1
Q
9. A 49-year-old man is rushed to accident and emergency complaining of a 20-minute history of severe, crushing chest pain. After giving the patient glyceryl trinitrate (GTN) spray, he is able to tell you he suffers from hypertension and type 2 diabetes and is allergic to aspirin. The most appropriate management is: A. Aspirin B. Morphine C. Heparin D. Clopidogrel E. Warfarin
A
D. Clopidogrel
9
2
Q
8. A 60-year-old man presents to accident and emergency with a 3-day history of increasingly severe chest pain. The patient describes the pain as a sharp, tearing pain starting in the centre of his chest and radiating straight through to his back between his shoulder blades. The patient looks in pain but there is no pallor, heart rate is 95, respiratory rate is 20, temperature 37°C and blood pressure is 155/95mmHg. The most likely diagnosis is: A. Myocardial infarction B. Myocardial ischaemia C. Aortic dissection D. Pulmonary embolism E. Pneumonia
A
C. Aortic dissection
3
Q
7. A 59-year-old man presents for a well person check. A cardiovascular, respiratory, gastrointestinal and neurological examination is performed. No significant findings are found, except during auscultation a mid systolic click followed by a late systolic murmur is heard at the apex. The patient denies any symptoms. The most likely diagnosis is: A. Barlow syndrome B. Austin Flint murmur C. Patent ductus arteriosus D. Graham Steell murmur E. Carey Coombs murmur
A
A. Barlow syndrome
4
Q
6. A 66-year-old woman presents to accident and emergency with a 2-day history of shortness of breath. The patient notes becoming progressively short of breath as well as a sharp pain in the right side of the chest which is most painful when taking a deep breath. The patient also complains of mild pain in the right leg, though there is nothing significant on full cardiovascular and respiratory examination. Heart rate is 96 and respiratory rate is 12. The patient denies any weight loss or long haul flights but mentions undergoing a nasal polypectomy 3 weeks ago. The most likely diagnosis is: A. Muscular strain B. Heart failure C. Pneumothorax D. Angina E. Pulmonary embolism
A
E. Pulmonary embolism
5
Q
5. A 55-year-old man has just arrived in accident and emergency complaining of 20 minutes of central crushing chest pain. Which feature is most indicative of myocardial infarction at this moment in time? A. Inverted T waves B. ST depression C. ST elevation D. Q waves E. Raised troponin
A
C. ST elevation
6
Q
- A 57-year-old man is reviewed in a hypertension clinic, where it is found that his blood pressure is 165/105mmHg despite standard doses of amlodipine, perindopril, doxazosin and bendroflumethiazide. Electrolytes and physical examination have been, and remain, normal. Which of the following would be your next stage in his management?
A. Arrange for his medication to be given under direct observation
B. Add spironolactone to his medication
C. Arrange urinary catecholamine assays
D. Request an adrenal CT scan
E. Add verapamil to his medication
A
A. Arrange for his medication to be given under direct observation
7
Q
4. A 79-year-old woman is admitted to the coronary care unit (CCU) with unstable angina. She is started on appropriate medication to reduce her cardiac risk. She is hypertensive, fasting glucose is normal and cholesterol is 5.2. She is found to be in atrial fibrillation. What is the most appropriate treatment? A. Aspirin and clopidogrel B. Digoxin C. Cardioversion D. Aspirin alone E. Warfarin
A
E. Warfarin
8
Q
- A 69-year-old woman complains of intermittent palpitations, lasting several hours, which then stop spontaneously. She also suffers from asthma. Holter monitoring confirms paroxysmal atrial fibrillation. Which of the following statements is correct regarding the management of this patient?
A. Digoxin effectively prevents recurrence of the arrhythmia
B. Anticoagulation is not necessary
C. Sotalol may be effective
D. Amiodarone should be avoided
E. Flecainide orally may be an effective as-needed treatment to abort an attack
A
E. Flecainide orally may be an effective as-needed treatment to abort an attack
9
Q
- An asymptomatic 31-year-old woman has been referred for cardiological assessment. After her ECG she was told that she had mitral valve prolapse and would like further information on this condition. Which of the following statements is correct?
