CVS

Question 1

Answer 1

AF

Question 2

Mid-systolic murmur with systolic click at apex

Answer 2

Mitral valve prolapse AND regurg

Question 3

Someone with chest pain radiating to the back and collapse. Presents with BP in the right arm much higher than in the left (210/100 vs 150/100) . Weakness in L arm and leg. Dx?

Answer 3

Aortic dissection

Question 4

Man comes in with left side central chest pain, and pain on inspiration. ECG given.

Answer 4

Acute pericarditis (widespread ST elevation and PR depression)

Question 5

Old guy with T2DM. Only medication he is on is Insulin. Comes in for routine diabetes check. Proteinuria in urine. BP consistently in 160s. ? what medication to start?

Answer 5

ACE-inhib (e.g. quinapril)

Question 6

IVDU, signs of right sided heart failure, elevated JVP with v waves, pansystolic murmur at LLSE, what’s the cause?
Mitral regurg
Mitral stenosis
Aortic regurg
Aortic stenosis
Tricuspid regurg
Tricuspid stenosis

Answer 6

pansystolic murmur at LLSE = from location can deduce this is tricuspid.

Systolic - must be regurgitation

Also regurg following IVDU infective endocarditis much more common than stenosis

Question 7

Some guy at urgent docs here on a business trip. He keeps having jaw pain. History of HTN. He had severe jaw pain when walking back from lunch today, but since resolved. Oral cavity and jaw appear fine on exam. What is an important immediate investigation you must do? Was the wording not something like what initial management would you do?
a. Cardiology referral
b. Dentist referral
c. ECG
d. Dental X-ray
e. Analgesia

Answer 7

ECG

Question 8

Asian lady on microgynon and salbutamol. Came in with pleuritic CP and dyspnoea. High JVP. hypotensive. Xray given [looked normal] and an ECG underneath [RV strain pattern with ?sinus or RBBB]. What would be the most appropriate treatment?
· Heparin
· Pericardiocentesis
· Cardioversion
- IV morphine

Answer 8

Heparin

Sounds like a pulmonary embolism

Microgynon = combined OC

Question 9

Fijian guy in a RTA, where he rear ended someone. Now has pain, ventricular ectopics, irregular HR and pulse of 100, JVP not elevated, BP 120/80. Can hear an anterior rub on auscultation. ECG shows multiple PVCs.
· Cardiac tamponade
· Aortic dissection
· Atrial fibrillation
· Myocardial infarction
· Myocardial contusion
· Pericarditis

Answer 9

Myocardial contusion (bruising)

Question 10

Chick with chest pain associated with inspiration. Hemodynamically stable BP 100-120ish/80ish and HR around 80
?maybe has fever

ECG shows Global ST - concave up,

Treatment?

Answer 10

NSAIDs for pericarditis

Question 11

Guy ~38 years old. Returned from recent overseas business trip. ECG + history. Sudden chest pain, short of breath, sweaty. Hypotensive. Appears to be ST elevation in aVF (and leads II, III, +1 with some ST depression in anteroseptal leads?

Answer 11

Inferior MI

Question 12

28yo female has hypertension, has history of fevers and enuresis as a child, what is
the hypertension

Essential hypertension, PCKD, reflux nephropathy, analgesic nephropathy, chronic
glomerulonephritis

Answer 12

This sounds like recurrent UTIs in childhood leading to kidney damage?

Probably reflux caused the recurrent UTIs –> enuresis, fevers…

Eventually leads to high blood pressure.

Question 13

AF in older person
Amiodarone and anticoagulant,
beta blocker,
CCB, amiodarone anticoag and cardioversion in 6 wks,
cardiovert

Answer 13

New onset AF <48 hours or haemodynamic instability could do cardioversion…

But i think this patient would be treated with beta-blocker and anticoagulation (warfarin/dabigatrin) - prob the best answer here is amiodarone + anticoag

Question 14

ECG of VT (wide complex QRS tachycardia). Treatment?

Answer 14

If acute –> cardiovert

Question 15

What happens in digoxin toxicity?

Answer 15

Hyperkalemia

Question 16

Pt with HTN with history of gout and asthma, already on ACEI but HTN still
uncontrolled, next drug to use?

Answer 16

CCB

Question 17

BNP
Produced in atria,
low levels in heart failure, high levels in CKD,
is an anti-natriuretic
Peptide

Answer 17

High levels in CKD

Question 18

chest pain 1-3 days after MI. changes with position

Answer 18

Pericarditis

Question 19

man accident. you don’t have a stethoscope. JVP is normal. percussion is normal. He
has cold peripheries. what is the cause of shock in this man?

Answer 19

?aortic dissection

Question 20

25-year-old found dead in bed prev. Healthy

Answer 20

Hypertrophic cardiomyopathy

Question 21

Obese patient with symptoms OSA, has (+) JVP bilaterally measured up to 6 cm.
jugular waves are present, lung function test given, raised JVP due to

Answer 21

RV failure due to chronic ischemia

Question 22

First line treatment for essential hypertension

Answer 22

Thiazide diuretic?

