Lana Alnusair Year 3 Case Based SBA Revision - PowerPoint Presentation

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Lana Alnusair

Year 3 Case Based SBA Revision

03/02/2022

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Awareness of all cardiology conditions and LOs required for year 3

Familiarise

students with the classical history of some of the main cardiology conditionsFamiliarise

students with some key investigations and management in cardiology

Familiarise

students with the typical exam questions asked

Highlight important buzzwords

Slide3

Abdominal aortic aneurysm

Amyloidosis

Aortic dissection

Aortic regurgitation

Aortic stenosis

Arterial ulcersAtrial fibrillation/flutterCardiac arrestCardiac failure (acute and chronic)CardiomyopathyConstrictive pericarditisDeep vein thrombosis Dyslipidaemia (hypercholesterolaemia & hypertriglyceridaemia)GangreneHeart block (1st, 2nd, 3rd degree)HypertensionInfective endocarditisIschaemic heart disease (angina pectoris, acute coronary syndrome, myocardial infarction)

Mitral regurgitation

Mitral stenosis

Myocarditis

Pericarditis

Peripheral vascular disease (acute and chronic limb ischaemia)

Pulmonary embolism

Pulmonary hypertension

Rheumatic fever

Supraventricular tachycardia

Tricuspid regurgitation

Varicose veins

Vasovagal syncope

Venous ulcers

Ventricular fibrillation

Ventricular tachycardia

Wolff–Parkinson–White syndrome

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Back pain

BradycardiaCalf swelling/painChest painConfusion (acute)CoughCyanosisDecreased consciousness

Dizziness/Blackouts (loss of consciousness)DyspnoeaECG abnormalities (P, PR, QRS, ST, T, QT changes)FatigueHypercalcaemia

Hypocalcaemia

Hyperkalaemia

HypernatraemiaHypokalaemiaHyponatraemiaHypotensionNausea & vomitingOedema (ankle/pitting)PalpitationsPostural hypotensionRaised inflammatory markers (CRP, ESR)Raised jugular venous pressureSweatingTachycardia

Slide5

A 64 year old man has chest pain and breathlessness. His temperature is 36.4℃, pulse rate 34 bpm, BP 85/64 mmHg, respiratory rate 15 breaths per minute and oxygen saturation 99% breathing air. Investigations: ECG: ST elevation in leads II, III and AVF with complete atrioventricular dissociation. Which is the next most appropriate step in management?

Adenosine

Amiodarone

Atropine

Epinephrine (adrenaline)

Flecainide

Slide6

A 64 year old man has chest pain and breathlessness. His temperature is 36.4℃, pulse rate 34 bpm, BP 85/64 mmHg, respiratory rate 15 breaths per minute and oxygen saturation 99% breathing air. Investigations: ECG: ST elevation in leads II, III and AVF with

complete atrioventricular dissociation

. Which is the next most appropriate step in management?

Adenosine

Amiodarone

AtropineEpinephrine (adrenaline)FlecainideAtria and ventricles work separately from each other  complete heart block3rd degree heart block is a medical emergency It can occur secondary to a STEMIPatient is also haemodynamically unstable

Used in SVTs

Treatment of arrythmias

Treatment of AF

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A 28-year-old man with no past medical history of note is admitted to the Emergency Department with palpitations. His blood pressure is 120/78 mmHg and his pulse is 165 bpm. An ECG is taken: What is the treatment of choice?

Intravenous amiodarone

Oral digoxin

Intravenous adenosine

Oral bisoprolol

Intravenous verapamil

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A 28-year-old man with no past medical history of note is admitted to the Emergency Department with

palpitations

. His blood pressure is 120/78 mmHg and his

pulse is 165 bpm

. An ECG is taken: What is the treatment of choice?

Intravenous amiodaroneOral digoxinIntravenous adenosineOral bisoprololIntravenous verapamilSVT is an umbrella term but can include AVRT and AVNRTECG changes:Regular narrow complex tachycardiaNarrow QRS complex P wave inversion in leads 2,3 and AVFST segment depression

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A 32-year-old man has a swollen left lower leg and deep vein thrombosis (DVT) is confirmed on Doppler ultrasound. He has a past medical history of curative radical inguinal orchiectomy for testicular cancer 5 years ago and hand surgery four weeks previously. He drinks 32 units of alcohol a week, and smokes 10 cigarettes a day. His BMI is 26.7kg/m2. Which of his risk factors most likely increased his risk for a DVT?

Alcohol history

BMI

Malignancy

Hand surgery

Smoking status

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A 32-year-old man has a swollen left lower leg and deep vein thrombosis (DVT) is confirmed on Doppler ultrasound. He has a past medical history of curative radical inguinal orchiectomy for testicular cancer 5 years ago and hand surgery four weeks previously. He drinks 32 units of alcohol a week, and

smokes 10 cigarettes a day

. His BMI is 26.7kg/m2. Which of his risk factors most likely increased his risk for a DVT?

Alcohol history

BMI

MalignancyHand surgery Smoking status Risk factors:Smoking Pregnancy Major surgery/ injury Active malignancy

Slide13

A 22 year old woman is tired all the time. She has started to feel too breathless to cycle to work. She has no past medical history and does not take any regular medications. Her temperature is 36.7℃, pulse rate 98 bpm irregularly irregular and BP 112/70 mmHg. Heart sounds 1 + 2 and a systolic murmur are heard, loudest at the apex, radiating to the axilla. Which is the most likely diagnosis?

Aortic regurgitation

Aortic stenosis

Mitral regurgitation

Mitral stenosis

Patent ductus arteriosus

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A 22 year old woman is

tired all the time

. She has

started to feel too breathless to cycle to work

. She has no past medical history and does not take any regular medications. Her temperature is 36.7℃, pulse rate 98 bpm

irregularly irregular and BP 112/70 mmHg. Heart sounds 1 + 2 and a systolic murmur are heard, loudest at the apex, radiating to the axilla. Which is the most likely diagnosis?Aortic regurgitationAortic stenosis Mitral regurgitationMitral stenosis Patent ductus arteriosusCauses of systolic murmur:MRAS generally

Accentuation technique:

Left lateral position and will radiate to axilla

Causes:

Infective endocarditis

Rheumatic heart disease

Cardiomyopathy

MI

Slide15

A 57 year old man has severe chest pain for two hours associated with nausea and breathlessness. He takes amlodipine for hypertension and smokes 10 cigarettes per day. His temperature is 37.0

, pulse rate 95 bpm, respiratory rate 18 breaths per minute and oxygen saturation 96% breathing air. His BP is 121/83 mmHg in his left arm and 119/76 in his right arm. Investigations: C reactive protein (CRP) 13mg/L (<5) Troponin T 983

µ

g/L (<0.01) ECG:

Which is the most likely diagnosis?

Anterolateral myocardial infarction

Inferolateral myocardial infarction

Inferoseptal

myocardial infarction

Viral myocarditis

Viral pericarditis

 

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16

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A

57 year old man

has

severe chest pain

for two hours associated with nausea and breathlessness. He

takes amlodipine for

hypertension

and

smokes 10 cigarettes per day

.

