CONTENTS
1. CARDIOLOGY
1
2. RESPIRATORY
53
3. NEPHROLOGY
95
4. NEUROLOGY
120
5. GIT
156
6. RHEUMATOLOGY
202
7. HAEMATOLOGY
230
8. ONCOLOGY
246
9. ENDOCRINOLOGY
264
10. INFECTIOUS DIASEASES
287
11. EMERGENCY MEDICINE
301
12. DERMATOLOGY 310
13. PSYCHIATRY 324
14. OPTHALMOLOGY 333
15. PHARMA/TOXOCOLOGY 343
16. STATISTICS 361
17. PLATES 367
MOHAMMED IS-HAG
1. A 46-year-old woman with permanent atrial fibrillation is experiencing rapid palpitations due to an elevated heart rate. Which from the following list of drugs are the three most
appropriate for controlling ventricular rate response? A : Adenosine B : Amiodarone C : Aspirin D : Atenolol E : Digoxin F : Doxasocin G : Flecainide H : Isoprenaline I : Lidocaine J : Magnesium K : Mexilitine L : Moxonidine M : Propafenone N : Verapamil O : Warfarin.
Comment : Beta-blockers, cardiac glycosides and calcium channel antagonists all have a negative chronotropic effect on the atrio ventricular (AV) node and are very useful in the acute and long-term control of ventricular rate in AF. Digoxin and verapamil however should be avoided in the rare patients who also have Wolf-Parkinson-White syndrome. While Amiodarone, Flecainide and Propafenone are commonly used to chemically cardiovert AF to sinus rhythm, they have only a small effect on AV nodal conduction and should not be chosen for rate control alone. Adenosine causes rapid but only very brief (a few seconds) blockade of AV nodal conduction. Lidocaine, Mexilitine and Magnesium are used only for the control of ventricular arrhythmias. Warfarin and Aspirin are commonly used in patients with AF for preventing thromboembolic complications. Isoprenaline is a beta agonist and would accelerate
ventricular response in AF.Doxazosin and Moxonidine are antihypertensive agents. D : E : N: 2.
A 19-year-old man presents to accident and emergency with a fast pounding in his throat and presyncope. He is found to be tachycardic and his ECG is as shown. What is the most likely arrhythmia?
A : Atrial fibrillation (AF)
B : Ventricular tachycardia (VT) C : Atrial tachycardia
D : Atrio-ventricular nodal re-entry tachycardia (AVNRT) E : Atrial flutter.
Comment : The ECG shows a regular narrow complex tachycardia at a rate of 170. This excludes VT (broad complex)and AF(irregular).Although atrial flutter and atrial tachycardia are possible diagnoses there are no visible p waves,which would be expected. The most likely diagnosis by far is AVNRT,which
is caused by a re-entry circuit formed within the AV node causing atria and ventricles to be activated
simultaneously.This can cause reflux of jugular venous blood and a sensation of pounding in the throat. D:
3. A 65-year-old lady is admitted with left sided pneumonia and pleural effusion. Pleural fluid is aspirated and sent for tests. Which of the following is an indication for inserting a chest drain? A : Pleural fluid pH <7.2
B : Serous pleural fluid
C : Blood stained pleural fluid
D : Pleural fluid glucose >2mmol/l
E : Pleural fluid lactate dehydrogenase > 200IU/l.
Comment : Infected pleural effusions should be drained. Infected pleural effusions should be drained if the pH<7.2, Gram stain shows organisms, the fluid is frankly purulent and clinical improvement is slow despite antibiotics. A :
4.
This is an angiogram from a 65-year-old man with limiting angina. He currently takes aspirin. The most appropriate treatment option is:
A : long acting oral nitrate
B : percutaneous coronary angioplasty with stenting C : coronary artery bypass grafting
D : oral beta blocker
E : intravenous GIIb/IIa receptor antagonist.
Comment : The angiogram demonstrates significant left main stem (LMS) and left anterior
descending artery (LAD) stenoses. Coronary artery bypass grafting has been shown to improve survival in patients with left main stem stenosis (> 60%), triple vessel disease and impaired left ventricular function and triple vessel disease with proximal left anterior descending artery disease, when compared to medical therapy. Angioplasty is exceedingly high risk and therefore is only contemplated when patients are deemed as non-operative candidates. C :
5. A 68-year-old female is referred to outpatients with a three-month history of dyspnoea and significant peripheral oedema. Clinical findings are solely of the oedema. Echocardiography demonstrates tickened myocardium with impaired relaxation and a bright speckled appearance. What is the likely diagnosis?
A : Hypertrophic cardiomyopathy B : Cor pulmonale
C : Sarcoidosis D : Amyloidosis
E : Secondary neoplastic myocardial deposition.
Comment : The commonest cause of death in amyloidosis is secondary to cardiac involvement. It may present with the insidious onset of vague symptoms, such as lethargy. Later peripheral oedema
becomes a prominent feature.Amyloid depositis in the heart produce generalized thickening of the myocardium (as opposed to asymmetrical septal hypertrophy commonly seen in hypertrophic
MOHAMMED IS-HAG
cardiomyopathy) and diastolic dysfunction. This produces a "stiffened" appearance to relaxation in the diastolic phase.A search for non-cardiac amyloid deposits is usually the most efficient way to coinfirm the diagnosis histologically. Cardiac biopsy may be useful. The treatment of cardiac amyloid is
supportive and generally it carries a very poor prognosis. D : 6.
A 75-year-old woman presents with palpitations. Her ECG shows: A : Atrial fibrillation
B : Atrial fibrillation with acute inferior myocardial infarction C : Atrial flutter
D : Atrial flutter with acute inferior myocardial infarction E : Atrioventricular re-entrant tachycardia.
Comment : The ECG shows atrial flutter with 4/1 block. There are no features to suggest myocardial infarction. C :
7. Which of the following statements regarding the natriuretic peptides ANP (atrial natriuretic peptide) and BNP (brain natriuretic peptide) is not correct?
A : They are both vasodilators.
B : BNP is produced by the ventricular myocardium.
C : They inhibit sodium reabsorption in the collecting duct of the kidney. D : They stimulate aldosterone production in the adrenal glomerulosa. E : ANP is released in response to atrial stretch.
Comment : ANP and BNP are members of the natriuretic peptide family. As its name suggests, ANP is primarily released from the atria in response to enhanced stretch. Although first discovered in porcine brain, BNP is found in large quantities in ventricular myocardium. Release of BNP is thought to occur in response to increased ventricular wall stress. ANP and BNP have similar biological properties, which include vasodilatation, natriuresis and diuresis.
ANP and BNP have direct effects on renal function. These include increasing glomerular filtration rate as a consequence of efferent glomerular arteriolar vasoconstriction and afferent vasodilatation. In addition, they directly inhibit sodium reabsorption in the collecting tubules. Both ANP and BNP also inhibit renin and aldosterone release.
Plasma ANP and BNP levels are elevated in patients with chronic heart failure and indeed levels may be used to aid in the diagnosis of heart failure. Furthermore, plasma ANP and BNP are helpful in providing prognostic assessment of patients with heart failure and post myocardial infarction.
In view of the potential beneficial haemodynamic effects of ANP and BNP, there is current interest in the therapeutic manipulation of the natriuretic peptide system in patients with heart failure. This could be achieved by inhibiting their breakdown (neutral endopeptidase inhibitors) or infusing exogenous synthetic peptide. D :
8. A 42-year-old man reviewed in outpatients has a 6-month history of increasing shortness of breath on exertion and feelings of lightheadedness when digging in his garden. His general
practitioner organised an open access echocardiogram which showed a septal thickness of 26mm and a left ventricular outflow gradient of 85mmHg. Which of the following is NOT a risk factor for sudden death in patients with hypertrophic cardiomyopathy?