A. Beta-blocker therapy is indicated
B. Angiotensin-converting enzyme (ACE) inhibitor therapy is indicated
C. One or both leaflets of the mitral valve are pushed back into the left atrium during systole
D. Significant mitral regurgitation will eventually develop E. Exercise should be restricted
A
C. One or both leaflets of the mitral valve are pushed back into the left atrium during systole
10
Q
37. A 25-year-old woman with known mitral valve prolapse develops a low grade fever, malaise and night sweats within a couple of weeks of a major dental procedure. Examination reveals a pulse rate of 110/minute, which is regular, tender vasculitic lesions on the finger pulps and microscopic haematuria. Which investigation is most likely to provide a definitive diagnosis? A. Full blood count B. ECG C. Autoantibody screen D. Blood culture E. Coronary angiography
A
D. Blood culture
11
Q
36. A 58-year-old man has made an excellent functional recovery after an anterior MI. He is entirely asymptomatic and there is no abnormality on physical examination. His blood pressure is 134/78mmHg and he is undertaking a cardiac rehabilitation programme. Which of the following would you not recommend as part of his secondary prevention planning? A. Aspirin B. Lisinopril C. Simvastatin D. Bisoprolol E. Omega-3 fatty acids
A
E. Omega-3 fatty acids
12
Q
- A 29-year-old woman goes to see her GP complaining of fatigue and palpitations. She says she has also lost weight, though without dieting. On examination, her pulse rate is approximately 120/min and irregularly irregular. Her blood pressure is 142/89mmHg and her body mass index is 19. There are no added cardiac sounds. The ECG confirms the diagnosis of atrial fibrillation. What would you suggest as the most useful next investigation.
A. Thyroid function tests (TSH, free T4)
B. ECG
C. Chest x-ray
D. Full blood count
E. Fasting blood sugar
A
A. Thyroid function tests (TSH, free T4)
13
Q
34. A 71-year-old man is being treated for congestive heart failure with a combination of drugs. He complains of nausea and anorexia, and has been puzzled by observing yellow rings around lights. His pulse rate is 53/minute and irregular and blood pressure is 128/61mmHg. Which of the following medications is likely to be responsible for these symptoms? A. Lisinopril B. Spironolactone C. Digoxin D. Furosemide E. Bisoprolol
A
C. Digoxin
14
Q
- A 45-year-old woman complains of increasing shortness of breath on exertion, as well as orthopnoea, for the previous 3–4 months. She had apparently recovered from pericarditis about a year earlier. On ECG there is low voltage, especially in the limb leads, and the chest x-ray shows pericardial calcification. The presumptive diagnosis is constrictive pericarditis. Which of the following physical signs would be consistent with this?
A. Increased jugular distention on inspiration
B. Third heart sound
C. Fourth heart sound
D. Rales at both lung bases
E. Loud first and second heart sounds
A
A. Increased jugular distention on inspiration
15
Q
32. A 56-year-old man presents to the accident and emergency department with a 2-hour history of central chest pain radiating to the left arm. He is anxious, nauseated and sweaty. His pulse rate is 120/minute in sinus rhythm and the ECG reveals ST elevation in leads II, III and aVF. The troponin level is significantly raised. This is certainly acute MI. Which is the most likely coronary vessel to be occluded? A. Circumflex artery B. Left anterior descending artery C. Right coronary artery D. Left main coronary artery E. Posterior descending artery
A
C. Right coronary artery
16
Q
- A 44-year-old woman presents with episodes of headaches, associated with anxiety, sweating and a slow pulse rate. At the time of her initial consultation, her blood pressure was 150/95mmHg seated, but 24 hour ambulatory monitoring shows a peak of 215/130mmHg, associated with the symptoms described above. Which of the following would be your initial diagnostic procedure?
A. Magnetic resonance imaging (MRI) scans of the abdomen and pelvis
B. Measurement of random plasma catecholamines
C. Measurement of urinary metanephrines over several 24 hour periods
D. Glucose tolerance test
E. Pharmacological provocation using clonidine
A
C. Measurement of urinary metanephrines over several 24 hour periods
17
Q
- A previously fit 19-year-old man presents with unusual shortness of breath on exertion. At times, this is also associated with central chest pain. On examination there is a loud mid-systolic murmur at the left sternal edge. Heart rate and blood pressure are normal and there is no oedema. The ECG shows left axis deviation and the voltage criteria for left ventricular hypertrophy and the echocardiogram reveals a significant thickened interventricular septum, with delayed ventricular filling during diastole. There is a family history of sudden death below the age of 50. Which of the following would be your initial therapy?
