5g/dl,WCC13x10^9/l,platelets500x10^9/l,sodium136mmol/l,potassium4.2mmol/l,ESR90mm/hr,CRP180mg/l.Shealsohas2splinterhaemorrhagesand2+ofbloodonurinedipstick.3setsofbloodculturesaretaken.Whichofthefollowingorganismsismostlikelytobegrowninthebloodcultures?
A.EcoliB.ListeriamonocytogenesC.haemolyticGroupAstreptococcusD.KlebsiellaE.Staphylococcusepidermidis
Answer:e)staphylococcusepidermidis.Inapatientwithprostheticvalve,causescanbedivided intoearly (within60daysofsurgery)andlatestages.Earlyprostheticvalveendocarditis isusuallytheresultofperioperativecontamination.Causativeorganisms includeStaphylococcusepidermidis (30%),Staphylococcusaureus(20%),andgramnegativeaerobes(20%).Late prosthetic valve endocarditis is usually the result of bacteremia from dental orgenitourinarysources,GIsurgery,or intravenousdrugabuse.Thecausativeorganismsare similar to those causing native valve endocarditis. These include Streptococcusviridans(30%),Sepidermidis(30%)andSaureus(12%).
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital20125
CardiologyQ004:A 65 year old lady has ischaemic cardiomyopathy and symptoms of breathlessnesswalking up one flight of steps. Her breath sounds are clear. Chest X ray showscardiomegaly and clear lung fields. She is currently on frusemide 40mg bd andperindopril4mgatnight.Whatmedicationshouldbeadded?
A.SpironolactoneB.CarvedilolC.DigoxinD.AmiodaroneE.Diltiazem
Answer:b)carvedilol.The twobestoptionsarecarvedilolandspironolactone.BothBblocker trials (CIBIS II,Merit HF, Copernicus) and spironolactone trials (RALES) have shown symptomaticimprovementanddecreasedmortality.Inthispatientwithlittlesignsoffluidoverload,abetablockercanbestartedfirst,andthenspironolactoneaddedaswell.
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital20126
CardiologyQ005:A55yearoldmanhasprogressiveshortnessofbreathandankleoedema.HehascomefromAfricaoriginallyandgivesahistoryofprobablytuberculosismanyyearsago.On examination,hehas abloodpressureof105/55mmHg, raised JVP+6 cmwith arapidydescentandsignificantankleoedema.Whatisthelikelydiagnosis?
A.CardiactamponadeB.AorticregurgitationC.RestrictivecardiomyopathyD.PericardialconstrictionE.Leftventricularimpairmentcausingheartfailure
Answer:D)pericardialconstriction.Thesignsofpericardialconstriction/constrictivepericarditisarerapidydescent,raisedJVPandKussmaulssign.The ydescent isoftenblunted in cardiac tamponade.A further clue is thehistoryoftuberculosiswhichpredisposestoconstrictivepericarditis.
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital20127
CardiologyQ006:A75yearoldmanhasbecomeprogressivelymorebreathless.Onexaminationhehasadisplaced cardiac apex and a third heart sound. Chest XR confirms cardiomegaly.AnechocardiogramshowsLeftventriclesizeof6.5cm (
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital20128
CardiologyQ007:A50yearoldmanhassufferedanuncomplicatedmyocardialinfarct3daysagoandatthemomenthehasnoproblems.Heisatouristandwishestotravelbackhomeassoonaspossible.How soon after an uncomplicated myocardial infarct may a patient travel by flightsafely?
A.3daysB.14daysC.4weeksD.2monthsE.3months
Answer:b)14days.Apatient shouldbe fit to fly14daysafteranuncomplicatedmyocardial infarct,afternormalactivitieshavebeenresumed.ForcomplicatedMIs,thepatienthastowaituntilsymptoms stabilise. Coronary artery bypass graft and other chest surgery recommended wait about 2 weeks so that any air introduced into chest will havebecomeabsorbed.
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital20129
CardiologyQ008:A65yearoldmanhasanangioplastytotheleftanteriordescendingartery.Inconsideringmedicaltherapy,whichofthefollowingreducesrestenosisratesfollowingangioplasty?
A.AngiotensinconvertingenzymeinhibitorsB.AbciximabC.BetablockersD.LowmolecularweightheparinE.Pravastatin
Answer:b)Abciximab.There is some data to suggest that the use of the antiplatelet glycoprotein IIb/IIIareceptor blocker (abciximab)may reduce the risk or restenosis in both diabetic andnondiabeticpatients.
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201210
CardiologyQ009:A50yearoldmanpresentswithpalpitations.HisECGshowsAVdissociation.WhichofthefollowingconditionsismostlikelytocauseAVdissociationonanECG?
A.1stdegreeAVblockB.AtrialflutterC.MobitztypeIIblockD.WenkebachE.Completeheartblock
Answer:e)Completeheartblock.Complete(3rddegree)heartblockandventriculartachycardiaaremost likelytocauseAVdissociationonanECG.
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201211
CardiologyQ010:A60yearoldmanhaspalpitations.AnadmissionECGshowsQTcprolongationof0.48s.Whichofthefollowingconditionsmightbeassociated?
A.DigitalisB.HyponatraemiaC.HyperthermiaD.HypocalcaemiaE.Hyperkalaemia
Answer:d)Hypocalcaemia.Hypokalaemia, hypocalcaemia , hypomagnesaemia and hypothermia can causeprolonged QT interval on the ECG. Prolonged QT is classified as a QTc interval(corrected)ofmorethan0.44seconds.
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201212
CardiologyQ011:A45yearoldmanhaschestpainwalkinguphills.Whichofthefollowinginvestigationsisthebestforriskstratificationofangina?
A.ECGB.TroponinTC.EchocardiogramD.CoronaryangiogramE.Thalliummyocardialperfusionscan
Answer:b)troponinT.The high risk factors are positive troponin and dynamic ST depression on ECGwithangina.Thoseinthehighriskgroupshouldbereferredforurgentcoronaryangiography.
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201213
CardiologyQ012:A65yearoldmanhaspalpitations.HehasabroadcomplextachycardiaontheECG.Inabroadcomplextachycardia.WhichofthefollowingwouldbethestrongestindicationtowardsadiagnosisofVT?
A.DiscordantQRScomplexesinthechestleadsB.ExtremerightaxisdeviationC.HemodynamicinstabilityD.TrifascicularblockonECGE.Cannonawaves
Answer:e)Cannonawaves.Any evidence of AV dissociation such as cannon a waves effectively rules out asupraventricular tachycardia. Features suggestive ofVT, rather than SVTwith bundlebranchblockare:
cannonawavesonJVPfusionand/orcapturebeatsLeftaxisdeviationQRSduration>140msecconcordanceoftheQRScomplexesinthechestleadshistoryofischaemicheartdisease
www
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www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201215
CardiologyQ014:A 75 lady was found to have Atrial Fibrillation on her ECG. She has a history ofhypertension.Theratewas85minandBPwas140/85mmHg.Whatmanagementshouldbeconsiderednext?
A.DigoxinB.AspirinC.WarfarinD.DCcardioversionE.Atenolol
Answer:C)Warfarin.Thepatientsheartrate isnotfast.Shescores2ontheCHADS65score(she isaboveage65andshehashypertension)thereisasignificantbenefitinformalanticoagulationwithwarfarininviewoftheriskofthromboembolism
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201216
CardiologyQ015:A30yearoldpatientcomplainsofdizzyspells.Uponadmission,hehasanECGwhichshowsaPRintervalof0.6sandQTintervalof0.5s.Whichoneofthefollowingmedicationscouldberesponsible?
A.AspirinB.AmoxycillinC.TerfenadineD.DigoxinE.Acetazolamide
Answer:c)terfenadine.AQT interval of >0.45 is prolonged.Common drugs are tricyclic antidepressants (eg.amitryptiline),quinidine,erythromycin,amiodarone,phenothiazines(chlorpropramide),antihistamines(terfenadine)andgrapefruitjuice.
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201217
CardiologyQ016:A65yearoldmanwithdiabetesmellitushasabloodpressureof190/90mmHg.Clinicalexaminationwasnormal.AnECGrevealsevidenceofleftventricularhypertrophy.Whichoneofthefollowingdrugsappropriatetreatmentforhypertension?
A.SodiumnitroprussideB.LabetalolC.AtenololD.DoxazosinE.Bendrofluazide
Answer:e)Bendrofluazide.TheBritishHypertensiveSocietyguidelineswouldsuggesteitheraDiureticorCalciumchannel blocker [C or D for older or black patient]. Although ACE inhibitor isrecommended for diabetic patients, this is not among the options, hence the bestchoiceisthediuretic(D).
www
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www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201220
CardiologyQ019:A50yearoldwomanwithpreviousrheumaticheartdiseasehasbeenlosttofollowupfor some time.Shenowhas symptomsofbreathlessness.Onexamination, shehasatappingapexbeat,diastolicmurmurandalargeVwaveintheJVP.Whatisthelikelydiagnosis?