A : Unexplained syncope
B : Sudden death from HOCM in 2 or more first degree relatives <40years of age C : Family history of sudden death
D : left ventricular wall thickness of >30mm E : Hypertension.
Comment : Major risk factors for hypertrophic cardiomyopathy are: · Cardiac arrest (ventricular fibrillation)
· Spontaneous sustained ventricular tachycardia · Family history of sudden death
· Minor risk factors · Unexplained syncope
· Left ventricualr wall thickness>30mm
· Abnormal blood pressure on exercise(failure to rise from baseline by 25mmHg) · Non sustained Ventricular tachycardia
· Left ventricular outflow obstruction · Microvascular obstruction · High risk genetic defect. E :
9. A 42-year-old man visits his GP, complaining of a recent onset of shortness of breath and dizziness upon exertion. His GP arranges for an echocardiogram, which showed hypertrophic obstructive cardiomyopathy (HOCM) with thickening of the septal wall and a left ventricular outflow gradient of 86mmHg. The man is referred to a cardiology outpatient clinic, where he volunteers that his father died suddenly of a heart attack aged 38 years of age and his younger brother died aged 17 years of age during a rugby scrum more than 20 years ago. He is not sure of the cause of death for his younger brother but does not think a post-mortem was ever carried out. He has two teenaged sons, both of whom are well, but his 14-year-old son fainted after scoring a goal for the school team last week. Which of the following statements are correct?
A : The majority of patients with HOCM are symptomatic throughout life. B : The overall mortality in patients with HOCM is 50% per year.
C : All first degree family members should undergo screening every 6 months. D : All patients should receive advice on avoiding dehydration and strenous exercise.
E : Patients with HOCM do not need prophylaxis against infective endocarditis. Comment : · The majority of patients with HOCM are ASYMPTOMATIC.
· The overall mortality in patients with HOCM is <1% per year.
· All first degree family members should undergo periodic screening with echocardigraphy every 5 years for this autosomal dominant disorder since hypertrophy may not occur until 6th or 7th decade of life. Annual screening is recommended for adolescents 12 to 18 years of age.
· All patients should be advised to avoid dehydration and strenuous exercise.
· All patients with HOCM should be advised to use prophylaxis against infective endocarditis. D : 10. You are asked to speak to a 58 yr old man and his wife on the ward. He has been admitted for routine surgery (cholecystectomy) and when clerked says that he worked in shipyards for many years. The house surgeon enquires about asbestos exposure, and this leads to a great deal of anxiety. His wife is very keen to know what medical risks this poses for him. Which one of the following statements regarding asbestos exposure or asbestos related disease is true? A : pleural plaques are often associated with restrictive defect in respiratory function tests. B : the risk of mesothelioma increases with smoking.
C : the risk of lung cancer increases by 50-fold in asbestos workers who smoked compared to persons who neither smoked nor worked with asbestos.
D : chemotherapy is the treatment of choice in patients with mesothelioma. E : adenocarcinoma is the predominant histological type in asbestos workers with lung cancer. Comment : Asbestos exposure is associetd with:
· pleural plaques
· diffuse pleural thickening
· lung fibrosis (also known as asbestosis) · lung cancer
· mesothelioma.
The commonest abnormality seen in asbestos workers is pleural plaques, which are well-circumscribed areas of thickening affecting the parietal pleura. Pleural plaques are even seen in patients with mild
MOHAMMED IS-HAG
asbestos exposure. In the majority of patients, these plaques are asymptomatic and do not cause any changes in respiratory function tests.
Mesothelioma is a tumour of the mesothlial cells or the pro-mesothelial cells. It affects the pleura and, to a lesser extent, the pericardium and the peritoneum. The incidence of mesothelioma increases in patients with heavy asbestos exposure and in those who were exposed to asbestos at a young age. Cigarette smoking does not increase the incidence of mesothelioma.
Mesothelioma is a fatal disease. The majority of patients die within 18 months of diagnosis. The disease is resistant to current treatment modalities such as chemotherapy and radiotherapy. Tumor resection is indicated in only a small proportion of patients.
Lung cancer is associated with heavy asbestos exposure. The effects of asbestos exposure and smoking are multiplicative. The risk of lung cancer in asbestos workers who never smoke is increased by 5-fold. In smokers the risk is about 55-fold that in non-smoking persons who never worked with asbestos. C : 11.
What does this angiogram show?
A : Left internal mammary artery graft B : Subclavian stenosis
C : Normal coronary artery D : Patent ductus arteriosus
E : Coronary artery vein graft to the left anterior descending artery. Comment : This angiogram demonstrates a left internal mammary arterial (LIMA) graft to the left anterior descending artery. Sternal wires can clearly be seen along with clips to occlude branches of the LIMA. The artery is cannulated via the left subclavian artery. In the majority of cases arterial grafts are preferred to saphenous vein grafts as their longevity is generally greater. Other arterial grafts commonly used are the right internal mammary artery (RIMA) and radial artery. A :
12. A 78-year-old man presents with an acute confusional state. He has postural hypotension and is dehydrated, with serum calcium 3.41 mmol/l. Which is the most appropriate initial
treatment?
A : Intravenous sodium pamidronate B : Intravenous 5% dextrose
C : Oral prednisolone (20-60 mg)
D : Intravenous frusemide (40 mg) E : Intravenous 0.9% sodium chloride.
Comment : The initial priority is to restore intravascular volume by giving 0.9% sodium chloride intravenously. When this has been done, frusemide can be used to increase calcium excretion and sodium pamidronate can be used to effect rapid reduction in serum calcium concentration.
The commonest causes of hypercalcaemia in an elderly man would be metastatic malignancy, myeloma and primary hyperparathyroidism. E :
13.
A 45-year-old female is admitted with chest pain. She has previously been fit and well, apart from a road traffic accident 4 years ago. Her radiograph shows which of the following?
A : It is normal B : Dextrocardia
C : Tension pneumothorax D : Hiatus hernia
E : None of the above.
Comment : This lady had traumatic rupture of her diaphragm when she had her RTA, leading to massive herniation of her large bowel into her left hemidiaphragm. Her chest pain was related to gastrooesophageal reflux. E :
14. A 58-year-old female is admitted acutely with pulmonary oedema and hypotension. She had a mitral valve replacement four years previously for mitral regurgitation. Clinical examination reveals a diastolic murmur and pulmonary oedema. Her biochemistry and full blood count is normal. Her INR is 1.8. Echocardiography demonstrates thrombus around the valve. What is the best treatment?
A : Intravenous heparin B : Thrombolysis
C : Urgent surgical intervention D : Increased dose of warfarin E : Low molecular weight heparin.
Comment : Mechanical mitral valves are more prone to thrombosis than aortic valves if the INR drops below the therapeutic level. This is a medical/surgical emergency. It is rapidly fatal without immediate surgical intervention. Thrombus in this context cannot be treated with anticoagulants/fibrinolytics. Anticoagulation is clearly an important consideration when considering what type of valve prosthesis should be considered for an individual. C :
15. A 66-year-old gentleman with known hypertension underwent coronary artery bypass grafting. Twelve hours later he becomes hypotensive despite inotropic support. What is the next most appropriate investigation? A : Urgent cardiac catheterization B : Re-exploration of surgery
C : Transoesophageal echocardiogram D : Ventilation perfusion scan
E : Serum potassium measurement.
Comment : The most likely explanation of this gentleman’s deterioration is cardiac tamponade. Although trans-thoracic echocardiogram would be of help it does not exclude the diagnosis. Pericardial effusions, particularly in the early post-operative period, can be localized and difficult to identify by trans-thoracic echocardiography. An effusion may only occur posteriorly and therefore the best way to visualize these would be through transoesophageal echo. C :
16. A 60-year-old gentleman is being investigated for chest pain and undergoes exercise tolerance testing. Which feature is associated with a worse prognosis?
