Cardiovascular Exam Questions PDF

CARDIOVASCULAR Which one of the following is not a differential diagnosis of shoulder tip pain? A. Pulmonary embolism. B. Myocardial infarction. C. Emphysema. D. Pneumothorax. E. Peptic ulcer disease. Incorrect. Correct answer is C 45% answered correctly Explanation: Correct Answer Is C Shoulder-tip pain is an important clinical sign and can be caused by local musculoskeletal trauma or inflammation or referral. The following are the differential diagnoses of referred shoulder-tip pain: Pulmonary embolism Pneumothorax Myocardial infarction Perforation of peptic ulcer disease Diaphragmatic irritation Emphysema is not a cause of shoulder-tip pain, unless a spontaneous pneumothorax occurs. References http://www.webmd.com/pain-management/tc/referred-s http://www.uptodate.com/contents/evaluation-of-the Last updated: Time spent: QID:14 2023-2-12 After percutaneous coronary intervention (PCI) in a patient with ST segment elevation myocardial infarction (STEMI), which one the following is the recommended period for antiplatelet therapy? A. Two weeks. B. Four weeks. C. Six weeks. D. 12 months. E. Lifelong Incorrect. Correct answer is D 45% answered correctly Explanation: Correct Answer Is D In nearly all patients in whom intra-coronary drug-eluting stent is placed, dual antiplatelet therapy is indicated for at least 12 months. Dual therapy is with aspirin and any of the following: Clopidogrel Prasugrel Ticagrelor References RACGP - AFP - Dual antiplatelet therapy Last updated: Time spent: QID:25 2023-2-12 Which one of the following is of predictive value for prognosis of a patient with systolic heart failure? A. Jugular venous pressure. B. Peripheral edema. C. Shortness of breath. D. Orthopnea. E. Chest pain. Correct 45% answered correctly Explanation: Correct Answer Is A Prognosis of systolic heart failure can be predicted by jugular venous pressure (JVP) and the third heart sound (S3). Increased JVP or the presence of S3 sound indicates poor prognosis. Other options are of diagnostic, not predictive values. References http://www.uptodate.com/contents/prognosis-of-hear Last updated: Time spent: QID:26 2023-2-12 You are called to see a 50-year-old Aboriginal woman with history of congestive heart failure, who has developed severe dyspnea and is in respiratory distress. On examination, she is pale and sweaty with a blood pressure of 110/75 mmHg and pulse rate of 120bpm. The respiratory rate is 26/min. Chest auscultation is significant for bilateral crackles. A chest X-ray shows bilateral whiteout of lungs from the lower lobes up to middle of the lung fields. An ECG shows no abnormality. Troponin level is normal on arrival and eight hours later. Which one of the following is the most likely diagnosis? A. Acute right heart failure. B. Acute pulmonary edema. C. Pleural effusion. D. Acute myocardial infarction. E. Pulmonary embolism. Incorrect. Correct answer is B 45% answered correctly Explanation: Correct Answer Is B Acute pulmonary edema presents with dyspnea, bibasilar coarse crackles, tachycardia, pallor and cold limbs due to hypoperfusion. The background history of congestive heart failure supports the diagnosis of pulmonary edema in this patient as the most likely diagnosis. (Option A) Acute right heart failure presents with ankle edema, raised JVP, hepatomegaly, shortenss of breath. With only lung congestion and no other findings that can be present in right heart failure, this diagnosis less likely. (Option C) Pleural effusion progresses slowly and usually does not cause acute-onset symptoms. Even an acute pleural effusion takes hours to days to develop. (Option D) With acute myocardial infarction ECG changes and positive cardiac enzymes should have been present. (Option E) A massive pulmonary embolism (PE) can be the second likely diagnosis on the list differential diagnoses. PE presents with shortness of breath, tachypnea and tachycardia as the hallmark symptoms. Pleuretic chest pain or shoulder-tip pain may be other finding. ECG may be normal or show S1Q3T3 pattern (prominent S wave in lead I, Q wave and T wave inversion in lead III), sinus tachycardia, T wave inversion in leads V1 –V3 and right bundle branch block. References http://www.heartfoundation.org.au/SiteCollectionDo Last updated: Time spent: QID:28 2023-2-12 Which one of the following is not indicated in management of pulmonary edema? A. Continuous positive airway pressure (CPAP). B. Bilevel positive airway pressure (BiPAP). C. Glyceryl trinitrate. D. Oral forusemide. E. Morphine. Incorrect. Correct answer is D 45% answered correctly Explanation: Correct Answer Is D Management of acute pulmonary oedema is as follows: Oxygen 10-15 L/min by Hudson mask and reservoir bag. Once the patient is stable continue oxygen 2-6 L/min by nasal cannula. Intravenous forusemide - it is one of the most essential steps in treatment of pulmonary oedema by decreasing the volume overload. If taken orally, forusemide takes time to work and is not effective in treatment. Glyceryl trinitrate – it reduces the preload; it is essential to titrate the dose to maintain systolic blood pressure above 100mmHg. Morphine – by decreasing the sympathetic tone, it results in vasodilation and reduction of preload CPAP and BiPAP – these non-invasive methods of ventilation are used to reduce alveolar and pulmonary edema by reducing the venous return and preload. References Therapeutic Guidelines - Cardiovascular http://www.racgp.org.au/download/documents/AFP/201 https://www.mja.com.au/journal/2011/194/8/2011-upd Last updated: Time spent: QID:29 2023-2-12 A 65-year-old woman presents with several episodes of acute lightheadedness, especially shortly after getting off the bed or a chair for the past 3 months. Her medical history is otherwise unremarkable. A table tilt test is arranged that is positive. Which one of the following would be the first-line management of this patient? A. Oral fludrocortisones. B. Oral hydrocortisone. C. Intravenous fluids. D. Increased salt and water intake. E. Indomethacin. Incorrect. Correct answer is D 45% answered correctly Explanation: Correct Answer Is D A positive table tilt test is highly suggestive of orthostatic (postural) hypotension. Orthostatic hypotension is an excessive fall in blood pressure when an upright position is taken on. The consensus drop is >20mmHg in systolic pressure, 10mmHg in diastolic pressure or both. The condition may be acute or chronic. Orthostatic hypotension is a manifestation of aberrant blood pressure regulation due to various conditions, not a specific disorder. A myriad of causes can lead to orthostatic hypotension. The most common causes of acute orthostatic hypotension include: Hypovolemia (e.g. blood lost) Drugs Prolonged bed rest Adrenal insufficiency The most common causes of chronic orthostatic hypotension: Age-related changes in blood pressure regulation Drugs Autonomic dysfunction The symptoms are related to diminished blood flow to central nervous system, especially the brain and include: Faintness Lightheadedness Confusion Blurred vision Syncope, falls or even seizures may be seen in severe cases Other symptoms may be caused by the underlying etiology of orthostatic hypotension rather than hypotension itself. The symptoms start within seconds to a few minutes of standing and resolve rapidly after lying down. Work-up for orthostatic hypotension starts with measuring the blood pressure and heart rate after 5 minutes in supine and at 1 and 3 minutes after standing (or sitting upright if the patient is not able to stand). Hypotension without a compensatory increase in heart rate (100 bpm or by >30 bpm) suggests hypovolemia Reproduction of symptoms in the absence of hypotension and an increase of more than 30 bpm in heart rate points towards postural orthostatic tachycardia syndrome (POTS) POTS, also known as postural autonomic tachycardia, or chronic or idiopathic orthostatic intolerance is a syndrome of orthostatic intolerance in younger patients. Various symptoms (e.g. fatigue, light-headedness, exercise intolerance, cognitive impairment) and tachycardia occur with standing; however, there is little or no fall in BP. The reason for symptoms is unclear. Table tilt test: This test may be done when autonomic dysfunction is suspected. It gives more consistent results than supine and upright blood pressure assessment and eliminates augmentation of venous return by leg muscle contraction. What is table tilt test and how it is interpreted? Tilt table testing is used to evaluate syncope in younger, apparently healthy patients and, when cardiac and other tests have not provided a diagnosis, in elderly patients. Tilt table testing produces maximal venous pooling, which can trigger vasovagal (neurocardiogenic) syncope and reproduce the symptoms and signs that accompany it, including nausea, light-headedness, pallor, hypotension, and bradycardia. After an overnight fast, a patient is placed on a motorized table with a foot board at one end and is held in place by a single strap over the stomach; an IV line is inserted. After the patient remains supine for 15 min, the table is tilted nearly upright to 60 to 80° for 45 minutes. If vasovagal symptoms develop, vasovagal syncope is confirmed. If they do not occur, a drug (eg, isoproterenol) may be given to induce them. Sensitivity varies from 30 to 80% depending on the protocol used. The false-positive rate is 10 to 15%. With vasovagal syncope, heart rate and BP usually decrease. Some patients have only a decrease in heart rate (cardioinhibitory); others have only a decrease in BP (vasodepressor). Other responses include a gradual decrease in systolic and diastolic BP with little change in heart rate (dysautonomic pattern), significant increase in heart rate (> 30 beats/min) with little change in BP (postural orthostatic tachycardia syndrome), and report of syncope with no hemodynamic changes (psychogenic syncope). Relative contraindications to the test include: Severe aortic or mitral stenosis Hypertrophic cardiomyopathy Severe coronary artery disease (CAD) In particular, isoproterenol should not be used in patients with hypertrophic cardiomyopathy or severe CAD. Conservative management Conservative measures should always be considered as the first-line management. These measures include increased sodium and water intake