Cardio

Question 1

Name the 3 ‘cardinal signs’ of heart failure

Answer 1

Ankle swelling
Dyspnoea
Fatigue

Question 2

Signs of infective endocarditis

Answer 2

Roth spots
Osler nodes
Janeway lesions
Splinter haemorrhages
Petechiae
Splenomegaly
Features of heart failure (raised JVP, bilateral crackles)
Note: Fever and a new murmur are also two common signs of infective
endocarditis but they were already stated in the context of the question.

Question 3

Pericardial rubg: ECG

Answer 3

Saddle-shaped ST elevation
PR depression

Question 4

The patient presents with fever and neutropenic sepsis – what treatment would you give (inc. class, drug and route of administration)?

Answer 4

IV (1) beta lactam (1) piperacillin + tazobactam (1) is the Tx for febrile neutropenia.

Question 5

Fe2+ iron deficiency anaemia tests

Answer 5

Ferritin
Iron Studies

Question 6

PAD

Answer 6

Pain in Buttocks = lower aorta or iliac
Pain in Thigh = iliac or common femoral
Pain in Upper 2/3 of calf = Superficial femoral
Pain in Lower 1/3 = popliteal
Pain in Foot = tibial or peroneal artery

Question 7

When can you best hear mitral regurgitation

Answer 7

left lateral position

Question 8

What should patients on atrial fibrillations be started on?

Answer 8

antihypertensives, a beta blocker
and a statin

Question 9

Barlow syndrome

Answer 9

mid systolic click followed by a late systolic
murmur is heard at the apex.

Question 10

A 57-year-old male is admitted complaining of headaches and blurring of vision.
His blood pressure is found to be 240/150 mmHg and he has bilateral papilloedema,
but is fully orientated and coherent. He had been known to be hypertensive for
about five years and his blood pressure control had been good on three drugs.
However, he had decided to stop all medication two months before this event.
Which of the following would be your preferred parenteral medication at this
point?

Answer 10

Sodium Nitroprusside

Question 11

Complication of ventral septal defect

Answer 11

Endocarditis

Question 12

A 49-year-old woman presents with increasing shortness of breath on exertion
developing over the past three months. She has no chest pain or cough, and has
noticed no ankle swelling. On examination, blood pressure is 158/61 mmHg, pulse
is regular at 88 beats per minute and there are crackles at both lung bases. There is
a decrescendo diastolic murmur at the left sternal edge. What is the most likely
diagnosis?

Answer 12

Aortic regurgitation

Question 13

Hypertrophic Cardiomyopathy Treatment

Answer 13

1st Beta blocker
2nd Followed by CCB

Question 14

A 71-year-old man is being treated for congestive heart failure with a combination
of drugs. He complains of nausea and anorexia, and has been puzzled by observing
yellow rings around lights. His pulse rate is 53/minute and irregular and blood
pressure is 128/61 mmHg. Which of the following medications is likely to be
responsible for these symptoms?

Answer 14

These symptoms are characteristic of digoxin (cardiac glycosides). The
yellow-tinged vision (xanthopsia) is particular to these drugs. The slow
pulse, with probable ectopics, together with the subjective symptoms,
suggests toxicity and plasma digoxin should be measured, with lowering
of the dosage or withdrawal of the drug, which is not considered first-line
therapy in any case in the management of congestive heart failure.

Question 15

most common cause of
apparent resistance to hypertensive therapy

Answer 15

Poor adherence to therapy

Question 16

CAP pneumonia

Answer 16

H. influenzae and S. pneumoniae
are organisms which are usually responsible for community-acquired
pneumonia.

Question 17

HAP pneumonia

Answer 17

S. aureus and Pseudomonas spp

Question 18

Atypical pneumonia

Answer 18

L. pneumophilia along
with Chlamydia spp. and Mycoplasma pneumoniae

A urinary antigen test is routinely used for
the detection of Legionella spp. Serological tests can be used for the
detection of Mycoplasma and Chlamydia spp. and also Legionella spp

Question 19

ECG findings on pulmonary embolism

Answer 19

Deep S-wave in lead I, pathological Q-wave in lead III and inverted
T-waves in lead III

Question 20

What is bronchiectasis

Answer 20

Bronchiectasis is defined as chronic infection of the bronchi and bronchioles
leading to permanent dilatation of these airways.

The main organisms
involved in this condition are H. influenzae, S. pneumoniae, S. aureus and
P. aeruginosa.

