1
Q
most individuals who present with a new onset bradycardia post-STEMI have suffered from a
A
right coronary artery occlusion
2
Q
part of the step four management of essential hypertension?
A
Cardio-selective beta blockers such as atenolol
3
Q
no ECG changes but typical presentation and raised troponin?
A
can be classified as NSTEMI
4
Q
patient has experienced a minor deterioration in renal function after the initiation of ramipril. Mx?
A
Common as ACE inhibitors cause efferent vasodilation of the renal glomeruli and reduce the eGFR.
NICE guidelines state that as long the eGFR does not reduce by more than 25%; the serum creatinine does not increase by more than 30% or the potassium does not increase above 5 mmol/L, management should only involve monitoring the renal function to see if there is further deterioration in kidney function.
Repeat bloods in 2 weeks
5
Q
A recent history of ischemic stroke within the past x months is an absolute contraindication to thrombolytic therapy
A
3
6
Q
thrombolytic therapy CI
A
Severe hypertension at presentation (systolic blood pressure >180 mmHg or diastolic blood pressure >110 mmHg) is a relative contraindication to thrombolytic therapy.
7
Q
HTN drugs swelling
A
ramipril = angioedema
amlodipine = peripheral oedema e.g. ankle swelling
8
Q
central chest pain on exertion and is strongly associated with the use of cocaine
A
coronary artery vasospasm
9
Q
acute pulmonary oedema and hypotension two days after an inferior MI, with a new soft apical murmur consistent with acute mitral regurgitation.
cause?
A
Papillary muscle rupture is the most likely cause, particularly involving the posteromedial papillary muscle, which has a single RCA blood supply. Urgent echocardiography (TTE, then TOE if needed) confirms the diagnosis. Surgical repair or replacement should occur within 24 hours.
10
Q
A 74 year old gentleman with a headache is referred to the medical team by his general practitioner. The patient is known to have hypertension, taking regular amlodipine and ramipril, and has been referred because his blood pressure reading is 210/142; the GP has double-checked this measurement. On assessment, the patient is alert and no abnormality, other than the hypertension, is noted on systemic examination. The patient has an IV cannula in situ.
Which of the following is the single best initial action?
A
not oral amlodipine as headache raises suspicion of end organ damage of brain bleed….
therefore give IV Labetalol 50mg for acute hypertensive emergency
11
Q
A 68-year-old man presents to the Emergency Department with sudden onset chest heaviness, breathlessness and sweating. He has a background of hyperlipidaemia and cigarette smoking. Clinical examination is unremarkable. A 12-lead ECG reveals ST elevation in V1-4. While waiting for a decision on his management he suddenly becomes unresponsive. Despite prompt CPR, he is unable to be resuscitated.
What is the most likely cause of death in this patient?
A
Ventricular fibrillation
Ventricular fibrillation is the most common arrhythmia and cause of death in acute myocardial infarction. It can occur as a consequence of acute ischaemia, but can also occur during reperfusion.
12
Q
CCB amlodipine weird side effect
A
gum hyperplasia and pain
13
Q
A
The inferior and posterior aspect of the left ventricle
This ECG shows ST-segment elevation in leads II, III and aVF, and inferior ST depression in leads V1-V3. This is highly indicative of a posterior infarct. A posterior infarct usually accompanies an inferior infarct (As in this case) or a lateral infarct. A posterior infarct indicates the involvement of the posterior aspect of the left ventricle
14
Q
valves
A
15
Q
aortic regurgitation vs stenosis pulsed
A
regurgitation - collapsing
stenosis - slow rising
16
Q
what indicates severe aortic stenosis on echo
A
A peak trans-valvular pressure gradient greater than 40 mmHg on echocardiogram indicates severe aortic stenosis.
or a valve area of under 1 cm
17
Q
A 72-year-old woman attends her General Practitioner feeling extremely fatigued. She has a background of chronic obstructive pulmonary disease (COPD), left-sided heart failure (with an ejection fraction of 40%) and hypertension. She describes progressive dyspnoea on exertion, which is now interfering with even basic activities such as walking short distances. On examination, her jugular venous pressure (JVP) is raised, and giant V waves are visible. She has peripheral oedema to her knees bilaterally. Examination of the abdomen reveals pulsatile hepatomegaly.