in the absence of heart failure or hypertension. This may expand intravascular volume and decreases the severity of symptoms. This approach carries the risk of heart failure, particularly in the elderly and patients with impaired myocardial function. NOTE - development of dependent edema without heart failure is not a reason to stop the treatment. Other conservative measures include: Patients requiring prolonged bed rest should be advised to sit up first on wakning and exercise in bed when possible. Elderly patients should avoid prolonged standing. Sleeping with the head of the bed raised may relieve symptoms by promoting Na retention and reducing nocturnal diuresis. Patients should rise slowly from a recumbent or sitting position, consume adequate fluids, limit or avoid alcohol, and exercise regularly when possible, because modest-intensity exercise promotes overall vascular tone and reduces venous pooling. If the case is postprandial hypotension, it should be recommended that the size and carbohydrate content of meals be reduced. The patient must minimize alcohol intake and avoid sudden standing after meals. Waist-high fitted elastic hose may increase venous return, cardiac output, and BP after standing. Medical management If conservative measures fail, the following medications may be uses to treat orthostatic hypotension: Fludrocortisone – being a potent mineralocorticoid, fludrocortisone exerts it effects through sodium retention, which results in volume expansion and relieving or decreasing the symptoms. It is only effective if sodium intake is adequate. This drug may also improve the peripheral vasoconstrictor response to sympathetic stimulation. Supine hypertension, heart failure, and hypokalemia may occur; K supplements may be required. Other drugs used include midodrine, NSAIDs, L-Dihydroxyphenylserine (a norepinephrine precursor), and propranolol or other beta blockers. For this patient with no heart fialure, increased water and sodium intake will be the next best step in management. References http://www.merckmanuals.com/professional/cardiovas http://www.merckmanuals.com/professional/cardiovas Last updated: Time spent: QID:136 2023-2-12 John, 35 years old, presents to the emergency department with pain and swelling of his left thigh since this morning. Investigations establish the diagnosis of deep venous thrombosis for which he is started on heparin in hospital. He has diabetes and hypertension and his wife mentions that is very busy and distracted and always forgets to take the drugs he is prescribed for treatment of his hypertension and diabetes. Which one of the following options would be the most appropriate management for him after the course of heparin is completed? A. No more treatment is needed. B. Warfarin for 6 months. C. Aspirin for 6 months. D. Surgical intervention. E. Caval filter. Incorrect. Correct answer is E 45% answered correctly Explanation: Correct Answer Is E Treatment of DVT starts with either unfractionated or low molecular weight heparin. Warfarin could be started at the same day (or within 48 hours). Heparin therapy should be continued for 5 days and stopped once INR is above 2 in two consecutive days. NOTE – Since anticoagulation is contraindicated in the presence of a bleeding diathesis, the following tests should be performed prior to heparinization: Activated partial thromboplastin time (APTT) International normalised ratio (INR) Platelet count Thrombophilia screen including: activated protein C resistance, fasting plasma homocysteine, prothrombin G20210A, antithrombin III, protein C, protein S, lupus anticoagulant, anticardiolipin antibody and lupus anticoagulant Warfarin should be continued for at least 3 months or more depending on the patient’s risk of recurrent venous thromboembolism. The objectives of anticoagulation therapy are treating the current DVT and prevention of pulmonary embolism. Studies have shown that as many as 33% of patients may develop PE while receiving adequate anticoagulation therapy. Cava filters are an alternative to systemic anticoagulation with warfarin (or heparin) in the following situation: DVT or PE in patients with contraindications to anticoagulation therapy; these patients include those with: Hemorrhagic stroke Recent neurosurgical procedure or other major surgery Major or multiple trauma Active internal bleeding (e.g. upper or lower gastrointestinal bleeding, hematuria, hemobilia) Intracranial neoplasm (either primary or metastatic) Bleeding diathesis (e.g. secondary thrombocytopenia, idiopathic thrombocytopenic purpura, hemophilia) Pregnancy Unsteady gate or tendency to fall (as seen in patients with previous stroke, Parkinson disease) Poor patient compliance with medications DVT or PE in patients with a complication of anticoagulation therapy (e.g. bleeding) Failure of anticoagulation therapy – the patient develops venous thromboembolism while on therapeutic dose of anticoagulant. Free-floating iliofemoral or caval thrombus PE prophylaxis - IVC filter placement has been advocated as a means of preventing PE in patients at high risk for thromboembolic events. Traditionally, such patients have included the following populations: Patients with DVT who are about to undergo surgery (lower-extremity orthopedic surgery, major abdominal surgery, neurosurgery) Patients with chronic pulmonary hypertension and a marginal cardiopulmonary reserve Patients with cancer Trauma patients, including those with (1) severe head injury with prolonged ventilator dependence, (2) major abdominal or pelvic penetrating venous injury, (3) spinal cord injury with or without paralysis, (4) severe head injury with multiple lower- extremity fractures, or (5) pelvic fracture with or without lower-extremity fractures As this patient is known be noncompliance with his medications he should have a inferior vena cava filter for prevention of PE. References http://emedicine.medscape.com/article/419796-overv http://www.ncbi.nlm.nih.gov/pubmed/22698970 Last updated: Time spent: QID:145 2023-2-12 A 32-year-old pregnant womam presents to the Emergency Department at 32 weeks pregnancy with right calf swelling and tenderness which is diagnosed as deep vein thrombosis (DVT). Which one of the following is the most appropriate management? A. Therapeutic dose of low molecular weight heparin for 3 months. B. Prophylactic dose of low molecular weight heparin for 3 months. C. No treatment is needed. D. Termination of pregnancy. E. Start her on warfarin and continue for 6 months with strict INR monitoring. Correct 45% answered correctly Explanation: Correct Answer Is A Current guidelines recommend that pregnant women with deep vein thrombosis (DVT)) should be started on therapeutic dose of subcutaneous low molecular weight heparin (LMWH) for the remainder of their pregnancy and at least 6 weeks postpartum. It must be ensured that a minimum of 3 months (12 weeks) of treatment with therapeutic dose is provided. In patient with PE, whether pregnant or not, unfractionated heparin (UH) is the initial choice which is then followed by LMWH once the patient is hemodynamically stable. Proximal DVT and PE require extended duration of treatment (usually a minimum of 6 months.) This patient has developed DVT at 32 weeks of her pregnancy. She needs to be started on therapeutic dose of LMWH for the rest of the pregnancy (approximately 8 weeks) and 6 weeks postpartum which in total adds up to 14 weeks of treatment after which she may be consider for prophylaxis with prophylactic dose of heparin for another 3 months. Warfarin is contraindicated in pregnancy due to risk of warfarin embryopathy. It occurs in approximately 5% of the fetuses exposed to warfarin between 6-13 weeks gestation. Warfarin embryopathy (fetal warfarin syndrome, aka DiSala syndrome) is associated with: Hypoplasia of the nasal bridge, depressed nasal bridge and deep groove between the nostrils and the nose tip Laryngomalacia Pectus carinatum Widely spaced nipples Congenital heart defects Enlargement of brain ventricles Agenesis of corpus callosum Stippled epiphyses – stippling of unclacified epiphyses during the first year of life Brachydactyly (shortened fingers) and mild hypoplasia of nails Severe mental retardation Deafness Reduced muscle tone Feeding difficulty Low birth weight and growth retardation (failure to thrive) Exposure to warfarin during second or third trimester carries an additional 5% risk of fetal intra-cerebral hemorrhage. A 76-year-old man comes to your clinic for a routine health check-up. He has blood pressure of 110/90 mmHg and a pulse rate of 92 bpm. He is on no medications except daily multivitamins. As a part of evaluation, an ECG is obtained which is shown in the following photograph. Which one the following is the next best step in management? A. Aspirin. B. Warfarin. C. Reassurance. D. Metoprolol. E. Atropine. Incorrect. Correct answer is C 45% answered correctly Explanation: Correct Answer Is C The ECG shows a sinus rhythm with increased PR interval characteristic of first-degree atrioventricular block. The condition can be caused by: Age-related fibrosis and degeneration of AV node – the most common cause Drugs: digoxin, beta blockers, calcium channel blockers Increased vagal tone. First-degree heart block is characterized by PR interval> 200 ms (0.2 s) on ECG, normal QRS complexes in terms of duration and spacing, and the presence of a P wave before each QRS. This is quite common among the elderly due to age-related fibrotic changes of the cardiac conductive system. Asymptomatic patients do not need treatment and must be reassured. With symptoms (e.g., dizziness, shortness of breath, chest pain, etc.) atropine or pacemaker (if unresponsive to atropine) is considered. References Therapeutic Guidelines – Cardiovascular Last updated: Time spent: QID:222 2023-2-12 A 79-year-old man collapses on the floor while waiting in the Emergency Department and becomes unresponsive. He has a blood pressure of 84/47 mmHg and rapid and barely perceptible pulse. Cardiopulmonary resuscitation is started immediately. The rhythm, obtained by defibrillator is shown in the accompanying photograph. Which one of the following is the next best step in management? A. Continue CPR until the patient regains consciousness. B. Cardioversion. C. Amiodarone infusion. D. Intravenous