A : Increased metabolic rate B : Ventricular tachycardia
C : Increase in blood pressure with exercise D : Rapid resolution of heart rate in recovery E : Absence of symptoms during exercise.
MOHAMMED IS-HAG
Comment : Exercise testing has long been an established method for identifying patients with underlying coronary disease. Apart from changes in the ST segments other features have been associated with underlying disease, including:
· ventricular arrhythmias
· inadequate blood pressure response · inadequate heart rate response · angina
· poor MET response. B :
17. The following measurements were made from a cardiac catheterisation of a 28-year-old gentleman with palpitations and breathlessness:
RA 6mmHg RV 22/6
PA 30/10 PAW 28
LV 128/10
What is the most appropriate next investigation? A : Exercise treadmill testing
B : Trans-oesophageal echocardiography C : Cardiac MRI
D : 24-hour tape
E : Coronary angiography.
Comment : The result of the catheterisation demonstrates a significant gradient across the mitral valve (PAW = pulmonary artery wedge, reflecting left atrial pressure)indicating mitral stenosis. The next investigation would be trans thoracic echocardiography to assess the suitability of the mitral valve for balloon valvuloplasty. General contra-indications to percutaneous balloon valvuloplasty are: significant mitral regurgitation, calcification of mitral valver leaflets, left atrial thrombus. All of these can be assessed by trans oesophageal echo. B :
18. A 63-year-old male with Marfan's syndrome presents with chest pain and is found to have an acute aortic dissection. Which two of the following cardiac conditions are associated with Marfan's? A : Atrial myxoma
B : Mitral stenosis
C : Pulmonary regurgitation D : Ventricular tachycardia E : Atrial septal defect
F : Ventricular septal defect G : Cardiac amyloid
H : Sarcoidosis
I : Mitral valve prolapse J : Aortic stenosis.
Comment : Cardiac complications of Marfan’s are relatively common. Usually they are related to aortic involvement. However, Marfan’s is associated with the following:
· Mitral valve prolapse and regurgitation · Left ventricular dilatation and cardiac failure · Pulmonary artery dilatation
· Regurgitation of the pulmonary valve. C : I:
19. A 45-year-old lady is seen in cardiac outpatients with a blood pressure of 160/80.
Consistently it has been greater than 145>85. However ambulatory monitoring demonstrated a mean BP of 130/75. Which of the following are inappropriate indications for ambulatory blood pressure monitoring?
A : Deciding diagnosis in borderline hypertension B : Making a diagnosis of left ventricular failure
C : Identification of nocturnal hypertension D : Diagnosing Phaeochromocytoma
E : Hypertensive patients resistant to treatment F : Hypertension of pregnancy
G : Diagnosis of hypotension
H : Monitoring hypertensive tretament I : Elderly patients
J : Exclusion of white coat hypertension.
Comment : A diagnosis of "white coat hypertension" was made in this lady and thus she did not require antihypertensive treatment. This is probably the strongest indication for ambulatory BP monitoring but the indications are broad. A diagnosis of left ventricular failure will not be made on BP alone. Equally a
phaeochromocytoma may have transient rises in BP but as most ambulatory monitors will only measure once or twice an hour it is unlikely to be helpful in this situation B : D :
20. A 40-year-old woman was referred for investigation of shortness of breath on effort over the preceding 1 year. Data from her cardiac catheterisation iare as follows:
Pressure (mmHg) Oxygen saturation (%) SVC 15 64 IVC 13 65 RA 13 82 RV 51/7 85 PA 53/31 83 LV 134/3 99 Aorta 135/82 99
Which of the following are true concerning her diagnosis?
A : This condition rarely presents in adulthood.
B : Paradoxical splitting of the second sound is common. C : A rumbling mid diastolic murmur may occur.
D : A systolic murmur is rare.
E : The ECG often shows left bundle branch block. F : The chest radiograph is usually normal.
G : Echocardiography shows left ventricular dilatation. H : Medical treatment is recommended in this case. I : Arrhythmias are rare with this condition.
J : In children, this condition may be associated with skeletal abnormalities. Comment : This patient has a secundum atrial septal defect as shown by a step-up in oxygen
saturations at atrial level. She also has pulmonary hypertension. Characteristic findings on auscultation include a wide fixed-split second sound, ejection systolic murmur and a mid diastolic murmur. The murmurs are caused by increased flow across the pulmonary and tricuspid valves respectively. The ECG often shows a right bundle branch block pattern and the chest radiograph shows right ventricular enlargement and prominent pulmonary arteries. Surgical or percutaneous closure is recommended in patients with symptoms, right ventricular dilatation, or a pulmonary: systemic flow ratio > 1.5. The Holt-Oram syndrome is the association of an atrial septal defect with bony abnormalities of the
extremities. C : J:
21. A 57-year-old diabetic man with stable angina wishes to use Sildenafil (Viagra) to treat impotency. Concomitant use of which two of the following cardiac medications is contraindicated?
A : Aspirin B : Clopidogrel C : Atenolol D : Amlodipine E : Digoxin F : Isosorbide mononitrate G : Lisinopril H : Nicorandil I : Simvastatin J : Warfarin.
Comment : Sildenafil enhances Nitric Oxide (NO) mediated smooth muscle relaxation by blocking the degradation of cGMP. Although it is relatively selective to the corpus cavernosum it does still have some systemic effect. Both Isosorbide Mononitrate and Nicorandil release NO and their action is potentiated by Sildenafil, which can lead to profound hypotension.
The other commonly used cardiac medications listed have no specific interaction with Sildenafil. F:H: 22. A 56-year-old man develops cardiogenic shock 8 hours after admission with an anterior myocardial infarction. He was thrombolysed with tPA on admission with rapid resolution of the ST elevation. He has a loud pansystolic murmur which is new. Which of the following are
inappropriate in the management of this patient? A : Repeat thrombolysis
B : Coronary angiography C : Intra aortic balloon pump D : Intravenous beta-blockers E : Inotropic support
F : Urgent echocardiography
G : Swann–Ganz pulmonary artery catheter H : Intravenous diamorphine
I : Transfer to cardiothoracic surgical centre J : Consider positive pressure ventilation.
MOHAMMED IS-HAG
Comment : Increasing revascularisation both with coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) has seen reductions in the number of deaths following acute myocardial infarction. However, shock remains the leading cause of death in hospital.
It is clear that this patient has most likely developed a post MI ventricular septal defect or acute mitral regurgitation. In the absence of new ECG changes, thrombolysis is clearly contraindicated. The use of intravenous beta-blockers in the shocked patient is also relatively contraindicated. The mainstay of treatment is therefore supportive and surgical intervention, if appropriate. A : D :
23. A 65-year-old man presents with increasing breathlessness and swelling of his legs. These symptoms have occurred over a period of 2 months. He has otherwise been previously well, apart from a 2-year history of diarrhoea which his gastroenterologists have been investigating. On echo, he is found to have severe tricuspid regurgitation and a diagnosis of carcinoid syndrome is made. Which of the following statements about carcinoid syndrome is NOT true?
A : Common sites of carcinoid tumours are the appendix and terminal ileum. B : After the tricuspid valve, the mitral valve is most commonly affected. C : Patients with cardiac carcinoid ususally die from valvular disease rather than carcinomatosis. D : Patients with cardiac involvement usually have more advanced disease. E : Patients with cardiac involvement usually have higher levels of 5-HIAA.
