CARDIOLOGY

1. A 50 yr old man underwent a hemicolectomy. A few days after his operation, he develops
chest pain and a temperature of 38.8C. He is having rigors and night sweats. On
auscultation, a SYSTOLIC murmur is heard. What is the next SINGLE most appropriate
investigation?
A. CT Scan of the chest
B. Abdominal UTZ
C. CXR
D. Blood Culture
E. LFT
- This is a case of Infective endocarditis. The most appropriate investigation is blood cultures
or echocardiogram. Since echocardiogram is not one of the options, blood cultures should
be picked.

2. A 69 yr old man has sudden onset chest pain radiating to his left arm while watching
television. An ambulance was rushed to the scene and an ECG shows ST elevation in II,III and
aVF. What is the SINGLE most appropriate analgesia to administer to him while in the
ambulance?
A. IV Morphine
B. Oral Morphine
C. IM Morphine
D. Oral Tramadol
E. IM Tramadol
- Myocardial infarction is a painful condition seen as tightness, pressure or squeezing pain in
the chest. The ECG is showing that he is having an inferior MI. Pain relief w/ GTN sublingual
or spray and/or IV opioid 2.5-5 mg diamorphine or 5-10 mg morphine IV with an anti-emetic
is often used as part of pre-hospital management. Remembers nitrates, bring relief to many
patients, but up to 1/3 of those who experience a MI have nitrate-resistant chest pain and
should receive morphine to help manage the pain. Avoid IM injections of opioid medication
even while in the ambulance, as absorptions is unreliable. In addition, the injection site may
bleed if the patient receives thrombolytic therapy.

3. A 60 yr old man was seen by his GP with symptoms of his heart racing and feeling light-
headed persisting for the past 3 days. His medical history includes HPN and is non-compliant
with his medication. His pulse rate was 125bpm and was irregularly-irregular. Additionally, a
MID DIASTOLIC MURMUR was audible at the APEX. Am ECG performed at the time, showed
NO P-WAVES, NARROW and IRREGULAR QRS complexes. He was prescribed metoprolol and
was booked to follow up. 5 days later during his follow-up, normal sinus rhythm is seen on
ECG. Which of the following is most likely diagnosis?
A. Atrial flutter
B. V. Fib
C. V. Tach
D. PAF
E. WPW Syndrome
- The pt’s chief complaint of being aware of his heartbeat described palpitations. Dizziness is a
f eature coomonly associated with palpitations, especially in the setting of atrial fibrillation.
CAUSES of ATRIAL FIBRILLATION
o HPN
o Valvular Heart Dse  Mid diastolic murmur (possible indicating MV Stenosis)
o HF
o Pneumonia
o Caffeine and Alcohol
- Paroxysmal Atrial Fibrillation AF reverting to sinus rhythm spontaneously or w/
intervention WITHIN & DAYS. In this particular case, the pt reverted to sinus rhythm 5 days
after the onset of AF. PAF may defgenerate into sustained AF. An alcoholic patient w/
features of HF and an arrhythmis Think of AF
- Common Features of AF
o Dyspnea
o Palpitation
o Syncope/dizziness
o Chest discomfort or pain
o Irregularly-irregular pulse
o Narrow QRS, Absent P waves
- WPW Syndrome-= Ventricular pre-excitatory syndrome casued by an impulse passing
through an accessory pathway. It is common in younger individuals. The ECG Finding include
PROLONGED/WIDE QRS complex, SHORT PR Interval and the presence of DELTA WAVES.
- V.Fib pts are NEVER STABLE, Broad QRS
- V.Tach BROAD COMPLEX TACHYCARDIA. Regular RR Interval
- Atrial Flutter SAW TOOTH Flutter waves, Narrow QRS, Regular RR

4. A 62 yr old man attends ED following a dull central chest pain that startyed earlier today. He
feels clammy and nauseous. His pulse is 70 bpm , RR-21 cpm, bp 130/85 and O2 sat 97%. An
ECG was done and shows the ff:
 A. Emergency Coronary Angiography
B. CT Chest w/ Contrast
C. Plain Chest CT
D. 24 hr ECG
E. Transthoracic Echocardiogram
- The ECG shows typical ECG findings of a LMCA occlusion which are:
o Widespread ST depression
o ST elevation in aVR
- ST elevation in aVR may also be seen in proximald LAD occlusion or severe triple-vessel
disease and therefore it is crucial to undergo a coronary angiogram to detect which vessels
are affected in order to plan interventional or surgical procedure

5. A 58 yr old white Englishman with a past history of MI and type 2 DM has a new diagnosis of
HPN. He is currently taking aspirin, atorvastatin and metformin. What is the SINGLE most
appropriate medication to be added
A. ACEi
B. Thiazide diuretic
C. Insulin
D. Beta-blocker
E. CCB
- First-line anti-HPN drug treatment in a HPN pt with DM should be an ACEi.(Reno protective,
positive effect on CHO metabolism) For people of African or Caribbean family origin with
DM, consider ARB before prescribing an ACEi

6. A 42 yr old man collapsed and died at home. The GP’s report states that he has type-2 DM
and has a BMI of 35. What is the SINGLE most likely cause of death?
A. MI
B. Hyperglycemia
C. HF
D. PE
E. Renal Failure
- “Silent MI” in DM pts. Although there are risk factors for MI and PE, MI in DM2 dan be
painless as the pt develops autonomic neuropathy. As this progresses, pt collapses and dies

7. A 50 yr old man attends the ED with complaints of SOB and palpitations which started 4 hrs
ago. He denies chest pain. He has a pulse of 160 bpm, bp- 110/80 and RR 20cpm. His PMH
includes HPN, Type 2 DM and angina. An ECG was performed which shows regular narrow
complexes w/o P waves. The narrow ORS complexes have a normal shape and there are
normal T waves. Carotid sinus massage was attempted but he is still tachycardic. What is the
SINGLE most appropriate next management?
A. Adenosine IV
B. Amlodipine orally
C. Aspirin orally
D. Verapamil IV
E. Digoxin IV
- The ECG findings are consistent with SVT (regular rhythm and a rate of 150-250bpm

- Acute Management if Hemodynamically stable:

o Vaslsalva maneuver/Carotid Massage
o Adenosine 6mg rapid IV bolus, if pt is asthmatic VERAPAMIL
 If adenosine unsuccessful in converting to NSR then give another 12mg IV
adenosine, if still unsuccessful give further 18mg IV adenosine
o Verapamil or Betablocker
o Electrical DC cardioversion
- Acute management in unstable:
o DC Cardioversion
- Prevention:
o Beta blockers
o RF Ablation