‘First-line choices can be a thiazide, an ACE inhibitor or ARB, or a calcium channel blocker’

Question 23

Best investigation for heart failure

Answer 23

bpac says ECG, blood tests for BNP too but not all that specific

Question 24

Murmur after MI, loud, harsh pansystolic in lower left sternal border

Answer 24

VSD from infarction

(A loud, harsh, holosystolic murmur at the lower left sternal border is common)

Question 25

Patient with chest pain on exertion, now pain while sitting/radiating to arms

Answer 25

Acute coronary syndrome e.g. unstable angina

Question 26

Patient presents with markedly raised jvp, R>L measured up to 8cm, jugular wave can’t be seen. Mediastinal enlargement. Most likely cause is

Answer 26

SVC obstruction

Question 27

10 year old with bilateral calf pain on walking and weak femoral pulses

Answer 27

coarctation of the aorta Can cause low blood flow to legs, radio-femoral delay

Question 28

MI = 2 days later breathless + pan systolic murmur

Answer 28

MR due to papillary muscle rupture

Question 29

Girl with chest pain, SOB, on OCP. Chest X-ray and ECG. What do you treat her with?

Answer 29

Heparin (PE)

Question 30

Patient with AF given warfarin, what other drug would you give

Answer 30

Beta blocker first line

Question 31

Asian lady with dyspnoea but normal cxr and tachy ecg, management. Has asthma and on pill comes in with acute dyspnoea and pleuritic pain. Hyperinflated lungs. ECG shows S1,Q3,T3.

Answer 31

LMWH or thrombolysis (only thrombolyse in cases of massive/saddle PE)

Question 32

Man with raised JVP, soft heart sounds. Investigation?

Answer 32

Echo as this sounds like tamponade. (soft heart sounds)

Question 33

40 y/o woman with paroxysmal AF with fast heart rate. What questions indicate diagnosis?

Answer 33

Palpitations when you get excited? Sudden death in the family? I have no idea.

Question 34

60 y/o severe retrosternal chest pain radiating to left arm. Palpable radial pulse in left arm but no pulse in right arm. Diagnosis?

Answer 34

Aortic dissection

Question 35

ECG showing concave ST segment.

Answer 35

Pericarditis

Question 36

70 y/o SOB on exertion. Dilated apex by 3cm. Diastolic murmur left sternal border 3/6.

Answer 36

Aortic regurg

Question 37

Middle aged lady with progressive SOB, only when she is is cycling to work in the morning. No other significant history, ?maybe family history of heart failure. All exams are fine. which investigation? Exercise ECG. CXR Echo Spirometry Haemoglobin estimation - simple anaemia

Answer 37

Lol i feel like if chest pain would do an exercise ECG... But just SOB - maybe just bloods at this point to see Hb + BNP...

Question 38

Post MI few days about to be discharged with chest pain, worse when lying flat and on inspiration, relieve by sitting forwards

Answer 38

Pericarditis

Question 39

HR 40. Treatment?

Answer 39

Atropine for bradycardia.

Question 40

Man with AAA which investigation do you use?

Answer 40

Duplex USS

Question 41

Māori man with non-acute hx of angina and reduced exercise intolerance, shows ECG with ST depressions in ALL leads presents with increasing fatigue, on thiazide. Flattened T waves. ECG also showed some subtle U waves. Diagnosis?

Answer 41

Hypokalemia (thiazides!!)

Question 42

Elderly man has just started taking doxazosin. Had recently had falls. Why?

Answer 42

Postural hypotension

Question 43

Single ECG strip showing 1st degree heart block, what vessel is most likely to be diseased?

Answer 43

RCA supplies both SA + AV nodes. (atrioventricular node artery comes off RCA)

Question 44

Asian lady on microgynon (COCP) and salbutamol. Came in with pleuritic chest pain and acute dyspnoea. High JVP. Normal X-ray, ECG sinus tachy with an RV strain pattern, S1Q3T3. What would be the most appropriate treatment? a) Cardioversion b) Defibrillate c) IM Adrenaline d) Low molecular weight heparin e) Pericardiocentesis f) Thoracocentesis g) Atropine

Answer 44

Low molecular weight heparin (this is a PE)

Question 45

40 year old Maori nurse presents with a history of palpitations. ECG shows irregularly irregular rhythm, no p waves, f waves. What is it?

Answer 45

AF

Question 46

Young women with chest pain associated with inspiration and fever. Hemodynamically stable BP 100-120/80 and HR 80. ECG given. Global saddle shaped ST elevation. Management? a) Cardiac catheter b) Thrombolytics c) IV GTN d) Oral NSAID e) Exercise/stress-test ECG

Answer 46

This is acute paricarditis

Question 47

Answer 47

??? AAA??