His temperature is 37.0

, pulse rate 95 bpm, respiratory rate 18 breaths per minute and oxygen saturation 96% breathing air. His BP is 121/83 mmHg in his left arm and 119/76 in his right arm. Investigations: C reactive protein (CRP)

13mg/L (<5)

Troponin T

983

µ

g/L (<0.01)

ECG:

Which is the most likely diagnosis?

Anterolateral myocardial infarction

Inferolateral myocardial infarction

Inferoseptal

myocardial infarction

Viral myocarditis

Viral pericarditis

 

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A 52-year-old man is admitted to the Emergency Department after a 999 call. Around one hour ago he suddenly developed the sensation of 'an elephant sitting on his chest'. He has been sick and tells staff he thinks he's going to die. His ECG is shown below:

A loading dose of aspirin and clopidogrel are given. He is also given sublingual glyceryl trinitrate and intravenous morphine for pain relief. What is the best next step in management?

Same-day coronary artery bypass graft

Synchronised

DC cardioversion

Give low-molecular weight heparin and do a troponin level in 5 hoursImmediate thrombolysisImmediate percutaneous coronary intervention

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A

52-year-old man

is admitted to the Emergency Department after a 999 call. Around one hour ago he suddenly developed the

sensation of 'an elephant sitting on his chest'.

He has

been sick and tells staff he thinks he's going to die. His ECG is shown below:A loading dose of aspirin and clopidogrel are given. He is also given sublingual glyceryl trinitrate and intravenous morphine for pain relief. What is the best next step

in management?

Same-day coronary artery bypass graft

Synchronised

DC cardioversion

Give low-molecular weight heparin and do a troponin level in 5 hours

Immediate thrombolysis

Immediate percutaneous coronary intervention

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What about long term management?

Distinction* question

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A 67-year-old male presents to the emergency department with sudden onset chest pain. The pain is located in his central chest, and started an hour ago. The pain was maximal at onset, and is not exacerbated with deep breaths. He describes it as the most intense pain he's ever experienced. He has not had any similar episodes previously. He has a past medical history of hypertension (for which he takes ramipril and

bendroflumethiazide

). He has a 15-pack-year smoking history. On examination he appears drowsy. He has left-sided ptosis and miosis of his left pupil. What is the most likely cause of this presentation?

Aortic dissection

Carotid artery dissection

Tension pneumothoraxST-elevation myocardial infarction (STEMI)Pulmonary embolism

Slide23

A

67-year-old male

presents to the emergency department with

sudden onset chest pain

. The pain is

located in his central chest, and started an hour ago. The pain was maximal at onset, and is not exacerbated with deep breaths. He describes it as the most intense pain he's ever experienced. He has not had any similar episodes previously. He has a past medical history of hypertension (for which he takes ramipril and bendroflumethiazide). He has a 15-pack-year smoking history. On examination he appears drowsy. He has left-sided ptosis and miosis of his left pupil. What is the most likely cause of this presentation?

Aortic dissection

Carotid artery dissection

Tension pneumothorax

ST-elevation myocardial infarction (STEMI)

Pulmonary embolism

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A 24 year old man is admitted to hospital with severe burns. An ECG is taken (see image).

Which electrolyte abnormality is the most likely cause of the ECG appearance?

Hypercalcaemia

Hyperkalaemia

Hypocalcaemia

Hypokalaemia

Hypomagnesaemia

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A 24 year old man is admitted to hospital with severe burns. An ECG is taken (see image).

Which electrolyte abnormality is the most likely cause of the ECG appearance?

Hypercalcaemia

Hyperkalaemia

Hypocalcaemia

Hypokalaemia

Hypomagnesaemia

In response to a burn or severe injury the body releases extra potassium into the blood

ECG Changes:

Peaked T waves

P wave can widen and flatten

 disappear

Prolonged PR segment

Bizarre QRS complexes

Short QT interval

Increased QT interval

Prolonged PR interval

ST depression

Flattened T wave

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How do you manage hyperkalaemia?

Slide28

A previously asymptomatic 30-year-old woman has presented to the emergency department with severe

dyspnoea

while jogging. She stated that this has occurred twice before in the last month but this time it was more serious which prompted her to seek help. She has not been diagnosed with any conditions. She is adopted and is aware that her biological mother suffered from rheumatic fever as a child and biological father had 'some sort of heart problem'. All vital signs were within normal range. An ECG was done and showed left ventricular hypertrophy. What is the most likely diagnosis?

Mitral stenosis

Aortic stenosis

Friedrich's ataxiaHypertrophic obstructive cardiomyopathy (HOCM)Wolff-Parkinson White

Slide29

A previously asymptomatic

30-year-old woman

has presented to the emergency department with s

evere

dyspnoea

while jogging. She stated that this has occurred twice before in the last month but this time it was more serious which prompted her to seek help. She has not been diagnosed with any conditions. She is adopted and is aware that her biological mother suffered from rheumatic fever as a child and biological father had 'some sort of heart problem'. All vital signs were within normal range. An ECG was done and showed left ventricular hypertrophy. What is the most likely diagnosis?Mitral stenosisAortic stenosisFriedrich's ataxiaHypertrophic obstructive cardiomyopathy (HOCM)Wolff-Parkinson White

Strong genetic link, if parent has it then 50% chance child will too.

Slide30

A 62-year old male presents to the emergency department with diffuse, central, sudden onset abdominal pain with some associated back pain. His left buttock and thigh have become painful over the past hour. He has a 20-pack year smoking history and is on irbesartan, but is unsure what for. He is visibly in pain, and his abdomen is soft with

generalised

tenderness. Observations: HR 95, BP 107/61, RR 25, SpO2 94% on air, Temp 37.2. Which of the following is true about the national screening

programme

for abdominal aortic aneurysms (AAA) in England?

Males aged 60 years and above are screened as a one-offMales aged 65 years and above are screened as a one-offMales aged 65 years and above are screened 5 yearly Males and females aged 65 years and above are screened as a one-offMales and females aged 60 years and above are screened as a one-off

Slide31

A

62-year old male

presents to the emergency department with d

iffuse, central, sudden onset abdominal pain

with some associated

back pain. His left buttock and thigh have become painful over the past hour. He has a 20-pack year smoking history and is on irbesartan, but is unsure what for. He is visibly in pain, and his abdomen is soft with generalised tenderness. Observations: HR 95, BP 107/61, RR 25, SpO2 94% on air, Temp 37.2. Which of the following is true about the national screening programme for abdominal aortic aneurysms (AAA) in England?Males aged 60 years and above are screened as a one-offMales aged 65 years and above are screened as a one-off

Males aged 65 years and above are screened 5 yearly

Males and females aged 65 years and above are screened as a one-off

Males and females aged 60 years and above are screened as a one-off

Slide32

An 80-year-old female presents to Emergency Department with headaches. On further questioning, the patient admits that she has been suffering from headaches, palpitations and dizzy spells for a few months. Upon examination you notice she is afebrile and has an irregularly irregular pulse at a heart rate of 140 beats per minute, blood pressure = 120/80 mmHg and respirations = 20/min. You, therefore, suspect the lady is in atrial fibrillation (AF) and perform an ECG to confirm this. What is the most appropriate first step in the management of her AF?