Given the likely diagnosis, which type of cardiac murmur would be heard on auscultation?
A
holosyctolic at left sternal border from tricuspid regurg
18
Q
loud 4th heart sound in aortic stenosis?
A
Left ventricular hypertrophy
19
Q
A 69-year-old woman reports worsening breathlessness over a year, progressing from walking 100m without difficulty to dyspnea at rest. Leaning forward relieves symptoms, and she cannot lie flat due to intolerable breathlessness.
She does not report any chest pain, but feels occasional palpitations and dizziness.
Her only past medical history is rheumatic fever as a teenager.
She is breathless at rest with an irregularly irregular pulse. Examination reveals a mid-diastolic murmur with an early snap, loudest on expiration, no peripheral edema, and normal JVP.
Chest XR shows an enlarged cardiac silhouette with some pulmonary oedema.
Which of the following complications of rheumatic fever is this patient symptomatic with?
A
Mitral stenosis
This is the correct answer. Isolated, mitral stenosis (MS) it is the most commonly encountered single valve lesion secondary to rheumatic heart disease. It is characterised by a diastolic murmur (typically mid-diastolic) exacerbated by expiration (hence left sided). Pliable valves sometimes have an audible opening “snap”.
The stenosis also leads to left atrial dilatation, increasing the risk of atrial fibrillation (AF), which is a common complication of MS
20
Q
A 50-year-old man with a history of hypertension presents to the emergency department with severe, frontal headache of a gradual nature, visual disturbances, confusion and shortness of breath. On examination, his blood pressure is 240/130 mmHg. Whilst in the emergency department, he has a seizures that lasts a duration of 4 minutes. Fundoscopy reveals papilloedema.
Which of the following complications of his condition is he most likely experiencing?
A
hypertensive encephalopahty - papilloedema/headaches/visual disturbance
21
Q
bus driver with angina
A
must tell DVLA
22
Q
pulse pressure
A
aortic stenosis - narrow, regurg - wide
23
Q
aortic stenosis sign of severe disease
A
This patient has presented with aortic stenosis. In this condition, a soft or inaudible aortic second heart sound indicates that the valve has become immobile and correlates with severe disease.
24
Q
prognosis improving drugs in angina
A
Patients with stable angina should all have as the first-line treatment an antiplatelet agent (aspirin) and a statin even if they have normal cholesterol.
25
In individuals under 65 years of age, what is the most common cause of aortic stenosis
a congenital bicuspid valve
calcification if over 65
26
This patient has presented with 3 typical features of anginal pain and has a negative troponin:
Constriction like pain in chest/neck/arm/jaw
Brought on by physical exertion
Alleviated by rest
Ix?
CT coronary angiogram
27
heart murmur
aortic stenosis - This ECG shows a widened QRS complex in V6, in particular, the R wave looks notched. There is also a deep S wave in V1. This is an ECG finding consistent with LBBB.
Aortic stenosis is a well-documented cause of LBBB. The reason is that the calcification that leads to aortic stenosis can extend beyond the valve into the conduction system of the heart (i.e. the left bundle branch)
28
mitral prolapse causes
mitral regurg
29
A 48 year old female patient presents to the general practitioner with gradually worsening shortness of breath and cough. She has no active medical conditions, is a non-smoker, and does not drink alcohol.
On physical examination there is an irregularly irregular pulse, a tapping apex beat, and a mid-diastolic murmur best heard over the apex.
Which of the following is the most likely cause for her presentation?
The patient has mitral stenosis. 95% of cases are caused by previous rheumatic fever. Atrial fibrillation is a common finding in mitral stenosis due to increases in left atrial pressure and concomitant left atrial dilation
30
weird sign of aortic regurgitation
nail bed pulsation
31
aortic stenosis vs pulmonary stenosis
Both ejection-systolic murmur.
However, radiation would be to the carotids in A and the shoulder in P
A would be loudest on expiration, P loudest on inspiration
A is associated with a reduced or absent S2. It is most commonly caused by calcification of the aortic valves.
