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A 50-year-old man had a mechanical aortic-valve replacement for severe aortic stenosis,
and was discharged home 10 days later. Two weeks later, he started feeling unwell and had
lethargy, nausea and pyrexia of 38.3 C. Echocardiography showed vegetations on the
aortic valve. Which of the following is the most likely causative organism?

A. Enterococci
B. Group D streptococci
C. Haemophilus influenzae
D. Staphylococcus epidermidis Correct Answer
E. Streptococcus viridans

Prosthetic valvular endocarditis in the immediate postoperative period (< 2 months) is

usually caused by antimicrobial-resistant contamination at surgery, especially with
Staphylococcus epidermidis, diphtheroids and Candida spp. All the other organisms
commonly cause endocarditis following asymptomatic bacteraemias from the mouth, gut
and urinary tract. You can be reasonably assured that a question on infective endocarditis
will come up for the exam, so study this topic in depth.


A 40-year-old woman is admitted with a stroke after a prolonged pyrexial illness. On

examination she is in sinus rhythm, has splenomegaly and a pansystolic murmur at the
apex. Blood cultures confirm an infective endocarditis. Which of the following is the most
common causative organism?

A. Streptococcus viridans Correct Answer

B. Staphylococcus aureus
C. Streptococcus bovis
D. Gram-negative bacilli
E. Staphylococcus epidermidis

Infective endocarditis on native valves prevalence of organisms:

Streptococci Viridans group 3040%

Enterococci 1015%
Other 2025%
Staphylococci Staphylococcus aureus 927%
Coagulase-negative 13%
Gram-negative bacilli Haemophilus spp. 38%
Anaerobes Rickettsia/fungi less than 2%

Members of the viridans group of streptococci are the commonest cause of subacute
endocarditis on native valves. These commensals of the upper respiratory tract may enter
the bloodstream on chewing, tooth brushing or at the time of dental treatment.
Staphylococcus aureus is a common cause of acute endocarditis originating from skin
infections, abscesses, vascular access sites or intravenous drug misuse. Staphylococcus
epidermidis is the most common organism causing postoperative endocarditis following
cardiac surgery.


A 25-year-old primigravida who is 26 weeks pregnant, presents to the casualty

department with symptoms of headache, flashing lights and vomiting. Her blood pressure
was recorded at 140/100 mmHg and her antenatal diary showed consistent systolic
readings of 110120 mmHg and consistent diastolic readings of less than 80 mmHg. Which
of the following would be the drug of first choice?

A. Hydralazine
B. Labetolol
C. Methyldopa Correct Answer
D. Nifedipine
E. Ramipril

Although any of the options from A to D can be used in pre-eclampsia, the drug of choice
still is methyldopa, because of its long and reliable track record. So, in most centres,
hydralazine, labetolol and nifedipine are mainly used as second-line drugs. ACE inhibitors
are contraindicated in pregnancy because they can cause oligohydramnios, renal failure
and intrauterine death.


A 75-year-old-man presents to A&E with a history of sudden collapse. This occurred

unexpectedly while he was walking his dog. There have been no similar episodes in the
past. On examination there were no positive findings. An ECG performed with carotid sinus
massage revealed a 5-second pause. Which of the following statements is true?

A. Carotid sinus hypersensitivity is due to atherosclerosis

B. Carotid sinus massage is contraindicated in patients with carotid vascular disease
Correct Answer
C. A permanent pacemaker has no role in the management of these patients
D. Carotid sinus hypersensitivity is related to vertebrobasilar ischaemia
E. Carotid sinus massage is contraindicated in patients taking -blockers

Carotid sinus baroreceptors consist of sensory nerve endings located in the internal carotid
artery just above the bifurcation of the common carotid artery. Cardioinhibitory carotid
sinus hypersensitivity is defined as cardiac asystole of > 3 s. The pure vasodepressor type
is defined as a systolic blood pressure drop of > 50 mmHg (in the absence of significant
bradycardia). A mixed type consists of a combination of cardioinhibitory and vasodepressor
responses. As AV block can occur during the periods of hypersensitive carotid reflex, some
form of ventricular pacing, with or without atrial pacing, is generally required. The
mechanism responsible for carotid sinus hypersensitivity is unknown, but possibilities
include a high level of resting vagal tone, hyperresponsiveness to acetylcholine or an
excessive release of acetylcholine.


A patient has tuboeruptive xanthomas, distributed subcutaneously and mainly on the

extensor surface of extremities. What is the probable diagnosis?

A. Type I hyperlipoproteinaemia
B. Type II hyperlipoproteinaemia
C. Type III hyperlipoproteinaemia Correct Answer
D. Type IV hyperlipoproteinaemia
E. Type V hyperlipoproteinaemia

Tuboeruptive xanthomas occur in type III hyperlipoproteinaemia. Eruptive xanthomas are

associated with hyperchylomicronaemia (type I and type V hyperlipoproteinaemia).
Xanthoma tendinosum, which are nodular swellings of tendons, usually occur in type II