A.IsolatedmitralstenosisB.MixedmitralvalvediseaseC.MitralstenosisandtricuspidregurgitationD.CardiactamponadeE.Aorticregurgitation
Answer:C)mitralstenosisandtricuspidregurgitation.Rheumatic fever has predisposed the patient tow ardsmitral stenosis,whichwouldmanifestassignsofalowrumblingdiastolicmurmurandatappingapexbeat.ThelargeVwave in the JVP suggests tricuspid regurgitationwhich is secondary to pulmonaryhypertension(alsomayhavealoudsecondheartsoundandarightventricularheave).
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201221
CardiologyQ020:A33yearoldmanpresentswithchestpainsandfatigueforseveraldays.Hisobservationsshowa temperatureof38C,pulse100bpm,BP100/70mmHg.ECGshows Twave inversion in the anterior and inferior leads. The troponin I is 3 ng/mL(
www
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www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201223
CardiologyQ022:A 40 year oldman presented because he is concerned about his family history ofhypertrophicobstructivecardiomyopathy.Hisbrotherhasrecentlydeceasedfromduetothecondition.Whatinvestigationshouldbeoffered?
A.TransthoracicechocardiogramB.TransoesophagealechocardiogramC.ElectrophysiologicalstudyD.CoronaryangiogramE.Cardiacthalliumscan
Answer:A)transthoracicechocardiogram.RelativesofpatientswithHOCMshouldbeofferedscreeningespeciallyinthecontextofa fatality. The best form is transthoracic echocardiogram, and beyond that genetictestingmaybehelpful.
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201224
CardiologyQ023:A42yearwomanwhohasreceivedradioactiveiodinemanyyearsagohasroutinebloodtests.Shedoesnothaveanysymptomssuggestiveofangina.Herresultsreveal:
FreeThyroxine10.2pmol/l(9.823)TSH13mU/l(0.54.5mU/l)Totalcholesterol7.8mmol/l(
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201225
CardiologyQ024:A65yearoldmanhassymptomsofbreathlessnessandchestpains.Hehascardiacriskfactorsof smoking andelevated cholesterol.Onexamination,hehas aharsh systolicmurmurandquietsecondheartsoundconsistentwithaorticstenosis.Echocardiographyrevealsagradientof75mmHgacrosstheaorticvalve.Whichofthefollowingisthemostusefulinvestigation?
A.TransoesophagealechocardiographyB.CoronaryangiographyC.RightheartcardiaccatheterD.CardiacelectrophysiologicalstudyE.CTpulmonaryangiogram
Answer:B)Coronaryangiography.Thediagnosisissevereaorticstenosiswithsignificantclinicalsymptoms.Thepatientislikely torequiresurgicalaorticvalvereplacement.Alongwith therisk factors, there ishigh risk of coronary artery disease. Coronary angiography should be the nextinvestigationtoinvestigatewhethercoronarybypassgraftsarenecessaryaswell.
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201226
CardiologyQ025:A65yearoldmanhadamyocardialinfarction2monthsago.HehashadastentplacedintheLADarteryfollowingangioplasy.DuringaroutinefollowupExerciseTesthehasa15beatrunofnonsustainedVT.ThenonsustainedVToccurredhalfwaythroughStage2.Whatisthenextdefinitiveinvestigation?
A.ThalliumscanB.CardiacelectrophysiologicalstudyC.EchocardiogramD.24hourtaperecordingE.Repeatcoronaryangiography
Answer:b)Cardiacelectrophysiologicalstudy.PostMIVTismostcommonlydueventricularscartissue.ThispatienthashadcoronaryrevascularisationandstillhassignificantrunsofVT.HenceanelectrophysiologicalstudytoattempttostimulateVTisnecessary.IfthestudydemonstratedVT,thenthepatientshouldhaveandefibrillator(ICD)inserted[MADITtrial,AmJCardiol1997;79:167].
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201227
CardiologyQ026:A55yearoldmanhaspalpitationsandbroadcomplextachycardiaontheECG.Inabroadcomplex tachycardia,whichof the followingsuggestsadiagnosisofsupraventriculartachycardia(SVT)?
A.CannonawavesB.TerminationwithadenosineC.QRSduration>140msecD.FusionbeatsE.ConcordanceofVleads
Answer:b)Terminationwithadenosine.FeatureswhichfavourofVTinclude:
evidenceofAVdissociation(cannonawavesonJVP)fusionand/orcapturebeatsleftaxisdeviation(between90and180degree)QRSduration>140msecconcordanceofVleads(monophasicQRS)
FeatureswhichfavorofSVT:LongshortcyclesequenceSlowingorterminationbyincreasingvagaltoneorwithadenosineTrileafedQRSinV1RPinterval
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201228
CardiologyQ027:A 70 year old man has a history of progressive tiredness and breathlessness. Onexaminationthere ispallor,hispulserate is65beatsperminute,and isslowrising innature.TheJVPisnotelevated.Hisapexbeat isatthe5th left intercostalspacemidclavicular lineand it isheaving innature.Thereisasystolicthrillintherightsternaledgeandthereisasystolicmurmurintheaorticarearadiatingtotheneck.Investigationsreveal:
Hb8.0g/dlMCV70fL.
Uponfurtherinvestigationofthispatientsanaemiathemostusefultestwouldbe:
A.CapsuleendoscopyB.BariumswallowC.ColonoscopyD.CTpneumocolonE.Flexiblesigmoidoscopy
Answer:c)Colonoscopy.Thepatienthasfeaturesofaorticstenosisand irondeficiencyanaemia.Aorticstenosismaybeassociatedwithangiodysplasiaofthecolonandthebesttesttoelucidatethisiscolonoscopy.
www
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www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201230
CardiologyQ029:A50yearoldmanpresentswithbroadcomplextachycardia.HehasaBPof100/70anda pulse rate of 170. The duty medical registrar is considering administration ofantiarrhythmics.Whichoneofthefollowingmedicationsiscontraindicatedinthispatient?
A.MagnesiumB.AmiodaroneC.VerapamilD.ProcainamideE.Lignocaine
Answer:c)verapamil.Thepatient is likely tohave ventricular tachycardia in viewof the very fast rate andbroadcomplexes.AllareusefulagentswhichcanbeusedinconjunctioncautiouslyforVTexceptforVerapamil.Verapamil is contraindicated in VT because it can cause the blood pressure to dropdrasticallyduetonegativeionotropicaction.
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201231
CardiologyQ030:A65yearoldmanhasasystolicmurmurintheaorticarea.Inassessinghim,whichofthefollowingisaclinicalfeatureofsevereaorticstenosis?
A.LoudmurmurB.SlowrisingpulseC.EnlargedleftatriumD.PalpableapexbeatE.Earlydiastolicmurmur
Answer:b)slowrisingpulse.Theclinicalsignsconsistentwithsevereaorticstenosisare:
Slowrisingpulsecharacter4thheartsoundSoftaortic2ndheartsoundSystolicthrillExtendedlengthofmurmurinsystole
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201232
CardiologyQ031:A 60 year old man has had previous myocardial infarction. He has symptoms ofbreathlessnessconsistentwithNYHAclass IIIheartfailure.EchocardiographyshowsanLVejectionfractionof35%.Whichofthefollowingcombinationsofmedicationismostappropriate?
A.ACEinhibitor,blocker,angiotensinIIblockerB.ACEinhibitor,blocker,aldosteroneantagonistC.ACEinhibitor,loopdiureticD.blocker,angiotensinIIblockerE.ACEinhibitor,blocker,statin
Answer:b)ACEinhibitor,blocker,aldosteroneantagonist.Of all the combinations, ACE inhibitor / angiotensin II blocker with blocker andaldosteroneantagonist(spironolactone,eplerenone) isthemostappropriategiventhefact that this patient has symptomatic heart failure. Trials have shown that thesemedicationshaveamortalityandalsosymptomaticbenefit.
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201233
CardiologyQ032:A45 yearoldCaucasianmanhashypertension.Hehasabloodpressure consistentlyabove160/90mmHg.Hedoesnothavesignsofmalignanthypertensionorrenalfailure.Whichofthefollowingisthemostappropriateantihypertensive?
A.DiltiazemB.MethyldopaC.SodiumnitroprussideD.LisinoprilE.Bendrofluazide
Answer:D)Lisinopril.AccordingtotheBritishHypertensionSocietyguidelines,apatientwhoisnonblackandunder55yearsofageshouldbeconsideredforanACEinhibitororBetablocker.InthiscasetheACEIlisinoprilisthebestchoice.
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Dr.KhalidYusufElzohrySohagTeachingHospital201234
CardiologyQ033:A32yearold ladycomplainsofperiodicepisodesofpalpitationsand lightheadednessfor about 2030minutes. It occurred once a week for the last few weeks. An ECGshowednormalsinusrhythm.Whatistheinvestigationofchoice?
A.24hrholtermonitoringB.EchoC.ExercisetestsD.PatientcontrolledLooprecorderE.Electrophysiologicalstudy
Answer:D)PatientcontrolledLooprecorderThe frequency of the symptoms is low , hence a 24 hour tapemay not capture anarrhythmia.Apatientcontrolled looprecorderallowsrecordingofrhythmsaroundthetimeoftheevent,henceamuchhigherlikelihoodofrecordinganabnormalrhythm.
