MCQ - General Medicine (Cardiovascular)

Question 1

65yo male presents with central crushing chest pain for the first time. He immediately gets transferred to the cardiac unit and undergoes percutaneous coronary intervention. There is thrombosis of the left circumflex artery. What changes will most likely be seen on ECG?

A. ST depression in leads V1-4

B. ST elevation in leads V5-6

C. ST elevation in leads V1-6

D. ST elevation in II, III and aVF

E. ST elevation in V1-2, aVR

Answer 1

B

• Non-STEMI suggets ischaemia and PCI should be done within 48hrs
• V1-4 would suggest the left anterior descending artery
• Leads II, III, aVF would suggest an inferior infarct (right anterior desceding artery)
• Leads V5-6 suggests left circumflex artery

Question 2

75yo female was admitted for heart failure. The underlying cause was determined to be aortic stenosis. Which sign is most likely to present?

A. Pleural Effusion on CXR

B. Raised JVP.

C. Bilateral pedal oedema

D. Bibasal Crepitations

E. Atrial Fibrillation

Answer 2

D

• AF is more commonly associated with mitral stenosis
• Would expect to hear crepitations before seeing pleural effusion, followed by raised JVP and pedal Oedema

Question 3

What findings point 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

• Murmurs heard loudes on inspiration points to a right-sided valve lesion
• Right 2nd intercostal space is landmark for aortic valve
• A murmur in the left lateral position is associated with mitral lesions; should check for murmur radiation
• Corrigan’s sign (visibly exaggerated pulsating carotids) is associated with aortic regurgitatoin
• Narrow pulse pressure is a sign of aortic stenosis

Question 4

A 56 year old man presents to ED with a fever of 38.5^oC. He has experienced progressive dyspnoea, chest pain and fevers over the past three months and does not have a history of recreational drug use. After a course of antibiotic therapy, his condition became more stable. A TTE was performed and gross vegetation was seen in a region of his heart. Written by Steven.

Which of the following is the most likely region?

A. Tricuspid valve

B. Pulmonary valve

C. Mitral valve

D. Aortic valve

E. None of the above

Answer 4

C - Mitral valve
The mitral valve is under the most regular pressure (from the left ventricle). It is more common for IV drug users to have a vegetation growing on the tricuspid valve.

Question 5

A 56 year old obese male was rushed to the emergency department after experiencing severe, ripping chest pain that radiates intrascapularly, after he was lifting a heavy object while taking a poo, on an airplane while coke’d out of his mind returning from a successful business trip. On examination he is sweaty, grey, shrot of breath and in agony, and has a diastolic murmur. BP is 190/120 in the right arm and 170/112 in the left arm. Written by Luke.

Select the most likely diagnosis:

A. AMI

B. PE

C. Dissecting thoracic aortic aneurysm

D. Unstable angina

E. Costochondritis

F. Takotsubo cardiomyopathy from airplane food sorrow

Answer 5

C - Dissecting thoracic aortic aneurysm.

Based on the pain quality, cocaine, obesity, straining, diastolic murmur and brachial pressure differential.

Question 6

32 year old man presents to the GP with a 2 day history of dyspnoea and retrosternal chest pain, which came on gradually. The patient cannot recall any trauma or abnormal exertion. He has a history of progressive chronic renal failure. The pain is stabbing in quality, radiates to the neck and left shoulder, is relieved by sitting upright and made worse by lying flat and coughing. Written by Melissa.

A. Pericarditis

B. AMI

C. Unstable angina

D. PE

Answer 6

A - Pericarditis

Hallmark: pain is positional; pain worse on lying flat and relieved by sitting forwards. Pericarditis can occur at about day 2 or 3 after a transmural myocardial infarct as an inflammatory response to the necrotic heart muscle. Pericarditis tends to cause a sharp pain which is variable in site/intensity.

Question 7

Regarding valvular heart disease, which one of the following pairs in INCORRECT? Written by Julien.

