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CARDIOLOGY > FORMATIVE QUESTIONS > Flashcards

FORMATIVE QUESTIONS Flashcards

1
Q

What features are seen with aortic incompetence?

A

Collapsing pulse
Early diastolic murmur
Wide pulse pressure
Quincke’s sign
De Musset’s sign

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2
Q

What features are seen with pericardial tamponade?

A

Pulses paradoxus
Absent Y descent on JVP due to limited right ventricular filling
Kussmaul’s sign
ECG - electrical alternans

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3
Q

What causes a left parasternal have?

A

Hypertrophied right ventricle

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4
Q

What conditions cause finger clubbing?

A

Cyanotic congenital heart disease
Bacterial endocarditis
Atrial myxoma

Lung cancer
CF, bronchiectasis, abscess
TB
Asbestosis and mesothelioma
Fibrosing alveoli this

Crohn’s
Cirrhosis and PBC
Graves’ disease

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5
Q

What does a slow y descent on JVP indicate?

A

Tricuspid stenosis or right atrial myxoma

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6
Q

What does a sharp y descent on JVP indicate?

A

Severe tricuspid regurgitation
Constrictive pericarditis

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7
Q

What does a absent x descent on JVP indicate?

A

AF

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8
Q

What does a prominent x descent on JVP indicate?

A

Acute cardiac tamponade
Constrictive pericarditis

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9
Q

What do dominant v waves on JVP indicate?

A

Tricuspid regurgitation

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10
Q

What does absent a waves on JVP indicate?

A

AF

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11
Q

What does cannon a waves (i.e. irregular, large) on JVP indicate?

A

Complete heart block

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12
Q

A 46 year old woman recently discharged following a hysterectomy collapses with acute central chest pain and profound breathlessness?

A

PE

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13
Q

A 56 year old overweight man is woken repeatedly at night with central burning chest pain.

A

Oesophagitis (nocturnal burning chest pain is typical of GORD)

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14
Q

A 76 year old male retired banker, enjoys golf, but is having difficulty on the uphill holes because of central chest discomfort and breathlessness.

A

Stable angina

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15
Q

A 24 year old man with sudden onset of left sided chest pain and breathlessness. Breath sounds on the left are diminished and the percussion note is resonant

investigation?

A

CXR - likely spontaneous pneumothorax

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16
Q

A 62 year old lady with chest tightness that comes on when doing housework such as hoovering. The resting ECG is normal
Next investigation?

A

MI perfusion imaging

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17
Q

A 58 year old man with acute onset of central chest pain, nausea and sweating being assessed in the Emergency Medicine Department triage
Next investigation?

A

12 lead ECG

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18
Q

A 24 year old woman with exertional breathlessness, dizziness, chest discomfort and central cyanosis

A

Pulmonary arterial hypertension

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19
Q

A 73 year old man having smoked 50 pack years with long-standing productive cough and wheeze presenting with slowly progressive breathlessness

A

COPD

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20
Q

A 35 year old man needs treatment for his newly diagnosed hypertension. He is known to have severe asthma with several previous hospital admissions. Which Antihypertensive drug is best avoided?

A

Beta blockers - can cause bronchospasm, peripheral vasoconstriction and alteration of glucose and lipid metabolism

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21
Q

A 67 year old woman complains that her new antihypertensive medication is making her ankles swell. Which drug the most likely culprit?

A

Dihydropyirdine CCB

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22
Q

A 78 year old man with recurrent gout needs treatment for his hypertension. Which drug is best avoided?

A

Thiazide diuretics - they can reduce the clearance of uric acid (loop diuretics can also but to a lesser effect)

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23
Q

A 71-year-old retired boiler lagger is referred to medical out-patients with a 6-month history of worsening exertional dyspnoea. Chest auscultation reveals fine bibasal inspiratory crepitations. His chest radiograph shows pleural plaques with diffuse lower zone reticular opacification. The arterial blood gases show: pH 7.39, PaCO2 4.1 kPa, PaO2 7.9 kPa, oxygen saturation 91%, bicarbonate 25 mmol/l, base excess 1.9 mmol/l.

A

Asbestosis

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24
Q

A morbidly obese 61-year-old man presents to his GP with exertional dyspnoea, early morning headaches and daytime somnolence. Spirometry reveals an restrictive defect and the arterial blood gases show: pH 7.37, PaCO2 7.9 kPa, PaO2 7.3 kPa, oxygen saturation 87%, bicarbonate 34 mmol/l, base excess 6.9 mmol/l. He improves with overnight non-invasive ventilation.