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Dr.KhalidYusufElzohrySohagTeachingHospital201235
CardiologyQ034:A 61 year old man with a previous history of myocardial infarction, presents withrecurrent loss of consciousness. On examination therewere signs of left ventricularaneurysm.BPwas110/70mmHgandpulseratewas90/min.CTheadwasnormal.Whatisthecauseoflossofconsciousness?
A.VasovagalsyncopeB.PulmonaryembolismC.StrokeD.VentriculartachycardiaE.Hypersensitivecarotidsyndrome
Answer:D)VentriculartachycardiaA patient with ischaemic heart disease and ventricular aneurysm is at high risk ofdevelopingventriculararrhythmias.Thiscancertainlyleadtothelossofconsciousness.
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Dr.KhalidYusufElzohrySohagTeachingHospital201236
CardiologyQ035:A50yearoldmanhasreversedsplittingofthesecondheartsoundonexamination.Whichofthefollowingconditionsisthisseenin?
A.AtrialseptaldefectB.PulmonaryregurgitatoinC.MildaorticstenosisD.LeftbundlebranchblockE.Ventricularseptaldefect
Answer:d)Leftbundlebranchblock.ReversedsplittingoccurswithreversalofthenormalA2P2pattern.ThusA2maybedelayedaswithsevereaorticstenosis,andleftbundlebranchblock(LBBB).P2mayalsobe early withWolffParkinsonWhite type B and Persistent ductus arteriosus. Atrialseptaldefectsshowwidefixedsplitting,andrightbundlebranchblock(RBBB)haswidesplitting.
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Dr.KhalidYusufElzohrySohagTeachingHospital201237
CardiologyQ036:With regard to the conducting system of the heart, where are the Purkinje fibressituated?
A.AtthesuperiorportionofthemyocardiumB.InthemiddleofthemyocardiumC.SubendocardialD.TransmuralE.Subepicardial
Answer:c)Subendocardial.ThePurkinjefibresruninasubendocardialposition.Thisresultsindepolarisationoftheheartfromtheendocardiumtotheepicardium.
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www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201240
CardiologyQ039:A50yearoldmanwhohadanangioplastyasksaboutClopidogrel.WhatisClopidogrel'smodeofaction?
A.ADPreceptorantagonistB.AffectsAPTTC.InhibitscyclooxygenaseD.HydroxymethylCoenzymeAinhibitorE.GlycoproteinIIb/IIIainhibitor
Answer:a)anADPreceptorantagonist.Clopidogrelpreventsplateletaggregation throughantagonismof theADP receptoronplatelets.
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Dr.KhalidYusufElzohrySohagTeachingHospital201241
CardiologyQ040:A 55 year oldmanwith breathlessness presents toA&E.On examination, he has aninspiratorysystolicfallinarterialpressureof10mmHg.Whichoneofthefollowingismostlikelytobeassociated?
A.MyocardialinfarctionB.PulmonarystenosisC.CardiactamponadeD.PneumoniaE.Myocarditis
Answer:c)cardiactamponade.Pulsus paradoxus is most commonly related to cardiac tamponade. The y descent(diastolic)phase isabsent intamponade.Pulsusparadoxus isdefinedasan inspiratorysystolicfallinarterialpressureof10mmHg.Itnotonlyoccursincardiactamponade,butalsoinmassivePE,severeCOPDandhypotension/shock.
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Dr.KhalidYusufElzohrySohagTeachingHospital201242
CardiologyQ041:A 70 year oldmanwith complete heart block has had a VVI permanent pacemakerimplantedaweekago.WhatistheECGlikelytoshownow?
A.ProminentpwavesB.DeltawavesC.STdepressionD.ProlongedPRintervalE.LBBB
Answer:e)LBBB.Permanentpacing can be single chamber atrial (e.g.AAI), single chamber ventricular(e.g.VVI)ordualchamber(e.g.DDD).AVVIpacemakerwouldmeanthatthepacingleadisplacedintherightventricle,causingaLBBBpattern.
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Dr.KhalidYusufElzohrySohagTeachingHospital201243
CardiologyQ042:A27yearoldmanpresentswith lethargy,poorexercisetoleranceandweight loss.Onexaminationhelooksveryslimandhasapulserateof120beatsperminuteregular.Thepulsevolumedecreasesduringinspiration.HisJVP iselevated5cmsandthe level increasesduring inspiration.Onauscultationofthe heart sounds an early diastolic sound is audible at the left sternal edge. Onexaminationoftheabdomenthereis4fingerbreadthsofhepatomegalyandascites.Whatisthediagnosis?
A.MitralvalveprolapseB.MitralstenosisC.ConstrictivepericarditisD.MyocardialinfarctionE.Aorticregurgitation
Answer:c)Constrictivepericarditis.The patient has the clinical features of constrictive pericarditis. In constrictivepericarditis,anearlydiastolic sound isheard (pericardialknock).This sound isdue toturbulence caused by the arrest of rapid ventricular filling into a nondistensiblepericardialsac.
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Dr.KhalidYusufElzohrySohagTeachingHospital201244
CardiologyQ043:A 70 year oldman has a ninemonth history ofworsening breathlessness.His bloodpressureis120/90mmHg,O2sats89%onair,temperatureis36.5C,thereisasystolicmurmurheardthroughouttheprecordium.Bloodtestsshow
Hb14g/dlWCC5x10^9/lPlatelets280x10^9/lurea7mol/lcreatinine75mol/lsodium142mmol/lpotassium4.2mmol/lcholesterol6.2mmol/ltriglyceride2.1mmol/l
Whichofthefollowingismostlikely?
A.DilatedcardiomyopathyB.AorticregurgitationC.AorticstenosisD.PericardialeffusionE.Coarctationoftheaorta
Answer:c)aorticstenosis.There is evidence of left sided heart failure clinically. The murmur throughout thepraecordium and narrow pulse pressure suggest aortic stenosis. The patient is alsopredisposedtothisbyahighcholesterol.
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Dr.KhalidYusufElzohrySohagTeachingHospital201246
CardiologyQ045:A 25 year old biology student presents with palpitations and has the ECG (above)recorded.Adenosineisgivenat6mgand12mgintravenously.Hefeltnauseousforafewsecondsandthereisarhythmchangetosinusrhythm.Howdoesadenosinework?
A.DecreasesensitivityofconductionbundletoelectrolytesB.AlteringPurkinjefiberresponseC.BlockinganaccessorypathwayD.BlockingAVnodeconductionE.QTprolongation
Answer:d)blockingAVnodeconduction.Adenosineworksbyslow ingatrioventricular(AV)conduction,hencebreakingthereentrycircuitwhichcanbeaAVNRTorAVRTinsupraventriculartachycardia.
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Dr.KhalidYusufElzohrySohagTeachingHospital201247
CardiologyQ046:A 10 year old patient has Down's syndrome. He has over the past year becomeprogressivelymorebreathless,islosingweightandfeelinglethargic.Heisalsobecomingbluewhenrunningwiththedogduringwalks.Whichofthefollowingcardiaclesionsmightberesponsible?
A.AtrialseptaldefectB.AorticregurgitationC.Tetralogyoffallot'sD.MitralstenosisE.Ventricularseptaldefect
Answer:e)ventricularseptaldefect.Anendocardialcushiondefect(betweentheatrialandventricularseptum)canleadtoASDorVSD.WithrapiddeteriorationaVSD ismost likelytocausebreathlessnessandcyanosis.
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Dr.KhalidYusufElzohrySohagTeachingHospital201248
CardiologyQ047:A60yearoldmanpresentswithcentralcrushingchestpainradiatingto theback.HehasaweakpulseintherightarmandsystolicBPis120mmHgintheleftarm,80mmHgsystolicintherightarm.Whichoneofthefollowingisafeatureofseverityrequiringimmediate(surgical)action?
A.PersistentvomitingB.HeadacheC.PulmonaryoedemaontheCXRD.HypertensionE.Louddiastolicmurmurintheaorticarea
Answer:e)louddiastolicmurmurintheaorticarea.Inaorticdissection,hypertensionshouldbetreatedwithaninfusionsuchaslabetalol.Aloud diastolic murmur in the aortic area suggests aortic regurgitation. Aorticregurgitationandpericardialeffusion (haemopericardium) suggestdissectiondown totheaorticroot.Thesefeatures,orpersistingchestpainsuggestthatthepatientrequirespromptsurgery.
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www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201250
CardiologyQ049:A70yearoldwomanhasahistoryofpalpitations for4months.AnECGat that timeshowedatrialfibrillation.Shewasgivendigoxin,diureticsandaspirin.Shenowpresentswithtwoshortlivedepisodesofalteredsensationintheleftface,leftarmandleg.Shealsohadintermittentdysphasia.Thereispoorcoordinationofthelefthand.AnechocardiogramwasnormalaswasaCTheadscan.Whatisthemostappropriatenextstepinmanagement?
A.CarotidendarterectomyB.AnticoagulationwithwarfarinC.ClopidogrelD.CorticosteroidtreatmentE.Noaction
Answer:B)anticoagulationwithwarfarin.The patient has thrombotic events related to atrial fibrillation, hence formalanticoagulationisrecommended.TheAgeandstrokegivesheraCHADS65scoreof3.ACHADS65scoreof2orabovesuggeststheneedforwarfarinisation.