Comment : Carcinoid heart disease is rare and usually affects the right-sided valves (i.e. tricuspid and pulmonary valves). Cardiac involvement is associated with more advanced disease and carries with it a poorer prognosis. It is associated with higher circulating levels of 5-HIAA. Most patients present with right-sided heart failure. Treatment of cardiac carcinoid involves management of the right-sided valve failure, pharmacotherapy to reduce secretion of tumour products and surgical intervention for the valvular pathology. B :
24. A 21-year-old university student complains of difficulty sleeping. She is in the middle of sitting her final exams and would like some medication for a few days to help her sleep. However, she is concerned about potential 'hang-over' effects and would prefer a drug which doesn't cause daytime drowsiness. Which agent would you prescribe?
A : Diazepam B : Midazolam C : Promethazine D : Loprazolam E : Clomethiazole.
Comment : Diazepam has a long half-life, principally because of its active metabolites. Midazolam is short-acting but is only used intravenously. Promethazine is an antihistamine with a 12-hour half-life and may cause daytime sedation. Clomethiazole is less safe in overdose, has dependence potential and is only licensed for sedation in the elderly. Loprazolam is short-acting (half-life 6–12 hours) and would be a reasonable choice. D :
25. A 68-year-old man with a past history of myocardial infarction, from which he made a good recovery, now presents with chest pain that might be due to cardiac ischaemia, but the history is not typical. He would not be able to perform a Bruce protocol treadmill test because of severe osteoarthritis of his knees and it is decided to perform radionucleotide myocardial perfusion imaging. Which two of the following statements about such imaging are correct?
A : It should be avoided in asthmatic patients.
B : It should be avoided in patients with aortic stenosis. C : It is useful in determining the functional severity of coronary lesions but does not predict
prognosis.
D : It can be used to risk stratify patients undergoing surgical procedures. E : It is not helpful in patients unable to physically exercise to maximal capacity. F : It is readily possible to differentiate between reversible ischaemia and infarcted areas of
myocardium.
G : It is of no value following coronary angiography.
H : False positives are seen more commonly in middle aged women as compared to conventional exercise testing
I : It should not be used in patients with very poor left ventriuclar function. J : A normal image indicates risk of of coronary events of 2-3% per year. Comment : Radionucleotide myocardial perfusion imaging is very useful in assessing the degree of coronary obstruction in patients with suspected coronary artery disease. It provides diagnostic and prognostic data. Patients can be stressed using conventional treadmill or pharmacological stress with agents such as adenosine or dobutamine. Adenosine should be avoided in asthmatics. A normal image indicates risk of coronary events of <1% per year.
The test can also be helpful in targeting intervention following angiography and in the detection of hibernating myocardium in patients with poor left ventricular function. D : F:
26.
plate 1
A 57-year-old lady is being pre-assessed for a gynaecological procedure and is found to have a murmur. What does her echo image show?
A : Aortic regurgitation B : Aortic stenosis
C : Mitral regurgitation D : Mitral stenosis
E : Infective endocarditis.
Comment : The image demonstrates a posteriorly directed jet of mitral regurgitation in a lady with anterior leaflet prolapse. C :
27. A 40-year-old female presents with a 6-month history of progressive breathlessness. Cardiac catheter data are as follows:
Pressure (mmHg) Oxygen saturation (%) IVC RA a 16; v 38 68 RV 81/17 67 PA 78/52 63 LV 123/6 97 Aorta 128/70 98
A pulmonary angiogram showed no evidence of thromboembolic disease. Which of the following is true concerning her condition:
A : The condition is more common in males.
B : Presentation is usually in the first decade of life. C : An ejection systolic murmur is commonly heart. D : A pan systolic murmur is commonly heard.
E : Pulmonary oedema is a common feature. F : The ECG often shows left axis deviation. G : Echo is usually unhelpful in the diagnosis. H : Warfarin is not recommended.
I : Calcium antagonists are contraindicated. J : Atrial septostomy may provide temporary improvement.
Comment : This lady has primary pulmonary hypertension with no evidence of right to left shunting. The high v wave pressure in the right atrium is due to tricuspid regurgitation. The condition is more common in females and usually presents in the fourth decade of life. Physical signs include parasternal heave, loud pulmonary second sound, pansystolic murmur (due to tricuspid regurgitation) and evidence of right heart failure. ECG typically shows right axis deviation and evidence of right ventricular
hypertrophy. Warfarin is recommended to all patients and high dose calcium antagonists only to those with a significant drop in pulmonary pressures with vasodilator testing. Patients with evidence of vasoactivity may also respond to prostacycline or nitric oxide therapy. Lung or heart-lung
MOHAMMED IS-HAG
28. A 25-year-old woman is referred because during a routine antenatal visit at 32 weeks of pregnancy the obstetrician hears a systolic murmur. She has no cardiac symptoms. Which are the two most likely causes of her murmur?
A : Aortic stenosis
B : Ventricular septal defect
C : Aortic regurgitation with flow murmur D : Atrial septal defect
E : Triscuspid regurgitation F : Peripartum cardiomyopathy
G : Hypertrophic obstructive cardiomyopathy H : Aortic sclerosis
I : Innocent systolic murmur J : Mitral valve prolapse.
Comment : Given that the woman is well, it is almost certain that the murmur has an innocent cause, being due to the hyperdynamic circulation of pregnancy. It is also possible that the obstetrician has heard a venous hum or a mammary soufflé. Mitral valve prolapse would be much the commonest of the ‘cardiac lesions’ listed in a 25-year-old woman.
The presence of symptoms should raise the suspicion of significant pathology, but it is important to remember that some degree of weakness, exertional dyspnoea, dizziness and peripheral oedema are common during pregnancy. It is therefore very important to gauge the severity of any symptoms in relation to the stage of pregnancy, and a great deal of unnecessary anxiety can be generated by doctors who fail to do so.
The investigation of choice to exclude a significant cardiac lesion is echocardiography. I:J: 29.
PLATE 2
A 37-year-old woman is seen in outpatients with frequent episodes of palpitations. She tells you that she has had them for only 2 years and gets chest discomfort during the attacks. See image for her ECG. What is the correct diagnosis?
A : Anxiety-producing sinus tachycardia B : Wolf-Parkinson-White syndrome C : Lown-Ganong-Levine syndrome D : Ventricular tachycardia
E : Left bundle branch block.
Comment : Wolf-Parkinson-White is the syndrome of pre-excitation secondary to antegrade
conduction down an accessory pathway from atrium to ventricle. This is characterized on the 12-lead surface ECG by a short PR interval, a delta wave and broad complexes (as a result of the delta wave). The accessory pathway can be in any location around the atrioventricular valves, i.e. mitral or tricuspid valves. Using various algorithms it is possible to accurately locate the position of the accessory pathway. In this patient's case the negative deflection of the delta wave in lead V1 suggests the pathway is on the right side, i.e. around the tricuspid valve. If it had been positive it would have pointed to a left-sided pathway. During an electrophysiological study she was found to have a right-sided posteroseptal pathway which was successfully ablated. Lown-Ganon-Levine syndrome differs from Wolf-Parkinson-White syndrome in that it has a short PR interval without a delta wave. This is thought to be due to accessory conduction tissue from the atria to the atrioventricular node. Whilst the complexes are broad, this is clearly sinus rhythm and not ventriuclar tachcardia. B :
30. A 78-year-old man presents with a 3-month history of syncopal episodes and chest pain, both occurring only on exertion. Select the two most likely diagnoses from the list below: A : Aortic stenosis
B : Epilepsy
C : Orthostatic hypotension D : Sick sinus syndrome
E : Coronary artery disease
F : Intermittent third degree heart block G : Supraventricular tachycardia
H : Atrial fibrillation I : Vasovagal syncope J : Hypertrophic obstructive cardiomyopathy.
