PM 23 from 41 to 80 ð«
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1
A 55-year-old man is reviewed in the rapid access chest pain clinic with a history of central chest
pain on exertion, relieved by rest. He is currently taking no regular medications and has no drug
allergies.
Which of the following therapies should he be prescribed to reduce the frequency of his
symptoms?
Bisoprolol
2
A 68-year-old man presents to you with intermittent left-sided crushing chest pain which is
brought on by walking his dog on an incline. The pain settles within a couple of minutes of rest
and glyceryl trinitrate (GTN) spray. The pain is not associated with shortness of breath or
lightheadedness.
He first presented to you with these same symptoms six months ago, at this time you gave him
lifestyle advice and prescribed bisoprolol, aspirin, GTN and atorvastatin. He has noted only
minimal improvement of his symptoms over the last six months.
On examination he is comfortable at rest, with blood pressure 124/73 mmHg, heart rate 63
beats/minute, oxygen saturation 99%, respiratory rate 18 breaths/minute and he is afebrile. His
chest is clear, and heart sounds are normal. ECG shows normal sinus rhythm, with no ischaemic
changes. He is also awaiting a CT coronary angiography.
What would be the next stage of treatment for this patient?
Add nifedipine
3
A 48-year-old man with known stable angina is reviewed in the cardiac clinic. He takes aspirin and
a statin and is established on a maximum dose calcium channel and beta-blocker however he is
still experiencing chest discomfort on exertions requiring the use of his sublingual glyceryl
trinitrate spray.
He is to be started on a third medication however due to the potential of tolerance with the
standard-release form of this medication, an asymmetrical dosing regime is required. The regime
and potential side effects are explained to the patient.
What medication is the patient due to be started on?
Isosorbide mononitrate
4
A 56-year-old male is seen in the cardiology clinic after experiencing episodes of chest tightness
on exertion. After appropriate investigation, his GP diagnosed angina and initially provided
lifestyle advice and started him on aspirin, a statin and a sublingual glyceryl trinitrate spray.
The patient otherwise well with no other past medical history and is not on any other regular
medications.
On review in the clinic today the patient, unfortunately, reports ongoing episodes of angina.
His examination and observations are normal and an ECG performed displays normal sinus
rhythm.
What is the most appropriate next course of action?
Commence on verapamil
5
A 52-year-old man is seen in the clinic after originally being referred with progressively increasing
central chest pain but base level investigations, including ECGs and troponin level return within
normal range.
The pain is exercise dependent with it occurring when the patient carries out activities such as
climbing stairs and resolving on rest. As such the patient was started on atenolol 100mg OD along
with a GTN spray and aspirin.
On review today the patient still reports symptoms of chest pain on exertion despite good
compliance.
What alteration should be made to this patientâs management?
Add nifedipine
6
A 72-year-old man is investigated for exertional chest pain and has a positive exercise tolerance
test. He declines an angiogram and is discharged on a combination of aspirin 75mg od,
simvastatin 40mg on, atenolol 50mg od and a GTN spray prn. Examination reveals a pulse of 72
bpm and a blood pressure of 130/80 mmHg. On review he is still regularly using his GTN spray.
What is the most appropriate next step in management?
Increase atenolol to 100mg od
7
An 82-year-old man is reviewed. He is known to have ischaemic heart disease and is still getting
regular attacks of angina despite taking atenolol 100mg od. Examination of his cardiovascular
system is unremarkable with a pulse of 72 bpm and a blood pressure of 148/92 mmHg. What is
the most appropriate next step in management?
Add nifedipine MR 30mg od
8
A 54-year-old man with atypical chest pain is referred to cardiology. An exercise ECG shows nonspecific ST and T wave changes. Following this an coronary angiogram is performed which
demonstrates no evidence of atherosclerosis. A diagnosis of Prinzmetal's angina is suspected.
What is the most appropriate first-line treatment?
Felodipine
9
A 60-year-old man who is investigated for exertional chest pain is diagnosed as having angina
pectoris. Which one of the following drugs is most likely to improve his long-term prognosis?
