Cardiovascular

Question 1

1. Myocardial infarction
   A 65-year-old man presents with central crushing chest pain for the first time. He
   is transferred immediately to the closest cardiac unit to undergo a primary
   percutaneous coronary intervention. There is thrombosis of the left circumflex
   artery only. Angioplasty is carried out and a drug-eluding stent is inserted. What
   are the most likely changes to have occurred on ECG during admission?
   A. ST depression in leads V1–4
   B. ST elevation in leads V1–6
   C. ST depression in leads II, III and AVF
   D. ST elevation in leads V5–6
   E. ST elevation in leads II, III and AVF

Answer 1

D

Question 2

2. Heart failure (1)
   A 78-year-old woman is admitted with heart failure. The underlying cause is
   determined to be aortic stenosis. Which sign is most likely to be present?
   A. Pleural effusion on chest x-ray
   B. Raised jugular venous pressure (JVP)
   C. Bilateral pedal oedema
   D. Bibasal crepitations
   E. Atrial fibrillation

Answer 2

D

Question 3

3. Valve lesion signs
   A patient is admitted with pneumonia. A murmur is heard on examination. What
   finding points to mitral regurgitation?
   A. Murmur louder on inspiration
   B. Murmur louder with patient in left lateral position
   C. Murmur louder over the right 2nd intercostal space midclavicular line
   D. Corrigan’s sign
   E. Narrow pulse pressure

Answer 3

B

Question 4

4. CHAD2 score
   A 79-year-old woman is admitted to the coronary care unit (CCU) with unstable
   angina. She is started on appropriate medication to reduce her cardiac risk. She is
   hypertensive, fasting glucose is normal and cholesterol is 5.2. She is found to be in
   atrial fibrillation. What is the most appropriate treatment?
   A. Aspirin and clopidogrel
   B. Digoxin
   C. Cardioversion
   D. Aspirin alone
   E. Warfarin

Answer 4

E

Question 5

5. Chest pain (1)
   A 55-year-old man has just arrived in accident and emergency complaining of 20
   minutes of central crushing chest pain. Which feature is most indicative of
   myocardial infarction at this moment in time?
   A. Inverted T waves
   B. ST depression
   C. ST elevation
   D. Q waves
   E. Raised troponin

Answer 5

C

Question 6

6. Shortness of breath (1)
   A 66-year-old woman presents to accident and emergency with a 2-day history of
   shortness of breath. The patient notes becoming progressively short of breath as
   well as a sharp pain in the right side of the chest which is most painful when taking
   a deep breath. The patient also complains of mild pain in the right leg, though there
   is nothing significant on full cardiovascular and respiratory examination. Heart
   rate is 96 and respiratory rate is 12. The patient denies any weight loss or long haul
   flights but mentions undergoing a nasal polypectomy 3 weeks ago. The most likely
   diagnosis is:
   A. Muscular strain
   B. Heart failure
   C. Pneumothorax
   D. Angina
   E. Pulmonary embolism

Answer 6

E

Question 7

7. Murmurs (1)
   A 59-year-old man presents for a well person check. A cardiovascular, respiratory,
   gastrointestinal and neurological examination is performed. No significant findings
   are found, except during auscultation a mid systolic click followed by a late systolic
   murmur is heard at the apex. The patient denies any symptoms. The most likely
   diagnosis is:
   A. Barlow syndrome
   B. Austin Flint murmur
   C. Patent ductus arteriosus
   D. Graham Steell murmur
   E. Carey Coombs murmur

Answer 7

A

Question 8

8. Chest pain (2)
   A 60-year-old man presents to accident and emergency with a 3-day history of
   increasingly severe chest pain. The patient describes the pain as a sharp, tearing
   pain starting in the centre of his chest and radiating straight through to his back
   between his shoulder blades. The patient looks in pain but there is no pallor, heart
   rate is 95, respiratory rate is 20, temperature 37°C and blood pressure is
   155/95 mmHg. The most likely diagnosis is:
   A. Myocardial infarction
   B. Myocardial ischaemia
   C. Aortic dissection
   D. Pulmonary embolism
   E. Pneumonia

Answer 8

C

Question 9

9. Chest pain management
   A 49-year-old man is rushed to accident and emergency complaining of a 20-minute
   history of severe, crushing chest pain. After giving the patient glyceryl trinitrate
   (GTN) spray, he is able to tell you he suffers from hypertension and type 2 diabetes
   and is allergic to aspirin. The most appropriate management is:
   A. Aspirin
   B. Morphine
   C. Heparin
   D. Clopidogrel
   E. Warfarin