Sotalol

Verapamil

Digoxin

Amiodarone

Bisoprolol

Slide33

An

80-year-old female

presents to Emergency Department with

headaches

. On further questioning, the patient admits that

she has been suffering from headaches, palpitations and dizzy spells for a few months. Upon examination you notice she is afebrile and has an irregularly irregular pulse at a heart rate of 140 beats per minute, blood pressure = 120/80 mmHg and respirations = 20/min. You, therefore, suspect the lady is in atrial fibrillation (AF) and perform an ECG to confirm this. What is the most appropriate first step in the management of her AF?SotalolVerapamilDigoxinAmiodaroneBisoprololThis would be a Beta Blocker or a rate limiting CCB

Choice of drugs is dependent on co morbidities

Beta blocker > CCB

Slide34

A 69 year old man has left foot pain of sudden onset. The left foot is cold and pale with decreased power and sensation. There is a good left femoral pulse but no palpable popliteal pulse. Investigations: ECG: QRS complexes at irregular intervals, at a rate of 100 beats/minute with no discernible P waves. Which is the next most appropriate step in management?

Arrange a cardiology review

Arrange a venogram

Perform left above-knee amputation

Start a prostacyclin infusion

Start intravenous heparin

Slide35

A

69-year-old man

has

left foot pain of sudden onset

. The

left foot is cold and pale with decreased power and sensation. There is a good left femoral pulse but no palpable popliteal pulse. Investigations: ECG: QRS complexes at irregular intervals, at a rate of 100 beats/minute with no discernible P waves. Which is the next most appropriate step in management?Arrange a cardiology reviewArrange a venogram

Perform left above-knee amputation

Start a prostacyclin infusion

Start intravenous heparin

Acute limb ischaemia

Slide36

A 71-year-old woman is reviewed in her local GP surgery. She has recently changed practices and is having a routine new patient medical. Her blood pressure is 146/94 mmHg. This is confirmed on a second reading. In line with recent NICE guidance, what is the most appropriate management?

Ask her to come back in 6 months for a blood pressure check

Arrange 3 blood pressure checks with the practice nurse over the next 2 weeks with medical review following

Arrange ambulatory blood pressure monitoring

Reassure her this is acceptable for her age

Start treatment with a calcium channel blocker

Slide37

A 35-year-old man, normally fit and well, presents to the emergency department with a 1 day history of chest pain. He describes it as left sided chest pain radiating into his neck, and is associated with shortness of breath. The chest pain worsens on lying down flat, and eases on sitting up and leaning forwards. He also describes feeling feverish and having a cough recently. Based on the likely diagnosis, what would be the most appropriate treatment option for this patient?

Co-amoxiclav

Glyceryl trinitrate

Ibuprofen

Low-dose corticosteroids

Pericardiocentesis

Slide38

A

35-year-old man

, normally fit and well, presents to the emergency department with a

1 day history of chest pain

. He describes it as left sided chest pain radiating into his neck, and is associated with shortness of breath.

The chest pain worsens on lying down flat, and eases on sitting up and leaning forwards. He also describes feeling feverish and having a cough recently. Based on the likely diagnosis, what would be the most appropriate treatment option for this patient?Co-amoxiclavGlyceryl trinitrateIbuprofenLow-dose corticosteroidsPericardiocentesis

Pericarditis

1

st

line treatment (non purulent):

NSAIDs

Slide39

A 34-year-old woman visits her GP regarding the appearance of her legs. This is her first presentation to the doctor. For several years, she has had visible, tortuous veins on both legs, which she feels are unsightly. They are not painful. She has never noticed any bleeding, nor any swelling of the legs themselves. She is otherwise fit and well, with no past medical history, nor family history. She does not take any regular medication. On examination, there are dilated, tortuous, superficial veins in both legs. There is no tenderness on palpation, nor any swelling. No skin changes are visible, nor bleeding, nor ulcers. Given the likely diagnosis, what would be the most appropriate management?

Referral for endothermal ablation

Referral for foam sclerotherapy

Compression stockings

Avoidance of physical activity

Ropinirole

Slide40

A 34-year-old woman visits her GP regarding the appearance of her legs. This is her first presentation to the doctor. For several years, she has had

visible, tortuous veins on both legs

, which

she feels are unsightly

. They

are not painful. She has never noticed any bleeding, nor any swelling of the legs themselves. She is otherwise fit and well, with no past medical history, nor family history. She does not take any regular medication. On examination, there are dilated, tortuous, superficial veins in both legs. There is no tenderness on palpation, nor any swelling. No skin changes are visible, nor bleeding, nor ulcers

. Given the likely diagnosis, what would be the most appropriate management?

Referral for endothermal ablation

Referral for foam sclerotherapy

Compression stockings

Avoidance of physical activity

Ropinirole

Conservative management is preferred and only refer to secondary care if severe

Conservative management includes:

Leg elevation

Weight loss

Regular exercise

Compression stockings

Slide41

A 70-year-old man presents with a sudden onset of central chest pain, radiating to his jaw and left shoulder. The chest pain occurred an hour ago when he was sitting on a chair after his dinner. He has a past history of hypertension. On examination, he is alert but appears to be sweaty, nauseous and short of breath. His pulse rate is 120 bpm and his blood pressure is 150/100 mmHg. ECG shows a T-wave inversion and an ST-segment depression in the anterior leads. Troponin levels, which were taken at 3 hours and at 6 hours after the symptom onset were not elevated. Which of the following is the most likely diagnosis?

Stable angina

Unstable angina

Prinzmetal

(variant) angina

Non-ST elevation myocardial infarction (NSTEMI)ST-elevation myocardial infarction (STEMI)

Slide42

A

70-year-old man

presents with a

sudden onset of central chest pain

, radiating to his jaw and left shoulder. The chest pain occurred an hour ago when he was sitting on a chair after his dinner. He has a

past history of hypertension. On examination, he is alert but appears to be sweaty, nauseous and short of breath. His pulse rate is 120 bpm and his blood pressure is 150/100 mmHg. ECG shows a T-wave inversion and an ST-segment depression in the anterior leads. Troponin levels, which were taken at 3 hours and at 6 hours after the symptom onset were not elevated. Which of the following is the most likely diagnosis?Stable anginaUnstable anginaPrinzmetal (variant) angina

Non-ST elevation myocardial infarction (NSTEMI)

ST-elevation myocardial infarction (STEMI)

Slide43

A 55-year-old woman presents with progressively worsening

dyspnoea

on exertion for the past few years. She also noticed that she requires more pillows for the past one year when she sleeps to prevent her from getting breathless. However, she recently wakes up in the middle of the night feeling breathless even though she uses three pillows to sleep. On auscultation, a loud first heart sound with an opening snap and a diastolic murmur can be heard. Based on the most likely diagnosis, what is the most common cause of this patient's condition?