Question 48

Tokeleuan male with 4.5cm AAA. What do you use to monitor? a) Duplex USS b) MRI c) CT

Answer 48

Duplex USS Monitor 3-6 months Over 5.5 needs repair

Question 49

Guy has epigastric pain for a few hours, which radiates to back. He dies before the ambos get to him. Diagnosis?

Answer 49

Ruptured AAA

Question 50

Māori man with non-acute hx of angina and reduced exercise intolerance, shows ECG with ST depressions in ALL leads presents with increasing fatigue, on thiazide. Flattened T waves. ECG also showed some subtle U waves. Cause?

Answer 50

Hypokalemia

Question 51

Man with acute pleuritic pain with SOB. No risk factors. First investigation? a) D dimer b) CXR c) CTPA d) VQ scan e) Doppler USS

Answer 51

D-dimer i think

Question 52

Answer 52

Long PR interval = AV node dysfunction What supplies the AV node? The AVN branch of RCA

Question 53

Man with raised JVP, soft heart sounds. Investigation? a) Echo b) ECG c) CXR

Answer 53

Known as Beck’s triad: low BP, distended jugular veins, muffled heart sounds = cardiac tamponade. Investigation = ECHO

Question 54

Man with hypertension not controlled by quinapril. Has asthma and gout. What treatment? a) Add CCB b) Add thiazide c) Swap to CCB d) Add beta blocker

Answer 54

No beta blocker (asthma), dont do thiazide (gout), add CCB

Question 55

Patient with AF given warfarin. What other drug would you give? a) Beta blocker b) Diltiazem c) Verapamil d) Amiodarone

Answer 55

Needs something for rate/rhythm control... Beta-blocker

Question 56

75 year old man on cilazapril, metoprolol, furosemide and aspirin. Ejection fraction of 29%. Breathless. Cr 10, K+ 4. What is next treatment? a) Spironolactone b) Diltiazem c) Digoxin

Answer 56

Spirinolactone HFrEF = reduced EF (<50%) – systolic dysfunction - Start with diuretic (reduce Na/water retention) 􏰀 add ACEi/ARB at max dose (reduce afterload) + beta blocker (reduce SNA) - If still sx despite max dose ACEi 􏰀 add spironolactone 􏰀 if still sx add Entresto or digoxin HFpEF = preserved EF (>=50%) – diastolic dysfunction - Start with diuretic 􏰀 add ACEi or beta blocker (don’t need max dose) - Add digoxin if AF

Question 57

Patient had an MI. 2 days later breathless and new pan-systolic murmur at apex. Diagnosis?

Answer 57

apex = mitral, regurgitation due to papillary muscle rupture

Question 58

Patient had an MI. Developed muffled heart sounds. Diagnosis? a) Papillary muscle rupture b) Ventricular free wall rupture c) Pericarditis

Answer 58

Tamponade - i think ventricular free wall rupture

Question 59

Patient had an MI. Developed pleuritic chest pain and pericardial rub. Diagnosis? a) Papillary muscle rupture b) Ventricular free wall rupture c) Pericarditis/Dressler syndrome

Answer 59

Pericarditis/Dressler syndrome dressler occurs a few weeks later - immune mediated response

Question 60

Patient with CHF, SOB and bilateral pulmonary oedema. How do you transport them? a) Transport sitting in ambulance b) Transport lying down in ambulance c) Car d) Walk e) Scooter

Answer 60

Transport sitting in ambulance

Question 61

Patient comes to GP with BP 150/100 and asymptomatic. Treatment? a) Bendroflumethiazide b) Furosemide c) Cilazapril d) Amlodipine

Answer 61

Essential HTN tx: thiazide = 1st line, CCB = 2nd line - ACEi/ARB = DM/HF, BB = post-MI

Question 62

Best investigation for heart failure? a) Rest ECG b) Exercise ECG c) BNP d) Echo

Answer 62

ECHO = gold standard

Question 63

25-year-old found dead in bed previously healthy. Family history of sudden death at young age. Most likely cause of death? a) Restrictive cardiomyopathy b) Hypertrophic cardiomyopathy c) Dilated cardiomyopathy d) Myocardial infarction

Answer 63

Hypertrophic cardiomyopathy - genetic hx, sudden death

Question 64

Obese patient with symptoms OSA, has JVP bilaterally measured up to 6 cm. Jugular waves are present. Raised JVP due to

Answer 64

RV failure due to chronic ischaemia

Question 65

Man in accident. You don’t have a stethoscope. JVP is normal. Percussion is normal. He has cold peripheries. What is the cause of shock in this man?

Answer 65

Aortic dissection

Question 66

Man just returned from a pacemaker insertion. HR 100, RR high, muffled heart sounds, high JVP +++. ECG showed AF. What imaging do you do? a) Echocardiogram b) CXR c) CT

Answer 66

Pacemaker insertion 􏰀 wire through heart 􏰀 cardiac tamponade muffled heart sounds = cardiac tamponade = ECHO