Aspirin
10
A 60-year-old man is referred to the cardiology clinic with recurrent exertional chest pain
associated with dyspnoea. It improves with rest. He has a history of ischaemic heart disease and
underwent PCI to the right coronary artery five years ago. A coronary angiogram six weeks ago
showed widely patent stents. His current medications include aspirin, ramipril, bisoprolol,
eplerenone, and atorvastatin. Recently, his GP started him on sildenafil for erectile dysfunction. On
assessment, his BP is 142/88 mmHg, and his heart rate is 70 bpm.
What medication should be added to improve his symptoms?
Nifedipine
11
A 64-year-old man presents to his general practitioner with chest tightness, worse on exertion. It
occurs after approximately 200m and then quickly subsides if he stops walking. He has a past
medical history of angina, hypertension and gastro-oesophageal reflux disease. He is currently
taking atenolol, lansoprazole, aspirin and atorvastatin.
The examination is unremarkable.
Given the likely diagnosis, what is the most appropriate management?
Add amlodipine
12
A 59-year-old woman is seen in clinic, with a history of chest pain upon exertion, relieved by rest.
Her pain never occurs at rest. She takes aspirin, atorvastatin and the maximum dose of atenolol,
but she is still persistently experiencing exertional chest pain. She has tolerated all medicines since
commencement.
What would be the best recommendation for the next step in her management?
Commence nifedipine
13
A 55-year-old man presents to the cardiology clinic with chest pain. He has a history of previous
ST-elevation myocardial infarction and angioplasty.
He describes periods of worsening stable angina limiting his exercise tolerance. His resting heart
rate is 60bpm. Recent echocardiography shows a left ventricular ejection fraction of 50-55%.
Current medications include amlodipine 10mg OD and bisoprolol 10mg OD.
What is the most appropriate medication to initiate while awaiting further investigation?
Isosorbide mononitrate (immediate release) BD at 0800 and 1400
14
An 87-year-old man with mild dementia presents to your GP practice.
He has a documented drug allergy to calcium channel blockers and has hypertension confirmed
on ambulatory blood pressure monitoring. He has developed an intolerable cough whilst trialling
ramipril.
He is otherwise fit and well and takes only donepezil. He is interested in taking anti-hypertensives
and you have a discussion with him regarding the anti-hypertensive most commonly used in this
scenario.
What is the mechanism of action of the next-line antihypertensive for this patient?
It prevents angiotensin 2 acting on AT1 receptors
15
You are the ST1 working on cardiology. The nurses have asked you to review a 56-year-old man
complaining of dyspnoea which is limiting his mobility.
He presented three days ago with an inferior STEMI. He was loaded with 300mg aspirin and
180mg ticagrelor before being taken to the cath-lab where he underwent primary PCI with a drug
eluting stent for a sub-total occlusion of the right coronary artery. He was subsequently
commenced on aspirin 100mg od, ticagrelor 90mg bd, atorvastatin 80mg od, bisoprolol 5mg od
and perindopril 5mg od. His echo demonstrated only mildly reduced LV systolic function (LVEF
50%).
His vital signs are stable with a blood pressure 125/70mmHg, heart rate 64bpm, oxygen
saturations 98% on room air and temperature 36.5ºC. Examination reveals dual heart sounds with
no murmurs and his chest is clear on auscultation with no wheeze. JVP is +2cm and there is no
peripheral oedema. His calves are soft and non tender. A Chest X-Ray shows mild atelectasis at
the bases. His bloods are unremarkable. His ecg shows normal sinus rhythm with inferior q waves.
With respect to his dyspnoea, what would be the next best step in his management?
Substitute ticagrelor for clopidogrel
16
A 75-year-old female presents diaphoretic and distressed with new onset sternal chest pain
radiating through to the back. She has a past history of hypertension on lercanidipine. On
examination her blood pressure is 190/70 mmHg and there is an early diastolic murmur heard
best at the left sternal edge. Her ECG is unremarkable. What is the next best course of action?
CT chest with contrast
17
Which one of the following conditions is most associated with aortic dissection?
