Diagnosis, Investigations, Examinations & Findings

Question 1

Aortic Dissection (4)

Answer 1

1. CXR showing:
2. Widened Mediasteinum

BEST:
2. CT Angiography if stable
SHOWING
3. False Lumen

4. Transoesophageal Echoe (TOE) if unstable for CT

Question 2

Atrial Myxoma (2)

Answer 2

1. Echo

showing:

2. Pedunculated Heterogenous mass attached to fossa ovalis

Question 3

Clinical Uses of BNP (3)

Answer 3

1. R/O heart failure in dyspnoeic patients (low BNP means HF unlikely)
2. Prognosis in Chronic HF
3. Guiding treatment in HF - lowering BNP means Tx is working

Question 4

Brugada Syndrome (2)

Answer 4

1. ECG - convex st elevation, J point elevation and inverted T waves in V1-3 = Brugada sign
2. Give Flecainide and repeat ECG - elicits sign

Question 5

Buerger’s Disease (2)

Answer 5

1. Angiogram shows
2. Corkscrew Collaterals in fingertips

Question 6

Outline how the cardiac enzyme: MYOGLOBIN reacts to stress (3)

Answer 6

Begins to rise at:
1. 1 - 2 hours

Peak value at:
2. 6 - 8 hours

Returns to normal at:
3. 1 - 2 days

Question 7

Outline how the cardiac enzyme: CK-MB reacts to stress (3)

Answer 7

Begins to rise at:
1. 2 - 6 hours

Peak value at:
2. 16 - 20 hours

Returns to normal at:
3. 2 - 3 days

Question 8

Outline how the cardiac enzyme: CK reacts to stress (3)

Answer 8

Begins to rise at:
1. 4-8 hours

Peak value at:
2. 16 -24 hours

Returns to normal at:
3. 2-3 days

Question 9

Outline how the cardiac enzyme: TROPONIN-T reacts to stress (3)

Answer 9

Begins to rise at:
1. 4 - 6 hours

Peak value at:
2. 12 - 24 hours

Returns to normal at:
3. 7 - 10 days

Question 10

Outline how the cardiac enzyme: AST reacts to stress (3)

Answer 10

Begins to rise at:
1. 12 - 24 hours

Peak value at:
2. 36 - 48 hours

Returns to normal at:
3. 3 - 4 days

Question 11

Outline how the cardiac enzyme: LDH reacts to stress (3)

Answer 11

Begins to rise at:
1. 24 - 48 hours

Peak value at:
2. 72 hours

Returns to normal at:
3. 8 - 10 days

Question 12

Investigating Angina-like chest pain (3)

Answer 12

1st Line:
1. CT Coronary Angiography

2nd Line:
2. Non-invasive functional testing / stress testing

3rd Line:
3. Invasive Coronary Angiography (contrast)

Question 13

Diagnosing Heart Failure (Test and action based on result)

Answer 13

1. NT-proBNP blood test
2. If HIGH (>2000) - referral to specialist assessment wihtin 2 weeks (for echo)
3. If RAISED (400 -2000) arrange for 6 weeks

Question 14

Coarctation of the Aorta (1)

Answer 14

1. Notching of inferior rib borders on CXR (from collateral vessels)

Question 15

Constrictive Pericarditis (3)

Answer 15

1. S3 or pericardial nock on auscultation
2. CXR showing
3. Pericardial Calcification

Question 16

Diagnostic workup for Heart Failure (7)

Answer 16

Bloods:
1. Broad Spec to look for causes
2. BNP as a way to r/o NOT confirm it and for prognosis indication

CXR
3. Pulmonary venous congestion
4. Interstitial oedema
5. Cardiomegaly

Echo:
6. recommended for new AHF or worseneing CHF
7. May show valvular cause, ischaemia, EF etc etc

realistically you’d do an ecg too

Question 17

What causes Heart Sound S1? (1)

Answer 17

1. Closure of Mitral and Tricuspid Valves

Question 18

What causes Heart Sound S2? (1)

Answer 18

1. Closure of Aortic and Pulmonary Valves

Question 19

Outline HS S1 and its variations / causes (3)

Answer 19

1. Closure of M and T valves
2. Soft if long PR or Mitral Regurg
3. Loud in Mitral Stenosis

Question 20

Cause of Loud S1 heart sound (4)

Answer 20

1. Mitral Stenosis
2. Left-Right Shunts
3. Short PR interval - atrial premature beats
4. Hyperdynamic states

Question 21

Cause of quiet / soft S1 Heart Sound (2)

Answer 21

1. Long PR interval
2. Mitral Regurgitation

Question 22

Outline HS S2 and its variations / causes (3)

Answer 22

1. Closure of A and P valves
2. Soft in AS
3. Splitting in Inspiration is normal

Question 23

Cause of soft S2 HS? (1)