Answer 9

D

Question 10

10. Ventricular tachyarrhythmia
    While on call you are called by a nurse to a patient on the ward complaining of
    light headedness and palpitations. When you arrive the patient is not conscious but
    has a patent airway and is breathing with oxygen saturation at 97 per cent. You try
    to palpate a pulse but are unable to find the radial or carotid. The registrar arrives
    and after hearing your report of the patient decides to shock the patient who
    recovers. What is the patient most likely to have been suffering?
    A. Torsades de Pointes
    B. Ventricular fibrillation
    C. Sustained ventricular tachycardia
    D. Non-sustained ventricular tachycardia
    E. Normal heart ventricular tachycardia

Answer 10

B

Question 11

11. Jugular venous pressure
    A 67-year-old man presents to accident and emergency with a 3-day history of
    shortness of breath. On examination you palpate the radial pulse and notice that
    the patient has an irregular heart beat with an overall rate of 140 bpm. You request
    an electrocardiogram (ECG) which reveals that the patient is in atrial fibrillation.
    Which of the following would you expect to see when assessing the JVP?
    A. Raised JVP with normal waveform
    B. Large ‘v waves’
    C. Cannon ‘a waves’
    D. Absent ‘a waves’
    E. Large ‘a waves’

Answer 11

D

Question 12

12. Heart failure (2)
    A 78-year-old woman is admitted to your ward following a 3-day history of
    shortness of breath and a productive cough of white frothy sputum. On auscultation
    of the lungs, you hear bilateral basal coarse inspiratory crackles. You suspect that
    the patient is in congestive cardiac failure. You request a chest x-ray. Which of the
    following signs is not typically seen on chest x-ray in patients with congestive
    cardiac failure?
    A. Lower lobe diversion
    B. Cardiomegaly
    C. Pleural effusions
    D. Alveolar oedema
    E. Kerley B lines

Answer 12

A

Question 13

13. First degree heart block
    A 56-year-old man presents to your clinic with symptoms of exertional chest
    tightness which is relieved by rest. You request an ECG which reveals that the
    patient has first degree heart block. Which of the following ECG abnormalities is
    typically seen in first degree heart block?
    A. PR interval >120 ms
    B. PR interval >300 ms
    C. PR interval <200 ms
    D. PR interval >200 ms
    E. PR interval <120 ms

Answer 13

D

Question 14

14. Mitral stenosis
    You see a 57-year-old woman who presents with worsening shortness of breath
    coupled with decreased exercise tolerance. She had rheumatic fever in her
    adolescence and suffers from essential hypertension. On examination she has signs
    which point to a diagnosis of mitral stenosis. Which of the following is not a
    clinical sign associated with mitral stenosis?
    A. Malar flush
    B. Atrial fibrillation
    C. Pan-systolic murmur which radiates to axilla
    D. Tapping, undisplaced apex beat
    E. Right ventricular heave

Answer 14

C

Question 15

15. Hypertension (1)
    A 48-year-old woman has been diagnosed with essential hypertension and was
    commenced on treatment three months ago. She presents to you with a dry cough
    which has not been getting better despite taking cough linctus and antibiotics. You
    assess the patient’s medication history. Which of the following antihypertensive
    medications is responsible for the patient’s symptoms?
    A. Amlodipine
    B. Lisinopril
    C. Bendroflumethiazide
    D. Frusemide
    E. Atenolol

Answer 15

B

Question 16

16. Palpitations
    A 62-year-old male presents with palpitations, which are shown on ECG to be atrial
    fibrillation with a ventricular rate of approximately 130/minute. He has mild
    central chest discomfort but is not acutely distressed. He first noticed these about 3
    hours before coming to hospital. As far as is known this is his first episode of this
    kind. Which of the following would you prefer as first-line therapy?
    A. Anticoagulate with heparin and start digoxin at standard daily dose
    B. Attempt DC cardioversion
    C. Administer bisoprolol and verapamil, and give warfarin
    D. Attempt cardioversion with IV flecainide
    E. Wait to see if there is spontaneous reversion to sinus rhythm