P = split S2, Right HF/noonans
32
A 57 year old male patient is reviewed on the ward following primary percutaneous coronary intervention for an anterior ST elevation myocardial infarction. He has become suddenly short of breath and pale a number of hours after his procedure.
On examination his saturations are 91% on 2 litres of oxygen and respiratory rate is 25 breaths/min, he has crackles bilaterally up to his mid zones. He has a heart rate of 125bpm and his blood pressure is 94/44 mmHg with a pansystolic murmur heard loudest at the apex. He is afebrile.
His ECG shows sinus tachycardia
What is the likely pathology driving this gentleman’s presentation?
Acute mitral regurgitation is commonly seen 2-10 days post myocardial infarction and can be seen with both anterior and inferior MIs. This can be due to papillary muscle rupture A rapid rise of pressure in a non-dilated and non-compliant left atrium and subsequent lack of forward flow causes hypotension and tachycardia. It is a medical emergency and needs mitral valve repair or replacement
33
endocarditis Ix after trans thoracic ECHO
TOE
34
Metallic heart valves should be anti-coagulated with
Warfarin
35
co prescribe ACEi and ARB?
no
36
In a hypertensive patient < 55 years old who is on an ACE-i and is intolerant to calcium channel blockers,
indapamide - thiazide-like diuretics are the next line therapy
37
A 50-year-old man presents to the GP for a review of his hypertension after being prescribed a new antihypertensive drug. Ambulatory blood pressure monitoring was performed before the appointment and showed an average reading of 130/78 mmHg.
He has been compliant with his treatment; however, since starting the new drug, he has been experiencing intermittent palpitations and dizziness and would like to discuss alternative treatments. An ECG is performed during an episode which demonstrates sinus tachycardia only, and no other changes.
What is the most likely cause?
Nifedipine causes peripheral vasodilation which may result in reflex tachycardia
38
If a patient with AF has a stroke or TIA, the anticoagulant of choice should be
warfarin or a direct thrombin or factor Xa inhibitor
39
In the context of a tachyarrhythmia, a systolic BP < 90 mmHg →
DC cardioversion
40
sarcoidosis stageing
41
A 79 year old woman sees her GP with progressive shortness of breath on exertion. She has an intermittent cough, mainly in the morning, during which she brings up white phlegm. smoker. Dx?
COPD
42
lynch syndrome gene
MLH1
APCC is FAP
43
A 67-year-old man becomes increasingly breathless with chest pain 3 hours after the removal of a chest drain. This was inserted to drain a right-sided pleural effusion secondary to lymphoma. 500ml of bloodstained fluid were drained before removal.
What is the most likely diagnosis?
pneumothorax
44
A 34 year old woman is admitted to the Acute Medical Unit with a 2 month history of fatigue, intermittent low-grade fevers, and unintentional weight loss of 4 kg. She also reports a cough and occasional shortness of breath on exertion, but no chest pain or wheeze. There is no recent travel or smoking history. On examination, she appears well, with no clubbing or cyanosis. Respiratory exam is normal. There is no palpable lymphadenopathy or hepatosplenomegaly. Observations are stable, and oxygen saturations are 97% on room air. Her chest x-ray shows the following: bilateral pilar lymphadenopathy
sarcoidosis
45
ph indication for a chest drain
A pleural fluid pH of < 7.2 would indicate that this patient has an empyema. In this case, this would suggest the urgent need for a chest drain to drain the infected fluid.
46
A 66-year-old woman presents to the Accident and Emergency with a four day history of dyspnoea and productive cough with white frothy sputum. She uses three pillows to sleep at night.
On examination she has bilateral basal coarse crackles. A chest X-ray is requested showing alveolar oedema and bilateral pleural effusions.
Which of the following strategies should be part of the patient’s long term management plan?