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Dr.KhalidYusufElzohrySohagTeachingHospital201251
CardiologyQ050:A13yearboyhadasyncopalepisode followedbygeneralised jerkingofallhis limbs,whilsthavingdentalfilling.Hewasparticularlynervousabouttheprocedure.Whenhewasassessedincasualty,hisBPwas145/80,O2satswere99%andECGshowednormalsinusrhythm.Whatisthelikelydiagnosis?
A.GeneralisedtonicclonicseizuresB.VasovagalsyncopeC.CarotidsinushypersensitivityD.VFarrestE.Meningitis
Answer:b)vasovagalsyncope.Vasovagalsyncope isnotuncommonduringaprocedurewhichapatient is frightenedof. Theremay be transient brain hypoxiawhichmay caused generalised seizure likeactivity.
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Dr.KhalidYusufElzohrySohagTeachingHospital201252
CardiologyQ051:A 60 year male diabetic presents to the clinic. He takes metformin 850 mg tds,bendrofluazide 2.5 mg and asprin 75 mg daily. He has had a previous myocardialinfarctionbutiscurrentlasymptomatic.Hisbodymassindexwas33.5kg/m2,hehasapulse of 90 beats perminute and a blood pressure of 160/9mmHg.His cholesterolconcentrationis3.8mmol/l(
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www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201254
CardiologyQ053:A55yearoldmanpresentedwithchestpain,facialflushingandelevatedjugularvenouspressurebutno legoedema.Hehadbeenexposedtotuberculosis inchildhood,hadastrongly positive tuberculin test and had been followed up in the tuberculosissurveillance program with regular chest xrays, but had never been diagnosed withtuberculosis.Chest xrayonpresentation showed calcifiedplaquesandmasses in thepericardiumandmediastinum.Coronary angiography showed 70% stenosis in the left anterior descending artery.Cardiaccatheterizationshowedequalisationofdiastolicpressuresinallfourchambers,withapositivesquarerootsign.Whatisthelikelydiagnosis?
A.PericardialeffusionB.CardiactamponadeC.ConstrictivepericarditisD.SarcoidosisE.Angina
Answer:c)Constrictivepericarditis.Thecardiaccatheterdatashowsapatternofventriculardiastolicpressurecharacteristicof constrictive pericarditis. Tuberculous pericarditis is seen in 1%2% of all cases ofpulmonary tuberculosisandcan lead toconstriction.Treatment iswithcorticosteroidsandantiTBtherapy.Theatrialwaveformmanifests:
augmentedawave,reflectingenhancedatrialcontractionintoastiffventriclearapidxdescentattributabletosubsequentacceleratedatrialrelaxationasteepydescentreflectingrapid,resistancefreeearlydiastolicfilling.
Right and left heart chamber filling pressures are typically increased and equalized(LVEDP=RVEDP),reflectingthecommonconstrainingeffectsofthepericardium.
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www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201256
CardiologyQ054:An30yearoldmanpresentswithahistoryofsyncope related toexercise.There isafamilyhistoryofsuddencardiacdeath.Onexamination,thecarotidpulseisjerky,thereisadoubleapicalpulsation.Onauscultationthere isafourthheartsound,anejectionsystolicmurmurheardatthebaseoftheheart.Theinheritanceofthisconditionismostlikely:
A.MitochondrialinheritanceB.XlinkeddominantC.XlinkedrecessiveD.AutosomalrecessiveE.Autosomaldominant
Answer:e)Autosomaldominant.
Hypertrophicobstructive cardiomyopathy ismost commonlyofAutosomaldominantinheritance.Itoccursinatleastonin1,000toonein500ofthegeneralpopulation.
www.MRCPass.com Cardiology
Dr.KhalidYusufElzohrySohagTeachingHospital201257
CardiologyQ055:A30yearoldmanisseenannuallyinthecardiacclinic.Duringauscultationofhisheartthereiswidefixedsplittingofthesecondheartsound.Inwhichoffollowingconditionsdoesthisoccur?
A.AtrialseptaldefectB.AorticregurgitationC.ConstrictivepericarditisD.Ebstein'sanomalyE.RightBundleBranchBlock
Answer:a)atrialseptaldefect.WidefixedsplittingisseeninASD.InRBBBthereiswidesplittingofS2butitnotfixed.
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Dr.KhalidYusufElzohrySohagTeachingHospital201258
CardiologyQ056:A 65 year old lady has recently had a cholecystectomy 2 days ago. She is now verybreathless,hascentralpleuriticchestpainandfeelsdizzy.Sheisonlyabletosayafewwordsandlookspale.Examinationrevealsasinustachycardiaandflowmurmuracrosstheaorticarea.Herbloodpressure is is85 /50mmHg,O2 saturationsare85%on6litresofO2.ECGshowsnonspecificTwaveabnormalities.Whatshouldbethenextmanagementstep?
A.CTpulmonaryangiogramB.IntravenousheparinC.CoronaryangiogramD.ThrombolysiswithtenecteplaseE.Transthoracicechocardiography
Answer:d)thrombolysiswithtenecteplase.Thispatienthasrecentlyhadsurgery,andherpresentationwouldbeconsistentwithlifethreateningmassive pulmonary embolus. She ismedically too unstable towait for adiagnostictestinradiology,thusthrombolysisshouldbedoneimmediately.Ifthisdoesnotworkthenthepatientmayneedventilation,CTtoconfirmthediagnosisandsurgicalembolectomy.
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Dr.KhalidYusufElzohrySohagTeachingHospital201259
CardiologyQ057:A75 yearoldman isadmittedwith suddenonset shortnessofbreath,poorexercisetoleranceandankleoedema.Whichofthefollowinglaboratorytestwouldidentifythereasonforhispresentation?
A.Alpha1antitrypsinlevelsB.SerumelectrophoresisC.SerumtriglyceridesD.BrainnatriureticpeptideE.Ureaandelectrolytes
Answer:d)Brainnatriureticpeptide.The clinical scenario fitswith acute pulmonary oedema. Brain or B type natriureticpeptide is increasingly used as a marker of congestive heart failure. It has highspecificityforthecondition.It isreleasedbyventricularcardiomyocytesduetostretchaspartofthepathophysiologyofcardiacfailure.
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Dr.KhalidYusufElzohrySohagTeachingHospital201261
CardiologyQ059:A45yearold ladyhasprevioushistoryof rheumatic fever.Shehasa loud firstheartsoundandadiastolicmurmursuggestiveofmitralstenosis.Whichoftheseisthebestindicatorofseveremitralstenosis?
A.IncreasedpulsepressureB.ClubbingC.LoudsecondheartsoundandrightparasternalheaveD.TappingapexbeatE.Rumblingmiddiastolicmurmur
Answer:c)loudsecondheartsoundandrightparasternalheave.A loudP2and featuresof rightheart strain is suggestiveofpulmonaryhypertension,henceseveremitralstenosis.
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Dr.KhalidYusufElzohrySohagTeachingHospital201262
CardiologyQ060:A80yearoldwomanisreferredbyherGPforhighbloodpressure.Overthelastthreemonthsherpressurehasbeenrecordedataround175/80mmHg for3occasions.Shehasabodymassindexof26kg/m2andisanonsmoker.Whichofthefollowingisthemostappropriatetreatmentforherbloodpressure?
A.CalciumchannelblockerB.BetablockerC.AlphaBlockerD.AngiotensinReceptorBlockerE.AngiotensinConvertingEnzyme(ACE)Inhibitor
Answer:a)Calciumchannelblocker.Thispatientisolatedsystolichypertension(systolicBP>160mmHg).Baseduponstudiessuch as the Systolic Hypertension in the Elderly Program (SHEP) the BHS guidelinessuggesttreatmentwitheitherCalciumantagonistsorDiuretics(CorD).
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Dr.KhalidYusufElzohrySohagTeachingHospital201263
CardiologyQ061:A65yearoldmanexperiences substernalchestpainuponexertion for6months.AnelectrocardiogramshowsTwave inversion in theanterolateral leadsat rest.Hehasatotalserumcholesterolof8mmol/l.Onangiography,hehasa95%narrow ingof theleftanteriordescendingartery.Whichoffollowingeventsislikelyoccurinthispatient?
A.PulmonaryembolismfromaleftventricularmuralthrombusB.PulmonaryembolismfromthrombosisinainternaljugularveinC.AsystemicarteryembolusfromthrombosisinathehepaticveinD.AsystemicarteryembolusfromaleftventricularmuralthrombusE.Asystemicarteryembolusfromaleftatrialappendagethrombus
Answer:d)Asystemicarteryembolusfromaleftventricularmuralthrombus.A significant stenosisof the left anterior descending arterymay lead to infarction ofanterior regionof the leftventricle.Thrombusmay formonanareaof thedyskineticventricle (muralthrombus).Thereforeheatriskofarterialembolusofthrombus fromtheLV.