Answer 16

B

Question 17

17. Murmurs (2)
    A 76-year-old male is brought to accident and emergency after collapsing at home.
    He has recovered within minutes and is fully alert and orientated. He says this is
    the first such episode that he has experienced, but describes some increasing
    shortness of breath in the previous six months and brief periods of central chest
    pain, often at the same time. On examination, blood pressure is 115/88 mmHg and
    there are a few rales at both bases. On ECG there are borderline criteria for left
    ventricular hypertrophy. Which of the following might you expect to find on
    auscultation?
    A. Mid-diastolic murmur best heard at the apex
    B. Crescendo systolic murmur best heard at the right sternal edge
    C. Diastolic murmur best heard at the left sternal edge
    D. Pan-systolic murmur best heard at the apex
    E. Pan-systolic murmur best heard at the left sternal edge

Answer 17

B

Question 18

18. Postmyocardial infarction (1)
    A 63-year-old male was admitted to accident and emergency 2 days after discharge
    following an apparently uncomplicated MI. He complained of rapidly worsening
    shortness of breath over the previous 48 hours but no further chest pain. He was
    tachypnoeic and had a regular pulse of 110/minute, which proved to be sinus
    tachycardia. The jugular venous pressure was raised and a pan-systolic murmur
    was noted, maximal at the left sternal edge. Which of the following is the most
    likely diagnosis?
    A. Mitral incompetence
    B. Ventricular septal defect
    C. Aortic stenosis
    D. Dressler’s syndrome
    E. Further myocardial infarction

Answer 18

B

Question 19

19. Hypertension (2)
    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?
    A. Glyceryl trinitrate
    B. Hydralazine
    C. Labetalol
    D. Sodium nitroprusside
    E. Phentolamine

Answer 19

D

Question 20

20. Mid-systolic murmur
    A 16-year-old male is referred for assessment of hypertension. On average, his
    blood pressure is 165/85 mmHg, with radiofemoral delay. There is a mid-systolic
    murmur maximal at the aortic area, and radiating to the back. Clinical findings and
    the ECG are compatible with left ventricular hypertrophy. What is the most likely
    underlying pathology?
    A. Hypertrophic obstructive cardiomyopathy
    B. Congenital aortic stenosis
    C. Coarctation of the aorta
    D. Patent ductus ateriosus
    E. Atrial septal defect

Answer 20

C

Question 21

21. Ventral septal defect
    A 16-year-old boy is diagnosed with a small ventricular septal defect, having been
    screened by echocardiography because of a family history of hypertrophic
    obstructive cardiomyopathy. He is entirely asymptomatic, plays several sports
    regularly and has no growth retardation. The echocardiogram also confirms a small
    left to right shunt, with pulmonary to systemic flow ratio only just above one.
    Which of the following is the most likely to be a significant complication of his
    condition?
    A. Pulmonary hypertension
    B. Heart failure
    C. Dysrhythmias
    D. Endocarditis
    E. Shunt reversal (right to left flow)

Answer 21

D

Question 22

22. Microscopic haematuria
    A 52 year-old woman has been treated for several years with amlodipine and
    lisinopril for what has been presumed to be primary hypertension. She is seen by
    her GP having complained of persistent left loin pain. Her BP is 150/95 mmHg. She
    is tender in the left loin and both kidneys appear to be enlarged. On urine dipstick
    testing, there is microscopic haematuria. Which of the following is likely to be the
    most appropriate investigation at this point?
    A. Urinary tract ultrasound
    B. Abdominal and pelvic computed tomography (CT) scan
    C. Microscopy of the urine (microbial and cytological)
    D. Renal biopsy
    E. Intravenous urogram

Answer 22

A

Question 23

23. Retrosternal chest pain
    A 61-year-old man presents with a 2-hour history of moderately severe retrosternal
    chest pain, which does not radiate and is not affected by respiration or posture. He
    complains of general malaise and nausea, but has not vomited. His ECG shows ST
    segment depression and T wave inversion in the inferior leads. Troponin levels are
    not elevated. He has already been given oxygen, aspirin and intravenous GTN; he
    is an occasional user of sublingual GTN and takes regular bisoprolol for stable
    angina. What would be the most appropriate next step in his management?
    A. IV low-molecular weight heparin
    B. Thrombolysis with alteplase
    C. IV nicardapine
    D. Angiography with stenting
    E. Oral clopidogrel

Answer 23

A

Question 24

24. Pulmonary embolism management
    A 41-year-old woman is referred for assessment after suffering a second pulmonary
    embolus within a year. She has not been travelling recently, has not had any
    surgery, does not smoke and does not take the oral contraceptive pill. She is not
    currently on any medication as the diagnosis is retrospective and she is now
    asymptomatic. What should be the next step in her management?
    A. Initiation of warfarin therapy
    B. ECG
    C. Thrombophilia screen
    D. Insertion of inferior vena cava filter
    E. Duplex scan of lower limb veins and pelvic utrasound

