Cardiology Exam For FCPS part 1 with Dr Sohrab

A 32-year-old man arrives at the emergency department. He has suffered from a non-productive cough for the past day or so, and has been a little under the weather. He attends on this occasion because of severe substernal chest pain that is aggravated by coughing, inspiration, and lying flat. When you examine him in the emergency department, he is hunched forward and clutching his chest. He is pyrexial, 37.8 °C and complains bitterly of pain. His blood pressure is 145/87 mmHg, and pulse is 85 bpm and regular. On examination he has a pericardial rub. Which one of the following is the change on the electrocardiogram (ECG) you are most likely to see?

A 50-year-old woman is referred to out-patients for a previously asymptomatic atrial septal defect (ASD). She is new to the area and was last seen around 10 years ago in her previous local hospital. She is a smoker but without other significant medical history. She now complains of shortness of breath on exertion, together with peripheral oedema. Clinical examination reveals her to be clubbed and cyanosed. Her pulse rate is 90 bpm and blood pressure 98/60 mmHg. Echo demonstrates a dilated right heart with an estimated right ventricular pressure of 90 mmHg and significant tricuspid and pulmonary regurgitation. What is the likely diagnosis?

A 55-year-old man presents to the emergency department with crushing pain in the centre of the chest radiating to the left arm. He has a history of type-II diabetes mellitus (for which he takes metformin) and angina (for which he takes bisoprolol) for symptom control. From his physical examination and electrocardiogram (ECG) findings you suspect a right ventricular myocardial infarction. Right ventricular myocardial infarction is characterised by which one of the following?

ST-segment elevation in leads II, III and aVF
Occlusion of the left coronary artery
Marked pulmonary vascular congestion
A rise in systolic blood pressure
Absent Kussmaul’s sign

A 30-year-old woman presents with a 3-month history of breathlessness. On auscultation, there is a midsystolic click and a late systolic murmur. Her ECG shows T-wave inversions in leads II and III, and aVF. Which one of the following statements concerning her condition is true?

Coronary artery disease is highly likely in this case
The click and murmur is likely to occur earlier in systole when the patient stands
An exercise stress test would likely show severe ST depression
Asymmetrical hypertrophy of the interventricular septum is revealed on echocardiography
Primary prophylactic ICD insertion should be considered

A 67-year-old man is admitted to the Emergency Department with complete heart block. He has a past medical history of ischaemic heart disease, diabetes mellitus type 2 and smoking-related airways disease. He takes medication for his heart disease and diabetes mellitus. On physical examination, his blood pressure is 100/80 mmHg, with heart rate 30 bpm and irregular. Which of the following would you most expect on auscultation?

A 17-year-old boy is reviewed in the clinic with increasing shortness of breath. He and his family have not consulted medical services for many years. On examination, he looks mildly cyanosed at rest and has a respiratory rate of 21/min. His blood pressure is 122/51 mmHg, and he has a pulse of 105 bpm. He has a continuous machinery murmur, loudest in the left upper chest, which is accentuated partially in systole. Colour-flow Doppler echocardiography identifies flow directly between the aortic arch and pulmonary artery. There are signs of pulmonary hypertension. Given the probable diagnosis, what is the likely nature of his pulse on clinical examination?

You are asked to review a 71-year-old man on the cardiology ward. He underwent stenting of coronary artery 3 days previously. He has a history of type-2 diabetes mellitus and ischaemic heart disease. Currently, he is asymptomatic. On examination, his blood pressure is 130/80 mmHg, heart rate is 60 bpm, and he has no abnormality on examination of the chest or heart. He has been treated post-procedure with aspirin and clopidogrel. Which one of the following correctly describes the mechanism of action of clopidogrel?

A 62-year-old man presents to the Emergency Department after haveing two transient episodes of loss of consciousness but feels fine at present. He has underlying ischaemic heart disease. Both episodes were preceded by a feeling of dizziness and ‘vision going black’. Witnesses report that he went very pale and then collapsed, lying motionless for a few seconds before making a rapid recovery. No abnormal movements were seen during the period of unconsciousness and there were no external signs of a head injury. His blood pressure is 135/75 mmHg and has a heart rate of 70 bpm and regular. There are bibasal crackles on auscultation of the chest; heart sounds are normal. Routine bloods are unremarkable, and a chest X-ray reveals cardiomegaly. Which of the following investigations should be ordered next?

A 21-year-old man with Down syndrome presents to the Emergency Department with worsening shortness of breath. He tells you this has increased significantly over the last few months and he is now unable to go out with his friends. On examination, he is clubbed and cyanosed at rest, his BP is 145/82 mmHg and pulse is 85/min. The patient has previously been noted to have a harsh systolic murmur at the left sternal edge which is now less audible. Routine chest X-ray carried out by his GP a few weeks earlier shows prominent pulmonary vasculature, but nil else of note. Which of the following is the most likely diagnosis?

A 35-year-old woman of African origin presents with a 4-month history of increasing swelling over her feet and abdominal distension. She has no history of cough, orthopnoea or breathlessness on exertion. Her heart rate is 98 bpm: irregularly irregular. Her JVP is markedly raised and she has pitting lower limb oedema. The heart sounds are soft, and there are no audible murmurs. Abdominal examination reveals hepatomegaly along with ascites. Chest X-ray reveals a normal cardiac size and clear lung fields. A lateral X-ray shows calcification around the heart border. Urinalysis is normal. Her ECG shows a low QRS voltage and lateral T-wave changes. What is the likely diagnosis?

