1- A previously well 27-year-old woman presents with a history of transient ischaemic attack affecting her right side and speech. She had returned to the United Kingdom from a holiday in New Zealand two days previously. On examination there was nothing abnormal to find. An ECG, chest X-ray, CT brain scan and routine haematology and biochemistry were all normal. What is the most likely underlying abnormality?
1) atrial myxoma
2) carotid artery stenosis
3) embolus from paroxysmal atrial fibrillation
4) patent foramen ovale
5) subarachnoid haemorrhage
Answer-4
This is a typical cause of stroke in a young person due to prolonged immobilty. Deep vein thrombosis with patent foramen ovale will cause paradoxical embolism
and stroke.
2- A 51-year-old woman has had several syncopal episodes over the past year. Each episode is characterized by sudden but brief loss of consciousness. She has no chest pain. She has no ankle edema. On brain MRI there is a 1.5 cm cystic area in the left parietal cortex. A chest X-ray shows no cardiac enlargement, and her lung fields are normal. Her serum total cholesterol is 6.5 mmol/L. Which of the following cardiac lesions is she most likely to have?
1) Cardiac amyloidosis
2) Ischemic cardiomyopathy
3) Left atrial myxoma
4) Mitral valve prolapse
5) Tuberculous pericarditis
Answer-3
Atrial myxomas are more often on the left. Though benign, they can occlude the mitral valve and produce sudden loss of cardiac output. They may embolize small
portions of themselves or thrombus forned over their surface.
3- A 66-year-old man has developed chronic renal failure with a serum urea of 60 mmol/L and creatinine of 650 micromol/L. Auscultation of the chest reveals a friction rub over the cardiac apex. He is most likley to have a pericarditis that is termed?
1) Constrictive
2) Fibrinous
3) Hemorrhagic
4) Purulent
5) Serous
Answer-2
The uraemia leads to exudation of fibrin onto the epicardial and pericardial surfaces. Haemorrhagic pericarditis is more typical of tuberculosis or metastatic
tumour. Serous pericarditis is more typical of collagen vascular diseases.
4- Which ONE of the following is a contraindication to thrombolysis?
1) age over 75 years
2) the presence of atrial fibrillation
3) asthma
4) pregnancy
5) background diabetic retinopathy
Answer-4
5- Which of the following anti-microbials is associated with prolongation of the QT interval?
1) Co-amoxiclav
2) Gentamicin
3) Cefuroxime
4) Erythromycin
5) Isoniazid
Answer-5
The macrolides are associated with a prolongation of the QT interval. Other
antimicrobials associated with prolonged QT include quinine, levofloxacin.
6- A 60-year-old man presents with an inferior MI and receives thrombolysis. 4 hours following initial presentation he becomes acutely breathless. His ECG demonstrates sinus tachycardia (rate 108bpm) with T wave inversion inferiorly. His ST segments are normal. On examination his JVP is elevated at 5 cm. Chest was clear to auscultation. Following 80 mg of Frusemide he deteriorates. His BP is now 80/60 and his urine output over the last 2 hours is 5 mls. What is the best investigative
measure?
1) Arterial Blood Gases
2) Central Venous Pressure Monitoring
3) Chest X-Ray
4) Echocardiography
5) Pulmonary Capillary Wedge Pressure Monitoring
Answer-5
7- Which of the following is a recognised feature of massive pulmonary embolism?
1) reduced plasma lactate levels
2) an increase in serum troponin levels
3) an arterial pH less than 7.2
4) blood gases show increased pCO2 on air
5) normal D-dimer levels
Answer-2
8- A 60-year-old man has worsening congestive heart failure with increasing pulmonary oedema. His blood pressure is normal. He has been healthy all his life with no major illnesses. A serum glucose is 5.6 mmol/L. His total serum cholesterol is 4.8 mmol/L. The serum creatine kinase is not elevated. The most likely explanation for these findings is?
1) Alcoholic cardiomyopathy
2) Aortic dissection
3) Calcified bicuspid aortic valve
4) Mitral valve annulus calcification
5) Tricuspid valve endocarditis
Answer-3
9- During auscultation of the heart you discover a wide fixed splitting of the second heart sound. In which of the following conditions does this occur?
1) an uncomplicated ASD
2) Fallot's tetralogy
3) aortic stenosis
4) Right Bundle Branch Block
5) constrictive pericarditis
Answer-1
There is a single sound in Fallot's because of an absent P2. Aortic stenosis leads to reversed splitting (also seen with LBBB and ventricular pacemaker). In RBBB there
is wide splitting of S2 but it is not fixed.
10- A 62 year old man has experienced substernal chest pain upon exertion with increasing frequency over the past 1 year. An electrocardiogram shows T wave inversion in the anterolateral leads at rest. He has a total serum cholesterol of 7.0 mmol/l. On angiography, he has an 85% narrowing of the left anterior descending artery. Which of the following events is most likely to occur in this patient?
1) A systemic artery embolus from thrombosis in a peripheral vein.
2) A systemic artery embolus from a left atrial mural thrombus.
3) Pulmonary embolism from a left ventricular mural thrombus
4) A systemic artery embolus from a left ventricular mural thrombus.
5) Pulmonary embolism from thrombosis in a peripheral vein.