A. Digoxin
B. Long-acting nitrates
C. Beta-blockers
D. Rate-limiting calcium channel blockers
E. Partial excision of the septum
A
C. Beta-blockers
18
Q
- A patient is admitted with pneumonia. A murmur is heard on examination. What finding points to mitral regurgitation?
A. Murmur louder on inspiration
B. Murmur louder with patient in left lateral position
C. Murmur louder over the right 2nd intercostal space midclavicular line
D. Corrigan’s sign
E. Narrow pulse pressure
A
B. Murmur louder with patient in left lateral position
19
Q
29. A 44-year-old woman attends her local accident and emergency department with a history of at least six months of frequent central chest pain in the early morning or during the night. She had no chest pain on exertion. This had been a particularly severe attack, lasting over 2 hours. Her pulse rate is 84/minute in sinus rhythm, and blood pressure is 134/86mmHg. The ECG shows anterior ST segment elevation, but troponin levels do not rise. Subsequent coronary angiography is normal. What is the most likely diagnosis? A. MI B. Stable angina C. Unstable angina D. Anxiety E. Variant angina
A
E. Variant angina
20
Q
28. A 21-year-old man is on his way home from a party when he experiences the sudden onset of rapid palpitations. He feels uncomfortable but not short of breath and has no chest pain. He goes to the nearest accident and emergency department, where he is found to have a supraventricular tachycardia (SVT) at a rate of 170/minute. Carotid sinus massage produced transient reversion to sinus rhythm, after which the tachycardia resumed. What would be the next step in your management? A. Repeat carotid sinus massage B. IV verapamil C. IV propranolol D. IV adenosine E. Synchronized DC cardioversion
A
D. IV adenosine
21
Q
27. A 49-year-old woman presents with increasing shortness of breath on exertion developing over the past three months. She has no chest pain or cough, and has noticed no ankle swelling. On examination, blood pressure is 158/61mmHg, pulse is regular at 88 beats per minute and there are crackles at both lung bases. There is a decrescendo diastolic murmur at the left sternal edge. What is the most likely diagnosis? A. Aortic regurgitation B. Aortic stenosis C. Mitral regurgitation D. Mitral stenosis E. Tricuspid regurgitation
A
A. Aortic regurgitation
22
Q
26. A 46-year-old man develops sudden severe central chest pain after lifting heavy cases while moving house. The pain radiates to the back and both shoulders but not to either arm. His BP is 155/90mmHg, pulse rate is 92 beats per minute and the ECG is normal. He is distressed and sweaty, but not nauseated. What would you consider the most likely diagnosis? A. Pneumothorax B. MI C. Pulmonary embolism D. Aortic dissection E. Musculoskeletal pain
A
D. Aortic dissection
23
Q
25. A 32-year-old woman attends her GP for a routine medical examination and is noted to have a mid-diastolic murmur with an opening snap. Her blood pressure is 118/71mmHg and the pulse is regular at 66 beats per minute. She is entirely asymptomatic and chest x-ray and ECG are normal. What would be the most appropriate investigation at this point? A. ECG B. Anti-streptolysin O titre C. Cardiac catheterization D. Thallium radionuclide scanning E. Colour Doppler scanning
A
D. Thallium radionuclide scanning
24
Q
- A 41-year-old woman is referred for assessment after suffering a second pulmonary embolus within a year. She has not been travelling recently, has not had any surgery, does not smoke and does not take the oral contraceptive pill. She is not currently on any medication as the diagnosis is retrospective and she is now asymptomatic. What should be the next step in her management?
A. Initiation of warfarin therapy
B. ECG
C. Thrombophilia screen
D. Insertion of inferior vena cava filter
E. Duplex scan of lower limb veins and pelvic utrasound
A
C. Thrombophilia screen
25
```
23. A 61-year-old man presents with a 2-hour history of moderately severe retrosternal chest pain, which does not radiate and is not affected by respiration or posture. He complains of general malaise and nausea, but has not vomited. His ECG shows ST segment depression and T wave inversion in the inferior leads. Troponin levels are not elevated. He has already been given oxygen, aspirin and intravenous GTN; he is an occasional user of sublingual GTN and takes regular bisoprolol for stable angina. What would be the most appropriate next step in his management?
