Cardiology

What valvular pathology would cause a murmur that radiates to the carotids?

Which artery supplies the posterior septal area of the heart?

Select the cardiac diagnoses that may cause hepatomegaly.

Which artery supplies the posterior aspect of the left ventricle

Which coronary artery supplies the inferior aspect of the left ventricle?

Which artery supplies the left atrium?

What blood test is most important in a patient who is starting and ACE inhibitor?

Which of the following medication do NOT have a role in the treatment of uncomplicated angina?

A 64 year old man who is known to have angina presents to A+E by ambulance with chest pain.

The pain started 2 hours ago and came on at rest. It is similar to his normal angina pain (central, constricting, radiating to his jaw), however it has not settled with rest or with his GTN spray. It has been fluctuating in severity slightly since it started and the patient states it may have improved a little since if first started.

There are no changes on serial ECGs and serial troponin measurements are normal.

What is the most likely diagnosis?

A 76 year old lady presents to the accident and emergency department complaining of central crushing chest pain. This came on at rest whilst she was eating breakfast 30 minutes ago. She rates this as 8/10 and is associated with anxiety. It radiates to her left shoulder and arm.

She is a smoker and is known to have severe COPD with frequent exacerbations (and is on a host of inhalers for her COPD), is on atorvastatin 20mg at night for high cholesterol, and has osteoarthritis for which she takes simple analgesia. She doesn’t have any allergies.

She has normal heart sounds, scattered wheezes throughout her chest with no crackles, and is haemodynamically stable. Her observations are as follows:

• Heart rate 87.
• Respiratory rate 16.
• Blood pressure 113/84.
• Oxygen saturations 93%.
• Temperature 36.8C.

Her ECG shows ischaemic changes but no ST elevation and she has a significantly raised troponin. ABG shows a chronic obstructive picture with a raised CO2, although she has compensated metabolically and is not acidotic. She is slightly hypoxic at pO2 of 9.2.

A diagnosis of NSTEMI is made.

Select the appropriate medications from the list below for the immediate management of this patient.

You are the oncall surgical FY1. You are called to see a 65 year old female patient who is post op day 2 after a laparoscopic right hemicolectomy. She started complaining of central crushing chest pain scoring 9/10 only 10 minutes ago.

On examination she looks unwell, is sweating, clammy and tachycardic at 105 beats per minutes. Her blood pressure is stable at 142/87. She is apyrexial, with saturations at 98% and respiratory rate of 18 / minute.

You perform an ECG that shows ST elevation in leads 1 aVL, V5 and V6.

What is the most appropriate initial management?

You are asked to review an 84 year old lady who has become acutely short of breath.

She was admitted 8 hours earlier with a left basal pneumonia. On admission she was septic with a high fever, hypotension and tachycardia. On admission her saturations were 96% and her respiration rate as 18 per minute.

She was treated with the septic six, including IV tazocin and fluid resuscitation. She did not require oxygen on admission.

She is now requiring 4 litres of oxygen via facemask to maintain saturations at 92%. She has a respiratory rate of 28 per minute. She is apyrexial, with a heart rate of 96 bpm and a blood pressure of 115/86.

She looks unwell and is using her accessory muscles to breath. She has bibasal crackles, worse on the left, a raised JVP, and an ejection systolic murmur radiating to her carotids.

What is the most likely diagnosis?

What blood investigation will be most helpful in diagnosing chronic heart failure?

What is the normal cardio-thoracic ratio?

Select from the list the medication that would be considered first line in chronic heart failure.

What point on the chest is the best overall position for listening for the third and fourth heart sounds?

What would be the best position on the chest wall to listen for aortic stenosis?

What would be the best position on the chest wall to listen for mitral stenosis?

Select the pathology from the list below that would be best heard by auscultation using the stethoscope bell rather than the diaphragm?

What valvular pathology may cause a murmur that radiates to the left axilla?

What statement would best describe a grade 3 murmur?

What is the most common cause of aortic stenosis?

A 64 year old presents complaining of shortness of breath, worse on exertion and when lying flat at night.

He is known to have ischaemic heart disease and is on medication for angina. He has had two previous NSTEMIs.

On ausculatation you hear a grade 3, pan-systolic murmur loudest at the apex.

What is the most likely cause for his murmur?

You are asked by your consultant to examine a patient with a murmur. She asks you to feel the patient’s carotid pulse.

When you feel the pulse, it feels as though the blood is shot up under high pressure, then immediately disappears.

What valvular pathology would this stereotypical pulse indicate?

You are clerking a patient on the acute medical take. She tells you she had surgery on her heart replacement three years ago and has been on warfarin ever since.

She is unsure what the surgery was, and what her normal dose of warfarin is.

On examination you notice a midline sternotomy scar, and hear a subtle click instead of S1, loudest over the apex.

What target INR would be most appropriate for this patient?

You are counselling a patient with severe mitral regurgitation on the pros and cons of replacement heart valves.

What is the most significant issue with mechanical heart valves when compared to bioprosthetic valves?

Other than atrial fibrillation, what can cause an irregularly irregular pulse?

What would be an appropriate first line treatment for atrial fibrillation in a sedentary 78 year old lady with a new diagnosis of atrial fibrillation who has no other health problems and no allergies?

What would be an appropriate first line treatment for atrial fibrillation in a sedentary 78 year old lady with a new diagnosis of atrial fibrillation who has no other health problems and no allergies? She is normotensive and has no evidence of heart failure.

What is the normal duration of a QRS complex?

What ventricular rate would you expect in atrial flutter?

You are asked to review a patient with a heart rate of 160 bpm.

They are otherwise haemodynamically stable and you decide to treat

The ECG reveals a regular, broad based tachycardia with QRS complexes around 0.25 seconds.

What would be an appropriate initial intervention in this scenario.

What is the most important thing to consider prior to administering amiodarone?

Match the following AV node abnormalities with the appropriate description

Select the antiarrythmic medication with a role in treating bradycardias from the list below.

You attend a crash call. The patient is unresponsive and no pulse can be found. The team commences resuscitation according to the ALS protocol. You connect the defibrillator and assess the rhythm.

Select the rhythms below that would appropriate to shock in this scenario.

You are asked by a nurse to review an ECG in a pre-operative patient.

You notice a thin vertical line before each P wave and each QRS complex.

What is the most likely cause?

You diagnose essential hypertension in a 45 year old black female patient who has ambulatory blood pressure monitoring demonstrating an average blood pressure of 156/89. She is otherwise fit and well and has no known allergies.

After discussing lifestyle interventions, you agree with the patient that medication should be commenced.

What would be the most appropriate first line medication from the list below?

A 48 year old white male patient presents with a dry cough since starting treatment with ramipril 2 months ago to control his essential hypertension. His blood pressure is controlled well on the ramipril, but he is getting frustrated with the cough.

You decide he would benefit from changing his medication.

What would be the most appropriate replacement for his ramipril?

Match the confirmed hypertensive patient with the most appropriate medication.