Bicuspid aortic valve
18
Each one of the following is associated with aortic dissection, except:
Ventricular septal defect
19
A 79-year-old man is referred to the acute medical unit following a fall. He is unsure why he
collapsed but is now fully alert. He is complaining of abdominal pain but his bowel habits are
unchanged.
He has a past medical history of prostatism and hypertension. He tells you he doesn't take any
medication.
On examination he has a Glasgow coma scale score of 15, a blood pressure of 98/46 mmHg and a
heart rate of 98beats per minute
...
...
Which of the following is the next most appropriate step in this man's management?
CT aortic angiogram
20
A 63-year-old man presents to the Emergency Department with sudden chest pain. He describes
the pain as 'tearing'. He has a history of hypertension, for which he normally takes amlodipine.
On examination, he has a tachycardia of 112 beats per minute, his blood pressure is 135/80 in the
left arm and 85/65 in the right arm. Pulses are diminished in the legs.
Initially, the doctors request a CT angiogram to confirm the suspected diagnosis, but the patient is
too unstable for this.
Which alternative investigation would be most useful instead, as per guidance?
Transoesophageal echocardiography (TOE)
21
A 57-year-old man presents with sudden-onset, tearing chest pain. He has a history of Marfan
syndrome and hypertension. On examination, he is visibly shocked and observations are as
follows:
Blood pressure of 78/65 mmHg
Heart rate of 161 beats/minute
Respiratory rate of 42 breaths/minute
Oxygen saturation of 95% on 8L/minute oxygen flow
What is the most appropriate diagnostic investigation?
Transoesophageal echo
22
A 64-year-old man is admitted to the Emergency Department with chest pain radiating through to
his back. On examination pulse 90 regular, BP 140/90. A CXR shows mediastinal widening. A CT
shows dissection of the descending aorta. What is the most suitable initial management?
IV labetalol
23
A 72-year-old man presents to the emergency department with left-sided tearing chest pain. He
has a past medical history of hypertension and hypercholesterolemia. He is on regular amlodipine,
ramipril and indapamide. She smokes 30 cigarettes per day and drinks 3-4 beers each night. He
lives alone and is usually independent of all activities of daily living.
His observations are heart rate 101 beats per minute, blood pressure 182/97 mmHg, respiratory
rate 21/minute, oxygen saturations 97% on room air and he is apyrexial.
On clinical examination, chest auscultation demonstrates equal air entry bilaterally. Both heart
sounds are audible and there is a diastolic murmur audible at the lower left sternal edge in endexpiration. Abdominal and neurological examinations are normal.
An ECG demonstrates sinus tachycardia.
A plain radiograph of the chest is normal.
Blood tests:
...
...
CT angiography of the chest is organized, which demonstrates an intimal flap proximal to the
brachiocephalic vessels.
Given the diagnosis, what is the appropriate management?
Control blood pressure (IV labetalol) + surgery
24
A 69-year-old man has been brought to the emergency department by ambulance with sudden
onset tearing chest pain.
Cross-sectional imaging has confirmed a thoracic aortic dissection, involving the descending aorta
only. There is no evidence of malperfusion.
He is currently alert and orientated. His pulse rate is 100bpm and his blood pressure is
156/98mmHg.
What is the most appropriate treatment strategy for this patient?
Intravenous labetalol
25
A 65-year-old man is referred to the hospital by his GP with a 2-week history of worsening
shortness of breath. He reports sleeping in a chair due to breathlessness when lying flat and
awakens several times at night, struggling to breathe. He has a history of well-controlled
hypertension and childhood rheumatic fever. His medications are ramipril and amlodipine.
Observations:
Heart rate: 98bpm
Blood pressure: 170/56mmHg
Temperature: 36.7 C
Respiratory rate: 18/min
Saturations: 98% on room air
On examination, you notice pulsation in the patient's nail bed.
What murmur would you expect to hear on auscultation?
Early diastolic murmur
26
Which one of the following is least associated with aortic regurgitation?
William's syndrome
27
Which of the following conditions is not associated with the development of aortic regurgitation?
Dilated cardiomyopathy
28
A 72-year-old man presents to his general practitioner with shortness of breath. He has no past
medical history.