Degenerative calcification of the valve

Congenital valve deformity

Past history of rheumatic feverMyocardial infarctionCarcinoid syndrome

Slide44

A 55-year-old woman presents with

progressively worsening

dyspnoea

on exertion

for the past few years. She also noticed that she

requires more pillows for the past one year when she sleeps to prevent her from getting breathless. However, she recently wakes up in the middle of the night feeling breathless even though she uses three pillows to sleep. On auscultation, a loud first heart sound with an opening snap and a diastolic murmur can be heard. Based on the most likely diagnosis, what is the most common cause of this patient's condition?Degenerative calcification of the valveCongenital valve deformityPast history of rheumatic feverMyocardial infarctionCarcinoid syndrome Mitral stenosis

MAIN CAUSE is rheumatic fever

Slide45

A 7-year-old girl is brought to the clinic because she has a rash and joint pains that are bothering her. Her past medical history is unremarkable other then a sore throat that resolved on its own about 2 weeks ago. Last week the patient noticed pain in her knees. This pain resolved after a few days, however now she complains of pain in her wrists and ankles. The patient has also developed a non-

pruiritc

pink rash on her back. Her temperate is 101.2°F, pulse is 87/min, and respirations are 18/min. A physical exam reveals both pain and stiffness in the wrists and ankles. A fait, erythematous rash with sharp borders is present on her trunk and proximal lines. The rest of her exam is non-contributory. Lab results are collected and are as follows: Leukocytes: 7,500/µL Hemoglobin: 12.9 g/dL, CRP: 38 mg/dL ** , ESR: 40 m/

hr

** platelets: 220,000/µL What diagnosis could explain this presentation?

Infective endocarditisCongenital heart diseasePericarditis Rheumatic feverMyocarditis

Slide46

A

7-year-old girl

is brought to the clinic because she has a

rash

and

joint pains that are bothering her. Her past medical history is unremarkable other then a sore throat that resolved on its own about 2 weeks ago. Last week the patient noticed pain in her knees. This pain resolved after a few days, however now she complains of pain in her wrists and ankles. The patient has also developed a non-pruiritc pink rash on her back. Her temperate is 101.2°F, pulse is 87/min, and respirations are 18/min. A physical exam reveals both pain and stiffness in the wrists and ankles. A fait, erythematous rash with sharp borders is present on her trunk and proximal lines. The rest of her exam is non-contributory. Lab results are collected and are as follows: Leukocytes: 7,500/µL Hemoglobin: 12.9 g/dL platelets: 220,000/µL , CRP: 38 mg/dL **

,

ESR: 40 m/

hr

**

What diagnosis could explain this presentation?

Infective endocarditis

Congenital heart disease

Pericarditis

Rheumatic fever

Myocarditis

Elevated in ARF

 usually in response to infection

Usually affects ages 5-15

Usually develops 2-4 weeks after a strep throat

Slide47

A 37-year-old female presents to the emergency department with a 1-week history of fever and shortness of breath. She has a 12-year history of IV drug use and a 40-pack-year smoking history. On examination, she has a temperature of 39°C and a pansystolic murmur. The lungs are clear. She has thin, reddish-brown lines under her fingernails which are in the direction of nail growth. ECG: normal sinus rhythm Urinalysis: nil protein, nil blood Chest x-ray: multiple cavitating nodular densities in both lung fields Echo: a valvular vegetation is visible Which of these would allow for a positive diagnosis of infective endocarditis with the Duke criteria?

Temperature 39°C, IV drug use, splinter

haemorrhages

, septic pulmonary emboli

Positive echo, tricuspid regurgitation murmur, splinter

haemorrhages, IV drug usePositive echo, temperature 39°C, IV drug use, septic pulmonary emboli Positive echo, temperature 39°C, IV drug use, a history of smoking Immunological phenomena, IV drug use, septic pulmonary emboli, tricuspid regurgitation murmur

Slide48

48

Slide49

A 37-year-old female presents to the emergency department with a

1-week history of fever

and shortness of breath. She has a

12-year history of IV drug use

and a 40-pack-year smoking history. On examination, she has a temperature of

39°C and a pansystolic murmur. The lungs are clear. She has thin, reddish-brown lines under her fingernails which are in the direction of nail growth. ECG: normal sinus rhythm Urinalysis: nil protein, nil blood Chest x-ray: multiple cavitating nodular densities in both lung fields Echo: a valvular vegetation is visible Which of these would allow for a positive diagnosis of infective endocarditis with the Duke criteria?Temperature 39°C, IV drug use, splinter haemorrhages, septic pulmonary emboli Positive echo, tricuspid regurgitation murmur, splinter haemorrhages, IV drug use

Positive echo, temperature 39°C, IV drug use, septic pulmonary emboli

Positive echo, temperature 39°C, IV drug use, a history of smoking

Immunological phenomena, IV drug use, septic pulmonary emboli, tricuspid regurgitation murmur

Slide50

A 75-year-old man presents to the GP with a 10-week history of worsening oedema in his lower legs and breathlessness that he feels is getting worse. Initially, he was only breathless walking up the stairs but now he feels he is breathless sitting in his chair at rest. Occasionally, he can wake up at night gasping for breath. On examination, pitting oedema is present up the mid-calf, his respiratory rate is 24 breaths/ minute, his heart rate is 110 beats/ minute, his blood pressure is 105/60 and his oxygen saturation on air is 91%. The GP refers the patient for an echocardiogram which shows a reduced left ventricular ejection fraction (LVEF). What is the first-line treatment for this patient's most likely diagnosis?

ACE inhibitor + beta blocker

ACE inhibitor + calcium channel blocker

ACE inhibitor only

Beta blocker only

Beta blockers + calcium channel blocker

Slide51

A

75-year-old man

presents to the GP with a

10-week history of worsening oedema in his lower legs

and

breathlessness that he feels is getting worse. Initially, he was only breathless walking up the stairs but now he feels he is breathless sitting in his chair at rest. Occasionally, he can wake up at night gasping for breath. On examination, pitting oedema is present up the mid-calf, his respiratory rate is 24 breaths/ minute, his heart rate is 110 beats/ minute, his blood pressure is 105/60 and his oxygen saturation on air is 91%. The GP refers the patient for an echocardiogram which shows a reduced left ventricular ejection fraction (LVEF). What is the first-line treatment for this patient's most likely diagnosis?ACE inhibitor + beta blockerACE inhibitor + calcium channel blockerACE inhibitor onlyBeta blocker only

Beta blockers + calcium channel blocker

1

st

line treatment for Hf with ref:

ACEi

and beta blockers and lifestyle changes

CCB should be avoided in HF patients with

rEF

because can depress cardiac function further

Slide52

A 54-year-old male was admitted with a 12-hour history of palpitations. On admission his observations are: Heart rate

incalcuable

, blood pressure 80/50mmHg, respiratory rate 20/min, temperature 36.9º, saturations 97% on air. The patient reports he has not experienced any previous similar episodes. He has no past medical history and takes no regular medications. On examination: Pulse is irregular with good volume, heart sounds are normal and fine-

bibasal

crackles are heard extending to the mid-zones of the lungs. A 12-lead ECG is performed and shows a irregular narrow complex tachycardia with a sawtooth baseline at rate 150-180 beats per minute.. What is the most appropriate management strategy of this patient?