Comment : A history of syncope that occurs only on exertion is suggestive of outflow tract
obstruction, when it results from reflex bradycardia and vasodilatation. Aortic stenosis is therefore one of the diagnoses to consider, but it would be most unusual for hypertrophic obstructive cardiomyopathy to present at this age.Arrhythmias can occur at any time, but they may happen only on exercise if they are sensitive to increased sympathetic outflow or ischaemia, and coronary artery disease would clearly be a likely diagnosis in a man of 78 years with these symptoms.The key physical signs to establish a diagnosis of aortic stenosis would be a slow rising carotid upstroke, an undisplaced thrusting apex, and an ejection systolic murmur radiating to the carotids, perhaps with a palpable thrill. A : E : 31. A middle-aged man is brought by ambulance to the Medical Admissions Unit. He was fitting when picked up and is still having a grand mal convulsion. The most appropriate treatment is: A : Lorazepam 2 mg intravenously
B : Fosphenytoin 15 mg/kg body weight phenytoin equivalent, intravenously at a rate of 100-150 mg phenytoin equivalent / min
C : Phenytoin 15 mg/kg body weight, intravenously at a rate of 50 mg/min D : Diazepam 10 mg intravenously
E : Phenobarbitone 10 mg/kg body weight, intravenously at a rate of 100 mg/min. Comment : All of these are recognized treatments for status epilepticus. First-line treatment should be with intravenous benzodiazepine, with lorazepam preferred to diazepam because of its longer duration of action. Fosphenytoin is the preferred second-line treatment (phenytoin if this is not available). Phenobarbitone is one of several agents that can be used as third-line treatment, but seek specialist advice if first and second-line treatments are ineffective. A :
32. An 83-year-old lady is admitted having been found on the floor by her home help. She had fallen 6 hours prior to admission and thought she may have blacked out, but was not able to give any more details. Which two of the following are correct?
A : Each year in the community 2/3 of people over 65 years have at least one fall/year.
B : Age-related changes affecting vision, vestibular system and proprioception have no overall effect on balance.
C : Among older people that fall serious injury is more likely in those with cognitive impairment. D : A prolonged lie time (time on the floor) is not associated with significant morbidity.
E : In older patients presenting to A and E with recurrent falls, carotid hypersensitivity is found in less than 5% of cases.
F : Orthosatic postural hypotension can be diagnosed if there is a fall in systolic blood pressure of 10mmHg.
G : If there is no history of joint pain, physical examination of the neck is unnecessary. H : There is no evidence that balance training reduces the incidence of falls in older people. I : The Get Up and Go test is useful for checking gait abnormalities. J : There is no evidence that reviewing medications in older patients prevents falls. Comment : A 1/3 of people aged 65 years and above have at least one fall/year. Age-related changes afffecting vision, proprioception, vestibular input, muscle strength and joint flexibilty can all
compromise balance. In older patients that fall, serious injury is more likely in women and in those with cognitive impairment, a low body mass index, or with two or more chronic conditions e.g. asthma, cancer and diabetes mellitus.A prolonged lie time is associated with bronchopneumonia, pressure sores, hypothermia, dehydration or rhabdomyolysis. About 1/3 of patients 50 years and over presenting to A+E after a fall have evidence of carotid hypersensitivity. Orthostatic postural hypotension can be diagnosed if lying and standing blood pressures show a sustained postural drop: systolic BP by at least 20mmHg, or diastolic BP by at least 10mmHg, on standing for at least two minutes. Examination should include movement of neck to see if this causes symptoms such as dizziness or syncope. There is evidence from seven randomized controlled trials that balance exercise can reduce the number of falls in older people. The Get Up and Go test is very useful for assessing mobility and checking for gait abnormalities. Careful review of the type and number of medications is an essential element to preventing further falls. There is evidence that reducing medications reduces falls. C : I:
MOHAMMED IS-HAG
33. A 68-year-old woman with ascites secondary to carcinoma of the ovary is complaining of early satiety and intermittent vomiting. The antiemetic of choice is:
A : Cyclizine B : Haloperidol C : Ondanestron
D : Metoclopramide E : Dexamethasone.
Comment : Metoclopramide as a prokinetic agent will increase the rate of transit of food through the gastrointestinal tract and alleviate her symptoms. She should also be advised to eat 'little and often'. D : 34. A 25-year-old woman presents with central chest pain. Which two of the following factors would most support the diagnosis of pericarditis?
A : Pain that came on suddenly B : Presence of a pleural rub C : Temperature 37.0 degrees C
D : Pain that was tearing in nature E : Preceding viral illness
F : Elevated jugular venous pressure (JVP) G : Pain that is variable with position
H : Previous pneumonia
I : Pain associated with reflux J : Pain that radiated to the back.
Comment : The commonest cause of pericarditis is viral infection. Other causes include: Post myocardial infarction (MI) / post cardiac surgery
· Rheumatoid arthritis and other autoimmune rheumatic disorders · Renal failure
· Hypothyroidism · Rheumatic fever · Malignancy
· Chest radiotherapy.
Pericarditic pain can be indistinguishable from ischaemic cardiac pain, but is sometimes perceived ‘more superficially’ and eased by sitting forward (perhaps because this allows pericardial fluid to move to the anterior surface of the heart).Pain that is of sudden onset, tearing in nature, and radiates to the back would be suggestive of aortic dissection. An elevated JVP could be due to pericardial effusion / constriction, but would not be expected in acute pericarditis. E :G:
35. Which of the following signs would you expect to find in a 50-year-old man with carcinoma of the lung and a large pericardial effusion causing diastolic right ventricular collapse? A : Sinus tachycardia
B : Ejection systolic murmur at left sternal edge radiating to the carotids C : Widely split second heart sound
D : Double apical impulse E : Wide pulse pressure F : Tapping apex beat
G : Early diastolic murmur H : Pulsus paradoxus
I : Ejection click
J : Loud aortic closure sound (A2).
Comment : Invasion of the pericardium by mediastinal tumours can give rise to effusive constrictive pericarditis. Patients may complain of dyspnoea, fatigue and sometimes chest pain. On examination they may be tachycardic, have pulsus paradoxus and a raised venous pressure with prominent X and Y descents. A : H: 36. A 45-year-old man is referred by his general practitioner with palpitations. He has no other associated symptons and specifically he is not presyncopal. Holter monitoring has demonstrated short non sutained runs of a monomorphic broad complex tachycardia. Which two of the following are the most likely arrhythmias?
A : Sinus tachycardia
B : Atrial fibrillation with intermittent rate associated bundle branch block C : Right ventricular outflow tract tachycardia
D : Atrial flutter with one to one conduction E : Wolff-Parkinson-White syndrome
F : Ischaemic ventricular tachycardia
G : Atrioventricular nodal reentry tachycardia H : Ventricular Fibrillation
I : Torsades de pointes
Comment : Whenever you approach a patient with a broad complex tachycardia it is always safest to presume they have ventricular tachycardia until proven otherwise. In fact, it is most likely that they will have a ventricular tachycardia rather than one of the other possibilities above, which may produce similar traces on a Holter monitor.
Patients are not always syncopal with ventricular tachycardia. In fact, right ventricular outflow tract tachycardia usually presents with just palpitations. It occurs as a result of a triggered focus in the right ventricular outflow tract and generally carries an excellent prognosis. It is best treated with
radiofrequency ablation. This is in contrast to ischaemic ventricular tachycardia which carries a very poor prognosis unless treated appropriately. In the context of impaired left ventricular function this invariably means with an implantable cardioverter defibrillator (ICD). C : F:
37.