adrenaline. E. Defibrillation. Incorrect. Correct answer is B 45% answered correctly Explanation: Correct Answer Is B The first step in management of a collapsed patient is management is calling for help (if possible) and starting CPR with chest compression and ventilation. Once the defibrillator is available obtain the cardiac rhythm with the pedals. The rhythm of this patient is characteristic of ventricular tachycardia (VT). In patients with unstable hemodynamic status, the next best step in management is synchronized cardioversion if the patient has a pulse, or defibrillation if no pulse is detected. Hemodynamic instability is manifested as: Chest pain Dyspnea Hypotension Perfusion-related confusion Collapse and/or unresponsiveness (Option A) Continuing the CPR without defibrillation is unlikely to help in this condition. (Option C) Amiodarone and other anti-arrhythmic drugs used for VT are indicated if the patient is hemodynamically stable. (Option D) Intravenous adrenalin is the first step in management, in conjunction with chest compression and ventilation, in patients with asystole, or ventricular fibrillation after two attempts of DC shock fail to convert the rhythm. (Option E) Defibrillation is the option when there is ventricular fibrillation or if the patient has pulseless VT. References Therapeutic Guidelines – Cardiovascular Last updated: Time spent: QID:223 2023-2-12 Which one of the following is NOT a contraindication to thrombolytics use in a patient with ST elevation myocardial infarction? A. Ischemic stroke in the past 3 months. B. Hemorrhagic stroke in the past 10 years. C. Heavy menstrual bleeding. D. Coagulation disorders. E. Gastrointestinal bleeding within the past 4 weeks. Incorrect. Correct answer is C 45% answered correctly Explanation: Correct Answer Is C Absolute contraindications for fibrinolytic use in STEMI include the following: Prior intracranial hemorrhage (ICH) Known structural cerebral vascular lesion Known malignant intracranial neoplasm Ischemic stroke within 3 months Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed head trauma or facial trauma within 3 months Intracranial or intraspinal surgery within 2 months Severe uncontrolled hypertension (unresponsive to emergency therapy) For streptokinase, prior treatment within the previous 6 months Relative contraindications for fibrinolytic use in STEMI include the following: History of chronic, severe, poorly controlled hypertension Significant hypertension on presentation (systolic blood pressure >180 mm Hg or diastolic blood pressure >110 mm Hg Traumatic or prolonged (>10 minutes) cardiopulmonary resuscitation (CPR) or major surgery less than 3 weeks previously History of prior ischemic stroke not within the last 3 months Dementia Recent (within 2-4 weeks) internal bleeding Noncompressible vascular punctures Pregnancy Active peptic ulcer Current use of an anticoagulant (e.g., warfarin) that has produced an elevated international normalized ratio (INR) higher than 1.7 or a prothrombin time (PT) longer than 15 seconds Of the given options, only heavy menstrul bleeding is not an absolute contraindication to thrombolytic therapy. References Medscape - Thrombolytic therapy - Thrombolytic Therapy for Acute Myocardial Infarction Queensland Government - Thrombolysis for STEMI Clinical Pathway Last updated: Time spent: QID:224 2023-2-12 A 70-year-old man presents to the Emergency Department with complaint of chest pain starting 15 minutes ago, central in location, and dull and aching in nature. He is given aspirin, sublingual glyceryl trinitrate, and oral antacid, and is put on supplemental oxygen by nasal cannula. These measures ameliorate the pain to a significant extent. On examination, his blood pressure is140/90mmHg, pulse 110 bpm, and respiratory rate 20 breaths per minute. A 12-lead ECG strip reveals no abnormality. He mentions that he has had these pains every time he exceeded a certain amount of physical activity, and that each time the pain subsides with rest or sublingual glyceryl trinitrate. He rates this current episode no more than the previous ones. Which one of the following is the most appropriate next step in management? A. Reassure and discharge him home. B. Book for an outpatient echocardiography. C. Admit him to coronary care unit (CCU), measure cardiac enzymes and repeat the ECG. D. Refer him for a stress ECG and echocardiography. E. Refer him to a gastroenterologist. Incorrect. Correct answer is D 45% answered correctly Explanation: Correct Answer Is D Central chest pain described as heaviness, dull and aching that may or may not radiate to the jaw, left arm, or epigastrium is more likely to be ischemic in nature. The duration of pain (less than 20 minutes), being brought on by a predictable amount of exertion and relieved by rest or nitrates is characteristic of stable angina, a condition in which an increased oxygen demand of the heart, induced by activity, leads to ischemia because the stenotic coronary arteries cannot keep up with increased need for oxygen. On the other hand, unstable angina is defined as any new ischemic chest pain, or one with deviation from the typical pattern of previous pains, in terms of either duration, intensity, frequency, or decreased amount of exertion required for its reproduction. The characteristics of the pain (duration, reversibility, and response to rest and nitrates), in addition to a normal ECG establishes the diagnosis of stable angina in this patient. In approaching to such patients, the next best step in management is urgently performing a stress test (either conventional treadmill, chemical, or nucleic) to establish the coronary artery stenosis if the ECG or diagnosis is equivocal (as is in this patient). A positive stress test (reproduction of the chest pain, ST segment depression>2mm or a drop in blood pressure>10mmHg) is then followed by angiography for further evaluation and treatment with either ballooning with or without stent placing or coronary artery bypass grafting surgery. (Option A) Reassuring and discharging the patient is not an appropriate action before the patient has been fully assessed. (Option B) Echocardiography may be a part of plan now or later on in outpatient setting, but is not the most appropriate management now. (Option C) Admission to CCU, cardiac enzymes and follow-up ECGs were indicated if the patient had any changes in the intensity of the pain or its duration, unresponsiveness to rest and nitrates, or aggravating or relieving factors. (Option E) Referring the patient to gastroenterologist is not correct because the pain is typical for cardiac ischemia. A 50-year-old man ipresents to the Emergency Department with chest pain felt behind the sternum radiating to his jaw. A 12-lead ECG strip is obtained and is as the following photograph. You give him aspirin and sublingual nitroglycerine and start him on supplemental oxygen by nasal cannula. A troponin level is ordered which comes back negative. Which one of the following is the next best step in management of this patient? A. Repeat troponin in 8 hours. B. Immediate reperfusion therapy. C. Repeat the ECG in 6 hours. D. Start him on beta blockers. E. Serial ECGs. Incorrect. Correct answer is B 45% answered correctly Explanation: Correct Answer Is B With ST elevation in leads II, III, and aVF on the given ECG, this patient has sustained an inferior ST-elevation myocardial infarction (STEMI) for which the next best step in management is either immediate percutaneous coronary intervention (PCI) as the preferred option, or thrombolytic therapy if not contraindicated. (Option A) Even with negative troponin, ST elevation of more than 1mm in two or more contiguous leads and chest pain makes the diagnosis certain. In fact with chest pain and ECG changes, no troponin level was required to guide the management, and reperfusion therapy should have been performed even without waiting for the results. (Option C) This patient has acute inferior MI and should be treated immediately. Waiting for 6 hours to obtain an ECG is definitely an incorrect answer. (Options D and E) Serial ECGs are indicated as well to further assess the possible evolution of the myocardial infarction. Beta blockers are effective in reducing the mortality, but neither ECG, nor beta blockers takes precedence over PCI. References Australian Prescriber - Management of acute coronary syndromes Medscape - Acute coronary syndrome Last updated: Time spent: QID:225 2023-2-12 A 60-year-old man presents with complaints of increasing tiredness and abdominal distention for the past four months. His past medical history is remarkable for smoking 20 cigarettes a day for the past 20 years. On examination, there is bilateral ankle edema and ascites. The liver is palpated 3cm below the costal margin. His jugular pulse is noted to drop on expiration and rise on inspiration. Which one of the following is the most likely diagnosis? A. Cardiac tamponade. B. Budd- Chiari syndrome. C. Superior vena cava obstruction. D. Constrictive pericarditis due to TB in the past. E. Hepatic cirrhosis. Incorrect. Correct answer is D 45% answered correctly Explanation: Correct Answer Is D Drop of jugular pulse on inspiration and its rising during expiration is a normal physiologic response. Dropped jugular venous pressure (JVP) during expiration and its rise on inspiration is a pathological sign called Kussmal sign. Kussmal sign is seen in restrictive cardiomyopathy, constrictive pericarditis, and cardiac tamponade. Of the options, only constrictive pericarditis due to TB infection can present with Kussmal sign. (Option C) Superior vena cava (SVC) obstruction leads to edema of the face not ankle edema. On the other hand, although the JVP is raised in SVC obstruction, there is no pulsation of the jugular vein. Budd-Chiari syndrome (option B) is associated with thrombus formation in the hepatic vein, leading to portal hypertension. It may present with fatigue, right upper quadrant pain, mild jaundice, and hepatosplenomegaly; however, JVP remains normal, without pulsation. In hepatic cirrhosis (option E), the liver is usually shrinked and not enlarged. Although fatigue, edema and ascites are commn findign, the Kussmal sign is not a feature. References http://emedicine.medscape.com/article/157096-clini Last updated: Time spent: QID:226 2023-2-12 A 