Question 21

Causes of bronchiectasis

Answer 21

Congenital: cystic fibrosis, Young’s
syndrome, primary ciliary dyskinesia, Kartagner’s syndrome; and (2)
Acquired: Post-infection with measles, pertussis, bronchiolitis, pneumonia,
TB and HIV

Question 22

Most common lung cancer in non-smokers

Answer 22

Adenocarcinoma

Question 23

What word is used to describe pleural effusion

Answer 23

‘Stony dullness’

Question 24

pulmonary embolism first line treatment

Answer 24

Treatment dose subcutaneous low molecular weight heparin
+ loading with warfarin and aim for INR between 2 and 3

Question 25

pleural aspirate analysis, would typically be found in a patient with an empyema?

Answer 25

pH <7.2, ↑ LDH, ↓ glucose

Question 26

Cystic fibrosis Gold Standard

Answer 26

Sweat test Sodium chloride >60 mmol/L

Question 27

Which of the following organisms, responsible for causing chronic pneumonia, is most commonly found in patients with longstanding cystic fibrosis?

Answer 27

Pseudomonas aeruginosa

Question 28

Long-term used medication causing pulmonary fibrosis

Answer 28

Amiodarone along with bleomycin, bulsulfan, nitrofurantoin, methotrexate and sulfasalazine are drugs that can cause pulmonary fibrosis with long-term use

Question 29

Bibasal pneumonia

Answer 29

L. pneumophilia

Question 30

Which of the drugs below would be the most appropriate to treat pulmonary Aspergillus spp. infection?

Answer 30

Amphotericin B

Question 31

aspiration pneumonia antibiotic regimen

Answer 31

Intravenous cefuroxime and metronidazole

Question 32

Infective endocarditis:

Answer 32

Typically affects mitral valve (LS) However in IVDU affects tricuspid valve

Question 33

Head trauma

Answer 33

Subarachnoid: Surgery + Nimodipine Subdural: Burr Hole + Craniotomy/IV mannitol Extradural: IV mannitol

Question 34

DEMENTIA

Answer 34

Question 35

Cranial nerve lesions

Answer 35

Question 36

Hypertension NICE

Answer 36

A – ACE inhibitor (e.g., ramipril) B – Beta blocker (e.g., bisoprolol) C – Calcium channel blocker (e.g., amlodipine) D – Thiazide-like diuretic (e.g., indapamide) ARB – Angiotensin II receptor blocker (e.g., candesartan) Step 1: Aged under 55 or type 2 diabetic of any age or family origin, use A. Aged over 55 or Black African use C. Step 2: A + C. Alternatively, A + D or C + D. Step 3: A + C + D Step 4: A + C + D + fourth agent (see below)

Question 37

Duke's Criteria Infective Endocarditis

Answer 37

Question 38

CHADSVASC

Answer 38

Question 39

Heart Block

Answer 39

Question 40

four stages of chronic limb ischaemia

Answer 40

Stage I: asymptomatic Stage II: intermittent claudication Stage III: rest pain/nocturnal pain Stage IV: necrosis/gangrene

Question 41

What is a consequence of regular blood transfusions and how do you treat this complication?

Answer 41

Iron overload Iron chelation – deferoxamine/deferasirox

Question 42

Medication used to stimulate Hbf production

Answer 42

Hydroxycarbamide

Question 43

First Line chemotherapy used for multiple myeloma

Answer 43

Bortezomid Thalidomide Dexamethasone

Question 44

Angina medication

Answer 44

1st GTN spray 2nd CCB/ Beta blocker (atenolol/veramapril)

Question 45

Signs for PAD

Answer 45

Hair loss , atrophic skin , brittle / slow-growing nails , ulcers, numbness in feet, absent distal pulses, intermittent claudication.

Question 46

Ulcers Diff

Answer 46

Question 47

Where can you best hear aortic stenosis

Answer 47

2nd intercostal space (1), left sternal border (1).

Question 48

A 9 year old boy presents to the hospital after an acute onset of anaemia, jaundice, diarrhoea, and dark urine. After taking a history from his parents, it is revealed he has just been to a restaurant and eaten a dish with Fava beans. What is the inheritance pattern of the most likely underlying condition?