A. Tricuspid regurgitation: Kussmaul’s sign and S3 on auscultation

B. Patent ductus arteriosus: Continuous murmur that radiates to the back

C. Aortic stenosis: Slow rising pulse and diamond waveform murmur

D. Mitral stenosis: Malar flush and high risk group of IVDU

E. Aortic regurgitation: Head nodding and wide pulse pressure

Answer 7

D - Mitral stenosis - Malar flush can be seen on the cheeks but MS is not really associated with the high risk group of IVDU (TR) + MS aetiology is mainly RHD (post-streptococcal infection)

Kussmaul’s sign: paradoxical rise in JVP on inspiration, indicative of poor RV filling

Patent ductus arteriosus refers to the failure of the ductus arteriosus to close after birth

Question 8

A 45yo patient presents to Maroondah Hospital with palpitations, shortness of breath at rest, and dizziness. The ECG shows this particular finding (below). What is this finding on ECG and what condition does this patient have? Written by Julien.

Answer 8

Finding: Delta wave (slurred upstroke at the indication of the QRS complex)

• Condition: Wolff Parkinson White syndrome
• Presentation: SOB, palpitations, dizziness, chest pain
• PRE-EXCITATION SYNDROME (‘rogue’ myocardial fibres)
• Generally treated via catheter ablation

Question 9

A patient has this ECG. Which of the following is the most likely cause?

A. The OCP causing a PE

B. Idiopathic short QT syndrome

C. AMI causing death of cardiac tissue

D. Hyperthyroidism causing AF

E. Amiodarone causing prolonged QT

Answer 9

E - Amiodarone causing prolonged QT.

This ECG shows ‘Torsades de pointes’. It is caused by prolonged QT intervals. This can be caused by drugs (amiodarone and a lot of psych drugs) or electrolyte abnormalities.

Question 10

A 20 y.o. patient presents with an URTI, chest pain and the following ECG. His troponins were 200. What is the most likely diagnosis? Written by Chole.

A. Inferolateral STEMI

B. Generalised STEMI

C. Pericarditis

D. Myopericarditis

E. Takotsubo

Answer 10

D - Myopericarditis

Generalised ST elevation = pericarditis, BUT this does not normally elevate troponins. For troponins to be elevated, myocardium must be inflamed/dying. This is therefore both.

Question 11

A 17-year old male dies suddenly at an athletics carnival. Looking back at the doctor’s notes, the male was noted to have a systolic crescendo- decrescendo murmur at the right upper sternal border that became louder with the Valsalva manouevre. A paradoxical split S2 heart sound was also heard. Which of the following is his likely diagnosis? Julien

A. Aortic stenosis

B. Aortic sclerosis

C. Dilated cardiomyopathy

D. Hypertrophic obstructive cardiomyopathy

E. Patent ductus arteriosus

Answer 11

D - Hypertrophic obstructive cardiomyopathy

Most common cause of sudden cardiac death in young athletes.

1. Valsalva manoeuvre: AS (DECREASED intensity of murmur) vs. HOCM (INCREASED intensity)
2. Carotid pulsation: AS (normal or pulsus tardus et parvus) vs. HOCM (brisk, jerky or bisferiens pulse - a collapse of the pulse followed by a secondary rise)

Question 12

An 80yo woman is admitted to the hospital 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 currently in AF. What is the most appropriate treatment?

A. Aspirin and Clopidogrel

B. Digoxin

C. Cardioversion

D. Aspirin alone

E. Warfarin

Answer 12

E

• Ideally, this patient should be started on antihypertensives, beta blocker and a statin.

Congestive Heart Failure 1

Hypertension 1

Age >75yo 1

Diabetes Mellitus 1

Previous stroke or TIA 2

• A score of >2 requires warfarin

Question 13

55yo male presented to the ED complaining of 20minutes of central crushing chest pain. Which feature is most indicative of MI at this moment in time?

A. Inverted T waves

B. ST depression

C. ST elevation

D. Q waves

E. Raised Troponin

Answer 13

C

• Inverted T waves and ST depression are signs of ischaemia
• ST elevation, Q waves and raised troponin are indicative of infarction.
• Troponin levels should be measured 12hrs after initial presentation of chest pain
• Q waves take longer to develop; indicates full thickness MI

Question 14

65yo female presents to ED with a 2-day history of progressively worsening dyspnoea. This is associated with a sharp pain in the right side of the chest, which is worse on deep inspiration. The patient also compains of mild pain in the right leg. The patient denies long flights or weight loss, but did undergo 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 14

E

• Clinical signs of PE include: pleural rub, coarse crackles and AF
• Symptoms include: Dyspnoea, pleuritic chest pain and haemoptysis
• In a massive PE, there can also be raised JVP, tachypnoea, tachycardia and hypotension
• Geneva scoring:

