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    11 views670 pages

    Cardiology MRCP 2 Pastest 2017

    Uploaded by

    sheryboy236

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 670
    Sea ered Oe aes Yond 3 dawral PAIS I- oe Back to Filters Question 1 of 337 An 88-year-old man is taken to the Emergency Department by his daughter as he had been feeling unwell that day with chest pains. An ECG reveals that he is suffering an inferior myocardial infarction. He has a heart rate of 33 beats per minute and a blood pressure of 90/60 mmHg. He is given 600 mcg of atropine, to no effect; this is repeated up to 3 mg. Your local hospital does not have an out-of- hours PCI service and you commence an infusion of TPA, but his rate is not immediately improving. Which of the following treatments would be most suitable to use for his arrhythmia? A Adrenaline B Glucagon e Temporary pacing D lsoprenaline = Implantation of a permanent pacemaker Previous Question Skip Question Calculator Normal Values Blog About Pastest Contact Us Help © Pastest 2017 PAIS I- oe Back to Filters Question 1 of 337 An 88-year-old man is taken to the Emergency Department by dai daughter as he had been feeling Unwell that day with chest pai An ECG reveals that he is suffering an inferior myocardial infarction. He has a heart rate of 33 beats per minute and a blood pressure of 90/60 mmHg. He is given 600 mcg of atropine, to no effect; this is repeated up to 3 mg. Your local hospital does not have an out-of- hours PCI service and you commence an infusion of TPA, but his rate is not immediately improving. Which of the following treatments would be most suitable to use for his arrhythmia? Your answer was correct A Adrenaline B Glucagon D lsoprenaline E Implantation of a permanent pacemaker Explanation xt Temporary pacing This patient has had an inferior myocardial infarction. The ‘inferior’ territory is supplied by the right coronary artery, which also supplies the sino-atrial and atrioventricular nodes. As such, inferior myocardial infarction commonly results in conduction deficits and heart block. Heart block and bradycardia are often temporary and can resolve with prompt treatment for the myocardial infarction. Temporary pacing is the correct option, as it will allow appropriate control of heart rate once inserted without precipitating further ischaemia. A Adrenaline Adrenaline acts as a non-selective adrenoceptor agonist. Administration would increase the patient’s heart rate. However, it will also increase myocardial oxygen requirements due to the positive inotropic effect. As such, adrenalin may worsen myocardial ischemia in this case. B Glucagon Glucagon is used in cases of B-blocker overdose. Glucagon activates adenyl cyclase and is theoretically able to exert a chronotropic effect not dependent on the adrenergic pathway. However, the evidence for effectiveness even in B-blocker overdose is limited. D lsoprenaline lsoprenaline acts as a B;-agonist and has a positive chronotropic effect. It is often utilised in patients with complete heart block or bradycardia as a bridging therapy to allow time for a pacing system to be implanted. However, it should not be used in patients with a myocardial infarction as it can worsen ongoing myocardial ischaemia. E Implantation of a permanent pacemaker While pacing is required temporarily, conduction deficits due to inferior myocardial infarctions often resolve. As such, implantation of a permanent system is unnecessary at this time. Rate this question: } Previous Question Tag Question Feedback End Session Difficulty: Easy Peer Responses % Session Progress Responses Correct: 1 Responses Incorrect: Oo Responses Total: 1 Responses - % Correct: 100% Blog About Pastest Contact Us Help © Pastest 2017 PAIS I- oe Back to Filters Question 2 of 337 A 32-year-old physiotherapist presents with a 2-week history of increasing shortness of breath and leg swelling. Previously well, she gave birth 8 weeks ago by planned Caesarean section and is breast-feeding. Over the last 4 weeks she became progressively breathless, and developed a dry cough and swollen ankles. She smoked in her teenage years. On examination, she is afebrile with a pulse of 108 bpm and irregular. Her blood pressure is 85/53 mmHg and her respirations at rest are 16 breaths/min, which increased to 24 on light exercise. Jugular venous pressure is elevated at 5 cm and she has pitting oedema of both lower limbs to mid-shin. A pan- systolic murmur, loudest at the apex, and a third heart sound can be heard. Percussion note is dull at the right base and is associated with decreased air entry. Coarse crackles are present at the left base. Her liver is mildly tender and enlarged 3 cm