Captopril, Bisoprolol and Pneumococcal vaccination
This is the correct answer. The patient has signs, symptoms and chest x-ray are consistent with left sided heart failure. Patients with chronic heart failure are managed with angiotensin converting enzyme inhibitors (ACEi) and beta blockers as first line management. ACE-i work on the renin angiotensin aldosterone axis to dilate blood vessels and decrease blood pressure. Beta blockers reduce the heart rate and improve the ejection fraction as the heart can fill more efficiently. Additionally, the pneumococcal vaccine is given to patients with chronic heart failure and those over the age of 65 to reduce the risk of developing a streptococcus pneumoniae pneumonia
47
A 29 year old man attends the GP for review of his asthma. He is currently taking a moderate-dose MART inhaler however he is waking up at night two-three times a week feeling wheezy. Examination and observations are normal.
What is most appropriate next step?
Check FeNO and blood eosinophil level
For patients on a moderate-dose MART who continue to experience symptoms, NICE recommends measuring FeNO and blood eosinophil levels to assess airway inflammation. This helps determine if additional treatment, such as a leukotriene receptor antagonist (LTRA), a long-acting muscarinic antagonist (LAMA), or biologics, may be required.
48
HIV pt with resp symptoms, PCP likely, tesT?
silver stain of fungus
49
A 55-year-old woman, persistent cough, productive of yellow sputum that is sometimes blood-tinged.
OE- finger clubbing and coarse inspiratory crepitations on ascultation.
Which of the following is the most appropriate treatment to initiate?
bronchiectasis - chest physio
50
preceding flu-like illness, dry cough, erythema multiforme (target-shaped lesions) and evidence of anaemia (shortness of breath and low haemoglobin) suggest
this is mycoplasma which is a common cause of atypical pneumonia
51
CURB 65
52
A 77-year-old female is being mechanically ventilated on ICU following admission for a very severe exacerbation of COPD. Her mechanical ventilation pressures have increased acutely but her observations are stable. On examination the right lung has reduced air entry and is hyper-resonant to percussion. There is no tracheal deviation.
What is the next most appropriate action for the doctor to take?
organise urgent CXR
53
salmeterol and tiotropium
LABA and LAMA
54
fluticasone
steroid
55
spirometry in bird causing pulmonary fibrosis
restrictive = proportional decrease, Normal FEV1/FVC ratio
56
what is formoterol
laba
57
first line mx for newly diagnosed asthma in person over 12
This aligns with NICE's first-line recommendation for people aged 12 and over with newly diagnosed asthma. The low-dose ICS/formoterol inhaler provides immediate symptom relief (via formoterol) and anti-inflammatory action (via the corticosteroid) in one inhaler.
58
weird EPO consequence of OSA
Increase in red blood cell mass
Chronic nocturnal hypoxaemia in obstructive sleep apnoea (OSA) stimulates erythropoietin release from the kidneys, driving increased red blood cell production. This compensatory mechanism improves the oxygen-carrying capacity through the production of red blood cells, but it causes blood hyperviscosity, which may worsen cardiovascular risk. It is the most frequent haematological consequence of OSA and often improves with effective CPAP therapy.
59
bradycardia give
atropine
60
PE mx in pt with anti phospholipid syndrome
The standard treatment for a pulmonary embolism (PE) in a patient with antiphospholipid syndrome (APS) is to use LMWH in combination with warfarin. LMWH is administered for at least 5 days or until the international normalised ratio (INR) reaches 2.0 on two separate occasions. This combined approach is necessary due to the need for rapid anticoagulation with LMWH and the delayed onset of action of warfarin.
61
Tachyarrythmias when signs of decompensation - chest pain, confusion, hypotension or signs of heart failure ... mx
DC cardioversion would be indicated. even with signs of mitral valve cause that would be sorted at a later date you would cardiovert first
62
WPW
63
aortic dissection signs
Radio-radial delay
Radio-femoral delay
Blood pressure differential between arms
64
aortic dissection classification
Stanford Type A: Involves the ascending aorta, arch of the aorta
Stanford Type B: Involves the descending aorta.
65
aortic dissection mx
A = surgery
B = surgery if end organ damage. Give Iv labetalol and morphine
66
A 34 year old woman presents with persistent nasal congestion, rhinorrhoea, and itchy eyes. Her symptoms have been ongoing for several months and worsen when she is at home. Over-the-counter cetirizine daily has provided minimal improvement.