8. A 28 yr old man presents w/ a 2 hour history of rapid palpitations. He feels light headed but
is otherwise well. On examination, he has a pulse of 170 bpm, regular. His bp 100/68. He had
2 similar episodes of feeling palpitations in the past 3 months. What is the SINGLE most
likely disturbance?
A. SVT
B. VF
C. V.Tach
D. Ectopic beats
E. AF
- SVT vs AF
o SVT  REGULAR QRS w/o P waves
o AF  IRREGULAR QRS W/O p WAVES
o If no life threatening features:
 Narrow QRS w/ REGULAR QRS Vagal maneuvers move to adenosine IV if
unsuccessful
 Narrow QRS with IRREGULAR QRS  Start w/ rate control ( Beta blockers)

9. A 55 yr old man brought to the ED from a shopping mall after collapseing 2 hours ago. He is
now fully conscious and answering questions. His ECG shows an irregular rhythm. His bp is
120/80. What is the SINGLE most appropriate investigation to carry out?
A. CT
B. MRI
C. 24-H ECG
 D. Echocardiogram
E. Exercise Testing
- Echocardiogram would be the nest option here. It is used to identify structural cardiac
abnormalities and assess LV function. It may show a clot in the atrial appendage responsible
for syncope which could be due to TIA secondary to AF. The most common valvular cause for
a syncope is AORTIC STENOSIS which needs an echocardiogram to diagnose it.

10. A 57 yr old woman who is suffering from HPN. Presents to the hospital with complaints of
recurrent falls when trying to get out of bed or getting up from sitting. She is on a CCB and a
thiazide diuretic. What is the SINGLE most likely cause of her falls?
A. CCB
B. Vertebrobasilar insufficiency
C. Thiazide
D. Hypoglycemia
E. Meniere’s dse
- AE of Thiazide: Postural hypotension. Both CCB and thiazide can cause postural hypotension
however thiazide diuretics are usualyy more of a culprit as they also induce dehydration by
their MOA.
- Common AE:
o Postural hypotension
o Hyponatremia, hypokalemia
o Gout

11. A 48 yr old woman has a sudden painful swollen left arm that started several hours ago. She
had been having fever for the past few days with malaise. She reports having breathlessness.
On examination, a LOUD S1 is heard with a MID DIASTOLIC MURMUR. She has NO LEFT
RADIAL PULSE. An ECg reveals NSR. An echogram was arranged which reveals leftATRIAL
MYXOMA. What is the SINGLE most appropriate action?
A. Perform embolectomy
B. Start anticoagulation
C. Start thrombolysis
D. Arrange CT angiography
E. Request ESR
- This pt has an embolic event in the left arm from a piece of the atrial myxoma (benign
tumor) that has broken off in the left atrium. This embolism has caused an acute limb
ischemia. An urgent embolectomy is required to save the left arm. In this setting, a catheter
embolectomy will be performed by an interventional radiologist where the embolism is
aspirated.
- Atrial myxomas are benign tumors. The majority of myxomas develop in the left atrium.
They are attached by a pedicale to the atrial septum. The tumor may obstruct the MV or a
piece may break off and form an emboli.
- Clinical features of atrial myxoma:
o Dyspnea
 o Syncope
o Loud S1
o Tumor plop ( often confused w/ S3 gallop) produced when the tumor hits the MV
o AFib
o Raised ESR
o Fever,malaise and wt. loss
- 3 BIG features of atrial myxoma
o Embolization
o Obstruction
o Arrythmia
o Platypnea- deifficulty breathing in the upright position with relief in the supine
position
o Investigation- Echocardiogram
o Ts: Surgical removal

12. A 58 yr old man presents to the ED with a dull chest pain and SOB that started 3 hours ago.
He has a history of HPN and takes medications for it. The ff ECg was taken

A. Post descending artery

B. Marginal branch of RCA
C. Left Circumflex Artery
D. RCA
E. Left Anterior Descending artery
- ST elevation can be seen in the anteroseptal leads which is indicative of LAD occlusion
13. A 54 yr old man has a temp of 39 c, a new murmur and symptoms of cardiac failure. He had
a dental extraction several days ago. What is the SINGLE most likely reason for his
symptoms?
A. Atheroma
B. Congenital
C. Regeneration of tissue
D. Infection
E. Neoplasm
- New murmur+fever Infective endocarditis. A dental extraction is a known source of
infection causing bacteremia which can result in infective endocarditis

14. A 45 yr old man has substernal chest pain which radiates to his shoulders which started 4
days ago. He had myocardial infarction 2 weeks ago but the initial pain has subsided. He
claims that the pain is much worse on inspiration and is often relived by sitting forward. The
pain is worse when he lies flat. His vital are temp 37.5, rr 20, bp- 110/70 o2 sat- 99% hr 70.
Given his clinical symptoms and likely diagnosis, which is a typical finding seen on ECg?
A. Saddle shaped ST elevation
B. Wide ST depression
C. Prolonged QT interval
D. PR segment elevation
E. Tall T waves
- This case is PERICARDITIS which an ECG would typically show a “SADDLE SHAPED ST
ELEVATION and PR SEGMENT DEPRESSION
- Acute Pericarditis
o Features:
 Chest pain described as sharp, stabbing, central chest pain with radiation to
the shoulders and upper arm
 Pleuritic pain and is often relieved by sitting forwards
 Pain may be made worse by inspiration, cough, swallowing or trunk
movement
 Pericardial friction rub on auscultation
o Causes
 Viral infections (Coxsackie)
 TB
 Uremia ( Fibrinous pericarditis)
 Trauma
 Post MI, Dressler’s syndrome
  Connective tissue disease

** POST MI AND POST VIRAL RTI ARE AN EXTREMELY IMPORATNAT CAUSE TO REMEMBER**

o ECG Changes
 Widespread “SADDLE SHAPED” St elevation
 PR Segment depression
o Management:
 Treating the underlying cause
 Viral Pericarditis- NSAIDs should suffice in most cases

15. A 68 yr old man attended the GP surgery to check his bp. His clicic bp is 158/96. He was
asked to do home bp measurements after the appointment. The average of 14 reading of his
home bp measurements is 145/92. His 10 yr risk of developing CVD is estimated to be at 7%
using a risk calculator. He is a non-smoker and otherwise completely healthy. What is the
SINGLE most appropriate management?
A. Start anti HPN meds
B. Offer lifestyle advice on exercise
C. No intervention required
D. Start a statin
E. Refer to cardiology
- Stage 1 HPN: clinic bp: > 140/90 and subsequent home bp average of > 135/85
- Stage 2 HPN: clinic bp: > 160/100 and subsequent home bp average of > 150/95
- The pt is classified as St. 1 HPN. Stage 1 HPN can be treated with anti-HPN meds if:
o <80 yrs old
o Target organ damage
o Established CVD
o Renal Dse
o DM
o 10 yr CV risk >10%
- Statins can be started if pt’s risk >10% and lifestyle modification were ineffective or
inappropriate
- Pt is only 68 yr old with a CV risk of 7% then no need for anti HPN meds to be started.
Lifestyle advice regarding exercise should be offered.