>65yo - 1

Previous DVT or PE - 3

Surgery of fracture <4weeks ago - 2

Malignancy - 2

Unilateral leg pain - 3

Unilateral oedema - 4

Haemoptysis - 2

HR: 75-94 - 3

HR >95 - 5

Question 15

59yo male presents for a routine check-up. Examination was normal except during auscultation, where a mid-systolic click followed by a late systolic murmur is heard at the apex. The patient denies 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 15

A

• Mitral valve prolapse (Barlow syndrome, click murmur syndrome)
• The murmur is heard at the apex as the thickened mitral valve leaflet is displaced into the left atrium during systole.
• Austin Flint murmur produces a low pitched, mid diastolic rumble at the apex. Usually due to mitral valve displacement or aortic regurgitation
• A patent ductus arteriosus produces a constant machinery murmur
• A Graham Steell murmur is best heard at the left sternal edge, 2nd intercostal space during inspiration; high-pitched early diastolic murmur associated with pulmonary hypertension
• Carey Coombs murmur is a short, mid-diastolic rumble heard best at the apex, due to turbulent flow over a thickened mitral valve. Often due to rheumatic heart disease

Question 16

60yo male presents to ED with a 3-day history of increasing chest pain. It is described as sharp, tearing pain starting in the centre of his chest and radiating straight through to his back between his shoulder blades. There is no pallor, heart rate is 90, respiratory rate of 20, blood pressure 155/95 and afebrile. The most likely diagnosis is:

A. MI

B. Myocardial Ischaemia

C. Aortic Dissection

D. PE

E. Pneumonia

Answer 16

C.

• A 3 day history makes MI unlikely
• Myocardial ischaemia tends to radiate to the jaw, arms and epigastrium and not the back; described as crushing pain
• PE presents with pleuritic chest pain, cough, haemoptysism which are not present in the patient
• Pneumonia is associated with fever and productive cough

Question 17

49yo male presents to ED with a 20-minute history of severe, crushing chest pain. GTN is administered. Has a positive history of hypertension, type 2 diabetes and is allergic to aspirin. The most appropriate mangagement is:

A. Aspirin

B. Morphine

C. Heparin

D. Clopidogrel

E. Warfarin

Answer 17

D.

• If GTN is given, then morphine no longer needs to be administered (NICE protocols)
• Aspirin should not be given due to allergy, otherwise that would be the answer; fear of anaphylaxis
• Warfarin and heparin are good anticoagulants, but are slow to act

Question 18

A patient on the ward comlains of light-headedness and palpitations. When you see the patient, the patient is unconscious but has patent airway and is breathing with O2 sats of 97%. However, you are unable to find the radial or the carotid pulse. The registrar decides to shock the patient. The patient most likely has:

A. Torsades de Pointes

B. Ventricular Fibrillation

C. Sustained Ventricular Tachycardia

D. Non-sustained ventricular tachycardia

E. Normal heart ventricular tachycardia

Answer 18

B.

There are 2 types of life threatening ventricular tachyarrhythmias: sustained ventricular tachycardia and ventricular fibrillation.

• In VF, the patient is pulseless and cardioversion is required
• Sustained ventricular tachycardia is characterised by cannon “a” waves on JVP, and broad QRS complexes
• Torsades de Pointes presents with irregular QES complexes and prolonged QT interval
• A non-sustained tachycardia is defined by more than 5 consecutive heart beats within 30sec

Question 19

79yi female was admitted with a 3 day history of dyspnoea and productive cough of white frothy sputum. On auscultation of the lungs, there are bilateral basal coarse inspiratory crackles. You request a CXR, which of the following signs is not typically seen on CXR in a patient with congestive cardiac failure?

A. Lower lobe diversion

B. Cardiomegaly

C. Pleural effusions

D. Alveolar oedema

E. Kerley B Lines

Answer 19

A.

• Besides A, the rest are typical signs

Instead of lower lobe diversion, an upper lobe diversion is seen on the CXR

Question 20

A 57yo woman presents with worsening dyspnoea and 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 20

C.

• Malar flush, AF, tapping apex beat and right ventricular heave, which occurs secondary to pulmonary hypertension, are all clinical signs associated with mitral stenosis
• A mid-diastolic murmur is heard in mitral stenosis
• A pan-systolic murmur is usually heard in mitral regurgitation, tricuspid regurgiation and ventricular septal defects.