Which of the following is the most appropriate next step in her management?
Prescribe intranasal corticosteroids
This is correct. This patient meets the criteria for moderate-to-severe persistent allergic rhinitis, as symptoms are chronic and affect sleep and functioning. NICE guidance recommends intranasal corticosteroids as first-line for these cases, due to their superior efficacy over antihistamines. Patients should be advised that onset is within 6–8 hours, but maximal effect may take 2 weeks.
67
pulmonary HTN ECG
Pulmonary hypertension is associated with a number of conditions (progression of bronchiectasis in this case) and typically presents with shortness of breath, fatigue and syncope. Some other indicative features are raised jugular venous pressure, loud second heart sound and pitting oedema.
P pulmonale is a right atrial abnormality that is seen on ECG as tall, peaked P waves. It is a feature that can be seen on ECG in patients with pulmonary hypertension, as it is a cause of right atrial enlargement.
68
malignant PE pleural fluid findings
Cytology is positive in >60% of malignant pleural effusions
69
dx and mx
atrial flutter, 2.5mg bisoprolol PO
6mg of adenosine would be for a fib but you can see flutter waves here
70
A 58 year old caucasian male attends the GP clinic for a routine review of his hypertension. On examination his blood pressure is 183/121. He denies any chest pain, leg swelling or shortness of breath. His current medications are amlodipine 5mg and atorvastatin 20mg.
What is the next step in this patient's management?
Urea & Electrolytes and perform fundoscopy
This patient has accelerated hypertension (BP >180/120). According to NICE guidance these patients need to be ruled out for chest pain, signs of heart failure, AKI and any ocular complications such as papiloedema and retinal haemorrhages. Many of these have already been excluded via examination but kidney function and ocular complications still need to be ruled out. If the patient has no signs of end organ damage they should be reviewed again in a week and perform ambulatory blood pressure monitoring in the meantime.
71
A 75-year-old male presents to A&E with multiple falls, he gives a poor history as he is intoxicated. A CT scan is performed, which shows multiple small infarcts throughout the brain.
Which of the following investigation findings is most likely to explain his presentation?
Irregularly, irregular rhythm on a 24hr Holter Monitor -
Atrial fibrillation is knowns to be a significant risk factor for stroke. In atrial fibrillation as the size of the clots forms vary, they can dislodge into different parts of the brain as well as a cause of infarcts of different sizes. The finding of atrial fibrillation, causing multiple mini-strokes is most likely to explain the appearance of this ECG
72
A 62 year old female presents to the Emergency Department with intermittent central chest pain. These episodes typically occurs at rest and has her symptoms have resolved by the time she reaches the Emergency Department. An ECG is performed on arrival and demonstrates deeply inverted T-waves in precordial leads V2-V4.
What is the likely diagnosis?
Wellens syndrome
Wellens syndrome is caused by severe proximal LAD stenosis and characterized by deeply inverted or biphasic T-waves in leads V2-V3. This patient's ECG findings and history of chest pain primarily at rest are consistent with Wellens syndrome.
73
A 53-year-old male is seen in respiratory clinic with a progressive, chronic dry cough that has gotten worse in the last 3 months. He reports occasional episodes of wheeziness and breathlessness, which usually spontaneously resolve when he takes time off work. He works at a tobacco company and has a 5-pack-year smoking history. Lung function tests show a reduced DLCO, a reduced FEV1, a reduced forced vital capacity (FVC) and a FEV1/FVC ratio of 0.9.
What is the most likely diagnosis?
extrinsic allergic alveolitis
74
becks triad pulsus paradoxes meaning
Pulsus paradoxus is the exaggerated drop in blood pressure >10mmHg at the end of inspiration that can be seen in cardiac tamponade.