PLATE 3
A 73-year-old man presents with a three month history of feeling non-specifically unwell, has lost 6 kg in weight and has recently noticed the rash shown in the enclosed image. The creatinine is 340 µmol/l. Urinalysis shows blood and protein. Renal ultrasound shows kidneys of 10.8 and 11.2 cm with increased cortical echogenicity. Which of the following statements is correct? A : Renal biopsy should be performed and is likely to show a focal necrotising glomerulonephritis B : The renal impairment is likely to be chronic (i.e. irreversible) C : Skin biopsy is likely to yield a specific diagnosis
D : Renal biopsy should be performed and is most likely to show membranous glomerulonephritis E : Laboratory blood tests are unlikely to yield a specific diagnosis. Comment : The rash shown is consistent with a leucocytoclastic vasculitis, and the history would be entirely consistent with ANCA (antineutrophil cytoplasmic antibodies) positive systemic vasculitis. A skin biopsy will not yield a specific diagnosis, whereas a test for ANCA is likely to be positive.In view of the preserved renal size, active urine sediment and rash, it is likely that there is an acute (i.e. reversible) component to the renal failure and a biopsy should be performed. This is most likely to show a pauci-immune, focal segmental glomerulonephritis, but it is important to exclude other conditions. A : 38. A 32-year-old gentleman is currently being investigated for hypertrophic cardiomyopathy (HCM). Which of the following statements are associated with sudden cardiac death and HCM? A : Family history of sudden cardiac death (SCD)
B : Chest pain C : Breathlessness
D : NSVT on 24-hour tape E : Age>40
F : Mutation in myosin-binding protein C G : Increased VO2 max
H : Male sex
I : LV wall thickness of 15mm J : T wave inversion on ECG.
Comment : Hypertrophic cardiomyopathy is associated with sudden cardiac death. The following features are particularly associated with an adverse prognosis (the presence of > 1 of these features increases an individual’s risk):
· LV septal thickness >30mm
· family history of sudden cardiac death · syncope
· ventricular arrhythmias on 24-hour tape. A : D :
39. A cachectic 87-year-old man is admitted with acute urinary retention and is found to have a creatinine of 520 micro mol/l. He has been on a number of medications. Which of the following is least likely to be nephrotoxic in this situation?
A : Ibuprofen B : Ramipril C : Allopurinol D : Lansoprazole E : Sulfasalazine.
MOHAMMED IS-HAG
Comment : As he has muscle wasting, a creatinine this high probably indicates severe renal impairment. This should improve with catheterisation and a good fluid input, but it is essential to stop all potentially nephrotoxic drugs.Do not rely on your memory -always check with the BNF as continuing a nephrotoxic drug at this stage may lead to irreversible renal failure. Of this list, only lansoprazole should be
continued until his renal function has improved. D :
40. A 17-year-old Afro-Caribbean girl presents herself as an emergency with a 7-day history of general arthralgia and a painful rash over her lower limbs. Chest radiograph shows bilateral hilar enlargement but routine full blood count and urea, electrolytes, liver function tests and calcium are normal. Clinical examination is normal, apart from a raised erythematous painful rash, and she is apyrexial. Which of the following is the most likely diagnosis?
A : Lymphoma
B : Primary pulmonary hypertension C : Sarcoidosis
D : Systemic lupus erythematosis E : Tuberculosis.
Comment : The clinical presentation is most likely to be sarcoidosis, based on her ethnic origins and the features of arthralgia, rash and bilateral hilar enlargement.Measurement of serum
angiotensin-converting enzyme (ACE) may help to make the diagnosis, but fibreoptic bronchoscopy with bronchial/transbronchial biopsies may be needed to confirm it. C :
41. A 74-year-old lady presents with severe peripheral oedema and hypotension over a 6-month period. Echocardiography has identified a thickened, calcified pericardium. She has previously been well apart from a past history of breast cancer. Which of the following are the most likely causes of her underlying condition?
A : Diabetes mellitus
B : Coronary artery disease C : Tuberculosis
D : Chronic renal failure
E : Recurrence of her breast cancer F : Viral pericarditis
G : Previous radiotherapy H : Bacterial sepsis I : Diabetes insipidus J : Drug induced.
Comment : This lady has constrictive pericarditis which causes impaired filling of the ventricles and reduced ventricular function. The commonest causes are tuberculosis, mediastinal irradiation and previous cardiac surgery. Imaging such as echocardiography, CT and MRI will usually demonstrate thickened and calcified pericardium. C : G:
42.
PLATE 4
A 40-year-old man has a transoesophageal echo for investigation of a soft systolic heart murmur after inadequate images are obtained from transthoracic imaging. He has no past history of note and is asymptomatic. Apart from the feature shown (see image), his study was normal. What is the most appropriate management?
B : Addition of aspirin
C : Reassurance and regular follow-up with echo D : Reassurance and no follow-up
E : Urgent referral for percutaneous closure
Comment : The above image shows a patent foramen ovale which occurs in 10% of the population and is found in 40% of patients with a past history of stroke.
If these defects are found in patients with a past history of a cerebrovascular accident, a right to left shunt must be looked for by injecting agitated saline and asking the patient to perform a Valsalva manoeuvre. If a significant right to left shunt is demonstrated, then either long-term anticoagulation or percutaneous closure is recommended, as there is a risk of paradoxical embolus. The results of ongoing studies should help determine whether percutaneous closure is superior to anticoagulation alone in this context. When seen as an incidental finding in patients without a history of stroke, no treatment is required. D :
43. A 48-year-old man is found to have a blood pressure of 176/112 when he attends his general practitioner for a ‘new patient check-up’. He takes occasional anxiolytics for anxiety, but his past medical history is otherwise unremarkable. Physical examination is normal, excepting for obesity (BMI 32). A ‘routinebiochemical screen is normal, excepting for potassium 3.3 mmol/l. The two most likely causes of his hypertension are:
A : Renal hypertension B : Hypothyroidism
C : Renovascular hypertension D : Cushing’s syndrome
E : Primary hyperaldosteronism (Conn’s syndrome) F : Acromegaly
G : Essential hypertension
H : Isolated clinic (‘white coat’) hypertension I : Phaeochromocytoma
J : Coarctation of the aorta.
Comment : All of the conditions listed, excepting hypothyroidism, might explain hypertension, but all other than essential hypertension and ‘white coat’ hypertension are rare (together accounting for less than 5% of cases).
Although a secondary cause of hypertension is very unlikely it would be important to look for clues in history and examination that might suggest renovascular disease (ischaemic heart disease, transient ischmaemic attack (TIA) / stroke, peripheral vascular disease), renal disease (previous nephritis, results of urine testing for e.g. insurance / employment medicals). Episodes of palpitations, sweating or headache may suggest phaeochromocytoma, but a less exotic cause such as anxiety would be a much more likely explanation. The serum potassium concentration is just below the lower limit of normal, but primary aldosteronism (Conn’s syndrome) remains exceedingly unlikely.
In the case of an obese man it is also important to note that the blood pressure reading may be falsely elevated as a result of inadequate blood pressure cuff size, and it would be important to ensure that readings were taken with appropriate equipment. G:H:
44. A 48-year-old male with Marfans syndrome presents acutely with a Type A aortic dissection. Which two of the following cardiac conditions are also associated with Marfans?
A : Hypertrophic cardiomyopathy B : Myocardial infarction
C : Amyloidosis D : Sarcoidosis
E : Ventricular septal defect F : Patent ductus arteriosus G : Ventricular tachycardia H : Mitral valve prolapse
I : Wolff-Parkinson-White syndrome J : Restrictive cardiomyopathy.
Comment : Cardiovascular complications of Marfans syndrome include the following: aortic dilatation and dissection (which may cause myocardial infarction), mitral valve prolapse and regurgitation, left ventricular dilatation, pulmonary arterial dilatation. Aortic regurgitation is common in the context of a dilated aortic root.
Beta blockers should be considered in any patient with Marfans and a dilated aortic root. However, surgical intervention is the definitive treatment. When the aortic root is greater than 5 cms then the risk is significant.
Marfans patients should generally be screened for cardiovascular complications on an annual basis. B : H:
MOHAMMED IS-HAG
45. A 78-year-old man is admitted weak and unable to stand after vomiting for several days. His plasma sodium concentration is 123 mmol/l and his urinary sodium concentration is 8 mmol/l. What is the likely cause of his hyponatraemia?