30-year-old man presents to the emergency department with chest pain that has started this morning and worsened over time. He mentions that deep breathing increases the pain intensity. On examination, pleuretic chest pain and a temperature of 38°C is noted. The BP is 140/85mmHg and the pulse 100bpm. He takes shallow breaths in a rate of 20/min. The rest of physical examination is inconclusive. A 12- lead ECG is obtained and is shown. Which one of the following is the most likely diagnosis? A. Myocardial ischemia. B. Pulmonary embolism. C. Infectious endocarditis. D. Acute myocardial infarction. E. Pericarditis. Incorrect. Correct answer is E 45% answered correctly Explanation: Correct Answer Is E The clinical picture of pleuretic chest pain (chest pain worsened with breathing), mildly elevated respiratory rate and a borderline pulse rate can be either to pericarditis or pulmonary embolism, but diffuse ST elevation in pericordial and limb leads favors pericarditis as the most likely diagnosis. (Option A) Although myocardial ischemia causes chest pain, the nature of the pain and the pattern of ST segment elevation makes this diagnosis less likely. (Option B) Pulmonary embolism can present similarly; however, the ECG changes are not consistent with this diagnosis. (Option C) Infectious endocarditis presents with a murmr and fever. The ST changes in the ECG are characterisitc for pericarditis. Infectious endocarditis does not cause such an ECG abnormality. (Option D) Acute myocardial infarction (MI) causes ST elevation in specific lead groups, depending on the coronary artery involved and its territory. The pleuretic nature of the chest pain, on the other hand, is against MI as a likely diagnosis. References http://www.racgp.org.au/download/documents/AFP/201 http://www.australiandoctor.com.au/cmspages/getfil Last updated: Time spent: QID:227 2023-2-12 A 70-year-old man in brought to the Emergency Department because of light-headedness for the past 4 hours. On examination, he is found to have bradycardia with an irregular pulse of 45 bpm and a blood pressure of 85/60 mmHg. Atropine is used as the treatment of symptomatic bradycardia but the pulse rate remains the same and the lightheadedness persists. An ECG strip is obtained which is shown in the following photograph. Which one of the following is the next best step in management? A. Metoprolol. B. Dopamine. C. Intravenous pacemaker. D. Permanent pacemaker. E. Adrenaline. Incorrect. Correct answer is C 45% answered correctly Explanation: Correct Answer Is C The rather constant PR intervals, and ‘p’ waves that are not followed by a QRS complex seen on ECG is characteristic of Mobitz II AV block. Symptomatic AV block should be initially be treated with temporary pacing. Percutaneous or intravenous pacemakers are often available in the emergency department and can be applied. If not, atropine is used instead. In the following situations temporary pace makers are the most appropriate option for the initial management: History of asystole Mobitz II AV block Complete heart block Ventricular standstill>3 seconds (Option A) Metoprolol is definitely the wrong option because using it in this situation can dramatically worsen the condition. (Option B) Dopamine is a drug used for increasing cardiac contractility and vascular tone and is not used in treatment of symptomatic bradycardias. (Option D) Permanent pacemakers are definitive treatment of such blocks and are considered after initial temporary pacing. (Option E) Adrenaline infusion is sometimes indicated to maintain an adequate heart rate after atropine, while waiting for pacemaker insertion. TOPIC REVIEW Second-degree (Mobitz) heart block Click here, for a useful video explaining this type of heart block and its ECG characteristics. The typical ECG findings in Mobitz I (Wenckebach) AV block—the most common form of second-degree AV block—are as follows: Gradually progressive PR interval prolongation occurs before the blocked sinus impulse The greatest PR increment typically occurs between the first and second beats of a cycle, gradually decreasing in subsequent beats Shortening of the PR interval occurs after the blocked sinus impulse, provided that the P wave is conducted to the ventricle Junctional escape beats may occur along with nonconducted P waves A pause occurs after the blocked P wave that is less than the sum of the 2 beats before the block During very long sequences (typically >6:5), PR-interval prolongation may be inapparent and minimal until the last beat of the cycle, when it abruptly becomes much greater Post-block PR-interval shortening remains the cornerstone of the diagnosis of Mobitz I block, regardless of whether the periodicity has typical or atypical features R-R intervals shorten as PR intervals become longer The typical ECG findings in Mobitz II AV block are as follows: Consecutively conducted beats with the same PR interval are followed by a blocked sinus P wave PR interval in the first beat after the block is similar to the PR interval before the AV block A pause encompassing the blocked P wave is equal to exactly twice the sinus cycle length The typical ECG findings in Mobitz II AV block are as follows: Consecutively conducted beats with the same PR interval are followed by a blocked sinus P wave PR interval in the first beat after the block is similar to the PR interval before the AV block A pause encompassing the blocked P wave is equal to exactly twice the sinus cycle length References Therapeutic Guidelines – Cardiovascular Medscape - Second-Degree Atrioventricular Block Last updated: Time spent: QID:229 2023-2-12 A 47-year-old man has developed central chest pain one hour ago. On examination in the Emergency Department he is sweating profusely, has a BP of 90/60 mmHg and a pulse rate of 50bpm. An ECG shows 2-mm ST elevation in leads II, III, and aVF. Which one of the following is the most common cause of death in pre-hospital setting in this condition? A. Ventricular tachycardia. B. Ventricular fibrillation. C. Bradycardia. D. Asystole. E. Hypotension. Incorrect. Correct answer is B 45% answered correctly Explanation: Correct Answer Is B The clinical and ECG findings are characteristic of inferior ST-elevation myocardial infarction (STEMI). Of all patients experiencing acute myocardial infarction (MI), usually in the form of ST-elevation MI, 25–35% will die of sudden cardiac death (SCD) before receiving medical attention, most often from ventricular fibrillation; however, ventricular tachycardia is the most common arrhythmia early in the course of MI. Patients suspected of having STEMI should be connected to defibrillator on the way to the hospital. Most ventricular fibrillations occur in the first 24 hour post-MI, with a half occurring within the first hour. References Research Gate - The clinical challenge of preventing sudden cardiac death immediately after acute ST-elevation myocardial infarction Last updated: Time spent: QID:230 2023-2-12 A 59-year-old man in brought to the emergency department of a tertiary hospital with compressing chest pain that has started 30 minutes ago.The pain is central in location and radiates to his jaw and left arm. A 12-lead ECG is obtained and is as follows. Which one of the following is the most appropriate management of this patient? A. Fibrinolytic therapy. B. Morphine. C. Aspirin. D. Cardiac catheterization. E. Rescue angioplasty. Incorrect. Correct answer is D 45% answered correctly Explanation: Correct Answer Is D The history is highly suggestive of angina pectoris. On ECG, there is ST elevation in leads I, aVl, V5 and V6 (lateral aspect of the heart) and ST elevation in V3 and V4 indicative of involvement of the anterior wall. The ECG is characteristic of an anterolateral ST-elevation myocardial infarction (STEMI). The most appropriate management of patients with STEMI is emergency reperfusion therapy either by fibrinolytics or percutaneous coronary intervention (PCI) if the presentation is within 12 hours after the onset of chest pain. Since the patient is in a tertiary hospital, PCI is the preferred method of reperfusion therapy. Provided that proper facilities and an experienced cardiac interventionist is available a PCI could be performed with 90 minutes after presentation. Cardiac catheterization is a general term that includes angioplasty, PCI, and balloon angioplasty. (Option A) Fibrinolytics are the preferred method if PCI cannot be performed and the patient has no major risk of bleeding. (Options B and C) Aspirin and morphine have to be administered for every patient with acute coronary syndrome as important steps but they are the primary steps and can be given while the patient is arranged to be transferred to catheterization laboratory. Aspirin could be the correct answer if the question asked about the next step. (Option E) Rescue angioplasty is a term used to describe emergency angiographic coronary intervention after fibrinolytics fail to control the ischemia. References MJA - Guidelines for the management of acute coronary syndromes Therapeutic Guidelines – Cardiovascular Medscape - Acute Coronary Syndrome Last updated: Time spent: QID:231 2023-2-12 Steven is a 65-year-old man, who is a known case of congestive heart failure. He had been stable on enalapril, metoprolol and digoxin until three weeks ago when his wife passed away from breast cancer. Since then, he stopped taking his medication. Today, he is brought to the emergency department by his son, with complaints of shortness of breath, night coughs and ankle edema. On examination, he has a blood pressure of 90/75mmHg, heart rate of 68 bpm, and respiratory rate of 26 breaths per minute. On auscultation, an S3 gallop is noted, but there is no crackle. You decide to start him on medication again. Which one of the following would be the best option to start with? A. Start him on enalapril. B. Start him on metoprolol. C. Start him on digoxin. D. Start him on enalapril, digoxin and metoprolol at the same time. E. Start him on enalapril and metoprolol. Correct 45% answered correctly Explanation: Correct Answer Is A The case describes a patient, with congestive cardiac failure, who has been under control with three medications, but his heart condition has been decompensated due to drug withdrawal. At this moment, and based on physical findings, the patient