Answer 24

C

Question 25

25. Mid-diastolic murmur
    A 32-year-old woman attends her GP for a routine medical examination and is
    noted to have a mid-diastolic murmur with an opening snap. Her blood pressure is
    118/71 mmHg and the pulse is regular at 66 beats per minute. She is entirely
    asymptomatic and chest x-ray and ECG are normal. What would be the most
    appropriate investigation at this point?
    A. ECG
    B. Anti-streptolysin O titre
    C. Cardiac catheterization
    D. Thallium radionuclide scanning
    E. Colour Doppler scanning

Answer 25

A

Question 26

26. Severe chest pain
    A 46-year-old man develops sudden severe central chest pain after lifting heavy
    cases while moving house. The pain radiates to the back and both shoulders but not
    to either arm. His BP is 155/90 mmHg, pulse rate is 92 beats per minute and the ECG
    is normal. He is distressed and sweaty, but not nauseated. What would you consider
    the most likely diagnosis?
    A. Pneumothorax
    B. MI
    C. Pulmonary embolism
    D. Aortic dissection
    E. Musculoskeletal pain

Answer 26

D

Question 27

27. Decrescendo diastolic murmur
    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?
    A. Aortic regurgitation
    B. Aortic stenosis
    C. Mitral regurgitation
    D. Mitral stenosis
    E. Tricuspid regurgitation

Answer 27

A

Question 28

28. Supraventricular tachycardia
    A 21-year-old man is on his way home from a party when he experiences the sudden
    onset of rapid palpitations. He feels uncomfortable but not short of breath and has
    no chest pain. He goes to the nearest accident and emergency department, where he
    is found to have a supraventricular tachycardia (SVT) at a rate of 170/minute. Carotid
    sinus massage produced transient reversion to sinus rhythm, after which the
    tachycardia resumed. What would be the next step in your management?
    A. Repeat carotid sinus massage
    B. IV verapamil
    C. IV propranolol
    D. IV adenosine
    E. Synchronized DC cardioversion

Answer 28

D

Question 29

29. Chest pain (3)
    A 44-year-old woman attends her local accident and emergency department with a
    history of at least six months of frequent central chest pain in the early morning or
    during the night. She had no chest pain on exertion. This had been a particularly
    severe attack, lasting over 2 hours. Her pulse rate is 84/minute in sinus rhythm, and
    blood pressure is 134/86 mmHg. The ECG shows anterior ST segment elevation, but
    troponin levels do not rise. Subsequent coronary angiography is normal. What is
    the most likely diagnosis?
    A. MI
    B. Stable angina
    C. Unstable angina
    D. Anxiety
    E. Variant angina

Answer 29

E

Question 30

30. Shortness of breath (2)
    A previously fit 19-year-old man presents with unusual shortness of breath on
    exertion. At times, this is also associated with central chest pain. On examination
    there is a loud mid-systolic murmur at the left sternal edge. Heart rate and blood
    pressure are normal and there is no oedema. The ECG shows left axis deviation and
    the voltage criteria for left ventricular hypertrophy and the echocardiogram reveals
    a significant thickened interventricular septum, with delayed ventricular filling
    during diastole. There is a family history of sudden death below the age of 50.
    Which of the following would be your initial therapy?
    A. Digoxin
    B. Long-acting nitrates
    C. Beta-blockers
    D. Rate-limiting calcium channel blockers
    E. Partial excision of the septum

Answer 30

C

Question 31

31. Hypertension (3)
    A 44-year-old woman presents with episodes of headaches, associated with anxiety,
    sweating and a slow pulse rate. At the time of her initial consultation, her blood
    pressure was 150/95 mmHg seated, but 24 hour ambulatory monitoring shows a
    peak of 215/130 mmHg, associated with the symptoms described above. Which of
    the following would be your initial diagnostic procedure?
    A. Magnetic resonance imaging (MRI) scans of the abdomen and pelvis
    B. Measurement of random plasma catecholamines
    C. Measurement of urinary metanephrines over several 24 hour periods
    D. Glucose tolerance test
    E. Pharmacological provocation using clonidine

Answer 31

C

Question 32

32. Chest pain (4)
    A 56-year-old man presents to the accident and emergency department with a
    2-hour history of central chest pain radiating to the left arm. He is anxious,
    nauseated and sweaty. His pulse rate is 120/minute in sinus rhythm and the ECG
    reveals ST elevation in leads II, III and aVF. The troponin level is significantly
    raised. This is certainly acute MI. Which is the most likely coronary vessel to be
    occluded?
    A. Circumflex artery
    B. Left anterior descending artery
    C. Right coronary artery
    D. Left main coronary artery
    E. Posterior descending artery