16. An 82 yr old male was walking in his garden when he suddenly fell to the ground and was
unconscious. He recovered completely within few minutes however, he described feeling
very hot and flushed after the episode. He remembers the events prior to the fall and
confidently says he did not trip. He denies feeling sweaty or dizzy prior to the fall. What is
the SINGLE best investigation to diagnose his problem?
A. ECG
B. Echocardiogram
C. CBG
D. Head CT
 E. CXR
- Pt who has an unannounced loss of postural tone leading to a period of unconsciousness
need to be investigated for three main causes which are:
o Irregular rhythms
o Low bp or postural drop
o Seizures
- Irregular rhythms and low bp or postural drop are easy to investigate/ complete recovery
within few minutes indicates that seizure is unlikely. cardiac syncopal events are the most
likely here as they are usually abrupt in onset with rapid recovery with flushing. This is the
reason that ECG is the answer here.

17. A 44 yr old woman in the postnatal ward develops sudden onset of chest pain and shortness
of breath. She had an emergency C-section for fetal distress two days ago. She feels the
breathlessness worsen when she lies down. She has a respiratory rate of 32cpm and a bp
100/60. Her O2 saturation is at 89% on room aire and temperature of 36.9. on examination,
she look pale and sweaty. Auscultation revesls widespread crepitations over both lung fields.
An ECG was performed which shows sinus tachycardia. O2 by FM was commenced. A CXR
confirms the diagnosis. Which SINGLE medication is used as part of the management?
A. Co Amoxiclav
B. Aspirin
C. Furosemide
D. LMWH
E. Alteplase
- The pt is suffering for ACUTE PULMONARY EDEMA brought upon by HF. It is worth noting
that this stem is likely tricky as there were no risk factors of HF mentioned and the
information that the woman had a recent C-section makes physician think of a pulmonary
embolism. However it is important to be aware that cardiac causes of breathlessness do
occur in pregnancy and post-delivery as well. This stem givens the history of orthopnea
which clearly point towards HF as the reason for the SOB.
- 4 important steps in managing pulmonary edema
o O2 support
o GTN
o Furosemide 40 IV
o Diamorphine (2.5-5) SIVP or Morphine 5-10mg SIVP can be used to relieve anxiety,
pain and distress the use of opiates is controversial and should not be routinely
given to patients with acute decompensated HF

18. A 68 yr old man is found collapsed at a shopping mall. An ECG reveals no connection
between P waves and QRS complexes with a rate of 35bpm. What is the SINGLE most likely
diagnosis?
A. 3rd degree heart block
B. V.Tach
C. 1st degree heart block
D. Mobitz Type I AV block
E. Mobitz type II AV block
 - This is a 3rd degree (complete) heart block. The P waves will occur regularly, usually at a rate
of around 75 bpm but are completely unconnected to the rhythm of the QRS complexes.

19. A 64 yr old man presents with palpitations, chest pain and shortness of breath. His bp was
82/40. He appeared confused and drowsy. ECG performed showed a narrow complex,
regular tachycardia with an approximate rate of 210 bpm. P waves were not visible. What is
the most appropriate management step?
A. Metoprolol
B. Adenosine
C. Carvedilol
D. Electrical cardioversion
E. Aspirin
- A narrow complex, regular tachycardia with the absence of P waves and a rate
approximately 180-220 bpm is characteristic of SVT
- In terms of management of SVT, 1st consider whether the pt is stable or not. If pt is stable try
vagal maneuvers followed by adenosine as initial management. If unstable, hypotension,
chest pain, shock, altered mental status, proceed immediately to electrical synchronized
cardioversion.

20. A 65 yr old man presents with recurrent lightheadedness for 1 month especially when he
gets up from bed in the morning. He also has occasional episodes of lightheadedness when standing
for prolonged periods of time. He suffers from HPN and type 2 DM. his regular medications include
atenolol, amlodipine, bendroflumehiazide and metformin. On PE, his bp 125/85 taken when he was
supine and 101/69 when standing. What is the SINGLE most likely diagnosis?
A. Acute HPN
B. Vasovagal faints
C. Postural hypotension
D. Postprandial hypotension
E. Aortic stenosis
- BP taken when lying down and standing up, a drop of more thatn 20mmHg after 3 mins of
standing.

21. A 55 yr old carpenter presents with a history of sudden chest pain which radiates to his jaw
accompanied by SOB which staretd 2 hours ago. An ECG was done which shows a NSR w/o
ST elevation. What is the SINGLE most appropriate investigation?
A. Cardiac troponins
B. CXR
C. Echocardiogram
D. Holter ECG
E. Exercise stress test

22. A 55 yr old man presents to the hospital with symptoms of increasing breathlessness over
the past few days and fatigue. He finds it more difficult to sleep during the nights because he
is short of breath. On auscultation of his chest, basal crepitations can be heard. He has a
 history of CHF and HPM of which he takes regular ramipril. Investigations were performed
and furosemide infusion is given in the department which rapidly improve his symptoms.
The medical team decide to discharged him on furosemide orally with a specialist nurse ff
up. What is the SINGLE most appropriate medication to be added on his discharged
medication list?
A. ARBs
B. Beta blocker
C. CCB
D. Dogoxin
E. Antiplatelet
- As this pt is already on ACEi, the next most appropriate class of medications would be a beta
blocker to manage his symptoms of CHF. Start with a low dose beta blocker and titrate up
once the low dose is tolerated.
23. A 64 yr old man presents with palpitation and mild shortnes of breath. His blood pressire is
132/80. He was talking in full sentences and appeared anxious. ECG is performed and is seen
below:
 What is the most appropriate management?
A. Metoprolol
B. Adenosine
C. Carvedilol
D. Electrical cardioversion
E. Aspirin
- A narrow complex, regular tachycardia with the ABSENCE of P waves and a rate of
approximately 180-220 bpm is a characteristic of SVT. In terms of immediate management
of SVT, first consider wheter the pt is hemodynamically stable. If stable, try vagal maneuver
followed by ADENOSINE as initial management. If unstable, then proceed immediately to
electrical synchronized cardioversion.