75
symptomatic despite adequate medical therapy for congestive cardiac failure. With LBBB, LVEF below 30%, marked limitation of physical activity
Cardiac resynchronisation therapy
This patient is symptomatic despite adequate medical therapy for congestive cardiac failure. He fulfils the criteria for consideration of CRT- cardiac resynchronisation therapy:
LBBB on ECG
LVEF <30%
NYHA Class III
76
NYHA classes
77
dose of atropine
500 micrograms IV every 3-5 mins, max dose 3mg
78
syncope ix
ECG first, then can do 24hour holter
79
WPW ECG
delta wave and short PR interval
80
J wave
hypothermia, hypercalcaemia or an intra-cranial bleed such as a sub-arachnoid haemorrhage
81
U wave
hypokalaemia or bradycardia
82
mid diastolic murmur
mitral regurg
83
endocarditis which organism only needs one positive blood culture
Coxiella
84
Patients with what present with a variety of symptoms, such as chest pain resembling typical angina, and also present with ECG changes which can be concerning. Troponin release is also common. However, patients may not fit the typical demographics of a patient with coronary artery disease (maybe younger, female, minimal risk factors) and sometimes have a history of precipitating viral illness
acute myocarditis
85
CCB common SE
peripheral oedema
86
A 45-year-old woman presents to the GP practice with a 3 month history of shortness of breath worse on exertion, a cough sometimes productive of blood and unintentional weight loss of 5 kilograms. She also has a long standing history of weakness in her arms and legs which gets better with walking.
She is a smoker of 33 pack years and has a history of diabetes and hypertension. On examination you note bilateral eyelid ptosis.
Which of the following antibodies is most likely to be present in this patient?
voltage gates calcium channels
This patient likely has Lambert-Eaton myasthenic syndrome (LEMS) caused by small-cell lung cancer. Leg and arm weakness which gets better with physical exertion is characteristic of LEMS. Ptosis and double vision can also occur in LEMS. LEMS is caused by voltage-gated calcium channel antibodies
(Acetylcholine receptor antibodies
This is present in patients who have myasthenia gravis which classically would present with muscle weakness which worsens on exertion. The weakness is typically worse at the end of the day. The eyes are usually affected first in myasthenia gravis. It is not usually a paraneoplastic syndrome)
87
SIADH
body retains too much water, dilutes sodium causing low sodium
88
A 55 year old gentlemen has a diagnosis of small cell lung cancer. He presents to A&E complaining of nausea and vomiting and is acutely confused with an AMTS of 3/10. He is triaged, IV fluid resuscitation is initiated and bloods taken. His blood tests show that his plasma sodium is 122 mmol/L (normal range 135-145). All other blood results are normal.
What is the single most likely diagnosis?
SIADH as euvolemic
89
management strategy for patients with rheumatic fever.
Secondary prophylaxis with long-term penicillin is the most appropriate management strategy for patients with rheumatic fever. It helps prevent recurrent group A streptococcal infections, which can lead to further episodes of rheumatic fever and potential complications, such as rheumatic heart disease.
90
CO2 retainer type of mask
venturi
91
cha2ds2vasc
92
A 68-year-old male with a 30-year pack history presents to Accident and Emergency department with a a persistent cough for the past three to four weeks. He attended hospital as he noted that although his sputum was clear, it has been streaked with blood. He does not report any coryzal symptoms or fevers but does say that over the past few months he has been feeling weak and irritable. On further questioning he explains that he is drinking more frequently and has been constipated despite a diet rich in fibre.
A CT chest scan (including the lower neck and upper abdomen) is performed with contrast. This shows a cavitating lesion in the right lung. What is the most likely diagnosis?
Squamous cell carcinoma
This is the correct answer. Squamous cell carcinomas are strongly associated with smoking and often cavitate. They can cause a paraneoplastic syndrome, associated with ectopic production of parathyroid hormone-related peptide (PTHrP). This results in hypercalcaemia with symptoms including constipation, myopathy, polydipsia and behavioural changes. Squamous cell carcinomas are also associated with cavitating lung lesions
93
shortens QT?
digoxin
94
when to be worried about kidney changes on bloods in ACEi
a fall in eGFR and hyperkalaemia are known effects of ACE-inhibitors. These effects are only problematic if they surpass empirically determined thresholds. NICE stipulates that the dose of ACE-inhibitors should not be modified if either the GFR decrease from pre-treatment baseline is less than 25%, or the serum creatinine increase from baseline is less than 30%.