Answer 23

1. Aortic Stenosis

Question 24

Cause of Loud S2 HS? (1)

Answer 24

1. HTN

Question 25

Cause of Splitting of S2 (non-pathological) (1)

Answer 25

1. Deep Inspiration

Question 26

Causes of Fixed Splitting of S2 (pathological) (1)

Answer 26

1. ASD

Question 27

Causes of Wide Splitting of S2 (pathological) (3)

Answer 27

1. RBBB 2. Pulmonary Stenosis 3. Severe Mitral Regurgitation

Question 28

Cause of Reversed Splitting (P2 before A2) of S2 (pathological) (4)

Answer 28

1. LBBB 2. Severe AS 3. WPW Type B (casues early P2) 4. Patent Ductus Arteriosus

Question 29

Outline HS S3 and its variations / causes (5)

Answer 29

1. Caused by diastolic filling of ventricles 2. Normal if <30 years old (or <50 in women) Heard in: 3. LV Failure (eg DCM) 4. Constrictive Pericarditis (pericardial knock as heart slaps against pathologically stiff pericardium in diastole) 5. Mitral Regurgitation

Question 30

Outline HS S4 and its variations / causes (6)

Answer 30

May be heard in: 1. AS 2. HOCM 3. HTN 4. Caused by Atrial contraction against a stiff ventricle 5. thus coincides with P wave on ECG 6. in HOCM a double apical beat may be felt as a result of a palpable S4

Question 31

Cause of HS S4 (1)

Answer 31

1. Atrial contraction against a stiff ventricle

Question 32

Where do you listen to the Pulmonary Valve? (2)

Answer 32

1. Left 2nd IC space 2. Upper Sternal border

Question 33

Where do you listen to the Aortic Valve? (2)

Answer 33

1. Right 2nd IC space 2. Upper sternal border

Question 34

Where do you listen to the Mitral Valve? (2)

Answer 34

1. Left 5th IC space 2. Just medial to Mid Clavicular line

Question 35

Where do you listen to the Tricuspid Valve? (2)

Answer 35

1. Left 4th IC space 2. Lower left sternal border

Question 36

Investigations needed after a HTN diagnosis (6)

Answer 36

check for end-organ damage basically or for future CVD risk 1. Fundoscopy - HTN retinopathy? 2. Urine Dipstick - checking for renal disease as cause or result of HTN 3. ECG - assess LVH or IHD Bloods: 4. U&Es - assess renal function 5. Lipid Profile: Checking for CVD risk due to hyperlipidaemia 6. HbA1c - r/o DM

Question 37

How to do Ambulatory BP Monitoring (2)

Answer 37

1. At least 2 measurements per hour during waking hours 2. Use average of at least 14 measurements

Question 38

How to do Home BP Monitoirng (4)

Answer 38

1. for each recoridng take 2 BPs 1 min apart sat down. 2. Record twice daily in AM and PM 3. Atleast 4-7 days 4. Discard day 1 and use the rest for average

Question 39

HOCM (9)

Answer 39

1. ECHO showing: MR SAM ASH 2. Mitral Regurgitation 3. Systolic Anterior Movement of Mitral valve 4. ASymmetric Hypertrophy 5. ECG showing: 6. LVH 7. Non specofic ST segment and T changes 8. Deep Q waves 9. Occaisonally AFib

Question 40

Diagnosing Infective Endocarditis (4)

Answer 40

DUKE Criteria Diagnosed if: 1. 2 major criteria 2. 1 Major and 3 minor 3. 5 Minor 4. Pathology confirms it form tests like material from surgery and biopsy

Question 41

Major Criteria for DUKEs criteria (Infective Endocarditis) (6)

Answer 41

POSITIVE BLOOD CULTURES: 1. TWO positive cultures showing consitent Endocarditis organisms - viridans, HACEK etc 2. Persistant bacteraemia in 2 cultures >12hrs apart with less specific organisms - S.Aureus, Staph Epidermidis 3. Postive serology for Coxiella burnetii, Bartonella or Chlamydia psittaci 4. Positive molecular assays for specific gene targets EVIDENCE OF MYOCARDIAL INVOLVEMNT: 5. Positive Echo = oscillating structures, abcess formation, new valve regurg, dihescence of prosthetic valves 6. New Valve regurg

Question 42

Minor Criteria in DUKES criteria for Infective Endocarditis (5)

Answer 42

1. Predisposing heart condition or IVDU 2. Microbiology doesn't satisfy major criteria 3. fever >38 degrees 4. Vascular phenomena: Major emboli, splenomegaly, clubbing, splinter haemorrhages, janeway lesions, petechia or purpura 5. Immunological phenomena: Glomerulonephritis, Osler's nodes, Roth spots

Question 43

Mitral Stenosis (2)