AmiodaroneFlecainideUnsynchronised defibrillationBisoprololSynchronised DC cardioversion

Slide53

A 54-year-old male was admitted with a 12-hour history of palpitations. On admission his observations are:

Heart rate

incalcuable

,

blood pressure 80/50mmHg

, respiratory rate 20/min, temperature 36.9º, saturations 97% on air. The patient reports he has not experienced any previous similar episodes. He has no past medical history and takes no regular medications. On examination: Pulse is irregular with good volume, heart sounds are normal and fine-bibasal crackles are heard extending to the mid-zones of the lungs. A 12-lead ECG is performed and shows a irregular narrow complex tachycardia with a sawtooth baseline at rate 150-180 beats per minute. What is the most appropriate management strategy of this patient?AmiodaroneFlecainideUnsynchronised defibrillationBisoprolol

Synchronised

DC cardioversion

Slide54

A 78-year-old man presents to his primary care physician complaining of 2 months of progressive shortness of breath on exertion. He first

recognises

having to catch his breath while gardening and is now unable to walk up the stairs in his house without stopping. Previously he was healthy and active without similar complaints. On physical examination there is a loud systolic murmur at the right upper sternal border radiating to the carotid vessels.

Which is the most likely

diagnsosis

?Aortic sclerosisAortic Stenosis Tricuspid Stenosis Mitral Stenosis Pulmonary stenosis

Slide55

A

78-year-old man

presents to his primary care physician complaining of

2 months of progressive shortness of breath on exertion

. He first

recognises having to catch his breath while gardening and is now unable to walk up the stairs in his house without stopping. Previously he was healthy and active without similar complaints. On physical examination there is a loud systolic murmur at the right upper sternal border radiating to the carotid vessels. Which is the most likely diagnsosis?Aortic sclerosisAortic Stenosis Tricuspid Stenosis Mitral Stenosis Pulmonary stenosis

Slide56

A 28-year-old man who is normally fit and well presents with palpitations. He has no chest pain. Apart from tachycardia his examination is unremarkable. His blood pressure is 105/70mmHg and his heart rate is 170 beats/min and regular. An electrocardiogram (ECG) is completed: ECG: Rate 170 beats/min, regular, QRS 140ms with uniform appearance, right bundle branch pattern. There is no previous ECG to compare to. Which is the most likely diagnosis?

Pericarditis

Non-sustained ventricular tachycardia

Sustained ventricular tachycardia

Acute

haemorrhage Panic/hyperventilation

Slide57

A 28-year-old man who is normally fit and well

presents with palpitations

. He has no chest pain. Apart from tachycardia his examination is unremarkable. His blood pressure is 105/70mmHg and his heart rate is

170 beats/min and regular

. An electrocardiogram (ECG) is completed: ECG:

Rate 170 beats/min, regular, QRS 140ms with uniform appearance, right bundle branch pattern. There is no previous ECG to compare to. Which is the most likely diagnosis?Pericarditis Non-sustained ventricular tachycardia Sustained ventricular tachycardia Acute haemorrhage Panic/hyperventilation

Slide58

A 60-year-old man with a history of diabetes,

hypercholesterolaemia

, and heavy smoking for over 20 years presents giving a 3-week history of increasing pain in his left forefoot, which is affecting his ability to walk and is disrupting his sleep. On examination, his left foot is pale, cold, devoid of hair, and his lateral two toes are dusky and

discoloured

. No foot pulses are palpable and are only just detectable by Doppler probe.

Dry gangreneVenous ulcerVaricose veinDeep vein thrombosisWet gangrene

Slide59

A

60-year-old man

with a history of

diabetes

,

hypercholesterolaemia, and heavy smoking for over 20 years presents giving a 3-week history of increasing pain in his left forefoot, which is affecting his ability to walk and is disrupting his sleep. On examination, his left foot is pale, cold, devoid of hair, and his lateral two toes are dusky and discoloured. No foot pulses are palpable and are only just detectable by Doppler probe.Dry gangrene

Venous ulcer

Varicose vein

Deep vein thrombosis

Wet gangrene

Slide60

You are a junior doctor covering the coronary care unit (CCU). You are called urgently to a 45-year-old man admitted yesterday following a non-ST-elevation myocardial infarction (NSTEMI). On arrival there are no signs of life and a cardiac arrest call has been put out. The senior nurse looking after him reports he was alert and talking moments ago before collapsing. You look up at the monitor and see rapid

disorganised

electrical activity in lead II compatible with VF. The nurse administers the first shock of 360J monophasic. The monitor still shows VF. What is the next correct action?

Feel for a carotid or radial pulse

Begin chest compressions at a ratio of 30:2

Begin uninterrupted chest compressionsAdminister amiodarone 300mgGive another shock

Slide61

You are a junior doctor covering the coronary care unit (CCU). You are called urgently to a 45-year-old man admitted yesterday following a non-ST-elevation myocardial infarction (NSTEMI). On arrival there are

no signs of life

and a cardiac arrest call has been put out. The

senior nurse looking after him reports he was alert and talking moments ago before collapsing

. You look up at the monitor and see

rapid disorganised electrical activity in lead II compatible with VF. The nurse administers the first shock of 360J monophasic. The monitor still shows VF. What is the next correct action?Feel for a carotid or radial pulseBegin chest compressions at a ratio of 30:2Begin uninterrupted chest compressionsAdminister amiodarone 300mgGive another shock

Slide62

Russel is a 62-year-old man who suffers from chest pain and severe shortness of breath. He also complains of shortness of breath when lying down. At night, he sometimes wakes up from his sleep feeling breathless. He is a heavy smoker and suffers from chronic obstructive pulmonary disease. Recently, his symptoms are getting worse. On examination, he has a bilateral expiratory wheeze. Abdominal examination reveals findings suggestive of hepatomegaly. He is found to have a pan systolic murmur loudest at the left sternal edge at the 4th intercostal space.

What is the cause of the man’s symptoms?

right ventricular infarction

pulmonary hypertension

rheumatic heart disease

infective endocarditis Infective exacerbation of COPD

Slide63

Russel is a

62-year-old man

who suffers from

chest pain

and

severe shortness of breath. He also complains of shortness of breath when lying down. At night, he sometimes wakes up from his sleep feeling breathless. He is a heavy smoker and suffers from chronic obstructive pulmonary disease. Recently, his symptoms are getting worse. On examination, he has a bilateral expiratory wheeze. Abdominal examination reveals findings suggestive of hepatomegaly. He is found to have a pan systolic murmur loudest at the left sternal edge at the 4th intercostal space. What is the cause of the man’s symptoms?

right ventricular infarction

pulmonary hypertension

rheumatic heart disease

infective endocarditis

Infective exacerbation of COPD

Slide64

You are working as an F2 doctor in the Emergency Department. There is a stand-by call for an unresponsive patient currently

en

route in an ambulance. The paramedics fax an ECG through:

What is shown on the ECG?

Atrial fibrillation

Ventricular fibrillationVentricular tachycardia (monomorphic)Wolff-Parksinson WhiteLeft bundle branch block

Slide65

You are working as an F2 doctor in the Emergency Department. There is a stand-by call for an

unresponsive patient currently

en

route in an ambulance

. The paramedics fax an ECG through:

What is shown on the ECG?Atrial fibrillationVentricular fibrillationVentricular tachycardia (monomorphic)Wolff-Parksinson WhiteLeft bundle branch block

Slide66

Which is a sign of arterial insufficiency?

Chronic dermatitis

Oedema of the lower leg

Lipodermatosclerosis

Shiny thin skin

Painless

Slide67

Which is a sign of

arterial insufficiency

?