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Dr.KhalidYusufElzohrySohagTeachingHospital201264
CardiologyQ062:A60yearoldmanpresentswithsharpchestpainradiatingtotheepigastrium.HehasSTelevation intheanterior leadsonhisECGand isthrombolysed.Thechestpainpersistsdespite thrombolysis.He develops a raised JVP up to the ear lobes andBPdrops to95/60.Therearesignsofpulsusparadoxus.Whatisthelikelydiagnosis?
A.AorticdissectionB.PericarditisC.PulmonaryembolismD.AnteriorMIwithmyocardialruptureE.Patentductusarteriosus
Answer:a)aorticdissection.Aorticdissectioncanpresentwithpainradiatingtotheepigastricregionorback.Ifthedissectionflapinvolvesclosetotheaorticroot,thenthecoronaryflowcanbeaffected,causing either inferior MI in right coronary artery or anterior MI in left anteriordescending artery involvement. Cardiac tamponade can also be caused by dissection(bloodflowingintopericardialspace)andleadingtoaraisedJVPandpulsusparadoxus.
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Dr.KhalidYusufElzohrySohagTeachingHospital201265
CardiologyQ063:A 60 year oldmanwas admittedwith severe chest pain.On examination his BloodPressurewas205/115mmHg.ECGshowed>2mmSTelevationinLeadsV24.Hewasgivenmorphineandaspirin.Whatisthenextappropriatemanagement?
A.IvtPAB.IvstreptokinaseC.IvGTND.ClopidogrelE.Tirofiban
Answer:C)ivGTNIn thispatient thebloodpressure is toohigh to safely administer thrombolysis.GTNshouldbegivento lowerthebloodpressure inthefirst instanceandtovasodilatethecoronaryarteries.
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Dr.KhalidYusufElzohrySohagTeachingHospital201266
CardiologyQ064:A72yearoldmanisreviewedatmedicaloutpatientcliniccomplainingoftiredness.Hetakesamiodarone,aspirin,atenololandatorvastatin.Hisheartrateonexaminationis85bpm. Recent 24hr ECG shows sinus rhythm throughout with occasional ventricularectopics.Investigationsreveal:FreeT432nmol/l(922)TSH
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Dr.KhalidYusufElzohrySohagTeachingHospital201267
CardiologyQ065:A60yearoldmanwhowaspreviouslyasymptomaticsuddenlydevelopssevereanteriorchestpain radiating to theback.Withinminutes,hebecomesunconscious.Hehas ahistoryofhypertension.Onexamination,hehasabloodpressureof120/60mmHgintherightarmand105/55mmHgintheleftarm.Anearlydiastolicmurmurwasaudibleinthelowerleftsternaledge.Whichofthefollowingisthemostlikelydiagnosis?
A.MalignanthypertensionB.InternalcarotidarterydissectionC.AcutemyocardialinfarctionD.AorticdissectionE.Pulmonaryembolus
Answer:d)aorticdissection.Theacutehistoryofsharppainradiatingtothebackissuggestiveofaorticdissection.Inaddition,there ispredisposingriskfactorofhypertensionandhecollapses(suggestingthat the dissection flap may have involved large vessels leading tow ards vascularinsufficiency)andhencetheneurologicalsymptoms.Whentheflapdissectsdowntotheaorticroot,aorticregurgitationmayalsobefound(earlydiastolicmurmur).
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Dr.KhalidYusufElzohrySohagTeachingHospital201269
CardiologyQ067:A60yearoldmanhashadamyocardialinfarction.Hispulserateis45andheisfeelinglightheaded.Bloodpressureis90/65.Inwhichoneofthefollowingconditionsistemporarypacing indicatedwhensymptomsarepresent?
A.FirstdegreeheartblockB.WenkebachC.2:1MobitztypeIIheartblockD.LeftbundlebranchblockE.Bifascicularblock
Answer:c)2:1MobitztypeIIheartblock.The first form of second degree heart block,Mobitz type I (Wenkebach) is due toprogressiveprolongationofPR intervalandthenmissingabeat.Mobitztype IIseconddegreeheartblockcanoccurwith2:1(only1QRSisconductedfor2pwaves)or3:1.Inapatientwho is compromisedwith symptoms andhypotension, temporarypacing isindicated.
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Dr.KhalidYusufElzohrySohagTeachingHospital201270
CardiologyQ068:A60yearoldwomanhasatrialfibrillationcontrolledwithdigoxinandbetablocker.Shehas a previous history of hypothyroidism but her last thyroid function tests werenormal.Shefeelslightheadedandisbroughttohospital.Herrenalfunctionisabnormalandshehasapulserateof35.Whatisthelikelydiagnosis?
A.MyxedemacrisisB.AddisoniancrisisC.HypercalcaemiaD.SicksinussyndromeE.Digoxintoxicity
Answer:E)digoxintoxicity.Factors which predispose to digoxin toxicity are renal impairment, hypokalaemia,hypomagnesaemiaandhypercalcaemia. Itcan lead tobradyarrhythmias firstdegreeheart block andWenkebach (Mobitz type II second degree heart block is rare), andcompleteheartblock.Otherfeaturesofdigoxintoxicityarexanthopsia (yellowvision),nausea&vomitinganddyspnoea.ThereversedticksignontheECGisnotafeatureoftoxicitybutisassociatedwithdigoxinuse.
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Dr.KhalidYusufElzohrySohagTeachingHospital201271
CardiologyQ069:A75yearoldmanwithdilatedcardiomyopathyremainssymptomatic inNYHAclass2group.He has chronic heart failure. On examination his BP 150/95.He is currentlytakingRamipril10mgodandFrusemide80mgOD.Whatisthebesttreatmentoption?
A.LosartanB.AmiodaroneC.BisoprololD.DigoxinE.Spironolactone
Answer:c)Bisoprolol.Beta blockers improvemortality quality of life in chronic heart failure (COPERNICUS,MERITHF,CIBIStrials).Theyshouldbe initiatedoncepatientsarestable(ratherthanintheacutesetting)andcanbeusedinallclassesofheartfailure.
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Dr.KhalidYusufElzohrySohagTeachingHospital201272
CardiologyQ070:A50yearoldladyhaspalpitations.HerECGshowsabroadcomplextachycardia.Whichofthesefeaturessuggeststhatthetachycardiaismorelikelytobeofventricularorigin?
A.QRSof180msB.LeftbundlebranchblockandleftaxisdeviationC.PwaveforeveryQRScomplexD.HistoryofatrialfibrillationE.Heartrateof150
Answer:a)QRSof180ms.FeaturesthatfavourVT:
QRSof>140msdissociatedpwaveshistoryofischaemicheartdiseaserightbundlebranchblockwithleftaxisdeviationHR>170beatsperminute
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Dr.KhalidYusufElzohrySohagTeachingHospital201273
CardiologyQ071:A50yearoldwomanhasnewsymptomsofpalpitations.Shehasnopreviouscardiachistory.AnECGrevealsatrialfibrillation.Whichoneofthefollowingdrugsismostlikelytorestoresinusrhythm?
A.DiltiazemB.DigoxinC.AtenololD.FlecainideE.Labetalol
Answer:d)flecainide.Flecainide is a class Ic antiarrhythmic drug. It helps restoration of sinus rhythm andpreventrecurrenceofAF.FlecainidemayprolongQTinterval.ThedrugwasusedintheCardiac Arrhythmia Suppression Trial (CAST) trial, andwas associatedwith increasedmortalityinpatientswithischaemicheartdisease.
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Dr.KhalidYusufElzohrySohagTeachingHospital201274
CardiologyQ072:A53yearoldmanpresentswithseverecrushingchestpains.HisECGshoweddominantRwavesinV1andV2leads.TheTwaveswerealsotall.Whatisthemostlikelycause?
A.LateralMIB.AnteriorMIC.InferiorMID.PosteriorMIE.Pulmonaryembolism
Answer:D)posteriorMI.The changes of posterior myocardial infarction are seen indirectly in the anteriorprecordialleads.LeadsV1toV3facetheendocardialsurfaceoftheposteriorwalloftheleft ventricle. As these leads record from the opposite side of the heart instead ofdirectlyovertheinfarct,thechangesofposteriorinfarctionarereversedintheseleads.TheRwavesincreaseinsize,becomingbroaderanddominant,andareassociatedwithSTdepressionanduprightTwaves.
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Dr.KhalidYusufElzohrySohagTeachingHospital201276
CardiologyQ074:A60yearoldmanisacutelyshortofbreath.ECGshowsatrialfibrillation.HisHRis170andBPis110/70.TherearenocardiacmurmursbuthehasaraisedJVPandfewbasalcracklesinthelungs.Whichoftheseisthebestmanagementstrategy?
A.Atenolol,frusemide,lowmolecularweightheparinB.DigoxinandlowmolecularweightheparinC.Ivamiodarone,ivfrusemideD.Digoxin,frusemide,lowmolecularweightheparinE.FrusemideandDCcardioversion
Answer:d)digoxin,frusemide,lowmolecularweightheparin.The patient has evidence of pulmonary oedema related to tachycardia and AF. Sheneeds anticoagulation, rate control and diuresis to relieve pulmonary oedema. Inaddition, if her blood pressure allows, a nitrate (GTN) infusionwould be helpful.DCcardioversionshouldbeconsideredifratecontrolispoorbutisassociatedwithhighriskofthromboembolismiftheAFisnotnew.