A

Pickwickian syndrome

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25
Q

What is pickwickian syndrome?

A

Obesity-hypoventilation syndrome - obesity, sleep disordered breathing and chronic hypercapnoa

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26
Q

A 69-year-old woman presents in the Emergency Department with acute shortness of breath. On examination, she is clammy, tachycardic and hypotensive. The arterial blood gases show: pH 7.13, PaCO2 3.5 kPa, PaO2 7.9 kPa, oxygen saturation 89%, bicarbonate 15 mmol/l, base excess 7.3 mmol/l. Her chest radiograph shows alveolar shadowing in a ‘batwing’ configuration.

A

Pulmonary oedema

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27
Q

A 35-year-old woman becomes acutely unwell, with shortness of breath and a dry cough and confusion. Chest X-Ray shows consolidation. Investigations reveal: Na+ 127 mmol/l, K+ 4.9 mmol/l, urea 7.4 mmol/l, creatinine 122 micromol/l. Arterial blood gases show: pH 7.33, PaCO2 3.7 kPa, PaO2 6.3 kPa, oxygen saturation 82%, bicarbonate 20 mmol/l, base excess 2.9 mmol/l. The diagnosis is later confirmed by urine antigen testing.

A

Legionella pneumonia

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28
Q

A 56-year-old man presents to his GP with a 12 month history of increasing exertional dyspnoea and dry cough. On examination, he has clubbing of the fingernails and auscultation of his chest reveals bilateral fine inspiratory crepitations. Spirometry shows a restrictive pattern.

A

Idiopathic pulmonary fibrosis

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29
Q

What ABG changes would you see in DKA?

A

Metabolic acidosis (due to accumulation of ketone bodies)
Resporatory alkalosis ( hyperventilation - Respiratory compensation)

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30
Q

What ABG changes would you see in motor neuron disease?

A

?

31
Q

What ABG changes would you see in opiate toxicity?

A

Respiratory depression
Hypoxaemia
Respiratory acidosis?

32
Q

What ABG changes would you see in a PE?

A

Hypoxaemia and hypocapnia (due to increased alveolar dead space caused by pulmonary artery blockage)
Respiratory alkalosis may be present due to hyperventilation

33
Q

What ABG changes would you see in COPD?

A

Hypoxaemia and hypercpania (due to VP mismatch and air trapping)
Respiratory acidosis may be present due to inadequate ventilation

34
Q

What ABG changes would you see in gastric outlet obstruction?

A

Normal

35
Q

What ABG changes would you see in hyperventilation?

A

Respiratory alkalosis

36
Q

What ABG changes would you see in third trimester of pregnancy?

A

Mild resp alkalosis potentially due to hyperventilation

37
Q

What drug class is tiotropium?

A

LAMA

38
Q

What is omalizumab used for?

A

It’s a monoclonal antibody that binds to IgE allergic antibodies and blocks its actions

39
Q

Outline the process of a bronchoscope?

A

A bronchoscope is inserted through the nose down into the lungs to examine the airways and collect tissue samples or remove foreign objects
The pt will usually be sedated
Pulse oximetry and ECG will be monitored

40
Q

A fit 68 year old man presents with a right hilar shadow, thought to be due to lung cancer. A CT scan of the chest confirms a localised mass arising in the right lower lobe main bronchus. What is the next most appropriate investigation?

A

PET scan to establish the localisation of the tumour and suitability for radical treatment
This should be done to determine the biopsy strategy which wil confirm staging and histology

41
Q

What is the most common mode of presentation of mesothelioma?

A

Breathlessness from pleural based tumour
(Haemoptysis from mediastinal/bronchial invasion is a late sign!)

42
Q

A 75 year old man presents with non-small-cell lung cancer. Curative surgery is contemplated. What would not be a consideration in determining the likely success of surgery?

A. Chronological age
B. Hilar lymphadenopathy
C. Horner’s syndrome
D. Recurrent laryngeal nerve palsy
E. Mediastinal invasion on CT scanning

A

Chronological age

(Surgery contraindications include poor general health, metastasis present, FEV1<1.5L, maligannt pleural effusion, tumour near hills, vocal cord paralysis, SVC obstruction)

43
Q

A 67 year old man presents with haemoptysis and a left hilar mass. Lung cancer is suspected. What will you particularly want to explore in the occupational history?
A. Asbestos exposure
B. Chlorine exposure
C. Coal mining
D. Paint spraying
E. Polyvinyl chloride exposure

A

Asbestos exposure!