Answer 32

C

Question 33

33. Constrictive pericarditis
    A 45-year-old woman complains of increasing shortness of breath on exertion, as
    well as orthopnoea, for the previous 3–4 months. She had apparently recovered
    from pericarditis about a year earlier. On ECG there is low voltage, especially in the
    limb leads, and the chest x-ray shows pericardial calcification. The presumptive
    diagnosis is constrictive pericarditis. Which of the following physical signs would
    be consistent with this?
    A. Increased jugular distention on inspiration
    B. Third heart sound
    C. Fourth heart sound
    D. Rales at both lung bases
    E. Loud first and second heart sounds

Answer 33

A

Question 34

34. Visual disturbance
    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?
    A. Lisinopril
    B. Spironolactone
    C. Digoxin
    D. Furosemide
    E. Bisoprolol

Answer 34

C

Question 35

35. Weight loss
    A 29-year-old woman goes to see her GP complaining of fatigue and palpitations.
    She says she has also lost weight, though without dieting. On examination, her
    pulse rate is approximately 120/min and irregularly irregular. Her blood pressure is
    142/89 mmHg and her body mass index is 19. There are no added cardiac sounds.
    The ECG confirms the diagnosis of atrial fibrillation. What would you suggest as
    the most useful next investigation.
    A. Thyroid function tests (TSH, free T4)
    B. ECG
    C. Chest x-ray
    D. Full blood count
    E. Fasting blood sugar

Answer 35

A

Question 36

36. Postmyocardial infarction (2)
    A 58-year-old man has made an excellent functional recovery after an anterior MI.
    He is entirely asymptomatic and there is no abnormality on physical examination.
    His blood pressure is 134/78 mmHg and he is undertaking a cardiac rehabilitation
    programme. Which of the following would you not recommend as part of his
    secondary prevention planning?
    A. Aspirin
    B. Lisinopril
    C. Simvastatin
    D. Bisoprolol
    E. Omega-3 fatty acids

Answer 36

E

Question 37

36. Postmyocardial infarction (2)
    A 58-year-old man has made an excellent functional recovery after an anterior MI.
    He is entirely asymptomatic and there is no abnormality on physical examination.
    His blood pressure is 134/78 mmHg and he is undertaking a cardiac rehabilitation
    programme. Which of the following would you not recommend as part of his
    secondary prevention planning?
    A. Aspirin
    B. Lisinopril
    C. Simvastatin
    D. Bisoprolol
    E. Omega-3 fatty acids

Answer 37

D

Question 38

38. Mitral valve prolapse
    An asymptomatic 31-year-old woman has been referred for cardiological
    assessment. After her ECG she was told that she had mitral valve prolapse and
    would like further information on this condition. Which of the following statements
    is correct?
    A. Beta-blocker therapy is indicated
    B. Angiotensin-converting enzyme (ACE) inhibitor therapy is indicated
    C. One or both leaflets of the mitral valve are pushed back into the left
    atrium during systole
    D. Significant mitral regurgitation will eventually develop
    E. Exercise should be restricted

Answer 38

C

Question 39

39. Paroxysmal atrial fibrillation
    A 69-year-old woman complains of intermittent palpitations, lasting several hours,
    which then stop spontaneously. She also suffers from asthma. Holter monitoring
    confirms paroxysmal atrial fibrillation. Which of the following statements is correct
    regarding the management of this patient?
    A. Digoxin effectively prevents recurrence of the arrhythmia
    B. Anticoagulation is not necessary
    C. Sotalol may be effective
    D. Amiodarone should be avoided
    E. Flecainide orally may be an effective as-needed treatment to abort an
    attack

Answer 39

E

Question 40

40. Hypertension management
    A 57-year-old man is reviewed in a hypertension clinic, where it is found that his
    blood pressure is 165/105 mmHg despite standard doses of amlodipine, perindopril,
    doxazosin and bendroflumethiazide. Electrolytes and physical examination have
    been, and remain, normal. Which of the following would be your next stage in his
    management?
    A. Arrange for his medication to be given under direct observation
    B. Add spironolactone to his medication
    C. Arrange urinary catecholamine assays
    D. Request an adrenal CT scan
    E. Add verapamil to his medication

Answer 40

A