April 2020 CR3

Question 1

A 77-year-old man presents to the Emergency Department complaining of chest pain that started one hour ago. Electrocardiogram shows ST elevation in leads V2, V3 and V4. He undergoes percutaneous coronary intervention.
Coronary angiography is likely to show a blockage in which blood vessel?
(Great cardiac vein/Left circumflex artery/left coronary artery/left anterior descending artery/right coronary artery)

Answer 1

Left anterior descending artery

Question 2

An 85 y/o woman visits her GP as she has been short of breath recently. On examination the GP notices a third heart sound. What does a third heart sound represent?
(The closing of the aortic valve/the oscillation of blood in a dilated ventricle/the opening of the pulmonary valve/the ventricles filling rapidly in diastole/the atria contracting against a stiff ventricle)

Answer 2

The ventricles filling rapidly in diastole

Question 3

An 80 y/o man presents to his GP complaining of some chest pain and shortness of breath over the past 3 months. O/E the GP notices an ejection systolic murmur. Which of the following is most likely to be causing this murmur?
(mitral regurgitation/tricuspid stenosis/HOCM/aortic stenosis/aortic regurgitation)

Answer 3

Aortic stenosis

Question 4

A 37 y/o lady presents to ED with palpitations. She appears very anxious. O/E she is thin, her heart rate is 100 bpm and the rhythm is irregularly irregular. She has a smooth, midline mass in the anterior triangle of the neck and in addition, she has a lid lag. What is the most likely underlying cause of her palpitations?
(Rheumatic fever/anxiety/ischaemic heart disease/congenital heart disease/thyrotoxicosis)

Answer 4

Thyrotoxicosis

Question 5

A 42 y/o woman has he blood pressure checked by her GP. It is measured as 140/85 mmHg. What is the next most appropriate step?
(refer for specialist investigations/do nothing/recheck BP in clinic and take the best of 3 readings/ambulatory blood pressure monitoring/start on amlodipine)

Answer 5

Ambulatory blood pressure monitoring

Question 6

A 70 y/o man with a hx of angina presents to ED with a 2 hr hx of chest pain. There are no dynamic changes seen on ECG. Which of the following investigations is most useful in assessing for myocardial damage in this patient?
(creatinine kinase (CK-MB)/lactate dehydrogenase (LDH)/aspartate transaminase (AST)/troponin T/myoglobin)

Answer 6

Troponin T

Question 7

A 20 y/o medical student is being examined by one of his colleagues who notes a systolic murmur. A cardiologist confirms the existence of a pansystolic murmur, hear loudest at the lower left sternal edge. The student has no symptoms and has no known medical conditions. Which one of the following tests would be most useful in making a diagnosis?
(cardiac MRI/CXR/ECG/echocardiogram/thyroid function test)

Answer 7

echocardiogram

Question 8

A 91 y/o woman on the care of the elderly ward is currently being treated for a UTI. Her blood test results come back as follows:
Na=135[135-145]/K=2.3[3.5-5.0]/Urea=6.9[2.5-6.7]/creatinine=108[60-110]
Her ECG is likely to show which of the following abnormalities?
(J waves/T wave flattening and U waves/prolongation of the QT interval/broad QRS complexes and inverted T waves/tall tented T waves)

Answer 8

T wave flattening and U waves

Question 9

An 87 y/o lady is brought into ED by her carers who are concerned that she has become increasingly confused. Her PMHx includes AF, HTN, and CKD. She is admitted under the medical team with an AKI, her ECG shows T wave inversion and sloping ST segment depression in the lateral chest leads. Which investigation would be most useful in investigating the cause of her ECG changes?
(troponin T/thyroid function tests/digoxin level/urea and electrolytes/bone profile incl Ca and Mg)

Answer 9

Digoxin level

Question 10

A 62 y/o man presents to his GP with a history of dizzy spells for the past 2 months. On examination, the GP hears an ejection systolic murmur. What is the most likely underlying cause of the valvular defect presenting here?
(rheumatic fever/Paget’s disease/Bicuspid aortic valve/William’s syndrome/Fabry’s disease)

Answer 10

Bicuspid aortic valve

Question 11

A 77/yo woman visits her GP with a 3 month hx of SoB. She does not have a cough and denies any wheeze or sputum production. On further questioning she admits to some ankle swelling and states that she is unable to lie flat at night. She has a hx of HTN, ischaemic heart disease and rheumatoid arthritis for which she is on a number of medications. Which of the following medications is likely to be contributing to her current presentation?
(atenolol/naproxen/omeprazole/simvastatin/ramipril)

Answer 11

naproxen

Question 12

A 57-year-old man is seen by his general practitioner for review. His blood pressure is measured as 200/120 mmHg. He denies any symptoms. He has been on bendroflumethiazide 2.5 mg daily. Fundoscopy is unremarkable. Urine dip shows a trace of leucocytes only. The GP calls the medical on call team for advice.