Answer 48

G6PD deficiency X-Linked recessive

Question 49

Pathophysiology of aortic stenosis

Answer 49

Narrowing of aortic valve 🡪 decreased stroke volume 🡪 increased afterload 🡪 increased left ventricular pressure 🡪 compensatory LVH 🡪 increased oxygen demand 🡪 ischaemia

Question 50

Pathophysiology of mitral regurgitation

Answer 50

Regurgitation into the left atrium 🡪 left atrial dilatation 🡪 left atrial enlargement 🡪 LVH (since ventricle needs to put in more effort to pump less blood) 🡪 pulmonary hypertension 🡪 right ventricular dysfunction

Question 51

Pathophysiology of mitral stensosis

Answer 51

Thickening and immobility of valve 🡪 obstruction of blood flow from right atrium to right ventricle 🡪 left atrial pressure increases 🡪 LAH 🡪 pulmonary venous, arterial and right heart pressures increase 🡪 pulmonary oedema 🡪 pulmonary HTN 🡪 RVH 🡪 tricuspid regurgitation

Question 52

Pathophysiology of aortic regurgitation

Answer 52

To maintain cardiac output more blood needs to be pumped out of the left ventricle to compensate for the backflow 🡪 LVH 🡪 heart failure Decreased coronary artery supply

Question 53

Most common viral cause of pericardial effusion

Answer 53

Viral is the most common infectious cause → coxsackie 19 virus often

Question 54

What drugs are contraindicated in pregnanct women

Answer 54

ACEi and ARB should always be discontinued in pregnancy as they cause fetotoxicity

Question 55

Thyroiditis

Answer 55

-

Question 56

Management of Addisons crisis

Answer 56

Intensive monitoring if they are acutely unwell Parenteral steroids (i.e. IV hydrocortisone) IV fluid resuscitation Correct hypoglycaemia Careful monitoring of electrolytes and fluid balance

Question 57

Top three cause sof SIADH

Answer 57

Post-operative SSRIs Small cell lung cancer

Question 58

Achalasia

Answer 58

Barium swallow: ‘bird’s beak’ sign Manometry = GOLD First line is upper GI endoscopy

Question 59

What hypersensitivity reaction is coeliac

Answer 59

Type 4

Question 60

Mnemonic for Absorption of Stuff in tummy

Answer 60

Dude Is Just Feeling Ill Bro = Duodenum (Iron), Jejunum (Folate), Ileum (B12)

Question 61

Pathophysiology for diverticular disease

Answer 61

The wall of the large intestine contains a layer of muscle called the circular muscle. The points where this muscle layer is penetrated by blood vessels are areas of weakness. Increased pressure inside the lumen over time, can cause a gap to form in these areas of the circular muscle. These gaps allow the mucosa to herniate through the muscle layer and pouches to form (diverticula). Diverticula do not form in the rectum, because it has an outer longitudinal muscle layer that completely surrounds the diameter of the rectum, adding extra support. In the rest of the colon, there are three longitudinal muscles that run along the colon, forming strips or ribbons called teniae coli. The teniae coli do not surround the entire diameter of the colon, and the areas that are not covered by teniae coli are vulnerable to the development of diverticula.

Question 62

Pathophysiology of appendicits

Answer 62

The appendix is a small, thin tube arising from the caecum. It is located at the point where the three teniae coli meet (the teniae coli are longitudinal muscles that run the length of the large intestine). There is a single opening to the appendix that connects it to the bowel, and it leads to a dead end. Pathogens can get trapped due to obstruction at the point where the appendix meets the bowel. Trapping of pathogens leads to infection and inflammation. The inflammation may proceed to gangrene and rupture. When the appendix ruptures, faecal contents and infective material are released into the peritoneal cavity. This leads to peritonitis, which is inflammation of the peritoneal lining.

Question 63

Causes of AKI

Answer 63

Question 64

Atherosclerosis formation

Answer 64

*Endothelial dysfunction*- NO is reduced in endothelial dysfunction 1. High LDL deposits in tunica intima. LDL becomes oxidised, activating endothelial cells 2. Adhesion of blood leukocytes to activated endothelium move to tunica intima 3. Macrophages take in oxidised LDLs, becoming foam cells 4. Foam cells promote the migration of smooth muscle cells from tunica media to the intima and smooth muscle cell proliferation 5. Increased smooth muscle cell proliferation and heightened synthesis of collagen 6. Foam cells die, causing lipid content released 7. Thrombosis plaque ruptures lead to blood coagulation and thrombus impeding blood flow.