On examination, abrupt distension and collapse of the carotid arteries are noted along with
visualization of capillary pulsations with light compression applied to the fingernail bed.
What type of murmur is likely to be heard on auscultation?
Early diastolic
29
Which one of the following clinical signs would best indicate severe calcified aortic stenosis?
Displaced apex beat
30
A 68-year-old man with a past history of aortic stenosis is reviewed in clinic. Which one of the
following features would most guide the timing of surgery?
Symptomatology of patient
31
Which one of the following features would best indicate severe aortic stenosis?
Fourth heart sound
32
Which one of the following clinical signs would best indicate severe aortic stenosis?
Soft second heart sound
33
A 53-year-old man is reviewed in the cardiology clinic with a history of chest pain and syncope.
On examination he has an ejection systolic murmur radiating to the carotid area. What is the most
likely cause of his symptoms?
Bicuspid aortic valve
34
An elderly man with aortic stenosis is assessed. Which one of the following would make the
ejection systolic murmur quieter?
Left ventricular systolic dysfunction
35
An 82-year-old man is referred to cardiology by his GP with increasing dyspnoea on exertion and
a systolic murmur. Examination demonstrates a blood pressure of 100/80 mmHg and a slow rising
pulse. What is the most likely cause of his underlying condition?
Calcification of the aortic valve
36
A 62-year-old man comes for review. In the past month he has had two episodes of 'passing out'.
The first occurred whilst going upstairs. The second occurred last week whilst he was getting out
of a swimming pool. There were no warning signs prior to these episodes. He was told by people
who witnessed the episode last week that he was only 'out' for around 15 seconds. He reports
feeling 'groggy' for only a few seconds after the episode. On examination pulse is 90 / minute,
blood pressure 110/86 mmHg, his lungs are clear and there is a systolic murmur which radiates to
the carotid area. Which one of the following investigations should be arranged first?
Echocardiogram
37
A 65-year-old man is found to have an ejection systolic murmur and narrow pulse pressure on
examination. He has experienced no chest pain, breathlessness or syncope. An echo confirms
aortic stenosis and shows an aortic valve gradient of 36 mmHg. How should this patient be
managed?
Regular cardiology outpatient review
38
A 72-year-old woman has presented to the emergency department with severe breathlessness.
On examination, she is breathless at rest with a slow-rising pulse and a raised jugular venous
pressure. She has significant pitting oedema to her thighs with a degree of sacral oedema.
Observations show that her pulse is 78beats per minute, blood pressure 98/52mmHg, oxygen
saturations 95% on 40% inspired oxygen and respiratory rate 32 breaths per minute.
On auscultation there are absent breath sounds to bilateral lower zones with crepitations
throughout both upper lung fields. Her heart sounds demonstrate a murmur with S4 heart sound.
Which valvular pathology is most likely to be seen on echocardiogram?
Aortic stenosis
39
You are reviewing a 78-year-old man who has been admitted via the emergency department with
chest pain. History reveals that he has been struggling with shortness of breath, and that his wife
is worried as he briefly lost consciousness on one occasion.
Echocardiogram reveals aortic stenosis.
What examination finding would suggest that his condition is severe?
Fourth heart sound
40
A 22-year-old man was out with his friends when he suddenly reported not feeling well. He
reported he could feel his heart beating very fast and then collapsed. A bystander started CPR and
an ambulance was called. Resuscitation attempts continued for an hour but were unsuccessful. A
post mortem was carried out to ascertain the cause of death as the young man had no medical
problems. During post mortem, the right ventricle was noticed to be thin-walled and histology of
the right ventricle revealed fibro-fatty infiltration.
What is the most likely cause of death in this case?