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Dr.KhalidYusufElzohrySohagTeachingHospital201278
CardiologyQ076:A55yearoldAfroCaribbeanman intheoutpatientclinichasuncomplicatedessentialhypertension.Hisbloodpressuretoday is160/100mmHgdespiteoptimizationofnonpharmacologicaltherapy.Whichoneofthefollowingdrugsshouldbeused?
A.Atenolol50mgodB.Amlodipine5mgodC.Enalapril5mgbdD.Nifedipine10mgtdsE.Lisinopril2.5mgod
Answer:b)Amlodipine5mgod.Studies indicatethatdrugssuchasACE(angiotensinconvertingenzyme) inhibitorsandBetareceptorantagonistsare lesseffective inAfroCaribbeans.Thereasonappears tobe related to the finding that the reninangiotensinaldosterone (RAA) system iscommonlysuppressed inthemajorityofAfroCaribbeans.Assuch,drugsthatsuppresstheRAAsystemarelesslikelytobeeffective.Calciumchannel blockers (CCBs) and diuretics appear to be more effective in thissubgroup. Shortacting CCBs do not provide prolonged BP control, can cause reflextachycardiaandmaybeassociatedwithhighermortality.Therefore, longactingCCBshouldbethe firstlinedrugofchoice. Ideally,aoncedailyagentwith thatprovidesasmooth24hourBPcontrol (e.g.NifedipineLA30mgodorAmlodipine5mgod).
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Dr.KhalidYusufElzohrySohagTeachingHospital201279
CardiologyQ077:A 65 year old patient diagnosed as having myocardial infarction on admission tohospital.4days laterhe suffered an attackofprolonged chestpainwhile still in thehospital.WhichoftheenzymeswouldbesthelpindiagnosingapossiblesecondMI?
A.TroponinIB.TroponinTC.LDHD.CKMBE.CK
Answer:d)CKMB.Troponinstendtobeelevated forupto14days.CKMBcomesdown tonormal levelwithin4872hours,andisthemostspecificoftheCKenzymes.Within4daysofthefirstMI,theCKMBfractionshouldnotberaised,andifso,indicatesapossiblesecondMI.
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Dr.KhalidYusufElzohrySohagTeachingHospital201280
CardiologyQ078:A65yearoldpatienthashadapreviousmyocardialinfarction5yearsagofollowedbycoronary artery bypass grafting. She is on aspirin, ramipril and furosemide. Duringreview,sheiswell.Bloodpressureis140/70mmHg,pulseis80andregular,JVPisnotraised.Herbreathsoundsareclear.Whichdrugshouldbeconsidered?
A.DigoxinB.LisinoprilC.CarvedilolD.ClopidogrelE.Tirofibran
Answer:C)Carvedilol.TheCarvedilolProspectiveRandomizedCumulativeSurvivalStudyinpatientwithseverechronic heart failure was stopped early because of a significant beneficial effect ofcarvedilolonsurvival.
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Dr.KhalidYusufElzohrySohagTeachingHospital201282
CardiologyQ080:A25yearoldman isbrought intohospitalwith symptomsofalcohol intoxication.Aninitial ECG reveals atrial fibirillation. The next morning he was found to havespontaneouslyrevertedtosinusrhythm.Anechocardiogramisnormal.Whatistheappropriatemanagement?
A.AdvicetostopdrinkingB.AmiodaroneC.SotalolD.Aspirin3monthsE.Warfarinforonemonth
Answer:a)Advicetostopdrinking.ExcessiveAlcoholisawellrecognizedcauseofatrialfibirillation,likelytobethecauseinthiscase. Ischaemicheartdisease isunlikely,as isstructuralheartdisease inviewofanormal echocardiogram. Therefore, advice to stop drinking is most likely to helpmaintainsinusrhythm.
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Dr.KhalidYusufElzohrySohagTeachingHospital201283
CardiologyQ081:A60yearoldsecurityguardpresentswithsuddenonsetofseverecrushingcentralchestpain.TheE.C.GshowssinusbradycardiawithSTsegmentelevationinleadsII,III,aVF.Whereisthelikelylesion?
A.DiagonalarteryB.LeftanteriordescendingC.RightcoronaryarteryD.CircumflexarteryE.Obtusemarginalartery
Answer:c)Rightcoronaryartery.The patient has an inferior myocardial infarction. This area of the myocardium issuppliedbytherightcoronaryartery.Thesinoatrialnode isalsosuppliedbyanarterywhich arises from the right coronary artery and hence theremay be bradycardia orheartblock.
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Dr.KhalidYusufElzohrySohagTeachingHospital201284
CardiologyQ082:A65yearoldmanhaspresentedwithchestpainandhasanteriorSTelevationontheECG which is thrombolysed with tenecteplase. He becomes very breathless. Onexamination, he has a loud pansystolicmurmur in the lower left sternal edge andbilateralcoarsecrepitationsinthelungbases.Whichofthefollowinginvestigationsismostimportanttoconfirmthediagnosis?
A.ChestXrayB.TransthoracicechocardiogramC.CTpulmonaryangiogramD.RepeatECGE.Arterialbloodgas
Answer:b)transthoracicechocardiogram.Althoughhe is likelytohavepulmonaryoedema,aCXRwillnotconfirmthediagnosis.Witha largeanteroseptalMI,hecouldhaveeitherhavemitralregurgitation(functionorpapillarymuscledamage)oraVSDcausingthesystolicmurmur.Asthisisinthelowerleftsternaledge,itwouldbeimportanttogetanurgentechocardiogramtoconfirmandreferforcardiothoracicsurgery.
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Dr.KhalidYusufElzohrySohagTeachingHospital201285
CardiologyQ083:A55yearoldwomanhasasystolicmurmurwhichisdiscoveredbytheGPwhoreferredthepatientforacardiacopinion.Shehasatransthoracicechocardiogramwhichshowsnormalleftventricularfunction.Thereisnosignificantcardiacenlargementandshehasamitralvalveprolapsewithmoderatemitralregurgitation.The leftatriumdiameter is4.3cm.Whatisthemostappropriatecourseofaction?
A.NoendocarditisprophylaxisnecessaryB.RegularoutpatientfollowupwithechocardiographyC.AnticoagulationwithwarfarinD.TransoesphagealechocardiographyE.Referforcardiacsurgery
Answer:B)Regularoutpatientfollowupwithechocardiography.The normal left ventricular function and dimensions, as well as moderate mitralregurgitationsuggeststhatcardiacsurgerycanbeheldoff.She is insinusrhythmanddoesnotrequireanticoagulation(leftatriumisonlymildlyenlarged
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Dr.KhalidYusufElzohrySohagTeachingHospital201286
CardiologyQ084:A 40 year old patient has a transthoracic echocardiogram as a follow up. He has adiagnosis of hypertrophic obstructive cardiomyopathy. Clinically he has a systolicmurmurheardloudestintherightuppersternaledge.HisECGshowsgrosslylargeQRScomplexeswithLVHstrainpattern.Whichofthefollowingsuggestshighestriskforsuddendeath?
A.Aleftventricularoutflowtractgradientof20mmHgB.TricuspidregurgitationC.SystolicanteriormotionofmitralvalveD.ECGshowingventricularectopicsE.Interventricularseptalthicknessof4cm
Answer:e)interventricularseptalthicknessof4cm.TheLVoutflowtractgradientisnotsignificantlyhighinthispatient,however,thismaybe variablewithexercise. The large interventricular septal thicknessof4 cm (normal
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Dr.KhalidYusufElzohrySohagTeachingHospital201287
CardiologyQ085:A60yearoldmanpresentswithbreathlessness,visualblurringandheadachestoA&E.Duringexamination,hehasageneralisedtonicclonicseizure.Hehasabloodpressureof 240/120. Fundoscopy reveals retinal haemorrhages and exudates. The optic discmarginisnotvisualised.Whichofthefollowingmedicationsisfirstline?
A.SodiumnitroprussideB.LabetalolC.DiltiazemD.AtenololE.Bendrofluazide
Answer:a)sodiumnitroprusside.Malignant hypertension can presentwith pulmonary oedema, chest pain, headache,visual disturbance and also seizures. A fundoscopic examination may reveal flameshapedretinalhemorrhages,softexudates,orpapilledema.SodiumNitroprussidehas an immediateonsetof action and shorthalflife. It actsbycausingrelaxationofvascularsmoothmuscle,resultinginvasodilationandinotropy.Thedose is 0.2510 mcg/kg/min IV. IV hydralazine, beta blockers and calcium channelblockerscanalsobeused.
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Dr.KhalidYusufElzohrySohagTeachingHospital201288
CardiologyQ086:A35yearoldpatientwithmildmitralstenosishasatrialfibrillation.ShepresentsunwellwithfastAFandwasDCcardiovertedsuccessfully.Whichofthefollowingmedicationsismosteffectiveformaintenanceofsinusrhythm?