has not pulmonary edema (no comments on basal crackles). Angiotensin converting enzyme (ACE) inhibitors (e.g. enalapril) improve prognosis in all patients in all grades of heart failure and should be used as initial therapy in all patients. Angiotensin II receptor blockers (ARBs) such as losartan are used when ACE inhibitors cannot be tolerated. Diuretics are added to ACE inhibitors to help control congestive symptoms and signs. Beta blockers should only be started when the patient is stable and euvolemic. As this patient has S3 gallop and ankle edema (signs of hypervolemia), any options suggesting beta blockers (e.g. metoprolol) as initial treatment would be incorrect. Digoxin is used in patients with heart failure if: Heart failure is caused by atrial fibrillation (often in conjuction with beta blockers if the patient is euvolemic) In patients with heart failure, who have sinus rhythm, but medications such as ACE inhibitors, diuretics have not adequately controlled their symptoms In patients with significantly decreased ejection fraction (EF) (5 3 Given the size of the AAA (3.8 cm), it should be monitored every 24 months with ultrasonography. References RACGP - Aortic aneurysms Screening, surveillance and referral Last updated: Time spent: QID:256 2023-2-12 Abdominal ultrasonography of a 68-year-old man for renal colic reveals an abdominal aortic aneurysm 4.5 cm in size as a chance finding. Which one of the following is the most appropriate management of his aneurysm? A. Refer him for elective surgical repair of the aneurysm. B. Repeat sonography in 6 months. C. Repeat sonography in 12 months. D. Repeat sonography in 24 months. E. Arrange for CT angiography. Incorrect. Correct answer is C 45% answered correctly Explanation: Correct Answer Is C Ultrasonography is the preferred method for screening and surveillance of asymptomatic abdominal aortic aneurysms (AAA). Recommended screening intervals for an asymptomatic AAA depends on the size of the aneurysm and is according to the following table: AAA diameter (cm) Surveillance interval (months) 3-3.9 24 4-4.5 12 4.6-5 6 >5 3 Given the size of the AAA (4.5 cm), it should be monitored every 12 months with ultrasonography. References RACGP - Aortic aneurysms Screening, surveillance and referral Last updated: Time spent: QID:257 2023-2-12 Which one of the following is not an indication for surgical repair of an abdominal aortic aneurysm (AAA)? A. AAA more than 5.0 cm in a male patient. B. AAA more than 5.0 cm in a female patient. C. AAA growth more than 1.0 cm/year. D. AAA with back pain. E. AAA with distal thromboembolism. Correct 45% answered correctly Explanation: Correct Answer Is A The following are indications for surgical repair of an aortic aneurysm: Asymptomatic abdominal aortic aneurysm greater than over 5.5 cm in men Asymptomatic abdominal aortic aneurysm over 5.0cm in women Thoracic aortic aneurysm over 6.0 cm Growth of more than 1.0c m/year Symptomatic abdominal aortic aneurysm (abdominal/back pain, distal thromboembolism) An asymptomatic aortic aneurysm of 5.0 cm in a male is not an indication for surgical repair. References RACGP - Aortic aneurysms Screening, surveillance and referral Last updated: Time spent: QID:258 2023-2-12 A 72-year-old man comes to the emergency department complaining of epigastric pain that radiates to his lower back. While waiting for further evaluation in the emergency department, he suddenly collapses. Physical examination shows a blood pressure of 80/50 mmHg and pulse of 110 bpm. He is pale, cold, and sweaty. Which one of the following is the next best step in management? A. Take the patient to the operating theatre immediately. B. Arrange for CT angiography. C. Non-contrast abdominal CT scan. D. ECG. E. Bedside ultrasonography. Incorrect. Correct answer is E 45% answered correctly Explanation: Correct Answer Is E The location of the pain and its radiation to the lower back, followed by signs of shock is consistent with a ruptured abdominal aortic aneurysm as the most likely provisional diagnosis. Before emergent transfer of the patient for surgery (option A), vascular surgeon should be contacted, and the diagnosis should be confirmed with bedside ultrasonography as the most readily available with acceptable sensitivity and specificity. In the meanwhile, resuscitative measures such as intravenous access, fluid administration, and supplemental oxygen should be taken in the emergency department. An ECG (option D) must be obtained pre-operatively but not the priority as the first step in management. Other diagnostic measures such as CT angiography (option B) or non-contrast CT scan (option C) are unnecessary and does not change the management plan. References RACGP - Aortic aneurysms Screening, surveillance and referral Last updated: Time spent: QID:259 2023-2-12 You are called to see a 58-year-old patient, who has presented with complaints of weakness and shortness of breath. A blood test reveals hemoglobin of 85 g/L (120-160). As a part of the workup for finding the cause of his anemia, an abdominal CT scan is performed showing a 10.5 cm infra-renal abdominal aortic aneurysm as an incidental finding. You tell the patient that he needs surgery for treatment of his aneurysm. He wants to know how dangerous it could be if he does not have the surgery. Which one of the following is the mortality rate of a ruptured abdominal aortic aneurysm? A. 10%. B. 25%. C. 50%. D. 80%. E. 100%. Incorrect. Correct answer is D 45% answered correctly Explanation: Correct Answer Is D Rupture of an AAA into the peritoneal cavity is often usually rapidly fatal, whereas, retroperitoneal rupture often stabilizes transiently providing a window of opportunity for life-saving surgical intervention and repair. Collectively, a ruptured AAA is catastrophic and carries a mortality risk of 80-90%. References RACGP - Aortic aneurysms Screening, surveillance and referral Last updated: Time spent: QID:260 2023-2-12 A 72-year-old man is brought to emergency department with ambulance after he sustained a sudden severe chest pain radiating to his back. On auscultation there is a diastolic murmur best heard over the left sternal border in the second intercostal space. ECG shows ST elevation in leads II, III and aVF. A CXR is remarkable for a widened mediastinum. Which one of the following is the most appropriate management? A. Give alteplase. B. Give aspirin, intravenous morphine, and beta blockers. C. Give morphine and beta blockers and arrange for emergency trans-esophageal sonography. D. Refer the patient to cardiology clinic. E. Arrange for emergency angiography. Incorrect. Correct answer is C 45% answered correctly Explanation: Correct Answer Is C The clinical findings of abrupt chest pain radiating to back and a widened mediastinum on CXR are consistent with diagnosis aortic dissection. The diastolic murmur signifies involvement of the proximal aorta resulting in aortic regurgitation and decreased blood flow to the coronary arteries and a consequent myocardial infarction (MI). Thrombolytics (e.g. alteplase) (option A) are absolutely contraindicated when aortic dissection is suspected. Aspirin (option B), clopidogrel and other anticoagulation medications are contraindicated as well due to increased risk of deterioration of the dissection, which is temporarily stable. The cornerstone of initial therapy in this situation is morphine for pain control (and its partial effect on lowering blood pressure) and beta blockers to maintain the systolic blood pressure below 120 mmHg. Trans-esophageal sonography should be emergently performed to confirm the diagnosis.Angiography using CT angiogram (CTA) (option E) is the preferred method if trans- esophageal sonography is not available. (Option C) Referring the patient to a cardiology clinic while he is in the hopsital and in urgent need for intervention is not an appropriate option. References http://www.ncbi.nlm.nih.gov/pmc/articles/PMC186140 http://www.ecinsw.com.au/aortic-dissection Last updated: Time spent: QID:261 2023-2-12 Which one of following is the most common cause of acute coronary syndrome? A. Cocaine toxicity and consequent coronary artery vasospasm. B. Acute thrombosis. C. Chest trauma. D. Arterial inflammation. E. Anxiety. Incorrect. Correct answer is B 45% answered correctly Explanation: Correct Answer Is B Atherosclerotic changes of coronary arteries remain the most common cause of ischemic heart disease. The most common cause of acute coronary syndrome is acute rupture of an atheroma followed by platelet aggregation and thrombus formation. Although other options can lead to acute coronary syndrome, they are far less common. References Medscape - Acute Coronary Syndrome Last updated: Time spent: QID:18 2023-2-12 Which one of the following is the most common cause of acute limb ischemia? A. Congestive heart failure. B. Thrombosis. C. Vasculitis. D. Embolism. E. Smoking. Incorrect. Correct answer is B 45% answered correctly Explanation: Correct Answer Is B Thrombotic occlusion is the most common cause of acute lower limb ischemia accounting for more than 80% of cases. (Option D) Occlusion from embolus is not as common, partly due to decline in rheumatic heart disease and prompt management of patients with atrial fibrillation with prophylactic anticoagulation. Atrial fibrillation accounts for two-thirds of acute limb ischemias due to embolism. (Options A, C and E) Congestive heart failure, vasculitis and smoking are less common risk factors of acute limb ischemia. References http://www.ncbi.nlm.nih.gov/pmc/articles/PMC11177 Last updated: Time spent: QID:262 2023-2-12 Which one of the following signs mandates emergency surgical intervention in acute limb ischemia? A. Pallor. B. Coldness. C. Paralysis. D. Pain at rest. E. Pulselessness. Incorrect. Correct answer is C 45% answered correctly Explanation: Correct Answer Is C Paralysis is present when a patient with acute limb ischemia is unable to wriggle the toes or fingers. It is the most reliable sign indicating acute limb ischemia requiring emergency surgical intervention. Paresthesia of the affected limb is another indicator of acute limb ischemia and can be used in the absence of paralysis. (Option A) Pallor is among the signs suggesting acute limb ischemia; however, the color of the limb may be affected by the ambient