Cardiology - Royal Brompton Questions

Question 1

1. A 43 year-old gentleman gives a 2-week history of fevers and lethargy. He is clinically stable
   but examination reveals a pan-systolic murmur at the apex and he is suspected to have infective
   endocarditis. Which is the most important initial investigation in this patient?
   a) transthoracic echocardiogram
   b) full blood count
   c) 12-lead ECG
   d) blood cultures
   e) chest x-ray

Answer 1

d) blood cultures

Question 2

2. In the investigation of infective endocarditis, which of the following statements are correct?
   a) According to the Duke criteria, auscultation of a new murmur fulfils a minor criterion for the
   diagnosis of infective endocarditis
   b) The presence of haematuria is a common finding in endocarditis
   c) The presence of a vegetation can usually be detected with transthoracic echocardiography
   d) Elevated levels of CRP and/or erythrocyte sedimentation rate (ESR) fulfil 1 minor criterion of the
   Duke criteria for diagnosing infective endocarditis.
   e) A normal transoesophageal echocardiogram rules out the diagnosis of infective endocarditis

Answer 2

b) The presence of haematuria is a common finding in endocarditis

Question 3

3. In a stable patient with atrial fibrillation and a fast ventricular rate (heart rate 120 bpm at
   rest) , what is the first line pharmacological treatment for rate control?

Answer 3

d) Atenolol

Question 4

4. A 48-year old patient gives a 5 day history of dyspnoea. He is found to be in atrial fibrillation.
   Which is the most appropriate management plan?
   a) chemical cardioversion with iv amiodarone
   b) chemical cardioversion with iv flecainide
   c) anticoagulation with warfarin and rate control
   d) Transthoracic echocardiogram to exclude thrombus followed by DC cardioversion
   e) anticoagulation with warfarin then initiation of oral amiodarone (loading)

Answer 4

c) anticoagulation with warfarin and rate control

Question 5

5. An 86 year-old man is admitted home with acute confusion and breathlessness. In A&E he
   remains confused but is comfortable and his SpO2 is 98% on oxygen. On reviewing the ECG
   (below), what would be your initial management?
   a) iv tissue plasminogen activator (tPA) + aspirin
   b) tPA alone
   c) aspirin + low molecular weight heparin
   d) iv streptokinase
   e) iv bisoprolol

Answer 5

c) aspirin + low molecular weight heparin

Question 6

6. Which of the following clinical findings are highly suggestive of cardiac tamponade
   a) hypoxia
   b) pulmonary oedema
   c) pulsus paradoxus
   d) pulsus alternans
   e) Corrigan’s sign

Answer 6

c) pulsus paradoxus

Question 7

7. Resuscitation
   In an unresponsive patient without respiratory effort, which the following should be performed
   first
   a) CPR with 30 chest compressions for every 2 ventilations
   b) CPR with 15 chest compressions for every single ventilation
   c) attachment of a defibrillator/monitor
   d) attachment of a pulse oximetry probe
   e) call resuscitation team

Answer 7

e) call resuscitation team

Question 8

8. In a patient with left ventricular heart failure and in New York Heart Association (NYHA)
   functional class II, which of the following medications is of prognostic benefit
   a) carvedilol
   b) digoxin
   c) frusemide
   d) spironolactone
   e) isosorbide monitrate

Answer 8

a) carvedilol

Question 9

9) Which of the following investigations is the most important in evaluating a patient with
confirmed left ventricular failure and recurrent syncope?
a) echocardiogram
b) exercise stress test
c) stress echocardiogram
d) Holter monitor
e) serum brain natriuretic peptide (BNP)

Answer 9

a) echocardiogram

Question 10

Clinical examination

a) heaving apical impulse
b) hyperdynamic, displaced apical impulse
c) tapping apex
d) pan-systolic murmur
e) sustained left parasternal impulse
f) Absent “a” wave of the jugular venous pulse
g) Fixed splitting of second heart sound
h) Absent femoral pulses
i) Malar flush
j) Pulsus paradoxus
Which of the clinical signs listed above would you expect to find in a patient with:

1) Atrial fibrillation

Answer 10

f) Absent “a” wave of the jugular venous pulse

Question 11

a) heaving apical impulse
b) hyperdynamic, displaced apical impulse
c) tapping apex
d) pan-systolic murmur
e) sustained left parasternal impulse
f) Absent “a” wave of the jugular venous pulse
g) Fixed splitting of second heart sound
h) Absent femoral pulses
i) Malar flush
j) Pulsus paradoxus
Which of the clinical signs listed above would you expect to find in a patient with:

2) Severe aortic stenosis

Answer 11

g) Fixed splitting of second heart sound

Question 12

a) heaving apical impulse
b) hyperdynamic, displaced apical impulse
c) tapping apex
d) pan-systolic murmur
e) sustained left parasternal impulse
f) Absent “a” wave of the jugular venous pulse
g) Fixed splitting of second heart sound
h) Absent femoral pulses
i) Malar flush
j) Pulsus paradoxus
Which of the clinical signs listed above would you expect to find in a patient with:

3) Severe aortic regurgitation

Answer 12

b) hyperdynamic, displaced apical impulse

Question 13

a) heaving apical impulse
b) hyperdynamic, displaced apical impulse
c) tapping apex
d) pan-systolic murmur
e) sustained left parasternal impulse
f) Absent “a” wave of the jugular venous pulse
g) Fixed splitting of second heart sound
h) Absent femoral pulses
i) Malar flush
j) Pulsus paradoxus
Which of the clinical signs listed above would you expect to find in a patient with:

5) Pulmonary hypertension

Answer 13

a) heaving apical impulse