What would be the most appropriate initial treatment for this patient?
(start oral amlodipine/admit and start phentolamine/admit for IV labetalol/admit and observe BP/Start oral ramipril)

Answer 12

Start oral amlodipine

Question 13

A 78-year-old man is admitted to the cardiology ward with congestive cardiac failure. Two days later he is found to have new onset atrial fibrillation. His observations are stable and he has no chest pain. He has been scheduled for cardioversion.

Which one of the following should be used to cardiovert him?
(unsynchronised DC cardioversion/synchronised DC cardioversion/adenosine/amiodarone/flecainide)

Answer 13

Amiodarone

Question 14

A 77-year-old woman is being discharged from the cardiology ward. She has been diagnosed with heart failure and started on a number of medications to improve her prognosis.

Which one of the following medications is useful for symptomatic relief only?
(ramipril/bisoprolol/sprironolactone/ivabridine/furosemide)

Answer 14

Furosemide

Question 15

A 90-year-old woman with a history of palpitations is treated for atrial fibrillation.

Which one of the following is a class two anti-arrhythmic drug?
(verapamil/flecanide/diltiazem/atenolol/amiodarone)

Answer 15

Atenolol

Question 16

A 38-year-old woman presents to her general practitioner as she has had a dry cough and worsening shortness of breath which has persisted over the past year. She has a past medical history of hepatitis. She is a lifelong non-smoker. On auscultation of the chest a widespread expiratory wheeze is audible. Her spirometry shows an obstructive picture and there is no significant reversibility following bronchodilator therapy.

What is the likely underlying cause of her presentation?
(CF/bronchiolitis obliterans/haemochromatosis/chronic untreated asthma/alpha1-antitrypsin deficiency)

Answer 16

alpha1-antitrypsin deficiency

Question 17

An 82-year-old woman is an inpatient on the care of the elderly ward having been admitted with a urinary tract infection two weeks previously. She spikes a temperature and is diagnosed with hospital acquired pneumonia.

Which one of the pathogens is the most likely cause of her illness?
(Mycoplasma pneumoniae/streptococcus pneumoniae/Legionella pneumophilia/haemophilus influenzae/staphylococcus aureus)

Answer 17

Staphylococcus aureus

Question 18

A 77-year-old man is found to have clubbing of his fingers.

Which of the following conditions is known to cause clubbing?
(asthma/asbestosis/extrinsic allergic alveolitis/COPD/emphysema)

Answer 18

asbestosis

Question 19

A 19-year-old woman with a history of asthma presents to the Emergency Department with worsening wheeze and shortness of breath of 3 hours duration.

Which of the following indicates life-threatening asthma?
(use of accessory muscles/cyanosis/heart rate 110 bpm/peak expiratory flow rate 45% predicted/respiratory rate 25 bpm)

Answer 19

Cyanosis

Question 20

A 70-year-old woman visits her general practitioner complaining of a 3 month history of productive cough and increasing shortness of breath. She says that she is a non-smoker but on further questioning admits that she smoked about 20 cigarettes a day in her twenties. She cut down to about 10 cigarettes a day when she had her children, in her thirties. She quit smoking a couple of months ago when this cough started.

Which one of the following is the estimated pack year history?
(40/35/20/30/25)

Answer 20

30

Question 21

A 25-year-old woman is brought into the Emergency Department by ambulance with sudden onset shortness of breath. Additionally, she complains of an acutely painful, swollen left leg. She has no past medical history of note. Her only medication is the oral contraceptive pill. She smokes 15 cigarettes per day and drinks approximately 10 units of alcohol per week. Observations are as follows: temperature 37.3°C, respiratory rate 22 bpm, oxygen saturation 95% on 4L oxygen, heart rate 110 bpm, blood pressure 122/77mmHg.

What is the first line investigation to confirm the diagnosis?
(ABG analysis/ventilation perfusion scan/doppler ultrasound/D-dimer/CT pulmonary angiography)

Answer 21

CT pulmonary angiography

Question 22

A 60-year-old woman with chronic shortness of breath has spirometry with the following results: FEV1/FVC ratio of 85%.

Which of the following pathologies is most likely to account for this?
(Bronchitis/COPD/bronchiectasis/pulmonary fibrosis/chronic bronchial asthma)

Answer 22

pulmonary fibrosis

Question 23

A 77-year-old woman with known chronic obstructive pulmonary disease presents to the Emergency Department with a cough and increased shortness of breath. Arterial blood gas shows the following:
pH=7.29[7.35-7.45]/ PaO2=7.9[>10.6]/ PaCO2=6.9[4.7- 6.0]/ HCO3-=31[24-30]
Which of the following statements best describes these results?
(metabolic acidosis with partial respiratory compensation/respiratory acidosis with partial metabolic compensation/metabolic alkalosis with respiratory compensation/metabolic acidosis/compensated respiratory acidosis)

Answer 23

Respiratory acidosis with partial metabolic compensation

Question 24

A 70-year-old man presents to the Emergency Department with worsening shortness of breath of 5 days duration. Chest X-ray shows a pleural effusion which is subsequently aspirated. Pleural fluid analysis shows a pleural fluid protein level of 40 g/L. His serum protein is 50 g/L.