Chronic dermatitis

Oedema of the lower leg

LipodermatosclerosisShiny thin skin Painless

Slide68

You are the F2 in general practice. You see a 78-year-old woman who is complaining of changes in the appearance of her legs. On examination, you can see areas of brown on the legs, dry skin, and the calves appear significantly wider at the knee than the ankle. Which of the following is this woman most at risk of?

Acute limb

ischaemia

Arterial ulcers

Neuropathic ulcers

Squamous cell cancerVenous ulcers

Slide69

You are the F2 in general practice. You see a

78-year-old woman

who is complaining of

changes in the appearance of her legs

. On examination, you can see

areas of brown on the legs, dry skin, and the calves appear significantly wider at the knee than the ankle. Which of the following is this woman most at risk of?Acute limb ischaemiaArterial ulcersNeuropathic ulcersSquamous cell cancerVenous ulcers

Slide70

Which of the following is the most accurate regarding vasovagal syncope?

Presyncopal

symptoms never occur

It is associated with a fixed event, such as micturition or deglutition

It is due to cardiac outflow obstruction

Bystanders may witness jerky, abnormal movementsIt is the least common type of syncope seen in young adults

Slide71

Which of the following is the most accurate regarding

vasovagal syncope

?

Presyncopal

symptoms never occur

It is associated with a fixed event, such as micturition or deglutitionIt is due to cardiac outflow obstruction Bystanders may witness jerky, abnormal movementsIt is the least common type of syncope seen in young adults

Slide72

Which protein can be implicated in familial cardiac amyloidosis?

Transthyretin

Light chain

Amyloid A

Alpha-synuclein

Tau

Slide73

Which

protein

can be implicated in

familial cardiac amyloidosis

?

Transthyretin Light chainAmyloid AAlpha-synucleinTau

Slide74

Which of the following tests is the criterion standard for the diagnosis of myocarditis?

Echocardiography

Cardiac MRI

Endomyocardial biopsy

Electrocardiogram

Serum creatinine

Slide75

Which of the following tests is the

criterion standard

for the diagnosis of myocarditis?

Echocardiography

Cardiac MRI

Endomyocardial biopsyElectrocardiogramSerum creatinine

Slide76

Which of the following is the most common classification of myocarditis?

Viral myocarditis

Fungal myocarditis

Bacterial myocarditis

Autoimmune myocarditis

Idiopathic myocarditis

Slide77

Which of the following is the

most common classification of myocarditis

?

Viral myocarditis

Fungal myocarditis

Bacterial myocarditisAutoimmune myocarditis Idiopathic myocarditis

Slide78

A 40-year-old man presents to surgery as he has noted an abnormality around his right eye: What is the most likely diagnosis?

Hypertriglyceridaemia

Hypercholesterolaemia

Hypothyroidism

Wilson's disease

Diabetes mellitus

Slide79

A

40-year-old man

presents to surgery as he has noted an

abnormality around his right eye

: What is the most likely diagnosis?

HypertriglyceridaemiaHypercholesterolaemiaHypothyroidismWilson's diseaseDiabetes mellitus

Slide80

A 22-year-old intravenous drug user is found to have a femoral abscess. The nursing staff contact the on call doctor as the patient has a temperature of 39°C. He is found to have a pan systolic murmur loudest at the left sternal edge at the 4th intercostal space. What is the most likely cause of the cardiac murmur in this patient?

Pulmonary stenosis

Mitral regurgitation

Tricuspid regurgitation

Aortic stenosis

Mitral stenosis

Slide81

A 22-year-old intravenous drug user is found to have a femoral abscess. The nursing staff contact the on call doctor as the patient has a temperature of 39°C. He is found to have a

pan systolic murmur loudest at the left sternal edge at the 4th intercostal space

. What is the most likely cause of the cardiac murmur in this patient?

Pulmonary stenosis

Mitral regurgitation

Tricuspid regurgitationAortic stenosisMitral stenosis

Slide82

You are a doctor attached to a cardiology clinic. You are about to see a 55-year-old male who has recently presented with progressive exertional

dyspnoea

,

orthopnoea

, and pitting ankle oedema. He went on to have an echocardiogram which showed dilation of all four chambers, thinning of both ventricular walls, tricuspid regurgitation, mitral regurgitation and a reduced ejection fraction. Which is the following is the most likely cause for this patients condition?

AmyloidosisChronic alcoholismObesitySmokingStress

Slide83

You are a doctor attached to a cardiology clinic. You are about to see a 55-year-old male who has recently presented with progressive exertional

dyspnoea

,

orthopnoea

, and pitting ankle oedema. He went on to have an echocardiogram which showed dilation of all four chambers,

thinning of both ventricular walls, tricuspid regurgitation, mitral regurgitation and a reduced ejection fraction. Which is the following is the most likely cause for this patients condition?AmyloidosisChronic alcoholismObesitySmokingStress

Slide84

A 35-year-old lady presents to the emergency department with a 2-day history of progressive right calf swelling, redness, and pain. She has a history of a curative mastectomy for breast cancer and is a casual smoker. She is otherwise fit and well and takes no medications. Observations: HR 95, BP 127/88, RR 18, SpO2 98%, Temp 37.2. The patient has a Wells score of 2 due to significant calf swelling and tenderness. What is the next best step?

MR Venogram

Commence anticoagulation

D-dimer

Duplex ultrasound

CT venogram

Slide85

A

35-year-old lady

presents to the emergency department with a

2-day history of progressive right calf swelling

,

redness, and pain. She has a history of a curative mastectomy for breast cancer and is a casual smoker. She is otherwise fit and well and takes no medications. Observations: HR 95, BP 127/88, RR 18, SpO2 98%, Temp 37.2. The patient has a Wells score of 2 due to significant calf swelling and tenderness. What is the next best step?MR VenogramCommence anticoagulationD-dimerDuplex ultrasoundCT venogram

Slide86

A 65-year-old man presents to the emergency department. He has a history of crushing chest pain, scored 9 out of 10, which started one hour ago. He is a smoker and he is taking amlodipine for his high blood pressure. After an ECG and troponin testing, he is diagnosed with non-ST segment elevation myocardial infarction (NSTEMI). You assess him using the GRACE score and his predicted 6‑month mortality is 2%. He does not have a high risk of bleeding. The nearest primary percutaneous intervention unit is more than one hour away. How should this patient be managed?

Immediate coronary angiography

Aspirin, clopidogrel and fondaparinux

Aspirin, ticagrelor and fondaparinux

Aspirin and fondaparinux

Thrombolysis

Slide87

A

65-year-old man

presents to the emergency department. He has a history of

crushing chest pain

, scored 9 out of 10, which started one hour ago. He is a

smoker and he is taking amlodipine for his high blood pressure. After an ECG and troponin testing, he is diagnosed with non-ST segment elevation myocardial infarction (NSTEMI). You assess him using the GRACE score and his predicted 6‑month mortality is 2%. He does not have a high risk of bleeding. The nearest primary percutaneous intervention unit is more than one hour away. How should this patient be managed?Immediate coronary angiographyAspirin, clopidogrel and fondaparinuxAspirin, ticagrelor and fondaparinuxAspirin and fondaparinux

Thrombolysis

Slide88

A 60-year-old man is admitted with severe central chest pain to the resus department. The admission ECG shows ST elevation in leads V1-V4 with reciprocal changes in the inferior leads. Which one of the following is most likely to account for these findings?