A : Syndrome of inappropriate antidiuresis (SIADH) B : Diuretic treatment
C : Loss of sodium in vomit
D : Hypovolaemic stimulation of ADH release E : Addison’s disease.
Comment : Plasma ADH concentration is normally controlled by plasma osmolality, but pain, nausea, hypovolaemia and anaesthesia are all powerful stimulants of ADH release and can generate much higher plasma levels than are seen in response to tonicity. Nausea and hypovolaemia are likely to have
stimulated very high ADH levels as the explanation for this man’s hyponatraemia.
In recognition of these facts, SIADH can only be diagnosed when the following criteria are satisfied: 1. The patient is clinically euvolaemic (JVP seen, no postural hypotension)
2. Decreased plasma sodium concentration and osmolality
3. Inappropriately high urine sodium concentration (>20 mmol/l) and osmolality (> plasma) 4. There is normal adrenal, thyroid and renal function. D :
46. A 71-year male has a witnessed tonic-clonic seizure whilst standing at a bar, enjoying a pint. He has had a prior anterior myocardial infarction 2-years ago. Examination is normal. ECG shows sinus rhythm with anterior Q waves. Which two of the following are the most appropriate initial investigations?
A : Alcohol provocation test B : Coronary angiography C : Carotid Dopplers
D : CT head
E : Echocardiogram
F : Electrophysiological study G : Exercise tolerance test H : Tilt test
I : 24-hour tape
J : Urinary cathecholamine levels.
Comment : A 24-hour tape is important to help to identify any brady or tachycardia (e.g. ventricular tachycardia) that might account for an arrhythmic cause of the seizure, as a consequence of cerebral hyoperfusion. A CT head scan is also mandatory in this age group to exclude a space-occupying lesion. Subsequent investigations will be dictated by the exact nature of the event – history from a witness is extremely valuable. D : I:
47. A 27-year-old female presented with a 6-month history of breathlessness. Her cardiac catheter data shows the following:
Pressure (mmHg) Oxygen saturation (%) IVC 19 51 RA 22 52 RV 120/15 55 PA 121/70 56 LV 112/11 77 Aorta 108/67 78
Which two statements are true of her condition?
A : The patient will appear pale.
B : Haemopysis is a frequent symptom.
C : The presence of clubbing should lead to an alternative diagnosis. D : A fixed split second sound will be heard.
E : Pulmonary oedema is a common finding. F : The condition usually presents in later life. G : Embolic complications may occur.
H : Pregnancy is safe.
I : Prognosis is good with medical treatment.
J : Surgical correction of the cardiac lesion is recommended.
Comment : This patient has Eisenmenger's syndrome. An uncorrected right to left shunt has resulted in systemic pulmonary pressures with subsequent shunt reversal as evidenced by desaturation in left ventricular blood. From these data one cannot determine the level of the shunt.The clinical features of this condition are of right heart failure, systemic oxygen desaturation (causing central cyanosis), and polycythaemia which can lead to embolic complications. Clubbing is common. Prognosis is very poor and pregnancy results in maternal death. Closure of the shunt at this stage does not change the prognosis. B : G:
48. An 87-year-old lady is admitted with left iliac fossa pain, tenderness and fever. Which of the following are true?
A : Colonoscopy is likely to be helpful.
B : Ultrasound or computerised tomography (CT) is indicated.
C : Diverticulosis affects 10% of the population over 50 years of age. D : Bleeding is an unusual complication of diverticular disease.
E : Colonoscopy is unhelpful in patients admitted with bright red rectal bleeding. F : Diverticulosis is associated with an increased risk of colorectal neoplasia. G : Recurrent urinary infections raise the possibility of a complication of diverticular disease.
H : A diverticular stricture is readily distinguished from a malignant stricture. I : Following a diverticular abscess, the affected diverticulae fibrose and further problems are uncommon. J : Uncomplicated extensive diverticulosis may explain weight loss.
Comment : Ultrasound and CT are useful in detecting bowel thickening, abscess formation and even fistulae. As diverticulitis is associated with multiple micro-perforations, colonoscopy is not advised. Diverticular disease is the commonest cause of colonic bleeding which may be detected and
endoscopically treated at colonoscopy.Recurrent urinary infections, pneumaturia or faeces in the urine are features of a colo-vesical fistula.Diverticulosis affects 50% of the population over 50. Most patients have few if any symptoms, but if complications occur (abscess, stricture or bleeding), recurrence is common and surgery should be considered. B : G:
49. A 70-year-old man, who is known to have ischaemic heart disease and has had short-lived episodes of atrial fibrillation in the past, presents with 48 hours of fatigue and breathlessness. He is not very ill, but his pulse is 150 / min in atrial fibrillation. Which two drugs would be most appropriate to achieve ‘chemical cardioversion’?
A : Digoxin B : Quinidine C : Procainamide D : Disopyramide E : Sotalol F : Atenolol G : Propanolol H : Verapamil I : Amiodarone J : Diltiazem.
Comment : Restoration of sinus rhythm can be achieved pharmacologically or by DC cardioversion. However, DC cardioversion is not likely to lead to permanent restoration of sinus rhythm in a patient who has had previous episodes of AF, hence in this case an attempt at ‘chemical cardioversion’ is appropriate.Class III agents – potassium channel blockers that prolong myocyte repolarisation – are most appropriate: sotalol or amiodarone.Digoxin can be used for rate control but does not promote return of sinus rhythm, indeed it’s use may make this more unlikely.Class I agents – e.g. quinidine, procaineamide and disopyramide, which prolong the action potential – have been used to try to restore sinus rhythm, but NOT in patients with ischaemic heart disease (such as this man). Use of these agents in atrial fibrillation has been superseded by that of sotalol and amiodarone. E :I:
50. A 77-year old man presents with 5 hours of chest pain at rest. He had previously undergone stenting to his left anterior descending artery 4 years previously. ECG shows inferior T-wave inversion, with ventricular ectopics. His troponin T is elevated at 0.4. He is already taking aspirin. Which two of the following would be considered appropriate intial therapeutic interventions? A : Amiodarone
B : Change aspirin to clopidogrel
C : Coronary artery bypass grafting D : Digoxin
E : Flecainide
F : GIIb/IIa receptor blocker
G : Percutaneous coronary intervention H : Dipyridamole (modified release)
I : Prophylactic dose of low molecular weight heparin J : Thrombolysis.
Comment : This patient has presented with a non-ST-segment elevation myocardial infarction
(NSTEMI). This group of patients has a high risk of further adverse cardiac events. The mainstay of initial treatment is aggressive anti-platetlet therapy: aspirin with the addition of clopidogrel, and consideration of an infusion of GIIb/IIa receptor blocker (blocks the platelet receptor). Therapeutic dose of low
molecular weight heparin should be commenced. Early angiography and percutaneous coronary intervention should also be considered. Thrombolysis has not been shown to benefit patients with NSTEMI. F:G:
MOHAMMED IS-HAG
51.
A 45-year-old man presents to the coronary care unit with central chest pain, breathlessness and a normal ECG. Cardiac enzymes are normal. He has an exercise tolerance test which demonstrates no ECG changes but he gets chest pain at peak exercise. Angiography of his right coronary artery is normal. The angiogram of his left coronary artery is shown (see image). Which of the following would be the most appropriate management?
A : Increased anti-anginal medication B : Coronary artery bypass grafting
C : Percutaneous transluminal angionplasty (PTCA) and stent deployment D : Off-pump coronary artery bypass grafting
E : PTCA alone. Comment :
This man's coronary angiogram demonstrates a severe stenosis of the proximal left anterior descending artery. This is certainly amenable to PTCA. Where possible if the anatomy allows, stent deployment offers less restenosis/occlusion rates than PTCA alone.