Answer 43

1. CXR showing left atrial enlargement 2. Echo showing tight mitral valve cross sectional area of <1 cm squared

Question 44

2 Causes of an Ejection Systolic Murmur that is louder on expiration (2)

Answer 44

1. AS 2. HOCM Tet of Fallot will also cauase an ESM

Question 45

2 causes of an Ejeciton Systolic Murmur that is louder on Expiration (2)

Answer 45

1. Pulmonary Stenosis 2. ASD Tet of Fallot will also cause a ESM

Question 46

2 causes of a Holosystolic / pansystolic murmur (

Answer 46

1. Mitral or Tricuspid Regurgitation (high pitched blowing) 2. VSD (harsh in character)

Question 47

How to differentiate the Pansystolic murmur heard in Mitral Regurg from that of Tricuspid Regurg? (2)

Answer 47

1. Tricuspid regurg gets louder on INSPIRATION 2. Mitral does not

Question 48

2 Causes of a late diastolic murmur (2)

Answer 48

1. Mitral Valve Prolapse 2. Coarctation of the Aorta

Question 49

2 causes of Early Diastolic Murmur (2)

Answer 49

1. Aortic Regurgitation (high pitched and blowing) 2. Graham-Steel murmur - Pulmonary Regurgitation (high pitched and blowing also)

Question 50

2 Causes of Mid-Late Diastolic Murmur (2)

Answer 50

1. Mitral Stenosis (rumbling caused by atria firing against a stenotic valve, to remeber timing remeber that diastole refers to VENTRICULAR diastole, which is actually when the atria contract - hence this is a "diastolic" murmur in relation to ventircles but is actually an atrial systolic murmur iygm) 2. Austin-Flint murmum from severe Aortic Regrug (rumbling also)

Question 51

Cause of continuous "Machine like murmur" (1)

Answer 51

1. Patent Ductus Arteriosis

Question 52

How to remember which murmurs are made louder by inspiration vs expiration? (1)

Answer 52

1. RILE Right sided= Inspiration Left sided = Expiration

Question 53

Myocarditis (6)

Answer 53

Bloods: 1. Inflammatory Markers raised in 99% 2. Raised cardiac enzymes 3. Raised BNP ECG: 4. Tachycardia 5. Arrhythmias 6. ST/T wave changes including elevation and T inversion

Question 54

Orthoststic Hypotension (definition) (1)

Answer 54

1. A drop of >20mmHg after 3 mins of standing

Question 55

Pulsus Paradoxus (define and 2 causes) (3)

Answer 55

1. Greater than a normal 10mmHg drop in BP on INSPIRATION Causes: 2. Severe asthma 3. Cardiac Tamponade

Question 56

Cause of Slow-rising / Plateau Pulse (1)

Answer 56

1. Aortic Stenosis

Question 57

Causes of Collapsing Pulse (3)

Answer 57

1. Aortic Regurgitation 2. Patent Ductus Arteriosus 3. Hperkinetic States (hyper blood-flowey staes) eg Anaemia, thyrotoxicosis, exercise, preganancy)

Question 58

Definitiona nd 1 cause of Pulsus Alternans (2)

Answer 58

1. Regularly alternating force of pulse 2. Severe LVF

Question 59

Define and give 2 causes of Bisferiens Pulse

Answer 59

1. Double-pulse, two systolic peaks felt 2. Mixed Aortic valve disease 3. HOCM occaisionally

Question 60

Cause of a' Jerky' Pulse (1)

Answer 60

1. HOCM

Question 61

Diagnostic Criteria for Rheumatic Fever (2)

Answer 61

1. 2 Major criteria or 2. 1 Major + 2 Minor

Question 62

List the Major Criteria for diagnosing Rheumatic Fever (5)

Answer 62

1. Erthema Marginatum 2. Sydenham's chorea - late feature 3. Polyarthritis 4. Carditis and valvulitis - regurg murmur 5. Subcutaneous nodules probably dont memorise this its super rare in the west

Question 63

Minor Criteria for Rheumatic Fever (4)

Answer 63

1. Raised ESR or CRP 2. Pyrexia 3. Arthralgia 4. Prolonged PR Interval probably dont memorise its super rare in UK

Question 64

Syndrome X (3)

Answer 64

Basically this is angina and ST changes without any artery issues on angiography - an ACS mimicker we don;t understand yet 1. Angina-like CP 2. ST depression on stress test 3. Normal coronaries on Angiography

Question 65

Takayasu's Arteritis (2)

Answer 65

1. MRA (MRI angiography of aorta) 2. CT Angiography (CTA Aorta)

Question 66

Stages of HTN according to NICE (3)

Answer 66

1. Stage 1 - Clinic 140/90, Abulatory - 135/85 2. Stage 2 - Clinic 160/100, Ambulatory - 150/95 3. Severe >180 / 120