75% occlusion of the left anterior descending artery

75% occlusion of the left circumflex artery

75% occlusion of the right coronary artery

100% occlusion of the left circumflex artery

100% occlusion of the left anterior descending artery

Slide89

A 60-year-old man is admitted with severe central chest pain to the resus department. The admission ECG shows

ST elevation in leads V1-V4 with reciprocal changes in the inferior leads

. Which one of the following is most likely to account for these findings?

75% occlusion of the left anterior descending artery

75% occlusion of the left circumflex artery

75% occlusion of the right coronary artery100% occlusion of the left circumflex artery100% occlusion of the left anterior descending artery

Slide90

A 68-year-old man presents to the emergency department with severe chest pain. The pain started two hours prior and he describes it as central in location. It radiates down his left arm and has not been improved by his glyceryl trinitrate (GTN) spray. He has a history of stable angina, does not drink, but has a 22-pack-year smoking history. Electrocardiogram (ECG) demonstrates ST-segment depression in leads I,

aVL

, V5 and V6. Point-of-care troponin is elevated. The patient is treated with aspirin and ticagrelor, and the decision is made to not attempt percutaneous coronary intervention (PCI). What further immediate treatment is most appropriate?

Fondaparinux

Oxygen

ParacetamolPrasugrelRamipril

Slide91

A

68-year-old man

presents to the emergency department with

severe chest pain

. The pain started two hours prior and he describes it as central in location. It radiates down his left arm and has not been improved by his glyceryl trinitrate (GTN) spray. He has a

history of stable angina, does not drink, but has a 22-pack-year smoking history. Electrocardiogram (ECG) demonstrates ST-segment depression in leads I, aVL, V5 and V6. Point-of-care troponin is elevated. The patient is treated with aspirin and ticagrelor, and the decision is made to not attempt percutaneous coronary intervention (PCI). What further immediate treatment is most appropriate?FondaparinuxOxygenParacetamol

Prasugrel

Ramipril

Slide92

A 56-year-old man has presented to his GP. He complains of having a headache that has been bothering him since yesterday. This headache is worse when he leans forwards. He also mentions that his vision has blurred on occasions over he past few days. On fundoscopy, the GP notes the presence bilaterally of retinal

haemorrhages

and

papilloedema

. The GP measures his blood pressure, which is 190/120 mmHg. What is the next appropriate step?

Admit for specialist assessmentArrange ambulatory blood pressure monitoringCommence amlodipineCommence enalaprilRepeat blood pressure measurement in 7 days

Slide93

A

56-year-old man

has presented to his GP. He complains of having a

headache

that has been bothering him since yesterday. This headache is

worse when he leans forwards. He also mentions that his vision has blurred on occasions over he past few days. On fundoscopy, the GP notes the presence bilaterally of retinal haemorrhages and papilloedema. The GP measures his blood pressure, which is 190/120 mmHg. What is the next appropriate step?Admit for specialist assessmentArrange ambulatory blood pressure monitoringCommence amlodipineCommence enalapril

Repeat blood pressure measurement in 7 days

Slide94

You are called to see a 74-year-old patient who is complaining that her heart is racing. On examination, her heart rate is 209bpm and she appears breathless. Cardiac monitoring confirms a rapid narrow complex tachycardia. She states that she is now experiencing chest pain. What is the most appropriate management step?

Atropine 500micrograms IV

Echocardiogram

Prescribe morphine for her chest pain

Salbutamol inhaler up to 10 puffs

Synchronised DC cardioversion

Slide95

You are called to see a 74-year-old patient who is complaining that her heart is racing. On examination, her heart rate is 209bpm and she appears breathless. Cardiac monitoring confirms a rapid narrow complex tachycardia. She states that she is now experiencing chest pain. What is the most appropriate management step?

Atropine 500micrograms IV

Echocardiogram

Prescribe morphine for her chest pain

Salbutamol inhaler up to 10 puffs

Synchronised DC cardioversion

Slide96

A patient with known heart failure is unable to carry out any physical activity without discomfort. Symptoms of heart failure are present even at rest with increased discomfort with any physical activity. What New York Heart Association class best describes the severity of their disease?

NYHA Class 0

NYHA Class I

NYHA Class II

NYHA Class III

NYHA Class IV

Slide97

A patient with known heart failure is

unable to carry out any physical activity without discomfort

.

Symptoms of heart failure are present even at rest

with increased discomfort with any physical activity. What New York Heart Association class best describes the severity of their disease?

NYHA Class 0NYHA Class INYHA Class IINYHA Class IIINYHA Class IV

Slide98

A 55-year-old man comes to see you following a myocardial infarction 4 weeks ago. He has been started on ramipril, bisoprolol, aspirin and clopidogrel following the event. He was also offered a statin but felt that he was being asked to start too many medications at the same time so he declined the statin at that time. He reports that since then he has been reading up about the beneficial effects of being on a statin and would like to start statin therapy. Which one of the following should this patient be started on?

Rosuvastatin 20mg

Simvastatin 40mg

Atorvastatin 20mg

Atorvastatin 40mg

Atorvastatin 80mg

Slide99

A

55-year-old man

comes to see you following a

myocardial infarction 4 weeks ago

. He has been started on ramipril, bisoprolol, aspirin and clopidogrel following the event. He was also

offered a statin but felt that he was being asked to start too many medications at the same time so he declined the statin at that time. He reports that since then he has been reading up about the beneficial effects of being on a statin and would like to start statin therapy. Which one of the following should this patient be started on?Rosuvastatin 20mgSimvastatin 40mgAtorvastatin 20mgAtorvastatin 40mgAtorvastatin 80mg

Slide100

A 57-year-old man with NYHA class III heart failure is currently treated with furosemide and ramipril. What is the most suitable beta-blocker to add to improve his long-term prognosis?

Acebutolol

Labetalol

Bisoprolol

Sotalol

Esmolol

Slide101

A 57-year-old man with

NYHA class III heart failure

is currently treated with furosemide and ramipril. What is the

most suitable beta-blocker

to add to

improve his long-term prognosis?AcebutololLabetalolBisoprololSotalolEsmolol

Slide102

These are the NICE Hypertension Guidelines. What is a possibility for gap (2)?

Beta Blocker + ACE Inhibitor

ACE Inhibitor + Angiotensin-2 Receptor Blocker

ACE Inhibitor + Calcium Channel Blocker

Calcium Channel Blocker + Beta Blocker

Calcium Channel Blocker + Thiazide Diuretic

Slide103

These are the

NICE Hypertension Guidelines

. What is a possibility for gap (2)?

Beta Blocker + ACE Inhibitor

ACE Inhibitor + Angiotensin-2 Receptor Blocker

ACE Inhibitor + Calcium Channel BlockerCalcium Channel Blocker + Beta Blocker Calcium Channel Blocker + Thiazide Diuretic

Slide104

A 55-year-old woman presents to the emergency department with a sudden onset of central chest pain while she was at rest. The pain was not relieved by her glyceryl trinitrate spray. She has a past history of angina and hypertension. ECG and cardiac biomarkers were positive for an ST-elevation myocardial infarction (STEMI). A few minutes later, she complained of worsening shortness of breath. On examination, her pulse was weak and thready. Her jugular venous pressure is increased. On chest auscultation, there was a new systolic murmur. Her pulse rate was 130 beats per minute and blood pressure was 80/55 mmHg. There were no new acute changes to the ECG. Which of the following is the most likely diagnosis?