24. A 65 yr-old man has chest pain. On initial assessment, he is noted to be pale. An ECG reveals
no connection between p waves and qrs complexes with a rate of 42 bpm. What is the
SINGLE most likely diagnosis?
A. Complete Heart Block
B. Ventricular Tachycardia
C. 1st degree Heart block
D. Mobitz type I AV block
E. Mobitz type II AV block
- This is a 3rd degree (COMPLETE) heart block. The P waves will occur regularly, usually at the
rate of around 75 bpm but are completely unconnected to the rhythm of the QRS complex.
The treatment include Atropine followed by transcutaneous pacing then a pacemaker.

25. A 55 yr old man with a history of a myocardial infarction three years ago presents with
progressive dyspnea. He had two previous admissions with heart failure in the past year and
complains of the inability to lie down flat on his bed. He has a respiratory rate of 31 cpm and
SBP 90. His O2 saturation is 90% at room air. On examination, he looks pale and sweaty, and
he has widespread crepitations over both lung fields. O2 by FM was commenced. What is
the most SINGLE most appropriate investigation to confirm the diagnosis?
A. CXR
B. Ct scan of the Chest
C. Electrocardioram
D. Full blood count
E. D dimer test
- This pt is suffering from acute pulmonary edema brought upon by heart failure. While it is
true that an ECG is important to look for arrhythmia, a CXR would be a better answer given
that it would be able to confirm pulmonary edema. This question is very debatable but the
 clinical picture here fits pulmonary edema slightly than a myocardial infarction. In reality,
both will be performed.

26. A 59 yr old man attends the ED following a dull central chest pain that started 4 hours ago.
He is still in pain and feels clammy. He has no previously known coronary artery disease. His
medical history includes HPN which he takes amlodipine regularly. His pulse rate is 98 bpm,
RR of 20, BP 150/95 and O2 sat is 97%. He was started on IV morphine for his chest pain.
Blood test have been taken fro troponin levels but have not yet come back yet. An ECG was
done which shows the following:

A CXR done in the department is normal. What is the SINGLE most appropriate next step?
A. Give ASA 300mg orally
B. CT Chest with contrast
C. Administer alteplase
D. Coronary angiogram
E. Transthoracic Echocardiogram
- The ECG shows T wave inversion in leads II,III, aVF without an ST elevation. Myocardial
ischemia and infarction should be considered in the presence of T wave inversion and
cardiac sounding chest pain. ASA 300mg should be given. A LMWH should also be given but
this is not an option here. These two medications should be given as soon as the diagnosis of
unstable angina or NSTEMI is made:
o A loading dose of 300mg clopidogrel in addition to ASA is alsogiven in certain
scenarios
o Some pts with NSTEMI or unstable angina are offered coronary angiogram w/ ff up
on PCI if indicated

27. A 62 yr old woman with longstanding anxiety is seen in the OPD. She complains of her heart
skipping a beat quite often. This particularly occurs when she is trying to get to sleep. The
palpitations are never sustained. What is the SINGLE most likely rhythm disturbance?
A. SVT
B. Ventricular fibrillation
C. Ventricular Tachycardia
D. Atrial Fibrillation
E. Ventricular Ectopics
- From the given options the most likely answer is ventricular ectopics. This is a classic
scenario where the patient would complain of having “missed beats”. They are usually
otherwise asymptomatic. If ventricular ectopics occurs in a normal heart though
symptomatic, it is benign and are of no clinical significance.
- Ventricular ectopics are caused by the premature discharge ofa ventricular ectopic focus
which produces an early and broad QRS complex.
- Etiology: IHD, Cardiomyopathy, Stress, alcohol, caffeine, medication, cocaine or
amphetamines. Sometimes they occur naturally.
- Patients may be symptomatic with palpitations often described as “skipped” or “missed”
beats but they may also have symptoms of dyspnea or dizziness. Over half the population
have silent, or asymptomatic ventricular ectopics which are discovered incidentally on a
routing ECG.

28. A 69 yr old woman was seen in the pre-assessment clinic for elective left knee replacement
surgery. During the assessment, her bp was 163/103. She was asked to recheck her bp with
her GP. When she was reviewed by her GP 2 weeks later, her bp in clinic was 148/87 and
146/86. She is not on any medications. What is the SINGLE most appropriate action?
A. Ambulatory BP Monitoring (ABPM)
B. Start amlodipine
C. Start lisinopril
D. Advice on lifestyle modifications
E. Reassure her that her BP is normal
- A clinic bp of 140/90 or above is considered to be in the range of HPN. It can be either the
systolic value > 140 or diastolic value > 90. In this particular case, it was the systolic value
that > 140 that would need to be further followed up with ABPM
- AnyBP between 140/90-180/120 should be offered ABPM to confirm the diagnosis of HPN
- Advice on lifestyle modification and starting anti_HPN would depend on the results of
ABPM.

29. A 20 yr old comes to the ED complaining of palpitations that began when he woke up earlier
today. The palpitation have been continuous and re still ongoing. He denies chest pain,
SOBor dizziness. His BP is 120/80. He has RR of 23. He is completely conscious throughout.
Below his ECD take in the ED. What is the SINGLE most appropriate initial management?
 A. Amiodarone
B. Adenosine
C. Radio-frequency ablation
D. Carotid massage
E. Metoprolol
- This ECG shows SVT. Carotid massage should be attempted before giving IV adenosine.

30. A 45 yr old lady who was previously fit and well is admitted due to breathlessness,
palpitations and a history of 2 episodes of syncope over the past 2 days. Upon further
questioning, she admits to having difficulty breathing when she sits upright. She finds great
relief when she lies down flat on her couch. Upon examination, the tips of her fingers are
noted to be blue and clubbing is noticed. Auscultation reveals a mid diastolic rumble which
changes when the patient changes position and a loud S1 at the cardiac apex. What is the
SINGLE most likely diagnosis?
A. Mitral Regurgitation
B. Ventricular ectopics
C. Pulmonary Regurgitation
D. Atrial Myxoma
E. Complete Heart Block
- Certain Hints that give the diagnosis of atrial myxoma that you need to look for in this
question:
o Loud S1 noted at the apex. The 1st heart sound is made by the mitral and tricuspid
heart valves closing. The MOST FREQUENT CAUSE in patients with left atrial
myxomas is the OBSTRUCTION of the MITRAL VALVE. The symptoms and signs of
left atrial myxomas often mimic mitral stenosis which also present a loud S1
o The symptoms of myxoma can happen anytime, although they MOST OFTEN OCCUR
when a person changes the position of their body. In some patients, platypnea
 occurs. Platypnea is the difficulty of breathing in the upright position with relief in
the supine position.