Question 65

Useful drugs in treating CAD

Answer 65

Aspirin – irreversible inhibitor of platelet cyclo-oxygenase Clopidogrel/ ticagrelor – inhibits of the P2Y12 ADP receptor on platelets Statins – inhibit HMG CoA reductase, reducing cholesterol synthesis

Question 66

Second line treatment options for angina

Answer 66

Ivabradine, ranolazine and nicorandil 1st: Amlodopine

Question 67

Pericarditis CARDIAC RIND

Answer 67

Collagen Vascular Disease * Aortic aneurysm * Radiation * Drugs * Infections * Acute Renal Failure * Cardiac infarction * Rheumatic Fever * Injury * Neoplasms * Dressler’s syndrome

Question 68

Pericarditis 1st line treatment

Answer 68

NSAID/aspirin

Question 69

Acute pericardits triad of symptoms

Answer 69

chest pain, friction rub and ECG changes

Question 70

Signs of Cardiac tamponade other than becks triad

Answer 70

Absent Y wave in the JVP

Question 71

Stanford system for aortic dissection

Answer 71

Type A – affects the ascending aorta, before the brachiocephalic artery Type B – affects the descending aorta, after the left subclavian artery

Question 72

X ray findings for aortic dissection

Answer 72

D:Dilated aortic arch W: Widened mediastinum E: Effusion (pleural) E: Effusion (pericardial) B: Blurring of aortic contour S: Separation of intimal calcification

Question 73

G.S for infective endocarditis

Answer 73

Transoesophageal echocardiography (TOE) is more sensitive and specific than transthoracic echocardiography. Vegetations (an abnormal mass or collection) may be seen on the valves. Special imaging investigations may be used in patients with prosthetic heart valves, where it can be more challenging to determine whether an infection is present in the prosthesis: 18F-FDG PET/CT SPECT-CT

Question 74

Modified Duks's Croteria

Answer 74

Modified Duke Criteria The Modified Duke criteria can be used to diagnose infective endocarditis. A diagnosis requires either: One major plus three minor criteria Five minor criteria Major criteria are: Persistently positive blood cultures (typical bacteria on multiple cultures) Specific imaging findings (e.g., a vegetation seen on the echocardiogram) Minor criteria are: Predisposition (e.g., IV drug use or heart valve pathology) Fever above 38°C Vascular phenomena (e.g., splenic infarction, intracranial haemorrhage and Janeway lesions) Immunological phenomena (e.g., Osler’s nodes, Roth spots and glomerulonephritis) Microbiological phenomena (e.g., positive cultures not qualifying as a major criterion)

Question 75

Management for infective endocarditis

Answer 75

Intravenous broad-spectrum antibiotics (e.g., amoxicillin and optional gentamicin)

Question 76

Budd-Chiari Syndrome

Answer 76

Question 77

Respiratory finding in pumonary embolism

Answer 77

Patients with a pulmonary embolism often have a respiratory alkalosis when an ABG is performed. This is because the high respiratory rate causes them to “blow off” extra CO2. As a result of the low CO2, the blood becomes alkalotic. It is one of the few causes of a respiratory alkalosis, the other main cause being hyperventilation syndrome. Patients with a PE will have a low pO2 whereas patients with hyperventilation syndrome will have a high pO2.

Question 78

Major risk factor for tetralogy of fallot

Answer 78

RUBELLA

Question 79

Tet spells options

Answer 79

Seen in tetralogy of fallot Beta blockers O2

Question 80

Murmur seen in ventricular septal defect

Answer 80

When you hear a pan-systolic murmur it is worth giving your top differential but also mention the other causes of this type of murmur. The causes of a pan-systolic murmur are ventricular septal defect, mitral regurgitation and tricuspid regurgitation. -Left lower sternal border in the 3rd and 4th intercostal space

Question 81

What is Eisenmenger syndrome

Answer 81

pulmonary pressure is greater than the systemic pressure

Question 82

Atrial septal defects and stroke

Answer 82

It is worth remembering atrial septal defects as a cause of stroke in patients with a DVT. Normally when patients have a DVT and this becomes an embolus, the clot travels to the right side of the heart, enters the lungs and becomes a pulmonary embolism. In patients with an ASD the clot is able to travel from the right atrium to the left atrium across the ASD. This means the clot can travel to the left ventricle, aorta and up to the brain, causing a large stroke. An exam question may feature a patient with a DVT that develops a large stroke and the challenge is to identify that they have had a lifelong asymptomatic ASD.

Question 83

Murmur for patent ductus arteriosus

Answer 83

continuous crescendo-decrescendo “machinery” murmur that may continue during the second heart sound, making the second heart sound difficult to hear.