below the right costal margin. Chest X-ray shows a pleural effusion at the right base, a blunted left costophrenic angle, alveolar shadowing at both bases and large pulmonary vessels. Atrial fibrillation with an occasional ectopic beat is evident on ECG. Investigations: Hb 112 g/| WCC 12.5 x 109/| PLT 246 x 109/| Na* 132 mmol/| K* 3.8 mmol/| Creatinine 84 mol/l Urea 45 mmol/| Bilirubin 20 umol/! Albumin 36 g/! ALT 106 U/| ALP 121 U/I CRP 34 mg/| TSH 1.23 mU/I Free Ty 18.2 nmol/| MCV 84.3 fl What is the most likely diagnosis? A Atypical pneumonia B Pulmonary embolus e Peripartum cardiomyopathy D Subacute bacterial endocarditis E Primary pulmonary hypertension Previous Question Skip Question Calculator Normal Values Blog About Pastest Contact Us Help © Pastest 2017 Back to Filters Question 2 of 337 A 32-year-old physiotherapist presents with a 2-week history of increasing shortness of breath and leg swelling. Previously well, she gave birth 8 weeks ago by planned Caesarean section and is breast-feeding. Over the last 4 weeks she became progressively breathless, and developed a dry cough and swollen ankles. She smoked in her teenage years. On examination, she is afebrile with a pulse of 108 bpm and irregular. Her blood pressure is 85/53 mmHg and her respirations at rest are 16 breaths/min, which increased to 24 on light exercise. Jugular venous pressure is elevated at 5 cm and she has pitting oedema of both lower limbs to mid-shin. A pan- systolic murmur, loudest at the apex, and a third heart sound can be heard. Percussion note is dull at the right base and is associated with decreased air entry. Coarse crackles are present at the left base. Her liver is mildly tender and enlarged 3 cm below the right costal margin. Chest X-ray shows a pleural effusion at the right base, a blunted left costophrenic angle, alveolar shadowing at both bases and large pulmonary vessels. Atrial fibrillation with an occasional ectopic beat is evident on ECG. Investigations: Hb 112 g/| WCC 125 x 10°/| PLT 246 x 109/| Nat* 132 mmol/| K* 3.8 mmol/| Creatinine 84 mol/l Urea 4.5 mmol/| Bilirubin 20 ymol/| Albumin 36 g/l ALT 106 U/| B ALP 121 U/| CRP 34 mg/| TSH 1.23 mU/! Free Ty 18.2 nmol/| MCV 84.3 fl What is the most likely diagnosis? Your answer was correct A Atypical pneumonia B Pulmonary embolus D Subacute bacterial endocarditis E Primary pulmonary hypertension Explanation a Peripartum cardiomyopathy Peripartum cardiomyopathy is an idiopathic condition occurring in the last month of pregnancy or in the first five months postpartum. It presents with heart failure secondary to left ventricular systolic dysfunction. The clinical vignette describes a patient with significant heart failure, and this is the most likely underlying diagnosis. Heart failure should be managed with B -blockade and diuretics, and ACE inhibitors can be considered postpartum. In many cases cardiac function recovers, but if it remains poor then heart transplant should be considered. A Atypical pneumonia The chest findings reported here could be confused with an atypical pneumonia, but the bilateral nature and the systemic features in keeping with heart failure make this less likely. B Pulmonary embolus The risk of pulmonary embolism increases in pregnancy and should be considered in peripartum individuals with dyspnoea. A large pulmonary embolism would lead to features of right-sided heart failure, including a raised JVP and peripheral oedema. However, typically with a pulmonary embolism there would be limited chest findings. D Subacute bacterial endocarditis This diagnosis should be considered in all patients with a new pan- systolic murmur. However, there are no additional features to suggest this diagnosis. The pan-systolic murmur present here is likely caused by mitral regurgitation secondary to left ventricular dilatation rather than endocarditis. However, in both cases an echocardiogram would be the next investigative option. E Primary pulmonary hypertension This condition normally presents over a longer time-frame than indicated in this case. Furthermore, the primary features are of dyspnoea with right-sided heart failure signs and symptoms developing. Examination of the chest is usually normal, as left ventricular function is often preserved. Rate this question: } Previous Question Tag Question Feedback End Session Difficulty: Easy Peer Responses % Session Progress Responses Correct: 2 Responses Incorrect: Oo Responses Total: Z Responses - % Correct: 100% Blog About Pastest Contact Us Help © Pastest 2017 PAIS I- oe Back to Filters Question 3 of 337 A 60-year-old man on long-term haemodialysis presents with chest pain and a troponin of 1.2 (

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