A.DigoxinB.AmiodaroneC.AtenololD.DiltiazemE.Labetalol
Answer:b)amiodarone.Amiodaroneismosteffectiveformaintenanceofsinusrhythm.However,becauseofitssideeffectprofile,inayoungpatient,itisusuallyworthtryingabetablockerorcalciumblockerbeforetreatingwithamiodarone.
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Dr.KhalidYusufElzohrySohagTeachingHospital201290
CardiologyQ088:A 60 year old lady is known to have severe mitral stenosis. She presents withbreathlessness.Onexamination,whichoneofthefollowingfeaturesisexpected?
A.ClubbingB.LoudfirstheartsoundC.WidepulsepressureD.EjectionsystolicmurmurE.Smallleftatrium
Answer:b)loudfirstheartsound.A loud first heart sound and tapping apex beat are common in significant mitralstenosis.Anarrowpulsepressure isexpected in severemitral stenosis. Leftatrium isinevitablydilatedonCXRandechocardiography.
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Dr.KhalidYusufElzohrySohagTeachingHospital201291
CardiologyQ089:A45yearoldpatienthasbeencommencedonnifedipineforhypertension.Whichofthefollowingeffectdescribestheactionofnifedipine?
A.ReducedsympatheticactivityB.DecreasedactivationofreninangiotensinaldosteroneaxisC.ReducedperipheralcapillarypressureD.ReducedperipheralvascularresistanceE.Decreasevascularreleaseofnitricoxide
Answer:d)reducedperipheralvascularresistance.Nifedipine isadihydropyridine.Themechanismofaction issmoothmusclerelaxationandreduction inperipheralvascularresistance.However,peripheralcapillarypressureis increased(thiscausesoedema intheankles),there is increasedsympatheticactivityand increased activation of the renin angiotensin aldosterone axis. There is alsoincreasedvascularreleaseofnitricoxide.
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Dr.KhalidYusufElzohrySohagTeachingHospital201292
CardiologyQ090:A70yearmanhasbeenshortofbreathfor1year.AnelectrocardiogramshowsTwaveinversionandqwaves in theanterolateral leadsat rest.Hehas cardiomegalyon thechestXray.Clinicalexaminationshowsathirdheartsound,asoftsystolicmurmurinthemitralareaandalsobilateralinspiratorycrepitationsinhislungs.Whichofthefollowingisheatriskof?
A.DeepveinthrombosisB.PulmonaryembolusC.SystemicarterialembolusfrommuralthrombusD.VenousthrombosisduetomuralthrombusE.Coronaryarterythrombusduetomuralthrombus
Answer:c)systemicarterialembolusfrommuralthrombus.Thismanhas features indicating thathehasanenlarged left ventricle frompreviousanteriormyocardial infarction intheLADarteryterritory.PoorLVfunctionalsocauseshissymptomsofheartfailure.Heisatriskofdevelopingmuralthrombuswithembolustothearterialcirculation.
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Dr.KhalidYusufElzohrySohagTeachingHospital201293
CardiologyQ091:A45yearoldmanwasreferredbytheGPforevaluationofamurmur.Onexamination,hewasfoundtohaveaslowrisingpulseandejectionsystolicmurmurintheaorticarea.Aorticstenosiswassuspected.Inapatientpresentingwithaorticstenosis,whichoffollowingfeatureswouldbehelpfulinestablishingadiagnosisofcongenitalbicuspidvalve?
A.CalcifiedleafletsB.OldageC.AsystolicejectionclickD.CommissuralfusionontheechocardiogramE.Historyofrheumaticfever
Answer:c)asystolicejectionclick.Anaorticejectionsound(ejectionclick)soonafterS1isespeciallycommonifabicuspidaorticvalveispresent.
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Dr.KhalidYusufElzohrySohagTeachingHospital201294
CardiologyQ092A40 yearold ladyhaspresentedwithbreathlessness.Her JVP isnoted tobe raised.ManometryrevealsarapidYdescent.On examination, she has hepatomegaly, ascites and ankle oedema. What is thediagnosis?
A.DilatedcardiomyopathyB.LeftventricularfailureC.ConstrictivepericarditisD.PericarditisE.Myocardialinfarction
Answer:c)constrictivepericarditis.Constrictivepericarditisleadstosignsofrightsidedheartfailurewhicharelistedabove.ThereisalsoaprominentandrapidXandYdescentofthewaveform.
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Dr.KhalidYusufElzohrySohagTeachingHospital201295
CardiologyQ093A57yearoldladywhohadapasthistoryofMyocardialInfarctionandsubsequentCABGwas known to have left ventricular dysfunction on the echocardiogram. She has nosymptomsatpresent.Shewasonaspirin,ramiprilanddiuretic.Onexamination therewerenosignsofheartfailure.Whatdrugshouldbeaddednext?
A.AmlodipineB.BisoprololC.ClopidogrelD.AtorvastatinE.Digoxin
Answer:B)Carvedilol.In a patient with left ventricular dysfunction and known history of ischaemic heartdisease,abetablockershouldbeadded(CIBISIIStudy).
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Dr.KhalidYusufElzohrySohagTeachingHospital201296
CardiologyQ094A35yearold ladyhasprogressiveshortnessofbreath.Followinganechocardiogram,she is found to have likely rheumatic mitral stenosis is now being considered forpercutaneousmitralvalvuloplasty.Whichofthefollowingwouldcontraindicatethisprocedure?
A.DilatedleftatriumB.AtrialfibrillationC.AorticregurgitationD.HeavycalcificationofthemitralvalveE.Longhistoryofmitralstenosis
Answer:d)heavycalcificationofthemitralvalve.The contraindications tow ards valvuloplasty are heavyMV calcification, thrombus inthe left atrial appendage on transoesophageal echocardiography and severe mitralregurgitation.Thesepatientsareindicatedformitralvalvesurgeryinstead.
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Dr.KhalidYusufElzohrySohagTeachingHospital201297
CardiologyQ095A25yearoldmanwhosebrotherhadhypertrophiccardiomyopathywasreferredforacardiologicalassessment.Hisechocardiogramconfirmedthecondition.Whichoneoffollowingechocardiographicfeaturesisthemostimportantriskfactorforsuddencardiacdeath?
A.ThicknessofseptalwallB.SystolicanteriormotionofthemitralvalveC.SeverityofmitralregurgitationD.GradientacrossleftventricularoutflowtractE.Anenlargedleftatrium
Answer:a)Thicknessofseptalwall.Thegreater thicknessof septum, themore likelihoodof left ventricularoutflow tractobstruction.Thenextmost importantfactorwouldbethegradientacrosstheoutflowtract.
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Dr.KhalidYusufElzohrySohagTeachingHospital201298
CardiologyQ096A 55 year old patient hadmyocardial infarction 6 days ago. He suddenly developsdyspnoea,coughandfrothysputum.Forthefirsttimeaharshsystolicmurmurisheardoverthepraecordium.Thissequenceofeventsmightbecausedby:
A.PulmonaryembolismB.AorticdissectionC.TricuspidregurgitationD.RupturedpapillarymuscleE.Rupturedaorticcusp
Answer:d)rupturedpapillarymuscle.FollowinganMI,rupturedpapillarymuscleor interventricularseptum ismost likelytocause the combination of pulmonary oedema and new murmur (either mitralregurgitationorduetoVSD).
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Dr.KhalidYusufElzohrySohagTeachingHospital201299
CardiologyQ097A30yearoldmanisbroughttoA&Ewithsevereacutechestpainradiatingtotheback.Heispaleandanxious.Onexamination thebloodpressure is150/90mmHg andhewasnoted tohavebluesclerae.Whichofthefollowingconditionshaspredisposedtothiscomplication?
A.CoarctationoftheaortaB.IschaemicheartdiseaseC.RheumaticfeverD.HypertrophiccardiomyopathyE.Marfan'ssyndrome
Answer:e)Marfan'ssyndrome.Marfan'ssyndrome isoneofthecausesofbluesclerae.Theclinicaldiagnosis isaorticdissection.Otherpredisposingdisorderstoaorticdissectionare:essentialhypertension,atherosclerosis ,bicuspidaorticvalve,connectivetissuedisorders,Marfanssyndrome,EhlersDanlossyndrome,adultpolycystickidneydisease.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012102
CardiologyQ100A 62 year old lady with known congestive heart failure and renal impairment. Shepresentswith features ofworsening heart failure, and alsomentioned about recentdecreasedurineoutput.Whatisthemostusefulinvestigationforthecurrentcondition?
A.ElectrolytesB.UreaC.CreatinineD.EchocardiogramE.Chestxray
Answer:D)echocardiogram.Apatientwithsymptomsofcongestivecardiacfailureandrenal impairmentmayhavedeterioratingleftventricularfunction.Thismaysubsequentlyleadtocardiogenicshock,theseverityofLVfunctionshouldbedocumentedtoguidefurthermanagement.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012103
CardiologyQ101A28yearwomanwhois20weekspregnantisseenintheoutpatientclinicandnotedtohaveasustainedbloodpressureof180/95mmHg.Whatisthemostappropriateantihypertensivetherapyforthispatient?