Arrhythmogenic right ventricular cardiomyopathy
PM 23 from 1 to 100 ð«
PM 23 from 1 to 100 ð«
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PM 23 from 1 to 100 ð«
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PM 23 from 81 to 100 ð«
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PM 23 from 81 to 100 ð«
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PM 23 from 101 to 120 ð«
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PM ð« 121 to 160
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PM ð« 161 TO 200
Mohamed Ahmed · 40å · 1幎åPM ð« 161 TO 200
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PM 23 from 1 to 40 ð«
Mohamed Ahmed · 40å · 1幎åPM 23 from 1 to 40 ð«
PM 23 from 1 to 40 ð«
40å ⢠1幎ååé¡äžèŠ§
1
A 55-year-old man is reviewed in the rapid access chest pain clinic with a history of central chest
pain on exertion, relieved by rest. He is currently taking no regular medications and has no drug
allergies.
Which of the following therapies should he be prescribed to reduce the frequency of his
symptoms?
Bisoprolol
2
A 68-year-old man presents to you with intermittent left-sided crushing chest pain which is
brought on by walking his dog on an incline. The pain settles within a couple of minutes of rest
and glyceryl trinitrate (GTN) spray. The pain is not associated with shortness of breath or
lightheadedness.
He first presented to you with these same symptoms six months ago, at this time you gave him
lifestyle advice and prescribed bisoprolol, aspirin, GTN and atorvastatin. He has noted only
minimal improvement of his symptoms over the last six months.
On examination he is comfortable at rest, with blood pressure 124/73 mmHg, heart rate 63
beats/minute, oxygen saturation 99%, respiratory rate 18 breaths/minute and he is afebrile. His
chest is clear, and heart sounds are normal. ECG shows normal sinus rhythm, with no ischaemic
changes. He is also awaiting a CT coronary angiography.
What would be the next stage of treatment for this patient?
Add nifedipine
3
A 48-year-old man with known stable angina is reviewed in the cardiac clinic. He takes aspirin and
a statin and is established on a maximum dose calcium channel and beta-blocker however he is
still experiencing chest discomfort on exertions requiring the use of his sublingual glyceryl
trinitrate spray.
He is to be started on a third medication however due to the potential of tolerance with the
standard-release form of this medication, an asymmetrical dosing regime is required. The regime
and potential side effects are explained to the patient.
What medication is the patient due to be started on?
Isosorbide mononitrate
4
A 56-year-old male is seen in the cardiology clinic after experiencing episodes of chest tightness
on exertion. After appropriate investigation, his GP diagnosed angina and initially provided
lifestyle advice and started him on aspirin, a statin and a sublingual glyceryl trinitrate spray.
The patient otherwise well with no other past medical history and is not on any other regular
medications.
On review in the clinic today the patient, unfortunately, reports ongoing episodes of angina.
His examination and observations are normal and an ECG performed displays normal sinus
rhythm.
What is the most appropriate next course of action?
Commence on verapamil
5
A 52-year-old man is seen in the clinic after originally being referred with progressively increasing
central chest pain but base level investigations, including ECGs and troponin level return within
normal range.
The pain is exercise dependent with it occurring when the patient carries out activities such as
climbing stairs and resolving on rest. As such the patient was started on atenolol 100mg OD along
with a GTN spray and aspirin.
On review today the patient still reports symptoms of chest pain on exertion despite good
compliance.
What alteration should be made to this patientâs management?
Add nifedipine
6
A 72-year-old man is investigated for exertional chest pain and has a positive exercise tolerance
test. He declines an angiogram and is discharged on a combination of aspirin 75mg od,
simvastatin 40mg on, atenolol 50mg od and a GTN spray prn. Examination reveals a pulse of 72
bpm and a blood pressure of 130/80 mmHg. On review he is still regularly using his GTN spray.
What is the most appropriate next step in management?
Increase atenolol to 100mg od
7
An 82-year-old man is reviewed. He is known to have ischaemic heart disease and is still getting
regular attacks of angina despite taking atenolol 100mg od. Examination of his cardiovascular
system is unremarkable with a pulse of 72 bpm and a blood pressure of 148/92 mmHg. What is
the most appropriate next step in management?
Add nifedipine MR 30mg od
8
A 54-year-old man with atypical chest pain is referred to cardiology. An exercise ECG shows nonspecific ST and T wave changes. Following this an coronary angiogram is performed which
demonstrates no evidence of atherosclerosis. A diagnosis of Prinzmetal's angina is suspected.