31. A 66 yr old is brought in by the paramedics after developing chest pain that started 6 hours
ago. He was given 300mg of aspirin, IV morphine and sublingual GTN by the paramedics
after performing an ECG which is shown below. He is uncomfortable and sweating. He has a
bp of 110/70, rr 21, heart rate of 90 and O2 saturation of 94%. What is the SINGLE most
appropriate management?

A. PCI
B. Oral Morphine
C. Propanolol
D. IV GTN
E. Thrombolysis
- Nausea, vomiting and diaphoresis are symptoms that usually accompany cardiac chest pain.
PCI would be the MOST APPROPRIATE management for MI if it is within 12 hours of
symptom onset.

32. A 2 wk old baby has developed dyspnea. His O2 saturation is 70% on air. He is cyanosed and
has an ejection systolic murmur. What is the SINGLE most likely diagnosis?
A. TOF
B. ASD
C. PDA
D. Transposition of Great Arteries
E. VSD
- TOF is the most likely diagnosis here. It usually presents with an ejection systolic murmur.
The low O2 saturation and cyanosis are consistent with TOF and are due to blood shunting
across the VSD into the aorta.
 33. A 66 yr old man with a history of HPN present to A&E with sudden, severe lower abdominal
pain and back pain. A tender pulsatile abdominal mass is plapated lateral and superior to the
umbilicus. His heart rate is 110/min and BP is 80/50. What is the SINGLE most appropriate
investigation?
A. Laparoscopy
B. Xray-KUB
C. Pelvic UTZ
D. Sigmoidoscopy
E. Abdominal UTZ

-This is a classical picture of a ruptured abdominal aneurysm. An UTZ scan is the only appropriate
investigation given the options.

Questions would usually have either an UTZ or Abdominal CT Scan as one of the choices for a
ruptured aneurysm. Both choices are correct. It is important to note that both USS or CT scan can be
performed. Although, it may be safer and quicker to perform USS in the ED rather than transfer the
patient for CT scan.

34. A 62 yr old man who attends the ED feeling chest discomfort and nausea. His medical history
includes HPN whih he takes anti-HPN for. An ECG was quickly which is seen below. What is
the SINGLE most likely diagnosis?

A. Inferior MI
B. Pericarditis
C. Hypokalemia
D. Hyperkalemia
E. Hypocalcemia
- The ECG here shows large T waves indicative of hyperkalemia. There is no loss of P waves or
widening of QRS complexes yet. He likely has a potassium level that is high above 5.5mmol/L
but probably less than 6.5mmol/L given there are no p wave changes.
- Anti HPN medications like ACEi can result to hyperkalemia

35. A 74 yr old man started having chest pain. He has a blood pressure of 70/50mmHG. His level
of consciousness is decreased. A radial pulse is felt. An ECG shows the following rhythm.
What is the SINGLE most appropriate management?

A. Cardioversion
B. Carotid Sinus Massage
C. Adenosine
D. Amiodarone
E. Lidocaine
- The ECG pattern between Vtach and Vfib can be rather hard to distinguish. But here, as the
patient is still conscious, it cannot be VFib as this would present without a pulse and the
patient would not be conscious. Thus the ECG shows VTach. Since the pt is hemodynamically
unstable, cardioversion would be the answer.

36. A 50 yr old female present with a shortness of breath and palpitations which has been on
going for the past few hours. She has ankle swelling which has been present for more than a
year and feels difficulty in breathing while lying down. She is a known alcoholic. A CXR shows
evidence of cardiac enlargement. What is the SINGLE most likely cause of her worsening
condition.
A. Ventricular Tachycardia
B. Paroxysmal SVT
C. Ventricular Fibrillation
D. Atrial Fibrillation
E. Ventricular Ectopic
o Ankle swelling and orthopnea are features of heart failure. There features in
combination with the history of alcoholism gives us the hints of an alcoholic
cardiomyopathy which is a type of dilated cardiomyopathy. Atrial fibrillation is the
MOST COMMON ARRHYTHMIA that develops n patients with dilated
cardiomyopathy. Acute decompensations can occur especially in patients with
asymptomatic LV dysfunction who develop atrial fibrillation. In some scenarios,
there is a setting of acute alcohol use or intoxication followed by palpitations,
dizziness and syncope which can be attributed to arrhythmias such as atrial
fibrillation or flutters. This is known as HOLIDAY HEART SYNDROME because the
incidence is increased following weekends and during holiday seasons.
37. A 50 yr old man with DM suddenly develops persistent crushing central chest pain radiating
to the neck and arm when he was driving. It is associated with nausea, vomiting, dyspnea
and palpitations. He has a pulse of 122/min, BP of 110/70, respiratory rate of 34/min. what
is the SINGLE most likely diagnosis?
A. Angina
B. Costochondritis
C. Dissecting Aneurysm
D. Myocardial Infarction
E. Pulmonary Embolism
- These characteristics are classic in MI. Do not get fooled into picking dissecting aneurysm.
Although the pain of MO can be somewhat similar to a dissecting aneurysm, a MI is much
more common than a dissecting aneurysm
- The examiners would have to include something specific to a dissecting aneurysms for that
to be the answer such as a history of a severe tearing chest pain radiating to the back with a
history of Marfan syndrome and unequal pulses in upper extremities. If you would see any
of these key phrases, you should stop and consider dissecting aneurysm as the answer.