Coronary artery bypass grafting for single vessel coronary artery disease is generally only considered if PTCA is not possible or has failed.
Off-pump coronary artery bypass grafting of the left anterior descending artery is an evolving concept utilizing equipment that holds the beating heart steadily enough to suture a graft into position. C : 52. A 58-year-old woman presents to casualty with back pain and has a blood pressure of 240/120. A CT scan of her chest and abdomen is organised and demonstrates an adrenal mass with type B aortic dissection, involving the left renal artery. Which of the following treatments are LEAST appropriate?
A : Methyl dopa
B : Endovascular aortic stenting C : Ramipril D : Surgical repair E : Intravenous GTN F : Sodium nitroprusside G : Atenolol H : Amlodipine I : Thiazides J : Phenoxybenzamine.
Comment : A type B aortic dissection includes all aortic dissections not involving the ascending aorta. Their downward course variably involves the splanchnic and renal arteries. Most cases are managed conservatively without the need for surgical repair or endovascular stenting, although these treatments may be needed. The priority is blood pressure control. All the above blood pressure lowering drugs are useful apart from angiotensin-converting enzyme (ACE) -inhibitors which should be avoided (one of the renal arteries is involved and there is an appreciable risk of coexistent renal artery atherosclerosis in patients with aortic atherosclerosis). The adrenal mass and marked hypertension in a relatively young woman raise the possibility of a phaeochromocytoma. Unopposed betablockade (that is without alpha blockade) should be avoided in such patients. C : G:
53. You see a 48-year-old Afro-Caribbean man in the outpatient clinic with uncomplicated essential hypertension. His blood pressure today is 154/102mmHg despite optimization of non-pharmacological therapy. Which one of the following drugs would you use as the first-line agent in this patient? A : Atenolol 50mg od B : Nifedipine 10mg tds C : Amlodipine 5mg od D : Ramipril 2.5mg od E : Enalapril 5mg bd.
Comment : Non-pharmacological therapy should always be optimized prior to commencement of medication, whenever possible. Hypertension is particularly common in Afro-Caribbeans and associated with particularly higher risk of complications. Therefore effective long-term treatment, with a low threshold for multiple therapy where necessary, is particularly important.
Studies indicate that drugs such as ACE (angiotensin-converting enzyme) inhibitors and Beta-receptor antagonists are less effective in Afro-Caribbeans. The reason appears to be related to the finding that the renin-angiotensin-aldosterone (RAA) system is commonly suppressed in the majority of Afro-Caribbeans. As such, drugs that suppress the RAA system are less likely to be effective.
Calcium-channel blockers (CCBs) and diuretics appear to be more effective in this subgroup. However, diuretics may not be suitable in this case as they are commonly associated with impotence. Short-acting CCBs do not provide prolonged BP control, can cause reflex tachycardia and may be associated with higher mortality. Therefore, long-acting CCB should be the first-line drug of choice. Ideally, a once-daily agent with that provides a smooth 24-hour BP control (e.g. Nifedipine LA 30mg od or Amlodipine 5 mg od) to improve compliance would be preferable. C :
54. A 55-year-old lady has a 2-year history of exertional chest pain and has a positive exercise test with significant ST segement depression. She then has a coronary angiogram which
demonstrates normal coronary arteries. She is told she has Cardiac Syndrome X. Which of the following statements about Syndrome X is incorrect?
A : Patients have typical symptoms of occlusive coronary artery disease. B : Myocardial perfusion imaging is usually normal in patients with Sydrome X. C : The condition carries with it a normal life expectancy.
D : Beta blockers, calcium antagonists and nitrates have all been shown to improve symptoms. E : It is caused by coronary microvascular dysfunction.
Comment : Cardiac Sydrome X is characterised by typical exertional angina, ST changes on ECG, normal coronary arteries on angiography, absence of coronary artery spasm and absence of cardiac disease associated with microvascular abnormalities such as diabetes and hypertension. About 50% will have abnormal myocardial perfusion imaging. B :
55. A 53-year-old woman presents with a digoxin overdose. Which of the following statements is false?
A : Tachyarrhythmias do not occur.
B : Peak effects can be delayed after ingestion by 6-12 hours. C : Digoxin can precipitate severe hyperkalaemia (>6.5mmol/l).
D : DC cardioversion can precipitate intractable ventricular fibrillation (VF) or asystole. E : Activated charcoal reduces absorption.
Digoxin is slowly absorbed, hence peak effects can be delayed by up to 12 hours after overdose. Oral activated charcoal may reduce absorption, although giving multiple doses is controversial. Nausea and vomiting occur early after poisoning; other features include confusion, headache and visual
disturbances. Any brady or tachyarrhthymia can occur. Treatment is with correction of hyperkalaemia and atropine for bradyarrhythmias. Digoxin-specific antibodies are useful in i) those with hyperkalaemia resistant to treatment, ii) bradyarrhythmias with hypotension non-responsive to atropine and iii)
tachyarrhythmias with hypotension. Anti-arrhythmic drugs and DC cardioversion should be avoided as they can precipitate intractable asystole or VF. A :
56. A 35-year-old woman is admitted with severe pulmonary oedema 2 months after her second pregnancy. A diagnosis of peripartum cardiomyopathy is made. Which of the following statements about peripartum cardiomyopathy is false?
A : It may occur at any stage of pregnancy. B : Maternal mortality is approximately 20%.
C : If cardiac function returns to normal there is an increased risk of recurrence in subsequent pregnancies.
D : Recovery of left ventricular function may take up to a year. E : Fifty per cent make a full recovery.
Comment : Heart disease is the highest cause of maternal death in the UK. Peripartum cardiomyopathy is defined as cardiac failure occurring in the last month of pregnancy or within 5 months of delivery. It is rare and thought to represent a form of myocarditis. Adverse risk factors include being older than thirty, giving birth to twins and multiparity. A :
MOHAMMED IS-HAG
57.
PLATE 5 What is the most likely diagnosis in this patient?
A : Subendocardial anterolateral infarction B : Hypothermia
C : Hypothyroidism D : Digoxin toxicity E : Hypokalaemia.
Comment : A junctional bradycardia associated with “inverse ticks” of the ST segments is strongly suggestive of digoxin toxicity. D :
58. A 74-year-old woman presents with breathlessness. She is a small woman (55 kg) with a chest infection. She is not very unwell, but is in atrial fibrillation at a rate of 170/min. Her
electrolytes are normal (K 4.2 mmol/l). As well as treating her pneumonia, you decide to digitalize by prescribing:
A : Digoxin 0.25 mg orally once daily
B : Digoxin 1.0 mg orally over 24 hours in divided doses C : Digoxin 1.0 mg intravenously over 20 min
D : Digoxin 0.125 mg orally once daily
E : Digoxin 0.25 mg orally three times daily for one week, then twice daily for one week, then once daily thereafter.
Comment :The options for treatment of atrial fibrillation are:
1. DC cardioversion if the patient is compromised haemodynamically or has ischaemic cardiac pain. 2. Digoxin - 1.0-1.5 mg orally in divided doses over 24 hours, but can be given intavenously in emergency (0.25-0.5 mg over 10-20 min, repeated after four to eight hours to total intravenous loading dose of 0.5-1.0 mg)
3. 'Medical cardioversion' with amiodarone or flecainide
In this clinical context it is likely that the atrial fibrillation (if new) will revert to sinus rhythm as the woman recovers from her pneumonia and most physicians would digitalize in preference to the other options described. B :
59. A 65-year-old gentleman attending the cardiology clinic complains of swelling and
tenderness of his breasts. You diagnose probable gynaecomastia. Which of the following drugs is most likely to be the cause?
A : Simvastatin B : Amiodarone C : Digoxin D : Aspirin E : Ramipril.