A.MethyldopaB.HydralazineC.NifedipineD.LisinoprilE.Atenolol
Answer:a)Methyldopa.Methyldopaisthesafestagenttouseinthefirstandsecondtrimesterofpregnancy.Betablockersmaycauseintrauterinegrowthretardation.ACEinhibitorshavealsobeensuggestedtohaveteratogeniceffects.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012104
CardiologyQ102Acardiactechnicianhasdoneanechocardiogramandrefersthepatienttoyouwithareport.Whichoneofthefollowingmeasuresisessentialforthecalculationofejectionfraction?
A.VentricularwallthicknessB.AorticvalvediameterC.LeftventricularenddiastolicdiameterD.StrokevolumeE.Aorticvalvevelocity
Answer:C)Leftventricularenddiastolicdiameter.Ejection fractionmeasurement requiresmeasurements during both the end systolicphaseorenddiastolicphasesonthetransthoracicechocardiogram.Thiscouldbeintheform of ventricular diameter measurement or area of the ventricle (in both casesvolumes are estimated by the echo machine). The end systolic and end diastolicvolumesarethensubtractedtoobtainanejectionfraction.Strokevolume itself isnotsufficient to give the ejection fraction hence needs comparison either systolic ordiastolicmeasurements.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012105
CardiologyQ103A55yearoldmanwithanginahasfamilialhypercholesterolaemia.Hisfatherandunclebothhavecoronaryheartdisease.Whichoneofthefollowingisatypicalfeatureforthecondition?
A.PlantarxanthomasB.AutosomalrecessiveC.IncreasedLDLconcentrationsD.HypertriglyceridaemiaE.IncreasedexpressionofLDLreceptors
Answer:c)increasedLDLconcentrations.Familial hypercholesterolaemia is an autosomal dominant condition. There areincreased LDL concentrations due to reduced numbers of LDL receptors.Hypertriglyceridaemia does not usually occur and HDL concentrations are usuallydecreased.Tendonxanthomasoccur,notplantarxanthomas.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012106
CardiologyQ104A48yearoldmaleisreferredwithimpotence.Hehasahistoryofangina,hypertensionandtype2diabetes.Which one of the following drugs that he takes would present a contraindicationtowardshimreceivingSildenafil?
A.AspirinB.BendrofluazideC.IsosorbideMononitrateD.LisinoprilE.Metformin
Answer:C)Isosorbidemononitrate.Thereisasignificantriskofhypotensionwhensildenafilisusedwithnitrates.Henceitiscontraindicatedinpatientswithahistoryofanginaorischaemicheartdisease.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012107
CardiologyQ105A 65 year oldwomanwho is on digoxin has symptoms of nausea and dizziness.Onexamination,herheartrateis35bpmandanECGshowsprolongedPRintervalwithfirstdegreeheartblock.Digoxintoxicityismorelikelywithwhichofthefollowingconditions?
A.HypocalcaemiaB.HypothyroidismC.RamipriluseD.HyperkalaemiaE.Hypokalaemia
Answer:e)Hypokalaemia.Hypomagnesaemia, hypokalaemia, and hypercalcaemia are common metabolicdisturbanceswhichmayworsendigoxintoxicity.Bradycardia,prolongedPR interval, shortenedQT intervaland various formsofheartblockcanoccurindigoxintoxicity.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012108
CardiologyQ106A70yearoldmanhasahistoryofsyncope.He is foundtohaverunsofnonsustainedventricular tachycardia on ECGs done in casualty. He has a pastmedical history ofhypertension.Investigationsshowaserummagnesiumof0.6mmol/l(0.751).Whichoneofthefollowingisthemostlikelycauseofhypomagnesaemia?
A.CalciumchannelblockersB.DiuretictherapyC.HyperphosphataemiaD.DiarrhoeaandvomitingE.Hypercalcaemia
Answer:b)Diuretictherapy.Magnesium ispresent ingreatestconcentrationwithinthecelland isthesecondmostabundant intracellular cationafterpotassium.Most renal reabsorptionofmagnesiumoccursintheproximaltubuleandthethickascendinglimboftheloopofHenle.Significantlossesofmagnesiumthatresultinhypomagnesemiamayresultfromchronicdiarrhea,laxativeabuse,inflammatoryboweldisease,orneoplasm,diuretics(thiazide,loopdiuretics).
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Dr.KhalidYusufElzohrySohagTeachingHospital2012109
CardiologyQ107A55yearoldladyhasdentalphobiabuthasfinallygonetothedentistfollowingseveretoothachesandistoldshehasdentalabscesses.SheisbroughtintoA+Ewithhighfeversbyarelative.Sheisfoundtohaveadiastolicmurmurintheaorticarea.Whichoneoftheseisasignofendocarditis?
A.RoslynsSpotB.HepatomegalyC.LossofperipheralpulsesD.PulmonaryfibrosisE.Bloodonurinedipstick
Answer:e)bloodonurinedipstick.Blood on the urine dipstick indicates renal vasculitis due to microemboli fromvegetationsinendocarditis.Oslersnodesaresmallreddishtenderareasonthepulpoffingersortoes.Janewaylesionsarereddishspotsonfingersortoes,butarepainless.Splenomegalyoccurs.Roth'sspotsarevasculiticlesionsontheretina.Bouchardsnodesoccurinosteoarthritis.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012110
CardiologyQ108A30yearold ladywasdiagnosedwith longQTsyndromeon routine investigation forherinsurancescheme.Whichoneofthefollowingdrugsshouldbestarted?
A.AtenololB.DigoxinC.AmiodaroneD.VerapamilE.Lignocaine
Answer:A)AtenololIn themanagement of a case of congenital LQT syndrome, betablockade is usuallyeffective inpreventingventriculartachyarrhythmiasinthepatient.Ifsymptomaticor ifthereareventriculararrhythmiasdocumented,anintracardiaccardioverterdefibrillatorshouldbeconsidered.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012111
CardiologyQ109A23yearoldmalepresentedwitha2yearhistoryofbreathlessnessonexertion.On examination, therewas a systolicmurmur in the pulmonary area andwide fixedsplittingofthesecondheartsound.Inwhichoftheseconditionsisfixedandwidesplittingofthesecondheartsoundseen?
A.Fallot'stetralogyB.VentricularseptaldefectC.AtrialseptaldefectD.PulmonarystenosisE.Aorticregurgitation
Answer:c)Atrialseptaldefect.ThesecondheartsoundtypicallyoccurswithA2(aortic)andP2(pulmonary).Widesplittingcanoccurwithdelayedpulmonaryclosure(P2)asinrightbundlebranchblock (RBBB),pulmonarystenosisandventricularseptaldefect (VSD).However,FIXEDwidesplittingonlyoccursinASD.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012112
CardiologyQ110A 65 year old man with a history of previous myocardial infarction presents withpalpitations.TheECGshowsabroadcomplextachycardiaatarateof150beats/minandabloodpressureof90/55mmHg.Thefirstlinetreatmentshouldbe:
A.SotalolB.FlecainideC.VerapamilD.AmiodaroneE.Lignocaine
Answer:d)Amiodarone.The likelydiagnosis isventricular tachycardia.Thereareearly signsofhaemodynamicinstability(bloodpressureislow).Inthiscase,amiodaroneisthebestagentasfirstline.Lignocaine and flecainide can also be used but are not considered first line whenpatientsareunstable.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012113
CardiologyQ111A50yearoldtaxidriverisfollowedup8weeksafterananteriormyocardialinfarction.He underwent rescue angioplasty with stenting to the LAD vessel following failedthrombolysis.Sincethenhehashadnofurthersymptomsofangina.Whichshouldbethenextinvestigation?
A.BruceprotocolexercisetestB.ModifiedBruceprotocolexercisetestC.RepeatcoronaryangiographytocheckstentpatencyD.DobutaminestressechocardiographyE.Cardiacthalliumscan
Answer:A)Bruceprotocolexercisetest.For public vehicle drivers and heavy goods vehicles driverswhich are classed underGroup2entitlementbytheDVLA,driving isdisqualifiedfor6weeksforMI,CABGandangioplasty.Followingthis,theyhavetoundergoaBruceprotocolexercisetesttostageIIIwithoutsignificantSTchangesoranginalsymptoms.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012114
CardiologyQ112A 45 year oldman hasworsening breathlessness.On examination, he has a systolicbloodpressureof115mmHgwhichdropsto90mmHgduringinspiration.Whichofthefollowingconditionsismostlikelytobepresent?
A.CongestivecardiacfailureB.CardiactamponadeC.AtrialfibrillationD.VentriculartachycardiaE.ICDimplantation
Answer:B)cardiactamponade.Theclinical feature ispulsusparadoxus.This isdefinedasadrop inbloodpressurebymore than20mmHgduring inspiration. It isadefinite signofcardiac tamponade,butmayoccasionallyoccurwithacuteconstrictivepericarditisandCOPD.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012115
CardiologyQ113A50yearoldladyiscurrentlyasymptomaticbutundergoesamedicalexamination.HerECGshowsleftbundlebranchblock.Duringclinicalexamination,whichoneofthesesignsislikelytobefound?
A.TricuspidregurgitationB.SystolicmurmurinthemitralareaC.ThirdheartsoundD.ReversedsplittingofthesecondheartsoundE.Diastolicmurmurinthepulmonaryarea
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