95
Clarithromycin
This ECG shows Torsades de Pointes, which can occur with severe prolongation of the QT interval. Long QT syndrome can be congenital and worsened by certain medications. QT prolongation can also occur from medications alone, particularly if taken in overdose. This includes tricyclic antidepressants (e.g. amitriptyline), citalopram, antipsychotics (e.g. haloperidol, quetiapine, olanzapine) and some antibiotics (e.g. macrolides, quinines, chloroquine).
96
bp in CURB65
90/60
97
most common cardiac tumour
Atrial myxomas are the most common type of cardiac tumour. They present with a triad of embolism, systemic symptoms and intra-cardiac obstruction. Other features include an audible ‘plop’ in diastole (tumour plop), clubbing, Raynaud’s phenomenon (due to microemboli) and pulmonary hypertension. This patient has a history of TIA, fever and weight loss and signs consistent with atrial myxoma. Investigations may show raised ESR, thrombocytopaenia, raised white cell count and haemolytic anaemia. Diagnosis is with trans-oesophageal echocardiography (TOE). Myxomas grow rapidly and can lead to systemic embolism and sudden death so should be urgently removed surgically.
98
He has widespread downsloping ST depressions with a characteristic “reverse tick” appearance.
digoxin effect - can check levels if concerned
99
A 54-year-old male presents to the emergency department with palpitations, shortness of breath, and lightheadedness. His ECG shows a broad complex tachycardia with a rate of 180 bpm.
Which of the following options is the most likely diagnosis?
V tach
Paroxysmal supraventricular tachycardia (PSVT) typically presents as a regular, narrow complex tachycardia with abrupt onset and termination. The ECG findings of a broad complex tachycardia, in this case, are more consistent with ventricular tachycardia.
100
commonest finding in PE on ECG
sinus tachycardia
101
A 73-year-old woman presents to the GP with a 3-month history of intermittent non-productive cough. This is associated with dyspnoea on exertion, general fatigue and some weight loss. She has a history of hypertension, hypercholesterolaemia and type 2 diabetes. She also has a 40-pack year smoking history. She is a retired accountant and has no pets. On examination, she has a respiratory rate of 26 and oxygen saturations of 94% at rest, and 91% on exertion. Chest auscultation reveals scattered fine inspiratory crepitations at both lung bases.
Which of the following investigations is most likely to confirm the diagnosis?
HRCT for pulmonary fibrosis
102
normal oxygen
94-98
103
Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a standard-dose thiazide diuretic. K+ > 4.5mmol/l - add an
alpha- or beta-blocker
if under 4.5 then spironolactone
104
hypokalaemia ECG
Alongside U waves, the following ECG features may be seen in hypokalaemia:
ECG features of hypokalaemia
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT
105
COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features → add
a LABA + ICS
106
other drug in CPR if PE suspected
alteplase
107
major bleeding pt on warfarin
Major bleeding - stop warfarin, give intravenous vitamin K 5mg, prothrombin complex concentrate
108
Patient with acute asthma who do not respond to full medical treatment
and are becoming acidotic should be intubated and ventilated, rather than given BiPAP/CPAP
109
A 72-year-old man presents to his general practitioner with new-onset constipation. This started about a week ago and coincided with the onset of regular stomach cramps. His wife reports that he has also been increasingly confused in the past few days, and has been very drowsy and lethargic, with weak muscles.
His past medical history is only significant for hypertension, for which he takes regular amlodipine, atenolol, bendroflumethiazide, and ramipril. He has taken over-the-counter macrogol in the past 7 days to try and help with his constipation.
Given the likely cause of his presentation, which medication could have this side effect?
Thiazide diuretics can cause hypercalcaemia and hypocalciuria
110
beta blocker weird side effect
insomnia
111
respiratory alkalosis with no metabolic compensation
112
T wave inversion + high trop?
NSTEMI
113
unwell and hypokalaemia, which heart med to stop
Loop diuretics may cause hypokalaemia e.g. bumetanide
114
digoxin moa
inhibits the Na+/K+ ATPase pump
115
chest pain worst on lying down Ix
All patients with suspected acute pericarditis should have transthoracic echocardiography
116
A 71-year-old man who is known to have atrial fibrillation comes for review. He had a transient ischaemic attack two weeks ago and takes bendroflumethiazide for hypertension but is otherwise well. His latest blood pressure is 124/76 mmHg. You are discussing management options to try and reduce his future risk of having a stroke. What is his CHA2DS2-VASc score?