38. A 77 yr old woman is seen by the GP surgery with complaints of increasing “water in her
legs” and worsening shortness of breath when she lies flat. Her symptoms have gradually
worsened over the past few months. She has a history of systolic heart failure diagnosed 2
years ago. She was admitted into the hospital 6 months ago for pulmonary edema which she
was treated with IV furosemide. Her medications include furosemide, carvedilol and
ramipril. On examination, she has normal vesicular breath sounds on auscultations. Her
heart sounds are normal. She has pitting edema on both her feet and ankles. She has a
temperature of 36.7, heart rate of 70bpm, BP of 130/80, RR of 15/min and O2 saturation of
97%. Her previous renal profiles were seen to be normal. What is the SINGLE most
appropriate management?
A. Change furosemide to bumetanide
B. Start amlodipine
C. Start tamsulosin
D. Prescribe GTN spray
E. Stop ramipril.
- In a patient with symptomatic heart failure where diuretic response is insufficient, the
appropriate options include:
o Increasing the dose of diuretic
o Switching furosemide to bumetanide or torasemide
o Considering admission for IV loop diuretics

39. A 61 yr old man presents to the ED with retrosternal chest pain which started 3 hours ago
while he was sitting down. The pain has not eased over the past 3 hours. He had a similar
episode 12 hours ago which he took aspirin and a GTN spray which relieved the chest pain.
 His BP 120/80 and his heart rate is 70/min. his o2 saturation is 98%. What is the SINGLE most
appropriate initial investigation?
A. Troponins
B. CXR
C. Echocardiogram
D. ECG
E. Exercise Stress Test
- We are suspecting a MI in this patient. He may have suffered from a stable angina in the past
which he was prescribed GTN spray for symptomatic relief, however , an ongoing chest pain
need to be investigated first using an ECG for signs of an ST elevation. Cardiac enzymes
would need to be requested too but an ECG is the most important 1st investigation.

40. A 77 yr old woman who lives alone was found by her neighbor on her kitchen floor. She was
found confused but conscious. It is estimated that she has been lying on the floor for the
past 20 hours after a fall. An ECG was performed, which is seen below. Which investigation
would likely be abnormal, taking into account the ECG findings.

A. Urea and Electrolytes

B. Echocardiogram
C. Troponin
D. CXR
E. Pro-BNP
- The ECG shows tall tented T waves. This would be consistent with hyperkalemia which urea
and electrolytes would show. This patient is likely suffering from complications of
rhabdomyolysis. Urea and electrolytes is a panel of blood test which include:
o Na
o K
o eGFR
o Urea level
o Creatinine level

41. A 66 yr old man has presented to the ED with a facial droop, arm weakness and speech
difficulties that started 2 hours ago. A CT scan of the head shows no evidence of an acute
hemorrhage. An ECG was performed which shows an atrial fibrillation. There is no history of
atrial fibrillation in the past. He was managed by the medical team and was thrombolysed
and currently awaiting discharge. He has been informed by the medical team that he
suffered from a non-disabling ischemic stroke. He has a known hypersensitivity to apixaban,
what is the SINGLE most appropriate long term prophylactic regimen for stroke prevention?
 A. Warfarin
B. Heparin
C. Aspirin
D. Statins
E. Beta blockers
- For non-disabling ischemic strokes, it depends on specific circumstances. Nonetheless, in this
question they are asking for a long term prophylactic regimen and thus warfarin is still the
best option whether it is started in 14 days time or right away.
- He has atrial fibrillation which could lead to another stroke which is the reason that
anticoagulation is extremely important. If atrial fibrillation was not included in this question,
then the answer would be aspirin for 2 weeks and clopidogrel long term for stroke
prevention.

42. A 60 yr old man with a history if IHD starts having chest pain. He has a heart rate of 170/min
and a BP of 70/45. An ECG reveals a broad complex tachycardia with absence of atrial
activity. He feels unwell and is now semi-conscious. What is the SINGLE most likely
diagnosis?
A. Stokes-Adams Syndrome
B. Ventricular Fibrillation
C. Ventricular Tachycardia
D. Complex Heart Block
E. Atrial Fibrillation
- The ECG revealing abroad complex tachycardia with absence of atrial activity in a conscious
person can only be a ventricular tachycardia. The hypotension seen here supports this.
Cardiac arrhythmias are more common in patients with IHD hence the given history.
Occasionally, in the exam, they may include a picture of an ECG showing a broad complex
tachycardia. Again, pick ventricular tachycardia if the patient is still awake as it is impossible
to see ventricular fibrillation in an awake patient.

43. A preterm neonate who was born at 32 weeks has a continuous murmur that disappeared at
the time of discharge from the PICU. What is the SINGLE most likely diagnosis?
A. PDA
B. TOF
C. TGA
D. ASD
E. VSD
- PDAs are very common in preterm babies and it also may close spontaneously. A continuous
murmur may be heard
44. A 74 yr old man started having chest pain. He has a blood pressure of 70/50. He is conscious
and a radial pulse is felt. An ECG shows the following rhythm. What is the SINGLE most likely
diagnosis
 A. SVT
B. V. Tachycardia
C. V. Fibrillation
D. Atrial Fibrillation
E. Atrial Flutter

45. A 43 yr old was brought into the A&E after being stabbed in the chest with a knife. His chest
is bilateraaly clear. He has muffled heart sounds and his neck veins looks distended. His
systolic BP 60 and a pulse of 120 bpm. what is the SINGLE most likely diagnosis?
A. Pulmonary Embolism
B. Pericardial Effusion
C. Cardiac Tamponade
D. Hemothorax
E. Pneumothorax
- The presence of BECK’S TRIAD is a classical finding on cardiac tamponade.

46. Which of the following may cause the abnormalities of the QRS axis on this ECG?

A. Inferior Myocardial Infarction

B. Pulmonary Embolism
C. Anterolateral MI
 D. Right Ventricular Hemiblock
E. Chronic Lung dse
- A common cause of left axis deviation is inferior myocardial infarction.

47. A 65 yr old man continues to experience chest pain 2 days after an AMI. He has a
temperature of 37.8C. His ECG shows widespread ST elevation with upward concavity. What
is the SINGLE most likely diagnosis?
A. Acute Pericarditis
B. Cardiac Tamponade
C. Atrial Thrombus
D. LV Aneurysm
E. Dressler Syndrome
- Chest pain and ECG findings of widespread ST elevation with an upward concavity is
diagnostic of acute pericarditis. The history of a MI supports this as one of the causes of
acute pericarditis is a recent MI. fever, night sweats and other constitutional symptoms
maybe present depending on the underlying cause
48. A 46 yr old man asked to come in to the GP surgery for the results of an abnormal blood
results. His blood test reveals the following:

HDL Cholesterol- 1.7 (0.9-1.93 mmol/L)

LDL Cholesterol 4.9 (<2mmol/L)
Triglycerides 1.5 ( 0.55-1.9 mmol/L)
Total Cholesterol 8.1 ( <5mmol/L)