A. IV low-molecular weight heparin
B. Thrombolysis with alteplase
C. IV nicardapine
D. Angiography with stenting
E. Oral clopidogrel
```
A. IV low-molecular weight heparin
26
22. A 52 year-old woman has been treated for several years with amlodipine and lisinopril for what has been presumed to be primary hypertension. She is seen by her GP having complained of persistent left loin pain. Her BP is 150/95mmHg. She is tender in the left loin and both kidneys appear to be enlarged. On urine dipstick testing, there is microscopic haematuria. Which of the following is likely to be the most appropriate investigation at this point?
A. Urinary tract ultrasound
B. Abdominal and pelvic computed tomography (CT) scan C. Microscopy of the urine (microbial and cytological)
D. Renal biopsy
E. Intravenous urogram
A. Urinary tract ultrasound
27
```
21. A 16-year-old boy is diagnosed with a small ventricular septal defect, having been screened by echocardiography because of a family history of hypertrophic obstructive cardiomyopathy. He is entirely asymptomatic, plays several sports regularly and has no growth retardation. The echocardiogram also confirms a small left to right shunt, with pulmonary to systemic flow ratio only just above one. Which of the following is the most likely to be a significant complication of his condition?
A. Pulmonary hypertension
B. Heart failure
C. Dysrhythmias
D. Endocarditis
E. Shunt reversal (right to left flow)
```
D. Endocarditis
28
20. A 16-year-old male is referred for assessment of hypertension. On average, his blood pressure is 165/85mmHg, with radiofemoral delay. There is a mid-systolic murmur maximal at the aortic area, and radiating to the back. Clinical findings and the ECG are compatible with left ventricular hypertrophy. What is the most likely underlying pathology?
A. Hypertrophic obstructive cardiomyopathy
B. Congenital aortic stenosis
C. Coarctation of the aorta
D. Patent ductus ateriosus
E. Atrial septal defect
C. Coarctation of the aorta
29
```
2. A 78-year-old woman is admitted with heart failure. The underlying cause is determined to be aortic stenosis. Which sign is most likely to be present?
A. Pleural effusion on chest x-ray
B. Raised jugular venous pressure (JVP)
C. Bilateral pedal oedema
D. Bibasal crepitations
E. Atrial fibrillation
```
D. Bibasal crepitations
30
```
19. A 57-year-old male is admitted complaining of headaches and blurring of vision. His blood pressure is found to be 240/150mmHg and he has bilateral papilloedema, but is fully orientated and coherent. He had been known to be hypertensive for about five years and his blood pressure control had been good on three drugs. However, he had decided to stop all medication two months before this event. Which of the following would be your preferred parenteral medication at this point?
A. Glyceryl trinitrate
B. Hydralazine
C. Labetalol
D. Sodium nitroprusside
E. Phentolamine
```
D. Sodium nitroprusside
31
```
18. A 63-year-old male was admitted to accident and emergency 2 days after discharge following an apparently uncomplicated MI. He complained of rapidly worsening shortness of breath over the previous 48 hours but no further chest pain. He was tachypnoeic and had a regular pulse of 110/minute, which proved to be sinus tachycardia. The jugular venous pressure was raised and a pan-systolic murmur was noted, maximal at the left sternal edge. Which of the following is the most likely diagnosis?
A. Mitral incompetence
B. Ventricular septal defect
C. Aortic stenosis
D. Dressler’s syndrome
E. Further myocardial infarction
```
B. Ventricular septal defect
32
17. A 76-year-old male is brought to accident and emergency after collapsing at home. He has recovered within minutes and is fully alert and orientated. He says this is the first such episode that he has experienced, but describes some increasing shortness of breath in the previous six months and brief periods of central chest pain, often at the same time. On examination, blood pressure is 115/88mmHg and there are a few rales at both bases. On ECG there are borderline criteria for left ventricular hypertrophy. Which of the following might you expect to find on auscultation?
A. Mid-diastolic murmur best heard at the apex
B. Crescendo systolic murmur best heard at the right sternal edge
C. Diastolic murmur best heard at the left sternal edge
D. Pan-systolic murmur best heard at the apex
E. Pan-systolic murmur best heard at the left sternal edge
B. Crescendo systolic murmur best heard at the right sternal edge
33
16. A 62-year-old male presents with palpitations, which are shown on ECG to be atrial fibrillation with a ventricular rate of approximately 130/minute. He has mild central chest discomfort but is not acutely distressed. He first noticed these about 3 hours before coming to hospital. As far as is known this is his first episode of this kind. Which of the following would you prefer as first-line therapy?