4
One point for hypertension, one point for being over the age of 65 years (but under the age of 75 years) and two points ('S2') for the recent TIA.
117
A 25-year-old woman presents to the GP with 1 year of exertional dyspnoea, wheezing, and dry cough. Her symptoms are worse at night and during cold weather. She previously smoked 15 cigarettes daily for the last 5 years but has since stopped. She has no past medical history or allergies.
Which option is the best next step?
FeNO for asthma
118
The cardiac arrest team is called to the bedside of a 67-year-old male patient, 2 days post-myocardial infarction. Two nurses are currently performing chest compressions and a manual defibrillator has just been attached. Chest compressions are paused briefly so that the rhythm can be analysed: pulseless electrical activity is observed.
Given the above, which of the following should happen in this scenario?
give adrenaline immediately
119
A 48-year-old man has heart failure. He attends the emergency department because he feels short of breath and has gained 11kg in weight. His blood pressure is 88/48 mmHg, heart rate 112 bpm, and is requiring 2L of oxygen. Capillary refill time is 3 seconds, and you can feel his liver edge 6cm below the costal margin. Regular medications include 40mg furosemide twice per day and ramipril.
worsening renal function
160mg IV furosemide
Increased doses of loop diuretics may be required in patients with poor renal function to ensure sufficient concentration is achieved within the tubules
120
drug that causes ED
beta blockers
121
angina, He is started on sublingual glyceryl trinitrate and oral verapamil, not working
Isosorbide mononitrate and isosorbide dinitrate are widely used long-acting nitrates. Glyceryl trinitrate (GTN) can be used in patch or ointment form for sustained release but is more commonly short-acting.
122
NSTEMI (managed conservatively) antiplatelet choice
NSTEMI (managed conservatively) antiplatelet choice
aspirin, plus either:
ticagrelor, if not high bleeding risk
clopidogrel, if high bleeding risk
123
Which patients with NSTEMI/unstable angina should have coronary angiography
Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-on PCI if necessary)?
immediate: patient who are clinically unstable (e.g. hypotensive)
within 72 hours: patients with a GRACE score > 3% i.e. those at intermediate, high or highest risk
coronary angiography should also be considered for patients if ischaemia is subsequently experienced after admission
124
what is the most common cause of an exudative pleural effusion
Pneumonia is the most common cause of an exudative pleural effusion
125
A 59-year-old man is admitted to the ward following primary percutaneous coronary intervention (PCI) for an acute inferoposterior myocardial infarction. He is recovering as expected until day 5 of his admission when he complains to the nurse that he is feeling suddenly short of breath.
His observations reveal a pulse rate of 118/min , respiratory rate of 24/ min, temperature of 36.8ºC and blood pressure of 90/60 mmHg.
On examination, an early-to-mid systolic murmur is audible and radiates to the axilla.
What is the most likely explanation for this man's current symptoms?
Rupture of the papillary muscle due to a myocardial infarction → acute mitral regurgitation → widespread systolic murmur, hypotension, pulmonary oedema
126
massive pE + hypotension
alteplase
127
sarcoidosis weird sign
bilateral parotid gland swelling
128
do you stop warfarin after surgery for A fib?
no
who've had a catheter ablation for atrial fibrillation still require long-term anticoagulation as per their CHA2DS2-VASc score
129
avoid what in HF
verapamil
130
A 31-year-old gravida 1 para 0 woman with known alpha-1 antitrypsin deficiency and COPD presents to the respiratory clinic after finding out she is pregnant. She is concerned about the well-being of her baby and the risk of inheriting alpha-1 antitrypsin.
What interventions can be offered to the mother and/or baby?
genetic counselling and prenatal testing
131
what may cause gingival hyperplasia
Amlodipine may cause gingival hyperplasia
132
mobitz T1 in athlete
normal variant, monitoring
133
Y 3 Medicine
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