44
Q

What are examples of nicotine replacement therapies?

A

Nicotine patches
Gum
Inhalers
Lozenges
Nasal spray

45
Q

Whats the moa of bupropion?

A

a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist

46
Q

Whats the moa of varenicline?

A

a nicotinic receptor partial agonist

47
Q

Which of the following statements is true with regard to smoking cessation treatment?

A. Bupropion is a form of nicotine replacement therapy.
B. Bupropion is available for purchase over the counter.
C. Smokers of 10 or more cigarettes a day should be recommended pharmacological aids to smoking cessation.
D. There is no evidence that medical advice alone leads to smoking cessation.
E. Up to 15% of smokers who want to stop smoking will abstain long term if using NRT.

A

C

48
Q

55 year old man presents with a 6 week history of persistent cough and a single episode of minor haemoptysis having just returned from a 2 week summer holiday in a hotel in Spain. He smoked 15 to 20 cigarettes per day from the age of 16 to 52. What would the most appropriate action for his GP to take on the basis of this information?

A

Arranage a CXR and 2 week wait referral

49
Q

When should you Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer?

A

have chest x-ray findings that suggest lung cancer
are aged 40 and over with unexplained haemoptysis

50
Q

When should you Offer an urgent chest x-ray (to be performed within 2 weeks) to assess for lung cancer?

A

in people aged 40 and over if they have 2 or more of the following unexplained symptoms, or if they have ever smoked and have 1 or more of the following unexplained symptoms: cough, fatigue, shortness of breath, chest pain, weight loss, appetite loss

51
Q

What amangement options are curative for localised non-small cell lung cancer?

A

radiotherapy
Surgery

52
Q

What causes a 3rd heart sound?

A

rapid ventricular filling - if over 40 it represents HF or volume overload

53
Q

What diseases can cause hypertension and excessive urinary losses of K+ due to hyperaldosteronism?

A

Renal artery stenosis
Tumours of adrenal gland - conns
Cushings
Deficiency of 11-beta-hydroxysteroid dehydrogenase type 2 enzyme

54
Q

What can cause a deficiency of the 11-beta-hydroxysteroid dehydrogenase type 2 enzyme?

A

Congenital or excessive licorice (due to excess glycyrrhizin)

55
Q

Outline the PEFR levels for grading severity of asthma?

A

Moderate - >50%
severe 33-50%
Life threatening <33%

56
Q

A 23 year old baker complains of intermittent episodes of wheezy breathlessness. You review him in the clinic where spirometry is normal, but you suspect occupational asthma. What would be the next most appropriate investigation to establish the diagnosis?

A

Serial peak flow - useful for looking at diurnal variation and investigating for occupational asthma

57
Q

What occupational exposure is a recognised hazard for the development of asthma?

Answers:
A. Aniline dyes manufacture
B. Coal mining
C. Stone masonry
D. Lagging and stripping asbestos
E. Spray painting

A

Spray painting, bakers, process food, nurses, chemical workers, working with animals, welders, hairdressers, timber workers

(Asbestos - fibrosis and mesothelioma)
(Coal miniming - fibrosis)
(Analine dyes - lung cancer)

58
Q

The eosinophil plays a key role in the pathogenesis of asthma. What is its main action in this respect?

A

Production of leukotrienes in response to allergens

59
Q

A 44 year old woman is admitted with an acute attack of asthma. What is most characteristic pathophysiology of such an episode?

A

Bronchial mucus plugging, airway inflammation, bronchospasm,

60
Q

A 57-year-old man has a dry cough and worsening shortness of breath which has developed over seven months. He has hypertension and difficult to control atrial fibrillation. His medication includes amiodarone, amlodipine, enalapril and rivaroxaban. He has smoked 20 cigarettes daily for 30 years. He used to work in a canning factory and has no history of asbestos exposure. He has a dog but no other pets.

He has a BP of 142/78 mmHg, respiratory rate 23 breaths per minute and his oxygen saturation is 91% on air. His fingers are not clubbed, but there are bilateral fine inspiratory crackles on chest auscultation. He does not have ankle oedema and his JVP is not visible.

Investigations:

FEV1 61% of predicted FVC 40% of predicted FEV1/FVC 90%

What is the most likely diagnosis?

A

Interstitial pneumonia is secondary to amiodarone causing fibrosis and a restrictive pattern on pulmonary function testing

61
Q

What are the different types of pulmonary toxicity due to amiodarone?