Question 84

Heart Block

Answer 84

First: Electrical Impulses are delayed. This results in a longer P wave but the P wave is followed by QRS complex Second degree 1: Wenckenback 2:

Question 85

Ventricular ectopics

Answer 85

Question 86

Mnemonics for tachycardias

Answer 86

Question 87

Acute management of supraventricular tachycardia

Answer 87

Step 1: Vagal manoeuvres Step 2: Adenosine Step 3: Verapamil or a beta blocker Step 4: Synchronised DC cardioversion

Question 88

ECG changes in Wolff-Parkinson-White syndrome are

Answer 88

Short PR interval, less than 0.12 seconds Wide QRS complex, greater than 0.12 seconds Delta wave

Question 89

Right-Sided Heart Failure Manifestations: “AW HEAD”

Answer 89

A: Anorexia and nausea W: Weight gain H: Hepatomegaly E: oEdema (Bipedal) A: Ascites D: Distended neck vein

Question 90

Left-Sided Heart Failure Manifestations: “DO CHAP”

Answer 90

D: Dyspnea O: Orthopnea C: Cough H: Haemoptysis A: Adventitious breath sounds P: Pulmonary congestion (crackles/rales)

Question 91

What does establishing a diagnosis for heart failure involve

Answer 91

Clinical assessment (history and examination) N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test ECG Echocardiogram

Question 92

Rheumatic fever

Answer 92

Rheumatic fever is caused by group A beta-haemolytic streptococcal, typically streptococcus pyogenes causing tonsillitis. This results in a type 2 hypersensitivity reaction, Throat swab for bacterial culture ASO antibody titres Echocardiogram, ECG and chest xray can assess the heart involvement A diagnosis of rheumatic fever is made using the Jones criteria Can cause mitral stenosis

Question 93

Tumour lysis syndrome

Answer 93

high potassium and high phosphate level in the presence of a low calcium

Question 94

Features of haemolytic anaemia

Answer 94

Anaemia Jaundice Splenomegaly

Question 95

autoimmune haemolytic anaemia G.S

Answer 95

Direct Coombs test

Question 96

What triggers G6PD deficiency

Answer 96

The key piece of knowledge for G6PD deficiency relates to triggers. In your exam look out for a patient that turns jaundice and becomes anaemic after eating broad beans, developing an infection or being treated with antimalarials. The underlying diagnosis might be G6PD deficiency.

Question 97

Haemolytic anaemia how are they carried on

Answer 97

Spherocytosis: autosomal dominant Elliptocytosis: autosomal dominant G6PD: X-linked recessive Warm: Idiopathic Cold: Cold allutination disease

Question 98

Lifecycle malaria

Answer 98

Malaria is spread by female Anopheles mosquitoes, most commonly at night time. Infected blood is sucked up by feeding mosquito. The malaria in the blood reproduces in the gut of the mosquito producing thousands of sporozoites (malaria spores). When that mosquito bites another human or animal the sporozoites are injected by the mosquito. These sporozoites travel to the liver of the newly infected person. They can lie dormant as hypnozoites for several years in P. vivax and P. ovale. They mature in the liver into merozoites which enter the blood and infect red blood cells. In red blood cells the merozoites reproduce over 48 hours, after which the red blood cells rupture releasing loads more merozoites into the blood and causing a haemolytic anaemia. This is why people infected with malaria have high fever spikes every 48 hours.

Question 99

What to look out for infectious mononucleosis

Answer 99

Look out for the exam question that describes an adolescent with a sore throat, who develops an itchy rash after taking amoxicillin. Mononucleosis causes an intensely itchy maculopapular rash in response to amoxicillin or cefalosporins.

Question 100

Heterophile antibody tests

Answer 100

Monospot test Paul-Bunnell test

Question 101

There are some key bits of information that you should learn to be able to spot which leukaemia is in the exam:

Answer 101

Acute lymphoblastic leukaemia: Most common leukaemia in children. Associated with Down syndrome. Chronic lymphocytic leukaemia: Most common leukaemia in adults overall. Associated with warm haemolytic anaemia, Richter’s transformation into lymphoma and smudge / smear cells. Chronic myeloid leukaemia: Has three phases including a 5 year “asymptomatic chronic phase”. Associated with the Philadelphia chromosome. Acute myeloid leukaemia: Most common acute adult leukaemia. It can be the result of a transformation from a myeloproliferative disorder. Associated with Auer rods.

Question 102

ITP is worth remembering as it is a key differential diagnosis of a

Answer 102

non-blanching rash

Question 103

What are petechiae

Answer 103

pin-prick spots (around 1mm) of bleeding under the skin. Purpura are larger (3 – 10mm) spots of bleeding under the skin. When a large area of blood is collected (more than 10 mm), this is called ecchymoses. These are all non-blanching lesions.