A. Anticoagulate with heparin and start digoxin at standard daily dose
B. Attempt DC cardioversion
C. Administer bisoprolol and verapamil, and give warfarin
D. Attempt cardioversion with IV flecainide
E. Wait to see if there is spontaneous reversion to sinus rhythm
B. Attempt DC cardioversion
34
```
15. A 48-year-old woman has been diagnosed with essential hypertension and was commenced on treatment three months ago. She presents to you with a dry cough which has not been getting better despite taking cough linctus and antibiotics. You assess the patient’s medication history. Which of the following antihypertensive medications is responsible for the patient’s symptoms?
A. Amlodipine
B. Lisinopril
C. Bendroflumethiazide
D. Frusemide
E. Atenolol
```
B. Lisinopril
35
14. You see a 57-year-old woman who presents with worsening shortness of breath coupled with decreased exercise tolerance. She had rheumatic fever in her adolescence and suffers from essential hypertension. On examination she has signs which point to a diagnosis of mitral stenosis. Which of the following is not a clinical sign associated with mitral stenosis?
A. Malar flush
B. Atrial fibrillation
C. Pan-systolic murmur which radiates to axilla
D. Tapping, undisplaced apex beat
E. Right ventricular heave
C. Pan-systolic murmur which radiates to axilla
This is a sign of mitral regurgitation.
36
```
13. A 56-year-old man presents to your clinic with symptoms of exertional chest tightness which is relieved by rest. You request an ECG which reveals that the patient has first degree heart block. Which of the following ECG abnormalities is typically seen in first degree heart block? A. PR interval >120ms
B. PR interval >300ms
C. PR interval <200ms
D. PR interval >200ms
E. PR interval <120ms
```
D. PR interval >200ms
37
```
12. A 78-year-old woman is admitted to your ward following a 3-day history of shortness of breath and a productive cough of white frothy sputum. On auscultation of the lungs, you hear bilateral basal coarse inspiratory crackles. You suspect that the patient is in congestive cardiac failure. You request a chest x-ray. Which of the following signs is not typically seen on chest x-ray in patients with congestive cardiac failure?
A. Lower lobe diversion
B. Cardiomegaly
C. Pleural effusions
D. Alveolar oedema
E. Kerley B lines
```
A. Lower lobe diversion
38
```
11. A 67-year-old man presents to accident and emergency with a 3-day history of shortness of breath. On examination you palpate the radial pulse and notice that the patient has an irregular heart beat with an overall rate of 140bpm. You request an electrocardiogram (ECG) which reveals that the patient is in atrial fibrillation. Which of the following would you expect to see when assessing the JVP?
A. Raised JVP with normal waveform
B. Large ‘v waves’
C. Cannon ‘a waves’
D. Absent ‘a waves’
E. Large ‘a waves’
```
D. Absent ‘a waves’
39
10. Ventricular tachyarrhythmia While on call you are called by a nurse to a patient on the ward complaining of light headedness and palpitations. When you arrive the patient is not conscious but has a patent airway and is breathing with oxygen saturation at 97 per cent. You try to palpate a pulse but are unable to find the radial or carotid. The registrar arrives and after hearing your report of the patient decides to shock the patient who recovers. What is the patient most likely to have been suffering?
A. Torsades de Pointes
B. Ventricular fibrillation
C. Sustained ventricular tachycardia
D. Non-sustained ventricular tachycardia
E. Normal heart ventricular tachycardia
B. Ventricular fibrillation
40
1. A 65-year-old man presents with central crushing chest pain for the first time. He is transferred immediately to the closest cardiac unit to undergo a primary percutaneous coronary intervention. There is thrombosis of the left circumflex artery only. Angioplasty is carried out and a drug-eluding stent is inserted. What are the most likely changes to have occurred on ECG during admission?
A. ST depression in leads V1–4
B. ST elevation in leads V1–6
C. ST depression in leads II, III and AVF
D. ST elevation in leads V5–6
E. ST elevation in leads II, III and AVF
D. St elevation in leads V5-6
Big Ass Clinical Medicine
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