A

Chronic interstitial pneumonitis is most common; other manifestations include organizing pneumonia, acute respiratory distress syndrome, and a solitary pulmonary mass. One characteristic finding in all patients exposed to amiodarone is the presence of numerous foamy macrophages in the air spaces. These cells are filled with amiodarone-phospholipid complexes

62
Q

Whats the maximum dose of amlodipine daily for management of hypoertension?

A

10mg OD

63
Q

A 49-year-old man is admitted for assessment of chest pain. The pain sounded musculoskeletal in nature and serial ECGs and troponin T measurements are normal. He has hypertension for which he takes amlodipine 5 mg once daily, indapamide 2.5 mg once daily and ramipril 10 mg once daily.

On examination pulse rate is 76 bpm, blood pressure is 164/92 mmHg and repeated measurements remain in the same range.

Investigations:

serum sodium 138 mmol/L (137-144) serum potassium 4.6 mmol/L (3.5-4.9) serum urea 7.4 mmol/L (2.5-7.0) serum creatinine 101 µmol/L (60-110)

What is the most appropriate next step in the management of his hypertension?

A

Increase amlodipine dose to 10mg daily

64
Q

A 49-year-old man is admitted for assessment of chest pain. The pain sounded musculoskeletal in nature and serial ECGs and troponin T measurements are normal. He has hypertension for which he takes amlodipine 5 mg once daily, indapamide 2.5 mg once daily and ramipril 10 mg once daily.

On examination pulse rate is 76 bpm, blood pressure is 164/92 mmHg and repeated measurements remain in the same range.

Investigations:

serum sodium 138 mmol/L (137-144) serum potassium 4.6 mmol/L (3.5-4.9) serum urea 7.4 mmol/L (2.5-7.0) serum creatinine 101 µmol/L (60-110)

What is the most appropriate next step in the management of his hypertension?

A

Stress echocardiography with exercise tolerance testing - This will provide information on the ability of the patient to exercise and thus about the severity of the aortic stenosis.

65
Q

A 61-year-old man has atrial fibrillation and has already been anti-coagulated with apixaban by the general practitioner. There is no significant past medical history. On examination, his pulse rate is 122 beats per minute irregular and his blood pressure is 110/70 mmHg.

The decision is made to use an oral drug to rate control the atrial fibrillation.

Which oral rate limiting medication will produce the quickest effect?

A. Amiodarone
B. Bisoprolol
C. Digoxin
D. Metoprolol
E. Verapamil

A

Metoprolol - a beta blocker with a short half life and rapid onset of action!

66
Q

Whats the duration and onset of amiodarone?

A

Extremely long duration and slow onset

67
Q

Whats the duration and onset of bisoprolol?

A

Long half life and slower onset of action than metoprolol (its a once a day drug(

68
Q

Whats the duration and onset of amiodarone?

A

Digoxin has a half-life of circa 35 hours and takes 5-7 days to reach steady state – it’s onset of action is therefore slow.

69
Q

A 57-year-old man has acute breathlessness and a cough productive of green sputum. He has ischaemic heart disease and takes amlodipine, aspirin, bisoprolol, ramipril and simvastatin. He is allergic to penicillin and his GP prescribes a course of clarithromycin for his chest infection.

Which of his existing drugs should be temporarily withheld as it is likely to cause a clinically significant interaction with the clarithromycin?

A

Simvastatin - increased risk of myopathy when clarithromycin is given with simvastatin

70
Q

Which drugs inhibit cytochrome P450 3A4 and therefore increase the risk of statin myopathy?

A

Ciclosporin
Macrolife antibiotics
Systemic azole antifungal
HIV and HCV protease inhibitors

71
Q

What are contraindications with statins?

A

Macrolife antibiotics - statins shold be stopped until pt finishes the course!

72
Q

What are the adverse efefcts of statins?

A

Myopathy
Liver impairment
May increase the risk of intracerebral haemorrhage in pt who have previously had a stroke

73
Q

What are ECG changes in right sided heart strain?

A

Right ventricular hypertrophy - large R waves on V1-3 and S waves on V4-6
RAD
RBBB

74
Q

How does pulmonary hypertension present?

A

SOB (particularly exertional)
Central cyanosis
Syncope + pre-syncope
Tachycardia
Raised JVP
Hepatomegaly
Peripheral oedema

CARDIOLOGY (19 decks)

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