light. (Option B) Coldness of the limb is the least reliable sign as it can be due to decreased body temperature of the patient to cold weather. (Option D) Pain (either with exertion or at rest) and pallor can be caused by chronic ischemia as well, and are not reliable indicators of the need for emergency surgical treatment. (Option E) Pulselessness can be a sign of acute limb ischemia, but paralysis remains the most critical indicator. References http://www.ncbi.nlm.nih.gov/pmc/articles/PMC111776 Last updated: Time spent: QID:263 2023-2-12 A 65-year-old man presents to the emergency department with sudden onset right-sided leg pain and paresthesia. On physical examination, the distal pulses of the right leg are absent and the limb is cold. A CT angiography is arranged showing thrombotic occlusion of the right femoral artery. Which one of the following is the next best step in management? A. Intravenous infusion of heparin and emergency embolectomy. B. Intravenous infusion of heparin for 24 hours and review. C. Complete bed rest with compression bandage and leg elevation. D. Start the patient on warfarin. E. Start the patient on aspirin and clopidogrel. Correct 45% answered correctly Explanation: Correct Answer Is A The clinical and imaging findings are quite consistent with acute limb ischemia. Paralysis, paresthesia and compartment syndrome are ominous signs that demand emergency surgical intervention after heparin has been started. The golden time for surgical intervention is 4 hours. Signs of ischemiaare are reversible if prompt action is taken within this period. Prolonged acute ischemia(>6 hours) leaves irreversible and permanent deficits. Heparin cover should be maintained and warfarin started. Heparin then can be safely withheld once the INR is 2-3. Warfarin alone is not recommended as it is pro-coagulation at the beginning. References http://www.ncbi.nlm.nih.gov/pmc/articles/PMC111776 Last updated: Time spent: QID:264 2023-2-12 A 70-year-old man presents with acute pain and paralysis of the right leg diagnosed to have been caused by acute leg ischemia. Heparin is started immediately. After emergency imaging, he is transferred to the operating room for embolectomy. Surgical intervention successfully restored blood supply to the affected limb after 3 hours. This patient is at risk of developing reperfusion injury as a result of prolonged ischemia. Which one of the following is not a characteristic feature of reperfusion injury? A. Hyperkalemia. B. Hypokalemia. C. Metabolic acidosis. D. Myoglobinuria. E. Elevate creatine kinase. Incorrect. Correct answer is B 45% answered correctly Explanation: Correct Answer Is B Reperfusion injury is a complication of blood restoration to a limb, which has been ischemic for a while. Characteristic features of reperfusion injury are all related to ischemia and its impacts on tissue (especially muscle cells). Features of reperfsuion syndrome include: Metabolic acidosis (lactic acidosis) Elevated creatine kinase Hyperkalemia Myoglobinemia and myoglobinuria These findings are caused by hypoxemia resulting in metabolic acidosis, and muscle cell breakdown and release of its cell into the blood. Hypokalemia is not a characteristic feature of reperfusion injury. The extent of the reperfusion injury depends on the following: Duration and the site of arterial blockage The extent of collateral flow to the affected area The previous health of the affected limb Approximately one third of all deaths from arterial occlusions are due to metabolic complications after revascularisation. References http://www.ncbi.nlm.nih.gov/pmc/articles/PMC111776 Last updated: Time spent: QID:265 2023-2-12 A 55-year-old man presents to the emergency department after sudden onset of pain and paresthesia in his left leg. On examination, the distal pulses of the left lower limb are absent and the limb is cold and painful. A CT angiogram is performed and establishes the presence of femoral artery embolism. The patient was started on intravenous heparin and embolectomy was carried out. Which one of the following is the next best step in management? A. Aspirin and warfarin for 6 months. B. Lifelong aspirin. C. Warfarin for 3-6 months. D. Low molecular weight heparin for six months and lifelong warfarin afterwards. E. Heparin for one week. Incorrect. Correct answer is C 45% answered correctly Explanation: Correct Answer Is C Every patient with acute limb ischemia must be started on anticoagulation therapy with warfarin after embolectomy is performed. Heparin cover should not be withheld until the INR is in the therapeutic range of 2-3. Long-term warfarin should be considered following embolism from a cardiac source; otherwise 3-6 months warfarin may suffice. Aspirin is indicated in patients with atherosclerotic changes of the peripheral arteries and chronic limb ischemia. It has no role in management of acute limb ischemia. Combination of aspirin and warfarin is not shown to benefit the patient more than warfarin alone in terms of preventing further thromboembolic events. Furthermore using these two drugs in combination increases the risk of bleeding. Heparin is only used until the INR is in the therapeutic range and withheld afterwards. This goal is usually achieved in 2-3 days. References http://www.ncbi.nlm.nih.gov/pmc/articles/PMC111776 Therapeutic Guidelines – Cardiovascular; available on: http://tg.org.au Last updated: Time spent: QID:267 2023-2-12 A 55-year-old man is on heparin after he developed an acute limb ischemia. Which one of the following tests is used for monitoring the response to anticoagulation therapy with heparin? A. Fibrinogen level. B. Prothrombin time (PT). C. INR. D. Activated partial thromboplastin time (aPTT). E. Bleeding time (BT). Incorrect. Correct answer is D 45% answered correctly Explanation: Correct Answer Is D Activated partial thromboplastin time (aPTT) is used to assess the integrity of the following coagulation pathways: Intrinsic pathway that includes prekallikrein, high molecular weight kininogen and factors VIII, IX, XI, and XII. Common pathway including factors II, V, X, and fibrinogen. aPTT is also used for monitoring the effects of maintenance therapy with heparin. Usually the goal of heparin maintenance therapy is to keep aPTT level 1.5- 2.5 times above patient’s aPTT baseline. When starting heparin therapy, aPTT is measured 6-hourly until it is within therapeutic range of 65-100 seconds, and 24 hourly afterwards. INR is used for monitoring warfarin therapy. It assesses extrinsic coagulation pathway, as does PT. Normal range of PT in an individual not on blood thinners is 11-13.5 seconds. PT and INR are prolonged if the patient is on warfarin, or deficient in factors II (prothrombin), III, IX, X, or fibrinogen, or has vitamin K deficiency. BT is used as a platelet function test with a normal range of 1-9 minutes. It is prolonged if the patient is on antiplatelet medications (aspirin, clopidogrel), has thrombocytopenia, or in those with platelet aggregation disorders e.g. Von-Willebrand disease. BT is not used routinely anymore. References Therapeutic Guidelines - Cardiovascular; available on: http://tg.org.au Last updated: Time spent: QID:268 2023-2-12 A 65-year-old man comes to your practice with complaint of pain in buttock and leg. He has the pain for the past three months, and describes it as cramping felt in the left buttock. The pain is only present when he starts walking and comes on after five minutes or so every time. It radiates to the left thigh and goes away few minutes after he stops walking. Which one of the following is the most likely diagnosis? A. Neurogenic claudication resulting from spinal canal stenosis. B. Stenosis of his left common iliac artery. C. Stenosis of the left superficial femoral artery. D. Osteoarthritis of the right hip joint. E. L4/L5 disc prolapse. Incorrect. Correct answer is B 45% answered correctly Explanation: Correct Answer Is B The nature of the pain (cramping) and its pattern (brought on by walking, relieved by rest) is characteristic of chronic limb ischemia. Exertional buttock pain that is ischemic in nature (buttock claudication) is due to obstruction of either common iliac or external iliac artery. Stenosis of superficial femoral artery leads to ischemic pain of lower leg on walking (calf claudication), not the buttock. (Option A) Spinal canal stenosis usually affects the mid or lower lumbar spine and can cause nerve root impingement presentation, which is pain brought on by standing and relieved by recumbency. Pain distribution is related to the nerve root distribution rather than muscle groups supplied by an involved artery. (Option C) Stenosis of the superficial femoral artery gives rise to leg rather than buttock claudication. (Option D) Osteoarthritis of the hip is associated with pain on activity and relif by rest. The pain is felt in the hip and can radiat to the knee. Buttock pain is not common. (Option E) L4/L5 disc prolapse can result in unilateral nerve root entrapment leading to neurological findings, not necessarily related to walking. The pain of L4/L5 disc prolapse is worse on lifting heavy objects, coughing, sneezing or straining at stool. Numbness and parsthesia are features that are commonly present in nerve root impingement, but not in chronic limb ischemia. References http://emedicine.medscape.com/article/460178-clini http://www.racgp.org.au/afp/2013/june/peripheral-a http://www.awma.com.au/publications/2011_awma_vlug Last updated: Time spent: QID:269 2023-2-12 A 76-year-old man comes to your office for evaluation. He mentions that he has difficulty walking because of the left leg pain. The pain is brought on after walking two blocks and gets better when he stops to rest. On examination, the leg skin is shiny and dark. The legs hair is lost and the muscles are atrophied. Distal pulses are difficult to palpate. Which one of the following is the most likely diagnosis? A. Acute limb ischemia. B. Deep vein thrombosis. C. Superficial vein thrombosis. D. Chronic obstructive arterial disease. E. Spinal canal stenosis. Incorrect. Correct answer is D 45% answered correctly Explanation: Correct Answer Is D Leg pain brought up by walking and relieved by rest and weak or absent distal pulses are characteristic of chronic limb ischemias as a result of chronic obstructive arterial