Which one of the following is most likely to be causing this man’s symptoms?
(heart failure/liver cirrhosis/nephrotic syndrome/pneumonia/hypoalbuminaemia)

Answer 24

pneumonia

Question 25

A 78-year-old man attends a chest clinic because of his chronic cough and haemoptysis. He is told that his CXR is suggestive of lung cancer. He wants to know his prognosis.

Which of the following is the most aggressive pathological subtype of lung cancer?
(Small cell lung cancer/alveolar cell carcinoma/adenocarcinoma/squamous cell carcinoma/large cell lung carcinoma)

Answer 25

small cell lung cancer

Question 26

A 66-year-old woman presents to her general practitioner with a rash on her lower legs. On examination, she has a number of tender, raised, erythematous lesions on both shins. Whilst she is being examined, she mentions that she has also had a cough and loss of weight for the past 6 months.

What is the most likely cause of her presentation?
(TB/small cell lung cancer/bronchiectasis/pulmonary fibrosis/non-small-cell lung cancer

Answer 26

TB

Question 27

A 65-year-old man with known chronic obstructive pulmonary disease visits his general practitioner (GP). He is currently taking inhaled salmeterol regularly. For the past 3 months he has been persistently breathless in mild exertion.

What is the next most appropriate management step?
(add inhaled terbutaline/add inhaled long acting muscarinic antagonist/add inhaled corticosteroid and long acting muscarinic antagonist/add oral montelukast/add inhaled short acting muscarinic antagonist)

Answer 27

add inhaled corticosteroid and long acting muscarinic antagonist

Question 28

A 55-year-old woman presents to the Emergency Department with a 48 hour history of a productive cough and a fever. She does not have any co-morbidities. On examination she appears sweaty and flushed but is alert. She has a temperature of 38.5°C, respiratory rate of 22 bpm, oxygen saturations of 96% on room air, heart rate of 98 bpm and blood pressure of 122/70 mmHg. Chest X-ray shows consolidation in the right lower zone and blood test results are as follows:
Hb=125[125-180]/WCC=14.4[4.0-11.0]/platelets=258[150-400]/Na=137[135-145]/K=4.5[3.5-5.0]/Urea=6.3[2.5-6.7]/Creatinine=100[60-110]/C-reactive protein=65[<10]
What is the most appropriate management for this patient?
(Withold antibiotics until blood culture results are availabe/commence on oral antibiotics and discharge home/commence on intravenous antibiotics and admit to intensive care/commence on oral antibiotics and admit to hospital/commence on intravenous antibiotics and admit to hospital]

Answer 28

Commence on oral antibiotics and discharge home

Question 29

A 77-year-old woman with lung cancer is being discharged home under the care of the community palliative care team. Her daughter and son-in-law have converted their living room and will be caring for her. They ask about the possibility of home oxygen.

Which of the following statements is correct?
(Oxygen may be given if it is thought to bring symptomatic relief/arterial pO2 must be <7kPa on 2 occasions to qualify for this treatment/oxygen may be given as long as it is used for at least 15 hours per day/oxygen is contraindicated when given with morphine due to the risk of respiratory depression)

Answer 29

Oxygen may be given if it is thought to bring symptomatic relief

Question 30

A 42-year-old man is commencing quadruple antibiotic therapy for tuberculosis.

Which of the following will require monitoring whilst he is taking rifampicin?
(liver function tests/urea and electrolytes/full blood count/visual acuity/rifampicin levels)

Answer 30

Liver function tests

Question 31

A 20-year-old man has a tooth extracted. The dentist notices that he bleeds profusely. Further tests show that he has haemophilia A.

Which clotting factor is he deficient in?
(factor IX/Factor VII/Von Willebrand’s factor/factor X/Factor VII)

Answer 31

Factor VIII

Question 32

A 55-year-old man presents to the Emergency Department with central crushing chest pain. He has no co-morbidities and is not currently taking any medication. On systems enquiry, he mentions that he has very itchy skin and that he occasionally gets painful, discoloured fingers and toes. Blood tests are as follows:
Hb=18[12.5-16.5]/WCC=10.9[4.0-11]/Platelets=390[150-400]/Troponin T=0.32[<0.105]
He is commenced on treatment for acute coronary syndrome and referred to haematology with a likely diagnosis of which of the following?
(myelodysplasia/polycythaemia rubra vera/CML/myelofibrosis/essential thrombocythaemia)

Answer 32

polycythaemia rubra vera

Question 33

A 30-year-old woman visits her general practitioner (GP) because she is tired all the time. She has menorrhagia but denies any other symptoms. On examination, the GP notices that her finger nails look abnormal.

What nail change is indicative of iron deficiency anaemia?
(leuconychia/pitting/onycholysis/koilonychia/clubbing)

Answer 33

Koilonychia