On questioning further, he states that his father died when he was 58 yrs old from a MI. he is
a smoker. He drinks an estimate of 10 units of alcohol a week. What is the most likely
diagnosis?
A. Cerebrotendinous xanthomatosis
B. Alcohol excess
C. Polygenic hypercholesterolemia
D. Mixed dyslipidemia
E. Familial hypercholesterolemia
- Familial hypercholesterolemia is an autosomal dominant condition. Heterozygous states
increased the risk of CV disease and early death. You should highly suspect familial
hypercholesterolemia if the patient has a total cholesterol more than 7.5mmol/L or a
family history of myocardial infarction in a 1st degree relative below 60 yrs old (or a 2nd
degree relative below 60 yrs old)

49. A 65 yr old man attends the ED with dizziness. He has a pulse rate of 51bpm. His BP 75/56
mmHg. An ECG shows a 3rd degree heart block. He is not on any medications. He has been
given atropine. What is the SINGLE most appropriate next step in management?
A. Adenosine
B. Temporary pacing
C. Permanent pacemaker
D. Glucagon
E. Amiodarone
- The initial management for all symptomatic bradycardia starts with atropine. This is inclusive
of a 3rd degree heart block. Symptomatic bradycardia would include adverse features such as
 syncope, heart failure and shock. Temporary Transcutaneous pacing is ideal if there is no
response to atropine in an emergency setting like in this case. It is the most appropriate next
step. Eventually he would go on to require a permanent pacemaker.

50. A 58 yr old man attends the GP surgery for the results of his cholesterol levels. His recent
blood test shows the following:
HDL- 1.7 (0.9-1.93
LDL- 2.1 (<2mmol/L)
Triglycerides 1.5 ( 0.55-1.9 mmol/L)
Total Cholesterol 5.3 ( <5mmol/L)
He is a smoker and has a BMI of 33m/kg2. His BP is 130/84. His QRISK score is calculated at
14%. He has no other medical conditions and does not take any regular medications. What is
the SINGLE most appropriate management to reduce his risk of CV disease?
A. Offer atorvastatin
B. Offer amlodipine
C. Offer ramipril
D. Offer amlodipine and simvastatin
E. No prophylaxis needed
- The QRISK3 algorithm calculates his risk of developing CVD over the next 10 years. If his
QRISK3 is 14%, he is at 14% risk of developing CVD over the period of the next 10 years.
People with a QRISK that is 10% or more who are aged 84 and younger should be offered
lipid-lowering treatment with statin.

51. A 56 yr old male with established lateral myocardial infarction as seen on ECG is taken to the
cardiology department for PCI. While in the catheterisation laboratory, the nurse in charge
noted that he became increasingly unwell and pale. He eventually carried out and his airway
was secured via an oropharyngeal mask and O2 was administered. His vitals are as follows:
BP-75/50
HR- 210
RR-4
Another ECG was performed and revealed a broad complex tachycardia. What is the SINGLE
next best step in management of this patient?
A. Intubation
B. IV amiodarone
 C. IV Adrenaline
D. Cardioversion
E. Magnesium Sulfate
- The scenario depicted here describes a typical complication of a MI- a tachyarrhythmia. As
clear from the stem, the pt is hemodynamically unstable. In addition, there is the presence
of a broad complex tachycardia on ECG. Therefore to answer this question correctly, it is
important to know about the management of a broad complex tachycardia.
- Steps of broad complex tachycardia management:
o 1. Check pulse- if no pulse, follow arrest protocol
o Administer o2
o If the patient is hemodynamically unstable- Synchronized cardioversion followed by
IV amiodarone.

52. A 59 yr old male is rushed to A&E by an ambulance with the complaint of dyspnea and
tachypnea following a road traffic accident. He looks acutely unwell with an altered mental
status. Which of the following are features of cardiac tamponade?
A. Meffled Heart sounds and decreased JVP
B. Muffled heart sounds and increased IVP
C. Muffled heart sounds and HPN
D. Bradycardia and distended neck veins
E. Increased intensity of heart sounds and pulsus paradoxicus
- The following signs may be appreciated in cardiac tamponade:
o Muffled or diminished heart sounds-BT
o Increased JVP- BT
o Distended neck veins
o Hypotension-BT
o Pulsus pardoxicus
o Tachycardia

53. A 72 yr old woman is brought in by her husband as she has sudden chest discomfort,
palpitation and epigastric pain which started 1 hour ago. She has been feeling nauseous. She
denies pain radiating to the arms or neck. There are ST elevations seen on leads II,III, aVF on
the ECG. O2 has been started. She was given sublingual GTN and diamorphine which has
improved her chest pain. Her heart rate is 90/minute and respiratory rate is 18/min. what is
the SINGLE most appropriate next step in management?
A. LMWH
B. PCI
C. Warfarin
D. Streptokinas
E. Alteplase
- As there is ST elevation in leads II, III and aVF this confirms the diagnosis of myocardial
infarction. PCI would be the best management for MI
54. A 65 yr old man attends the ED with dizziness. He has a pulse rate of 48bpm. His BP 75/36.
His RR is 21/minute. An ECG shows a 3rd degree heart block. He is not on any medications.
What is the SINGLE most appropriate initial management?
A. Atropine
B. Temporary pacing
C. Permanent pacemaker
D. Glucagon
E. Refer to cardiology department
- The initial management for all symptomatic bradycardia starts with ATROPINE.

55. A 59 yr old male with known CKD presents to A&E in an acute confusional state with
shortness of breath and a fever of 39.4. his heart rate is 115/min and his RR is 28/min.
auscultation of his chest reveals a pansystolic murmur which has not been heard before. An
examination is significant for a 1cm non-tender, hemorrhagic macular lesion on the right
sole and petechiae on the upper trunk. What is the SINGLE most appropriate initial
investigation to help achieve a diagnosis?
A. Blood Culture
B. Transthoracic Echocardiogram
C. CXR
D. Serology testing fro S. viridans
E. ECG
- Petchiae is one of the most common manifestations of immune complex deposition. The
patient has Janeway lesions. Janeway lesions are non-tender, small erythymatous or
hemorhaggic macular or nodular lesions on the palms or soles as a result of septic micro-
emboli that deposit bacteria under the skin. Janeway lesions are usually seen in acute
endocarditis. Isolation of the causative bacteria from blood cultures is imperative for the
diagnosis and treatment planning. The patient has a new pansystolic murmur already which
indicates cardio involvement. Doing the blood culture first is more important to be initiated
at this case due to the fact that it will dictate the course of antibiotic therapy to be
implemented for the patient.