disease. Atrophied muscles and shiny hairless skin supports the diagnosis. The clinical findings in chronic limb ischemia include: Weak or absent distal pulses – the hallmark finding Shiny and hyperpigmented skin Hair loss and leg ulcers Thickened nails Muscular atrophy Vascular bruits (Option A) Acute limb ischemia presents with sudden onset pain, pallor, paralysis, paresthesia, pulselessness and poikilothermia. This patient has features of chronic limb ischemia. (Option B) Leg pain due to deep vein thrombosis can be brought on by walking and relieved by rest (similar to chronic limb ischemia), but other features such as sparse leg hair, pigmentation, muscle atrophy, etc are not feautres of DVT. DVT presents with leg pain and tenderness, swelling and warmth. (Option C) Superficial thrombophlebitis presents with pain, erythema, induration and tenderness along the course of a superficial vein. (Option E) Leg pain caused by neurogenic claudication due to spinal canal stenosis tends to get worse with erect posture and relieved by recumbency. Absence of neurological deficits makes this diagnosis less likely. References http://emedicine.medscape.com/article/460178-clini http://www.racgp.org.au/afp/2013/june/peripheral-a http://www.awma.com.au/publications/2011_awma_vlug Last updated: Time spent: QID:270 2023-2-12 A 60-year-old man presents with leg pain for the past 6 months. The pain becomes worse with walking and is relieved when he rests. There is no pain at rest. He has smoked 20 cigarettes per day for the past 30 years. On examination, he is obese with a BMI of 31 and has a blood pressure of 160/110 mmHg on two readings 20 minutes apart. Distal pulses of the left lower limb, including dorsal pedis, are barely perceptible. The skin of the legs is shiny and hairless. Mild muscular atrophy of the leg is noted. Ankle-brachial index (ABI) is 0.7. Which one of the following would be the most appropriate management and advice? A. Smoking cessation, exercise and follow-up in three months. B. Smoking cessation, statins and ACE inhibitors. C. Duplex Doppler venous ultrasonography. D. Aspirin, metoprolol and statins. E. Referral for vascular surgery. Incorrect. Correct answer is B 45% answered correctly Explanation: Correct Answer Is B With intermittent calf claudication, presence of the risk factors and an ABI of 0.7, the diagnosis of chronic peripheral arterial disease is almost established. Management of peripheral arterial disease includes the following: Smoking cessation - smoking is the most important predisposing factor for peripheral arterial disease (PAD). Smoking cesation alone is associated with an improvement in the distance of pain-free walk, doubled 5-year survival and better post-op outcomes. Exercise – exercise on an as tolerated basis, improves the pain-free walking distance and time and should be advised for all patients. ACE inhibitors – evidence suggests that ACE inhibitors may improve walking ability in patients with intermittent claudication. The ACE inhibitor with greatest evidence of benefit is ramipril. It is unknown if the improvement in walking distance associated with ramipril is due to a class effect of ACE inhibitors or whether it is specific to this medicine. The ABI does not seem to improved though. Statins – statins improve revascularisation, pain-free walking distance and survival. Of all lipid-lowering agents, only statins have been proved to lower the mortality in patients with vascular diseases due to atherosclerotic changes. It should be started for patients with coronary artery disease, PAD, aortic disease (e.g. abdominal aortic aneurysm), carotid artery disease and diabetes mellitus. Clopidogrel and aspirin – they are often prescribed to reduce the overall risk of myocardial infarction and stroke, but are not associated with improvement of PAD symptoms. Beta blockers (e.g. metoprolol) are not indicated in the absence of cardiac disease. They have no effect on PAD. More detailed management of PAD is highly dependent on the severity of the disease. ABI is the mostly used predictor for this purpose. ABI is interpreted as follow: ABI value Interpretation Action Nature of ulcers if present Abnormal vessel stiffness (usually >1.4 Refer routinely from peripheral vascular disease) Venous ulcers 1.0-1.4 Normal Borderline – discussion with a Use full-compression vascular surgeon may be None 0.9 bandage appropriate depending on the patient’s symptoms and risk factor Manage risk factors Mixed ulcers – do not use 60, or age Moderate disease 40-60 and history of DVT/PE or estrogen therapy or other risk factors Major surgery with age4.0) are as follows: Advanced age (65 years and older) Atypical hyperplasia of breast (biopsy proven) Certain inherited genetic mutations ( BRCA1, BRCA2, TP53, ATM, CDH1); RR 4-8 Ductal or lobular carcinoma in situ (DCIS/LCIS); RR 8-10 Family history of early ovarian cancer (age 40) Dense breasts (25-50%, compared with 11-25% mammographically) Benign breast conditions:Non-atypical ductal hyperplasia, fibroadenoma, sclerosing adenosis, microglandular adenosis, papillomatosis, radial scar Never breastfed a child Nulliparity (no full-term pregnancies) Late menopause (age >55) Type II diabetes mellitus Obesity (post-menopausal) Personal history of uterine, ovarian, or colon cancer Recent and long-term use of hormone replacement therapy (HRT) containing estrogen and progestin Recent oral contraceptive use Occupation: night shift Tobacco abuse Sedentary lifestyle Inferior cardiovascular health High bone mineral density Factors that reduce risk of breast cancer (RR 2cm OR lymphangitic Dicloxacillin/ flucloxacillin streaking OR extension beyond superficial fascia, deep-tissue Moderate infection abscess, gangrene OR extension to muscle, tendon, joint or bone; NO Metronidazole must be added if the wounds discharges are systemic involvement odorous (anaerobe activity) Piperacillin + tazobactam or Infection as above AND systemic toxicity or metabolic instability e.g. Severe infection fever, chills, tachycardia, hypotension, confusion, vomiting, Ticarcillin + clavulanate or (if penicillin allergic) leukocytosis, sever hyperglycemia, or azotemia Ciprofloxacin PLUS either clindamycin or lincomycin This patient has a 1cm ulcer. There is no comment regarding surrounding inflammation or cellulitis to suggest infection. Moreover, the wound secretions are clear and non- infective. Management of such wounds, after initial debridement, includes deep wound swabs (if not already taken) and wound dressing and daily check to assess the healing process. Although numerous topical medications and gels are promoted for ulcer care, relatively few have proved to be more efficacious than warm wet dressing. NOTE – If the presence of peripheral vascular disease, dry wound dressing should be applied and the patient referred for specialist vascular assessment and care. (Options A and B) Antibiotics are used when the wound is associated with infection/inflammation. Oral amoxicillin-clavulanate is indicated for ulcers with minimal infection or those without signs of infection but with odorous secretions. Parenteral antibiotics are indicated when there is marked infection. For deep or widespread infections or those associated with osteomyelitis, antibiotics such as piperacillin- tazobactam, ticarcillin-clavulanate, meropenem, ertapenem, carbapenem, moxifloxacin, or ciprofloxacin PLUS metronidazole, or a third-generation cephalosporin PLUS metronidazole are used. (Option C) MRI is indicated where osteomyelitis is suspected based on clinical or laboratory studies. (Option E) Topical antiseptics, such as povidone iodine, are toxic to the healing wound. References NPS - Managing foot infections in patients with diabetes MJA - Australian Diabetes Foot Network: management of diabetes-related foot ulceration — a clinical update Therapeutic Guidelines – Antibiotics Last updated: Time spent: QID:1132 2023-2-12 Which one of the following tests is most likely to differentiate hypercalcemia caused by hyperparathyroidism and cancer? A. PTH. B. Calcium level. C. Phosphate. D. Alkaline phosphatase. E. Vitamin D level. Correct 45% answered correctly Explanation: Correct Answer Is A Primary hyperparathyroidism and malignancy are the most common causes of hypercalcemia, accounting for more than 90% of cases. Primary hyperthyroidism is the more common of these two. It is usually not difficult to differentiate between them. Malignancy is often evident clinically by the time it causes hypercalcemia, and patients with hypercalcemia of malignancy have higher calcium concentrations and are more symptomatic from hypercalcemia compared to individuals with primary hyperparathyroidism. However, it may be difficult to differentiate the two problems clinically when the presentation is less typical. As an example, some patients with occult malignancy may present with mild hypercalcemia. Alternatively, patients with hyperparathyroidism can occasionally have acute onset of severe, symptomatic hypercalcemia (parathyroid crisis). In such cases, measurement of intact PTH usually distinguishes these two conditions. Intact PTH concentrations are generally undetectable or very low in hypercalcemia of malignancy and are elevated or high-normal in primary hyperparathyroidism. It is uncommon for patients with hypercalcemia of malignancy to have elevated PTH levels. A suppressed PTH level is often indicative of malignancy. However, in rare cases there might be concomitant primary hyperparathyroidism or a PTH secreting tumor. References http://www.uptodate.com/contents/primary-hyperpara Last updated: Time spent: QID:1072 2023-2-12 A 30-year-old man presents to your practice with complaints of anxiety and palpitation. He mentions that he is always afraid that something bad is going to happen soon. On examination, he has a blood pressure of 160/80mmHg and heart rate of 110bpm. His palms are wet. Which one of the following is the most likely diagnosis? A. Hyperthyroidism. B. Panic disorder. C. Pheochromocytoma. D. Generalized anxiety disorder. E. Hypothyroidism. Correct 45% answered correctly Explanation: Correct Answer Is A There are some points to take into consideration in this scenario. First is the feeling of ‘always afraid that something bad is going to happen soon’. This subjective feeling also described as ‘impending