A 54-year-old man is referred with increased swelling of his ankles and abdomen, and a degree of shortness of breath on exertion. His jugular venous pressure (JVP) is elevated with prominent x- and y-descents. Apex beat is normal. ECG shows atrial fibrillation with widespread non-specific ST-segment abnormalities. Echo reveals preserved left ventricular systolic function with biatrial enlargement and an estimated pulmonary artery systolic pressure of around 60 mmHg. Chest X-ray shows atrial enlargement but no other abnormalities. What is the most likely cardiac diagnosis?

A 35-year-old woman gives a history of progressive exertional dyspnoea and fatigue over the last year. Examination reveals features of right-sided heart failure with pulmonary hypertension, but there are no crackles to suggest fibrosis. Pulmonary function testing rules out obstructive airways disease. Lung perfusion scanning and pulmonary angiography fail to detect pulmonary thromboembolic disease. An echocardiogram shows enlarged right heart chambers. ANCA and HIV testing are negative. Which one of the following is the likely diagnosis?

A 34-year-old professional footballer is evaluated for symptoms of ‘dizziness’ during exercise. Physical examination reveals a laterally displaced apical impulse. On auscultation, there is a 2/6 mid-systolic murmur in the aortic area that increases on sudden standing. The ECG shows LVH and Q waves in the V2–V5 leads. What is the most likely diagnosis?

An 18-year-old man with Marfan syndrome attends for review in the cardiology clinic, after an abnormal screening electrocardiogram that showed left axis deviation and prominent Q waves in II, III, aVF and V3–V6. His blood pressure is 140/60 mmHg and his heart rate is 70 bpm. Which cardiac abnormality is most likely?

A 55-year-old African-American businessman attends clinic with a 12 months history of intermittent pain in his legs. He notices the pain when he is walking to the train station, but once he is sitting on the train, it recedes. He does not have any arm pain or chest pain, and is otherwise well. On examination, he looks comfortable. His left arm blood pressure is 156/110 mmHg and the right arm is 132/80 mmHg. The radial pulse volume is unequal, but there is no radioradial or radio-femoral delay. Regular blood pressure readings remain constant 3 months later. What is the most likely explanation for the difference in blood pressure between his left and right arm?

A 26-year-old woman attends her GP for an insurance medical. Her previous medical history is unremarkable. On examination, her BMI is 21, blood pressure is 105/62 mmHg, and auscultation of the heart reveals a mid systolic click and a late systolic murmur at the apex, which is accentuated in the standing position. What diagnosis fits best with this clinical picture?

A 45-year-old man attends for review. He has been suffering increasing shortness of breath over the past few years. He is a non-smoker who drinks 20 units per week of alcohol and has no significant past cardiovascular history. Now he presents with what seems to have been a transient ischaemic attack (TIA), with weakness and co-ordination problems affecting his left side, which have resolved over the past 24 hours. On examination blood pressure is 142/95 mmHg and he is in sinus rhythm. There is no opening snap, but there is a diastolic murmur, which changes in character according to posture. C-reactive protein (CRP) is just above the normal range. Which one of the following diagnoses fits best with this clinical picture?

A 62-year-old man presents with central crushing chest pain, palpitations and a syncopal episode, which occurred in the local supermarket. He has a history of ischaemic heart disease and has suffered a previous inferior myocardial infarction. He arrives in the Emergency Department with a broad complex tachycardia and a pulse approaching 200 BPM on the monitor. His BP is 95/60 mmHg. Which of the following would prompt you to think that this is VT rather than SVT with aberrant conduction if you saw it on the 12-lead ECG?

A 67-year-old man with chronic heart failure is reviewed in the cardiology clinic. He has a history of ischaemic heart disease as a cause of his chronic heart failure. He is currently taking a number of medications and would like a review of his drug therapy. Which one of the following treatments has no proven mortality benefit?

A 64-year-old woman presents with an episode of syncope while out shopping. On more direct questioning she also reports a few episodes of fast regular palpitations, which she is able to tap out on her hand. She is discharged to await an outpatient 24-h ECG Holter recording. Unfortunately, she is readmitted after suffering a fit while in bed, her husband felt her pulse at the time and claims that she was pulseless for a few seconds. What diagnosis fits best with this clinical picture?

A 62-year-old man presents to the clinic with increasing shortness of breath. He has a history of smoking 10 cigarettes per day and hypertension for which he takes ramipril 10 mg daily. On examination his BP is 152/87 mmHg, his pulse is 75 bpm and there is reversed splitting of the second heart sound. There are no signs of cardiac failure. Which one of the following is the most likely finding?

A 40-year-old salesman presents with frequent flushing of his face and neck, abdominal pain, watery diarrhoea, fatigue, breathlessness, anorexia and nausea. On examination, there is jugular venous distension with prominent v waves, hepatomegaly and dependent oedema. On auscultation, a blowing pan-systolic murmur is heard on inspiration at the lower left sternal edge. What is the most likely cardiac abnormality in this case?

A 56-year-old man presents to the cardiology clinic for review. He has known tricuspid regurgitation. On examination, his blood pressure is 130/80 mmHg and his heart rate is 60 bpm. His chest is clear and he has no peripheral oedema. Which part of the jugular venous pressure (JVP) waveform is likely to be most prominent?

A 17-year-old girl with a history of Turner’s syndrome attends the reproductive endocrinology clinic for routine follow up. She has a history of hypertension which is managed with amlodipine, but nil else of note. On examination her BP is 142/82 mmHg, and there is a systolic murmur best heard at the right sternal edge. Which of the following is the most likely cause of the murmur?

A 36-year-old woman presents with a cerebral infarct following treatment for a deep vein thrombosis. Cardiovascular examination is entirely normal What is the most likely underlying cardiac abnormality?