What is the most appropriate first-line treatment?
Felodipine
9
A 60-year-old man who is investigated for exertional chest pain is diagnosed as having angina
pectoris. Which one of the following drugs is most likely to improve his long-term prognosis?
Aspirin
10
A 60-year-old man is referred to the cardiology clinic with recurrent exertional chest pain
associated with dyspnoea. It improves with rest. He has a history of ischaemic heart disease and
underwent PCI to the right coronary artery five years ago. A coronary angiogram six weeks ago
showed widely patent stents. His current medications include aspirin, ramipril, bisoprolol,
eplerenone, and atorvastatin. Recently, his GP started him on sildenafil for erectile dysfunction. On
assessment, his BP is 142/88 mmHg, and his heart rate is 70 bpm.
What medication should be added to improve his symptoms?
Nifedipine
11
A 64-year-old man presents to his general practitioner with chest tightness, worse on exertion. It
occurs after approximately 200m and then quickly subsides if he stops walking. He has a past
medical history of angina, hypertension and gastro-oesophageal reflux disease. He is currently
taking atenolol, lansoprazole, aspirin and atorvastatin.
The examination is unremarkable.
Given the likely diagnosis, what is the most appropriate management?
Add amlodipine
12
A 59-year-old woman is seen in clinic, with a history of chest pain upon exertion, relieved by rest.
Her pain never occurs at rest. She takes aspirin, atorvastatin and the maximum dose of atenolol,
but she is still persistently experiencing exertional chest pain. She has tolerated all medicines since
commencement.
What would be the best recommendation for the next step in her management?
Commence nifedipine
13
A 55-year-old man presents to the cardiology clinic with chest pain. He has a history of previous
ST-elevation myocardial infarction and angioplasty.
He describes periods of worsening stable angina limiting his exercise tolerance. His resting heart
rate is 60bpm. Recent echocardiography shows a left ventricular ejection fraction of 50-55%.
Current medications include amlodipine 10mg OD and bisoprolol 10mg OD.
What is the most appropriate medication to initiate while awaiting further investigation?
Isosorbide mononitrate (immediate release) BD at 0800 and 1400
14
An 87-year-old man with mild dementia presents to your GP practice.
He has a documented drug allergy to calcium channel blockers and has hypertension confirmed
on ambulatory blood pressure monitoring. He has developed an intolerable cough whilst trialling
ramipril.
He is otherwise fit and well and takes only donepezil. He is interested in taking anti-hypertensives
and you have a discussion with him regarding the anti-hypertensive most commonly used in this
scenario.
What is the mechanism of action of the next-line antihypertensive for this patient?
It prevents angiotensin 2 acting on AT1 receptors
15
You are the ST1 working on cardiology. The nurses have asked you to review a 56-year-old man
complaining of dyspnoea which is limiting his mobility.
He presented three days ago with an inferior STEMI. He was loaded with 300mg aspirin and
180mg ticagrelor before being taken to the cath-lab where he underwent primary PCI with a drug
eluting stent for a sub-total occlusion of the right coronary artery. He was subsequently
commenced on aspirin 100mg od, ticagrelor 90mg bd, atorvastatin 80mg od, bisoprolol 5mg od
and perindopril 5mg od. His echo demonstrated only mildly reduced LV systolic function (LVEF
50%).
His vital signs are stable with a blood pressure 125/70mmHg, heart rate 64bpm, oxygen
saturations 98% on room air and temperature 36.5ºC. Examination reveals dual heart sounds with
no murmurs and his chest is clear on auscultation with no wheeze. JVP is +2cm and there is no
peripheral oedema. His calves are soft and non tender. A Chest X-Ray shows mild atelectasis at
the bases. His bloods are unremarkable. His ecg shows normal sinus rhythm with inferior q waves.
With respect to his dyspnoea, what would be the next best step in his management?
Substitute ticagrelor for clopidogrel
16
A 75-year-old female presents diaphoretic and distressed with new onset sternal chest pain
radiating through to the back. She has a past history of hypertension on lercanidipine. On
examination her blood pressure is 190/70 mmHg and there is an early diastolic murmur heard
best at the left sternal edge. Her ECG is unremarkable. What is the next best course of action?