doom’ often indicates the presence of anxiety and can be seen during a panic attack, in patients with pheochromocytoma, and in those with hyperthyroidism and thyrotoxicosis. Impending doom is described by patients as if something very bad is just about to happen but they do not know what it is, or as if the world is going to end, or like they are going to die of a heart attack. Some other conditions that can cause such sensation include: Generalized anxiety disorder Temporal lobe epilepsy Excessive caffeine use Sleep deprivation Depression in adults Agoraphobia Thyroid storm Hyperthyroidism Hyperventilation Hypopituitarism Anaphylaxis Increased perspiration and palpitation are features seen almost in every hypermetabolic and hypersympathetic state. Sweaty hands can be seen in episodic attacks of pheochromocytoma, hyperthyroid states, anxiety, and during a panic attack. Pheochromocytoma, hyperthyroidism and acute panic attack can present with tachycardia and hypertension. Unless the patient is experiencing an acute panic attack right now, it does not seem to be the case. Elevated blood pressure on examination goes against generalized anxiety disorder (option D) and panic disorder (option B), making these two less likely, but still possible. Sustained elevation of blood pressure is not a typical feature of anxiety disorders. In fact, of the options, pheochromocytoma and hyperthyroidism top the list of differentials. The most common presentation of pheochromocytoma is with episodic headache, tachycardia, hypertension, anxiety and sweating. Although some patients with pheochromocytoma appears to have sustained increased blood pressure, the absence of headache, which is one of the components of the classic triad of the disease (headache, palpitation, and diaphoresis), makes pheochromocytoma (option C) less likely. Moreover, there is no comment regarding episodic nature of the symptoms. Having said these, hyperthyroidism would be the most likely diagnosis. Anxiety, the senses of something bad is going to happen, palpitations, sweatiness and elevated systolic blood pressure are reasonably justified by such a diagnosis. The most frequent symptoms of hyperthyroidism are nervousness (anxiety), heat intolerance, palpitations, and fatigue and weight loss. Common signs on examination include agitation, sinus tachycardia, elevated systolic blood pressure, fine tremors and hyper-reflexia. Hypothyroidism (option E) causes bradycaria and dry skin, and is not associated with anxiety and the sense of impending doom References UpToDate - Overview of the clinical manifestations of hyperthyroidism in adults Medscape - Hyperthyroidism and Thyrotoxicosis Medscape - Panic Disorder Medscape - Pheochromocytoma Last updated: Time spent: QID:1068 2023-2-12 A 30-year-old man presents to your practice with complaints of anxiety and palpitation. He mentions that he is always afraid that something bad is going to happen soon. On examination, he has a blood pressure of 160/80mmHg and heart rate of 110bpm. His palms are wet. Which one of the following is the most likely diagnosis? A. Hyperthyroidism. B. Panic disorder. C. Pheochromocytoma. D. Generalized anxiety disorder. E. Hypothyroidism. Correct 45% answered correctly Explanation: Correct Answer Is A There are some points to take into consideration in this scenario. First is the feeling of ‘always afraid that something bad is going to happen soon’. This subjective feeling also described as ‘impending doom’ often indicates the presence of anxiety and can be seen during a panic attack, in patients with pheochromocytoma, and in those with hyperthyroidism and thyrotoxicosis. Impending doom is described by patients as if something very bad is just about to happen but they do not know what it is, or as if the world is going to end, or like they are going to die of a heart attack. Some other conditions that can cause such sensation include: Generalized anxiety disorder Temporal lobe epilepsy Excessive caffeine use Sleep deprivation Depression in adults Agoraphobia Thyroid storm Hyperthyroidism Hyperventilation Hypopituitarism Anaphylaxis Increased perspiration and palpitation are features seen almost in every hypermetabolic and hypersympathetic state. Sweaty hands can be seen in episodic attacks of pheochromocytoma, hyperthyroid states, anxiety, and during a panic attack. Pheochromocytoma, hyperthyroidism and acute panic attack can present with tachycardia and hypertension. Unless the patient is experiencing an acute panic attack right now, it does not seem to be the case. Elevated blood pressure on examination goes against generalized anxiety disorder (option D) and panic disorder (option B), making these two less likely, but still possible. Sustained elevation of blood pressure is not a typical feature of anxiety disorders. In fact, of the options, pheochromocytoma and hyperthyroidism top the list of differentials. The most common presentation of pheochromocytoma is with episodic headache, tachycardia, hypertension, anxiety and sweating. Although some patients with pheochromocytoma appears to have sustained increased blood pressure, the absence of headache, which is one of the components of the classic triad of the disease (headache, palpitation, and diaphoresis), makes pheochromocytoma (option C) less likely. Moreover, there is no comment regarding episodic nature of the symptoms. Having said these, hyperthyroidism would be the most likely diagnosis. Anxiety, the senses of something bad is going to happen, palpitations, sweatiness and elevated systolic blood pressure are reasonably justified by such a diagnosis. The most frequent symptoms of hyperthyroidism are nervousness (anxiety), heat intolerance, palpitations, and fatigue and weight loss. Common signs on examination include agitation, sinus tachycardia, elevated systolic blood pressure, fine tremors and hyper-reflexia. Hypothyroidism (option E) causes bradycaria and dry skin, and is not associated with anxiety and the sense of impending doom References UpToDate - Overview of the clinical manifestations of hyperthyroidism in adults Medscape - Hyperthyroidism and Thyrotoxicosis Medscape - Panic Disorder Medscape - Pheochromocytoma Last updated: Time spent: QID:1068 2023-2-12 A 64-year-old woman presents to your practice with complaints of palpitation and anxiousness. She has past medical history of hypertension and ischemic heart disease. He also has hypothyroidism, for which she is currently on levothyroxine 150 mcg, daily. Based on the history and clinical findings, you suspect hyperthyroidism caused by overtreatment of her hypothyroidism. A serum thyroid stimulation hormone (TSH) confirms the diagnosis. You decrease the dose of levothyroxine to 100 mcg, daily. When you should perform a follow-up TSH level again? A. After one day. B. After one week. C. After two weeks. D. After four weeks. E. After six months. Incorrect. Correct answer is D 45% answered correctly Explanation: Correct Answer Is D Thyrotoxicosis is common in the Australian community and is frequently encountered in general practice. The most frequent symptoms of thyrotoxicosis are nervousness, heat intolerance, palpitations, fatigue and weight loss despite increased appetite (weight gain occurs in 10% of patients). Common signs on examination include agitation, sinus tachycardia, fine tremor and hyper- reflexia. Elderly patients often present with nonspecific symptoms. Up to 20% of the elderly patients have atrial fibrillation (AF). Most presentations of thyrotoxicosis are due to Graves disease, toxic multinodular goiter, toxic adenoma and thyroiditis. Graves disease is by far the most common cause of thyrotoxicosis. Exogenous thyroid hormone is another cause of thyrotoxicosis. Exposure to excess thyroid hormone usually occurs with overtreatment of hypothyroidism and intentional ingestion in factitious disorder. Overtreatment with thyroid hormone should always be suspected when a patient, who is on with thyroxin replacement therapy for hypothyroidism, presents with signs and symptoms of hyperthyroidism. This patient has presented with the history and clinical findings consistent with hyperthyroidism and thyrotoxicosis. The diagnosis is established with presence of depressed TSH levels. As the most appropriate option, thyroxin should be discontinued or the dose reduced. When therapy is stopped, serum T4 concentration falls about 50% in 7 days. Response to treatment should be monitored at 4-to 6-week intervals, and dose adjustment performed until the patient is euthyroid again. NOTE - After starting the treatment of hypothyroidism, the first follow-up with TSH should be performed in 6-8 weeks. This is different from the above where followup after dose reduction is required. References RACGP - Evaluating and managing patients with thyrotoxicosis UpToDate - Exogenous hyperthyroidism Last updated: Time spent: QID:1041 2023-2-12 A 29-year-old woman presents to your GP clinic with complaints of mood swings, palpitation, and fine tremors for the past few weeks. Laboratory tests are ordered and the results are remarkable for a decreased TSH level and normal T3 and T4. Which one of the following is most likely to be the cause of this presentation? A. Grave’s disease. B. Pregnancy. C. A toxic thyroid nodule. D. Hyperthyroidism. E. Hypothyroidism. Correct 45% answered correctly Explanation: Correct Answer Is A The constellation of symptoms is suggestive of hyperthyroidism. The laboratory findings consistent with the diagnosis are expected to be a subnormal TSH with elevated serum T4, T3, or both. This patient has a subnormal TSH level in the presence of normal T3 and T4 values – an entity termed subclinical hyperthyroidism. It should be noted that subclinical versus overt hyperthyroidism are only biochemical definitions because hyperthyroid symptoms may be present in those with subclinical hyperthyroidism, and absent in those with overt hyperthyroidism. In other words any patient with suboptimal TSH and symptoms of thyrotoxicosis such as palpitations, sweating, increased appetite, tremors, etc. has hyperthyroidism despite of normal T4 and T3. The cause of subclinical hyperthyroidism are the same as the causes of overt hyperthyroidism with Graves disease being the most common cause for both. (Option C) A

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