- Email: [email protected]
CPD – questions
SELF ASSESSMENT/CPD
Self-assessment/CPD
in association with
This self-assessment section is brought to you in association with Elsevier’s ExamPrep (www.elsevierexamprep.co.uk/individual). Every month we will feature three MRCP (UK) style questions based on the chapter’s topic. Answers are provided online only at www.medicinejournal.co.uk/content/cpd
Questions
Select the ONE single best answer from the five alternatives:
Question 1 A 45-year-old man presented with a 6-week history of progressive breathlessness. He had previously been fit but at a routine examination 3 years previously an asymptomatic cardiac murmur had been found.
collapsed and died suddenly during a football match. His death was reported as being of natural causes.
On examination, the apex beat was displaced to the anterior axillary line in the sixth interspace and a loud pansystolic murmur, maximal in the axilla, was heard over the whole precordium.
Investigations
Clinical examination revealed normal heart sounds with no added sounds or murmurs.
ECG Echocardiography
Investigations Chest X-ray ECG Transthoracic echocardiogram
Exercise testing Cardiomegaly but clear lung fields Sinus rhythm with left ventricular hypertrophy Degenerative mitral valve with a flail posterior mitral leaflet and severe mitral regurgitation, left atrial dilatation, left ventricular enlargement and mildly impaired left ventricular function
24-h Holter monitor
Sinus rhythm. No repolarization anomalies. QT interval of 430 ms Good bi-ventricular function. Maximal left ventricular wall thickness 11 mm Test discontinued after 14 min of the Bruce protocol. The patient developed bi-directional ventricular tachycardia that resolved spontaneously on cessation of exercise. The tachycardia was associated with palpitations and dizziness One episode of ventricular tachycardia while sprinting
What is the most appropriate treatment? What is the most appropriate management? A
anticoagulation replacement
followed
by
mitral
valve
A
amiodarone
B
bisoprolol
C
disopyramide
B
coronary artery bypass grafting
D
flecainide
C
furosemide and ramipril
E
verapamil
D
furosemide and ramipril followed by mitral valve repair if he fails to improve
E
mitral valve repair without further delay
Question 3 A 35-year-old man presented to the Accident and Emergency Department with a 1-week history of intermittent chest pain, breathlessness and malaise. The pain was sharp and central, and worsened by lying flat and with deep breathing. He had initially experienced myalgia that later abated. He had a history of similar episodes that had been treated with ibuprofen and he had begun taking this again. He was a non-smoker.
Question 2 An 18-year-old tri-athlete presented with a 2-month history of regular episodes of palpitations. He experienced these on exertion, particularly during 200e400 m sprints. They were of sudden onset, fast and regular, and occasionally associated with shortness of breath and dizzy spells. His symptoms subsided within a few minutes of stopping exercise. He had never experienced syncope, had no other medical history of note and was taking no medical treatment. His paternal uncle had
MEDICINE 42:11
On examination, his temperature was 38 C, his pulse was 90 beats/min, his blood pressure was 120/75 mmHg with no paradoxical pulse, and his jugular venous pressure
676
SELF ASSESSMENT/CPD
was not elevated. A rub was heard widely over the precordium on leaning forward during auscultation. Breath sounds were normal. Investigations ECG Chest X-ray
Sinus rhythm with widespread 1 mm ST elevation and biphasic T waves Normal
What is the most appropriate next step in management? A
add aspirin
B
add colchicine
C
add prednisolone
D
refer for pericardiectomy
E
substitute indometacin
For the answers, please visit
www.medicinejournal.co.uk/content/cpd For exclusive offers on ExamPrep, go to
www.elsevierexamprep.co.uk/ individual
MEDICINE 42:11
677
Self-assessment/CPD
in association with
This self-assessment section is brought to you in association with Elsevier’s ExamPrep (www.elsevierexamprep.co.uk/individual). Every month we will feature three MRCP (UK) style questions based on the chapter’s topic. Answers are provided online only at www.medicinejournal.co.uk/content/cpd
Questions
Select the ONE single best answer from the five alternatives:
Question 1 A 45-year-old man presented with a 6-week history of progressive breathlessness. He had previously been fit but at a routine examination 3 years previously an asymptomatic cardiac murmur had been found.
collapsed and died suddenly during a football match. His death was reported as being of natural causes.
On examination, the apex beat was displaced to the anterior axillary line in the sixth interspace and a loud pansystolic murmur, maximal in the axilla, was heard over the whole precordium.
Investigations
Clinical examination revealed normal heart sounds with no added sounds or murmurs.
ECG Echocardiography
Investigations Chest X-ray ECG Transthoracic echocardiogram
Exercise testing Cardiomegaly but clear lung fields Sinus rhythm with left ventricular hypertrophy Degenerative mitral valve with a flail posterior mitral leaflet and severe mitral regurgitation, left atrial dilatation, left ventricular enlargement and mildly impaired left ventricular function
24-h Holter monitor
Sinus rhythm. No repolarization anomalies. QT interval of 430 ms Good bi-ventricular function. Maximal left ventricular wall thickness 11 mm Test discontinued after 14 min of the Bruce protocol. The patient developed bi-directional ventricular tachycardia that resolved spontaneously on cessation of exercise. The tachycardia was associated with palpitations and dizziness One episode of ventricular tachycardia while sprinting
What is the most appropriate treatment? What is the most appropriate management? A
anticoagulation replacement
followed
by
mitral
valve
A
amiodarone
B
bisoprolol
C
disopyramide
B
coronary artery bypass grafting
D
flecainide
C
furosemide and ramipril
E
verapamil
D
furosemide and ramipril followed by mitral valve repair if he fails to improve
E
mitral valve repair without further delay
Question 3 A 35-year-old man presented to the Accident and Emergency Department with a 1-week history of intermittent chest pain, breathlessness and malaise. The pain was sharp and central, and worsened by lying flat and with deep breathing. He had initially experienced myalgia that later abated. He had a history of similar episodes that had been treated with ibuprofen and he had begun taking this again. He was a non-smoker.
Question 2 An 18-year-old tri-athlete presented with a 2-month history of regular episodes of palpitations. He experienced these on exertion, particularly during 200e400 m sprints. They were of sudden onset, fast and regular, and occasionally associated with shortness of breath and dizzy spells. His symptoms subsided within a few minutes of stopping exercise. He had never experienced syncope, had no other medical history of note and was taking no medical treatment. His paternal uncle had
MEDICINE 42:11
On examination, his temperature was 38 C, his pulse was 90 beats/min, his blood pressure was 120/75 mmHg with no paradoxical pulse, and his jugular venous pressure
676
SELF ASSESSMENT/CPD
was not elevated. A rub was heard widely over the precordium on leaning forward during auscultation. Breath sounds were normal. Investigations ECG Chest X-ray
Sinus rhythm with widespread 1 mm ST elevation and biphasic T waves Normal
What is the most appropriate next step in management? A
add aspirin
B
add colchicine
C
add prednisolone
D
refer for pericardiectomy
E
substitute indometacin
For the answers, please visit
www.medicinejournal.co.uk/content/cpd For exclusive offers on ExamPrep, go to
www.elsevierexamprep.co.uk/ individual
MEDICINE 42:11
677