CT chest with contrast
17
Which one of the following conditions is most associated with aortic dissection?
Bicuspid aortic valve
18
Each one of the following is associated with aortic dissection, except:
Ventricular septal defect
19
A 79-year-old man is referred to the acute medical unit following a fall. He is unsure why he
collapsed but is now fully alert. He is complaining of abdominal pain but his bowel habits are
unchanged.
He has a past medical history of prostatism and hypertension. He tells you he doesn't take any
medication.
On examination he has a Glasgow coma scale score of 15, a blood pressure of 98/46 mmHg and a
heart rate of 98beats per minute
...
...
Which of the following is the next most appropriate step in this man's management?
CT aortic angiogram
20
A 63-year-old man presents to the Emergency Department with sudden chest pain. He describes
the pain as 'tearing'. He has a history of hypertension, for which he normally takes amlodipine.
On examination, he has a tachycardia of 112 beats per minute, his blood pressure is 135/80 in the
left arm and 85/65 in the right arm. Pulses are diminished in the legs.
Initially, the doctors request a CT angiogram to confirm the suspected diagnosis, but the patient is
too unstable for this.
Which alternative investigation would be most useful instead, as per guidance?
Transoesophageal echocardiography (TOE)
21
A 57-year-old man presents with sudden-onset, tearing chest pain. He has a history of Marfan
syndrome and hypertension. On examination, he is visibly shocked and observations are as
follows:
Blood pressure of 78/65 mmHg
Heart rate of 161 beats/minute
Respiratory rate of 42 breaths/minute
Oxygen saturation of 95% on 8L/minute oxygen flow
What is the most appropriate diagnostic investigation?
Transoesophageal echo
22
A 64-year-old man is admitted to the Emergency Department with chest pain radiating through to
his back. On examination pulse 90 regular, BP 140/90. A CXR shows mediastinal widening. A CT
shows dissection of the descending aorta. What is the most suitable initial management?
IV labetalol
23
A 72-year-old man presents to the emergency department with left-sided tearing chest pain. He
has a past medical history of hypertension and hypercholesterolemia. He is on regular amlodipine,
ramipril and indapamide. She smokes 30 cigarettes per day and drinks 3-4 beers each night. He
lives alone and is usually independent of all activities of daily living.
His observations are heart rate 101 beats per minute, blood pressure 182/97 mmHg, respiratory
rate 21/minute, oxygen saturations 97% on room air and he is apyrexial.
On clinical examination, chest auscultation demonstrates equal air entry bilaterally. Both heart
sounds are audible and there is a diastolic murmur audible at the lower left sternal edge in endexpiration. Abdominal and neurological examinations are normal.
An ECG demonstrates sinus tachycardia.
A plain radiograph of the chest is normal.
Blood tests:
...
...
CT angiography of the chest is organized, which demonstrates an intimal flap proximal to the
brachiocephalic vessels.
Given the diagnosis, what is the appropriate management?
Control blood pressure (IV labetalol) + surgery
24
A 69-year-old man has been brought to the emergency department by ambulance with sudden
onset tearing chest pain.
Cross-sectional imaging has confirmed a thoracic aortic dissection, involving the descending aorta
only. There is no evidence of malperfusion.
He is currently alert and orientated. His pulse rate is 100bpm and his blood pressure is
156/98mmHg.
What is the most appropriate treatment strategy for this patient?
Intravenous labetalol
25
A 65-year-old man is referred to the hospital by his GP with a 2-week history of worsening
shortness of breath. He reports sleeping in a chair due to breathlessness when lying flat and
awakens several times at night, struggling to breathe. He has a history of well-controlled
hypertension and childhood rheumatic fever. His medications are ramipril and amlodipine.
Observations:
Heart rate: 98bpm
Blood pressure: 170/56mmHg
Temperature: 36.7 C
Respiratory rate: 18/min
Saturations: 98% on room air
On examination, you notice pulsation in the patient's nail bed.