Mitral regurgitation 2nd MC heart valve disorder Soft s1 and s2,

MVP Common in Marfan’s
Ehlers-Danlos and
Osteogenesis Imperfecta
Mitral Stenosis RHD is the MC cause of MS
PANSYSTOLIC MURMUR
which radiates to the axilla
“when cooking you do not
want to REGURGITATE into
the PAN”
Mid systolic CLICK followed
by a mid-late systolic
murmurs
Mid diastolic murmur with
an opening click
“Michael Schumacher had
a terrible accident in the
MIDdle of his ski trip which
he almost DIAd”
 Aortic Regurgitation Early diastolic Murmur
Aortic Regurgitation

56. A 38 yr old man present to the ED feeling unwell and dizzy. He is increasingly short of breath
and has mild chest discomfort. He has a heart rate of around 35/min. his BP is 70/30. His
ECG shows broad complexes with AV dissociation. What is the SINGLE most appropriate first
line treatment?
A. Atropine
B. Adenosine
C. Dopamine
D. Epinephrine
E. Carotid massage
- The ECG findings in this case show the atrial activity not conducted to the ventricles which
are termed THIRD DEGREE (Complete) HEART BLOCK.
- Narrow QRS Complex- proximal block, AV node or Budle of His takes over
- Broad Complex- distal AV block
- In the UK, atropine is the 1st drug of choice for symptomatic bradycardia despite the ECG
rhythm. The dose in the bradycardia ACLS algorithm is 1mg IV push and may repeat up to a
total dose of 3mg. In the UK, atropine is tried first before transcutaneous pacing or
dopamine.

57. A 57 yr old man presents to A&E with central abdominal and lower back pain with feeling
faint and sweaty. The pain started very suddenly and it is very severe. His heart rate is
105/min and BP 88/50. On PE, there is a tender pulsatile abdominal mass nad his left
femoral pulse is absent. What is the SINGLE most appropriate initial investigation?
A. UTZ
B. Sigmoidoscopy
C. Barium Enema
D. Abdominal XRay
E. MRI of the Abdomen
- This is a classic picture of a ruptured abdominal aneurysm. An UTZ is the only appropriate
investigation given the options.

58. A 76 yr old man with no significant medical history presents to the clinic for his annual check
up. His only complaint is mild exercise intolerance that he attributed to his advanced age. His
physical examination is only significant for an ejection systolic murmur in the upright
position. What is the SINGLE most likely cardiac defect that this patient has?
A. Tricuspid regurgitation
B. Mitral regurgitation
C. Mitral stenosis
D. Aortic stenosis
E. Aortic regurgitation
59. A 58 yr old woman presents to A&E with the complaint of a fall. Her medical records reveal
that she has been in attendance to A&E quite frequently over the last few months because
of recurrent falls. On examination, she looks slightly pale and she jokes that she is clumsier
nowadays. Her past medical history includes asthma, HON and a previous MI 3 yrs ago. She
is on a salbutamol inhaler, beclamethasone inhaler, amlodipine, aspirin,atenolol and
bendroflumethiazide. What is the SINGLE most appropriate investigation to be carried out?
A. 24 hour ECG
B. BPM
C. Peak Flow Meter
D. Echo
E. CT Head
- Her regular medications include multiple anti HPN meds which are known to cause postural
hypertension. BP monitoring would be most appropriate in this scenario to assess and
review her medication therapy.

60. A 46 yr old man was brought into the A&E after being stabbed in the chest with a knife. His
chest is bilaterally clear. He has muffled heart sounds and his neck veins look distended. His
BP is 84/40 and pulse is 110bpm. What is the SINGLE most appropriate investigation that can
lead to a diagnosis?
A. Echocardiogram
B. CXR
C. CTPA
D. Spirometry
E. Blood cultures
- This case is cardiac tamponade. The presence of Beck’s triad is a classical finding. This is
diagnosed with an Echocardiogram.

61. A 22 yr old man iseen in the cardiology clinic following investigations for his recurrent
fainting episodes while exercisiong. His ECG recently shows the following:
Rate: 80bpm
 Normal QRS
Normal PR Interval
Prolonged QT Interval
A. Sick Sinus rhythm
B. Ventricular tachyarrhythmia
C. AV block
D. Atrial Fibrillation
E. Atrial Flutter
- This man likely has a form of congenital long QT syndrome. Long QT syndrome with syncope
while exercising is associated with cardiac arrest due to ventricular tachyarrhythmias.
Torsades de pointes is one of the cardiac arrhythmias seen in association with long QT
syndrome. It usually terminates spontaneously but it may lead on to ventricular fibrillation.
This is one reason some patients with long QT syndrome choose to stay on life long beta
blocker.

62. A 53 yr old man notices occasional left sided chest pain for the past few weeks that lasts less
than 30minutes following exercise. The pain is relieved when resting. He smokes 10
cigarettes a day for the past 20 years. What is the SINGLE most likely diagnosis?
A. Unstable angina
B. Decubitus Angina
C. Stable angina
D. Coronary spasm
E. Myocardial Infarction
- Angina is chest pain or discomfort that is cause when heart muscles do not get enough
blood. In stable angina, the pain is precipitated by predictable forces like exercise. This
occurs because the o2 demand is more than o2 supply to the ehart. The pain is relieved by
rest. GTN would also bring relief.

63. A 72 yr old man is found not breathing in the CCU with the following rhythm. His pulse can
not be felt. What is the SINGLE most likely diagnosis?
A. SVT
B. V. TACH
C. V. FIB
D. A. FIB
E. A. FLUTTER

64. A 46 yr old African-Carribean man is found to have a BP 160/90 on 3 separate occasions in

the clinic. He was given an ABPM to take home. He returned the following week with an
average reading of 163/95. What is the SINGLE most appropriate initial treatment?
A. ACEi
B. BB
C. ARBs
D. Thiazide
E. CCB
65. A 62 yr old woman who had a stroke a year ago now reports having increased dyspnea on
exertion. An ECG was performed which showed atrial fibrillation. A CXR shows a straight left
heart border. What is the SINGLE most likely diagnosis?
A. Aortic Regurgitation
 B. Acute Mitral Regurgitation
C. Mitral Valve Prolapse
D. Pulmonary Stenosis
E. Mitral Valve Stenosis
- The clincher here is the CXR that shows a straight left heart border. This is classic for mitral
stenosis where the left atrium enlarges. The rest of the symptoms also match the diagnosis
of mitral stenosis. The history of stroke given in this question is a clue that she has had atrial
fibrillation for a while and had a systemic embolism ( stagnation of blood in an enlarged left
atrium)