Answer-4
The suggestion here is that this man has coronary artery disease with an impending myocardial infarction. Infarction of the LAD would cause necrosis of the left ventricle. Thrombus may form on an area of dyskinetic ventricle. Therefore he is most at risk of embolus of thrombus from the LV.
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1) atrial myxoma
2) carotid artery stenosis
3) embolus from paroxysmal atrial fibrillation
4) patent foramen ovale
5) subarachnoid haemorrhage
Answer-4
This is a typical cause of stroke in a young person due to prolonged immobilty. Deep vein thrombosis with patent foramen ovale will cause paradoxical embolism
and stroke.
2- A 51-year-old woman has had several syncopal episodes over the past year. Each episode is characterized by sudden but brief loss of consciousness. She has no chest pain. She has no ankle edema. On brain MRI there is a 1.5 cm cystic area in the left parietal cortex. A chest X-ray shows no cardiac enlargement, and her lung fields are normal. Her serum total cholesterol is 6.5 mmol/L. Which of the following cardiac lesions is she most likely to have?
1) Cardiac amyloidosis
2) Ischemic cardiomyopathy
3) Left atrial myxoma
4) Mitral valve prolapse
5) Tuberculous pericarditis
Answer-3
Atrial myxomas are more often on the left. Though benign, they can occlude the mitral valve and produce sudden loss of cardiac output. They may embolize small
portions of themselves or thrombus forned over their surface.
3- A 66-year-old man has developed chronic renal failure with a serum urea of 60 mmol/L and creatinine of 650 micromol/L. Auscultation of the chest reveals a friction rub over the cardiac apex. He is most likley to have a pericarditis that is termed?
1) Constrictive
2) Fibrinous
3) Hemorrhagic
4) Purulent
5) Serous
Answer-2
The uraemia leads to exudation of fibrin onto the epicardial and pericardial surfaces. Haemorrhagic pericarditis is more typical of tuberculosis or metastatic
tumour. Serous pericarditis is more typical of collagen vascular diseases.
4- Which ONE of the following is a contraindication to thrombolysis?
1) age over 75 years
2) the presence of atrial fibrillation
3) asthma
4) pregnancy
5) background diabetic retinopathy
Answer-4
5- Which of the following anti-microbials is associated with prolongation of the QT interval?
1) Co-amoxiclav
2) Gentamicin
3) Cefuroxime
4) Erythromycin
5) Isoniazid
Answer-5
The macrolides are associated with a prolongation of the QT interval. Other
antimicrobials associated with prolonged QT include quinine, levofloxacin.
6- A 60-year-old man presents with an inferior MI and receives thrombolysis. 4 hours following initial presentation he becomes acutely breathless. His ECG demonstrates sinus tachycardia (rate 108bpm) with T wave inversion inferiorly. His ST segments are normal. On examination his JVP is elevated at 5 cm. Chest was clear to auscultation. Following 80 mg of Frusemide he deteriorates. His BP is now 80/60 and his urine output over the last 2 hours is 5 mls. What is the best investigative
measure?
1) Arterial Blood Gases
2) Central Venous Pressure Monitoring
3) Chest X-Ray
4) Echocardiography
5) Pulmonary Capillary Wedge Pressure Monitoring
Answer-5
7- Which of the following is a recognised feature of massive pulmonary embolism?
1) reduced plasma lactate levels
2) an increase in serum troponin levels
3) an arterial pH less than 7.2
4) blood gases show increased pCO2 on air
5) normal D-dimer levels
Answer-2
8- A 60-year-old man has worsening congestive heart failure with increasing pulmonary oedema. His blood pressure is normal. He has been healthy all his life with no major illnesses. A serum glucose is 5.6 mmol/L. His total serum cholesterol is 4.8 mmol/L. The serum creatine kinase is not elevated. The most likely explanation for these findings is?
1) Alcoholic cardiomyopathy
2) Aortic dissection
3) Calcified bicuspid aortic valve
4) Mitral valve annulus calcification
5) Tricuspid valve endocarditis
Answer-3
9- During auscultation of the heart you discover a wide fixed splitting of the second heart sound. In which of the following conditions does this occur?
1) an uncomplicated ASD
2) Fallot's tetralogy
3) aortic stenosis
4) Right Bundle Branch Block
5) constrictive pericarditis
Answer-1
There is a single sound in Fallot's because of an absent P2. Aortic stenosis leads to reversed splitting (also seen with LBBB and ventricular pacemaker). In RBBB there
is wide splitting of S2 but it is not fixed.
10- A 62 year old man has experienced substernal chest pain upon exertion with increasing frequency over the past 1 year. An electrocardiogram shows T wave inversion in the anterolateral leads at rest. He has a total serum cholesterol of 7.0 mmol/l. On angiography, he has an 85% narrowing of the left anterior descending artery. Which of the following events is most likely to occur in this patient?
1) A systemic artery embolus from thrombosis in a peripheral vein.
2) A systemic artery embolus from a left atrial mural thrombus.
3) Pulmonary embolism from a left ventricular mural thrombus
4) A systemic artery embolus from a left ventricular mural thrombus.
5) Pulmonary embolism from thrombosis in a peripheral vein.
Answer-4
The suggestion here is that this man has coronary artery disease with an impending myocardial infarction. Infarction of the LAD would cause necrosis of the left ventricle. Thrombus may form on an area of dyskinetic ventricle. Therefore he is most at risk of embolus of thrombus from the LV.
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