What murmur would you expect to hear on auscultation?
Early diastolic murmur
26
Which one of the following is least associated with aortic regurgitation?
William's syndrome
27
Which of the following conditions is not associated with the development of aortic regurgitation?
Dilated cardiomyopathy
28
A 72-year-old man presents to his general practitioner with shortness of breath. He has no past
medical history.
On examination, abrupt distension and collapse of the carotid arteries are noted along with
visualization of capillary pulsations with light compression applied to the fingernail bed.
What type of murmur is likely to be heard on auscultation?
Early diastolic
29
Which one of the following clinical signs would best indicate severe calcified aortic stenosis?
Displaced apex beat
30
A 68-year-old man with a past history of aortic stenosis is reviewed in clinic. Which one of the
following features would most guide the timing of surgery?
Symptomatology of patient
31
Which one of the following features would best indicate severe aortic stenosis?
Fourth heart sound
32
Which one of the following clinical signs would best indicate severe aortic stenosis?
Soft second heart sound
33
A 53-year-old man is reviewed in the cardiology clinic with a history of chest pain and syncope.
On examination he has an ejection systolic murmur radiating to the carotid area. What is the most
likely cause of his symptoms?
Bicuspid aortic valve
34
An elderly man with aortic stenosis is assessed. Which one of the following would make the
ejection systolic murmur quieter?
Left ventricular systolic dysfunction
35
An 82-year-old man is referred to cardiology by his GP with increasing dyspnoea on exertion and
a systolic murmur. Examination demonstrates a blood pressure of 100/80 mmHg and a slow rising
pulse. What is the most likely cause of his underlying condition?
Calcification of the aortic valve
36
A 62-year-old man comes for review. In the past month he has had two episodes of 'passing out'.
The first occurred whilst going upstairs. The second occurred last week whilst he was getting out
of a swimming pool. There were no warning signs prior to these episodes. He was told by people
who witnessed the episode last week that he was only 'out' for around 15 seconds. He reports
feeling 'groggy' for only a few seconds after the episode. On examination pulse is 90 / minute,
blood pressure 110/86 mmHg, his lungs are clear and there is a systolic murmur which radiates to
the carotid area. Which one of the following investigations should be arranged first?
Echocardiogram
37
A 65-year-old man is found to have an ejection systolic murmur and narrow pulse pressure on
examination. He has experienced no chest pain, breathlessness or syncope. An echo confirms
aortic stenosis and shows an aortic valve gradient of 36 mmHg. How should this patient be
managed?
Regular cardiology outpatient review
38
A 72-year-old woman has presented to the emergency department with severe breathlessness.
On examination, she is breathless at rest with a slow-rising pulse and a raised jugular venous
pressure. She has significant pitting oedema to her thighs with a degree of sacral oedema.
Observations show that her pulse is 78beats per minute, blood pressure 98/52mmHg, oxygen
saturations 95% on 40% inspired oxygen and respiratory rate 32 breaths per minute.
On auscultation there are absent breath sounds to bilateral lower zones with crepitations
throughout both upper lung fields. Her heart sounds demonstrate a murmur with S4 heart sound.
Which valvular pathology is most likely to be seen on echocardiogram?
Aortic stenosis
39
You are reviewing a 78-year-old man who has been admitted via the emergency department with
chest pain. History reveals that he has been struggling with shortness of breath, and that his wife
is worried as he briefly lost consciousness on one occasion.
Echocardiogram reveals aortic stenosis.
What examination finding would suggest that his condition is severe?
Fourth heart sound
40
A 22-year-old man was out with his friends when he suddenly reported not feeling well. He
reported he could feel his heart beating very fast and then collapsed. A bystander started CPR and
an ambulance was called. Resuscitation attempts continued for an hour but were unsuccessful. A
post mortem was carried out to ascertain the cause of death as the young man had no medical
problems. During post mortem, the right ventricle was noticed to be thin-walled and histology of
the right ventricle revealed fibro-fatty infiltration.
What is the most likely cause of death in this case?
Arrhythmogenic right ventricular cardiomyopathy