Arrhythmia

Aortic regurgitation

Aortic stenosis

Mitral regurgitation

Left ventricular aneurysm

Slide105

A 55-year-old woman presents to the emergency department with a sudden onset of central chest pain while she was at rest. The pain was not relieved by her glyceryl trinitrate spray. She has a past history of angina and hypertension. ECG and cardiac biomarkers were positive for

an ST-elevation myocardial infarction (STEMI

).

A few minutes later, she complained of worsening shortness of breath

. On examination, her

pulse was weak and thready. Her jugular venous pressure is increased. On chest auscultation, there was a new systolic murmur. Her pulse rate was 130 beats per minute and blood pressure was 80/55 mmHg. There were no new acute changes to the ECG. Which of the following is the most likely diagnosis?ArrhythmiaAortic regurgitationAortic stenosisMitral regurgitationLeft ventricular aneurysm

Slide106

A 75-year-old man presents with difficulty breathing at night, occasional palpitations and tight chest pain. On examination, he has a collapsing pulse and a laterally shifted apex beat. You also notice his head bobs in time with his pulse. What would you expect to hear on auscultation of the precordium?

A pansystolic murmur

An ejection systolic murmur

A continuous 'machinery' murmur

A late diastolic murmur

An early diastolic murmur

Slide107

A

75-year-old man

presents with

difficulty breathing at night

,

occasional palpitations and tight chest pain. On examination, he has a collapsing pulse and a laterally shifted apex beat. You also notice his head bobs in time with his pulse. What would you expect to hear on auscultation of the precordium?A pansystolic murmurAn ejection systolic murmurA continuous 'machinery' murmurA late diastolic murmurAn early diastolic murmur

Slide108

A 26-year-old female is admitted to hospital with palpitations. ECG shows a shortened PR interval and wide QRS complexes associated with a slurred upstroke seen in lead II. What is this condition?

1

st

degree heart block

Wolff-Parkinson-White Syndrome

3rd degree heart block Complete heart block 2nd degree heart block

Slide109

A

26-year-old female

is admitted to hospital with

palpitations

. ECG shows a

shortened PR interval and wide QRS complexes associated with a slurred upstroke seen in lead II. What is this condition? 1st degree heart block Wolff-Parkinson-White Syndrome3rd degree heart block Complete heart block 2

nd

degree heart block

Slide110

A 43-year-old lady presents with central chest pain, worse on deep inspiration, and shortness of breath. After her history and examining her, you suspect a pulmonary embolus (PE). Her Wells' score is 9. You plan to do a CTPA, but the radiologists request you order one further investigation prior to a CTPA. What investigation is this likely to be?

Ultrasound doppler of right leg

Chest

xray

High resolution CT Chest

V/Q scanD-Dimer

Slide111

A

43-year-old lady

presents with

central chest pain

,

worse on deep inspiration, and shortness of breath. After her history and examining her, you suspect a pulmonary embolus (PE). Her Wells' score is 9. You plan to do a CTPA, but the radiologists request you order one further investigation prior to a CTPA. What investigation is this likely to be?Ultrasound doppler of right legChest xrayHigh resolution CT Chest

V/Q scan

D-Dimer

Slide112

Where is the site of action of furosemide?

Proximal collecting duct

Ascending loop of Henle

Descending loop of Henle

Distal collecting duct

Macula densa

Slide113

Where is the site of action of furosemide?

Proximal collecting duct

Ascending loop of Henle

Descending loop of Henle

Distal collecting duct

Macula densa

Slide114

A 60-year-old man presents with a 2-week history of

dyspnoea

and leg swelling. On examination, he has a raised JVP that doesn't fall with inspiration. His lung bases are clear and a pericardial knock is heard on auscultation. His only past medical history is angina for which he was recently investigated with a coronary angiogram. Given this presentation, which of the following is the most likely cause of his presentation?

Constrictive pericarditis

Acute heart failure

Acute pericarditisInfective endocarditisCardiac tamponade

Slide115

A

60-year-old man

presents with a

2-week history of

dyspnoea

and leg swelling. On examination, he has a raised JVP that doesn't fall with inspiration. His lung bases are clear and a pericardial knock is heard on auscultation. His only past medical history is angina for which he was recently investigated with a coronary angiogram. Given this presentation, which of the following is the most likely cause of his presentation?Constrictive pericarditisAcute heart failureAcute pericarditisInfective endocarditisCardiac tamponade

Slide116

A 2-year-old boy is seen by the general practitioner as his parents are concerned that he is struggling to gain weight and is excessively short of breath on exertion. He was previously diagnosed with congenital pulmonary stenosis which was managed conservatively however the parents are now questioning whether surgical intervention may be required. What murmur is likely to be heard on examination?

Ejection systolic, louder on expiration

Ejection systolic, louder on inspiration

Holo-systolic, louder on expiration

Holo-systolic, louder on inspiration

Late systolic

Slide117

A 2-year-old boy is seen by the general practitioner as his parents are concerned that he is struggling to gain weight and is excessively short of breath on exertion. He was previously diagnosed with

congenital pulmonary stenosis

which was managed conservatively however the parents are now questioning whether surgical intervention may be required. What murmur is likely to be heard on examination?

Ejection systolic, louder on expiration

Ejection systolic, louder on inspiration

Holo-systolic, louder on expirationHolo-systolic, louder on inspirationLate systolic

Slide118

A 35-year-old woman presents to the emergency department with chest pain and shortness of breath. She describes the pain as sharp and it came on fairly suddenly. There is a past medical history of depression for which she takes sertraline, asthma which she uses a steroid inhaler for, and takes the combined contraceptive pill. She is alert and talking to you, observations are blood pressure 87/59 mmHg, heart rate 112 bpm, respiratory rate 25/min and temperature 37.8ºC. ECG shows sinus tachycardia and a chest X ray has no abnormal findings. Pulmonary embolism is suspected. Given the most likely diagnosis, what would the most suitable treatment plan be?

Aspirin then lower molecular weight heparin

Inferior vena cava filter

Lower molecular weight heparin

Thrombolysis

Rivaroxaban for at least 3 months

Slide119

A

35-year-old woman

presents to the emergency department with

chest pain

and

shortness of breath. She describes the pain as sharp and it came on fairly suddenly. There is a past medical history of depression for which she takes sertraline, asthma which she uses a steroid inhaler for, and takes the combined contraceptive pill. She is alert and talking to you, observations are blood pressure 87/59 mmHg, heart rate 112 bpm, respiratory rate 25/min and temperature 37.8ºC. ECG shows sinus tachycardia and a chest X ray has no abnormal findings. Pulmonary embolism is suspected. Given the most likely diagnosis, what would the most suitable treatment plan be?Aspirin then lower molecular weight heparinInferior vena cava filterLower molecular weight heparinThrombolysis

Rivaroxaban for at least 3 months

Slide120

LO: please insert relevant Learning objective reference here

120

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