CardioResp ICA
A 55-year-old man presents to the ED with *central crushing chest pain*. He has no co-
morbidities and is not currently taking any medication. On systems enquiry, he mentions
that he has *very itchy skin* and that he occasionally gets *painful, discoloured fingers
and toes*.
Blood tests are as follows:
Haemoglobin 18.0 g/dL (12.5 - 16.5 g/dL)
White cell count 10.9 × 109/L (4.0 - 11 × 109/L)
Platelets 390 × 109/L (150 - 400 × 109/L)
Troponin T 0.32 ng/mL (<0.105 ng/mL)
He is commenced on treatment for ACS and referred to haematology with a likely
diagnosis of which of the following?
myelodysplasia
chronic myeloid leukaemia
essential thrombocythaemia
myelofibrosis
polycythaemia rubra vera - ✔️✔️Polycythaemia rubra vera
Myeloproliferative condition where too many RBCs are made (JAK2 mutation)
Symptoms:
- *itching, burning pain in hands and feet*
- *red/blue discolouration*
- *Post-bath pruritis*/aquagenic pruritis
- Splenomegaly -- early satiety, LUQ pain
- gout
- headache blurred vision
- thrombosis (central crushing chest pain)
He has a high haemoglobin level and is approaching a raised WCC.
Would have *elevated HCT and RCM*
A 77-year-old man presents to the Emergency Department complaining of chest pain
that started one hour ago.
Electrocardiogram shows *ST elevation in leads V2, V3 and V4*. He undergoes
percutaneous coronary intervention.
,Coronary angiography is likely to show a blockage in which blood vessel?
great cardiac vein
left anterior descending artery
right coronary artery
left circumflex artery
left coronary artery - ✔️✔️Left anterior descending
Elevation in V1-V4 = anterior-septal MI
Most likely *left anterior descending artery*
An 85-year-old woman visits her general practitioner (GP) as she has been short of
breath recently. On examination, the GP notices a *third heart sound*
What does a third heart sound represent?
a) the atria contracting against a stiff ventricle
b) the oscillation of blood in a dilated ventricle
c) the ventricles filling rapidly in diastole
d) the opening of the pulmonary valve
e) the closing of the aortic valve - ✔️✔️The ventricles filling rapidly in diastole
_____________________________________
S1 = closure of mitral and tricuspid valves
S2 = closure of aortic and pulmonary valves
S3 = *ventricular filling* (ventricular gallop)
large volume of blood striking a compliant LV
cordae tendinae
(normal in children, if heard in adults associated with *ventricular dilatation - systolic
failure*)
S4 = oscillation of ventricular wall, due to stiffened (non-complicant) ventricle e.g.
hypertropy, ischaemia, old age
ALWAYS ABNORMAL (atrial gallop)
Third heart sound - ✔️✔️Produced by passive filling of the LV --> large volume of blood
*striking very compliant LV wall*
Heard just after S2, is low-pitched
Can be a normal finding in children, pregnant women, athletes.
In older adults often indicates *systolic heart failure* - overly compliant dilated LV
,Fourth heart sound - ✔️✔️S4 atrial gallop sound - heard during filling when atria
contract to force blood into *non-compliant, stiff left ventricle*. The sound is the blood
striking the still ventricle wall.
ALWAYS ABNORMAL - noncompliant LV
Heard just before S1
Sign of diastolic heart failure (LVH) or ischaemia
An 80-year-old man present to his general practitioner (GP) complaining of some chest
pain and shortness of breath over the past three months. On examination, the GP
notices an *ejection systolic murmur*.
Which of the following is most likely to be causing this murmur?
aortic stenosis
hypertrophic obstructive cardiomyopathy
tricuspid stenosis
aortic regurgitation
mitral regurgitation - ✔️✔️Aortic stenosis
*Ejection systolic murmur*
- aortic stenosis (radiates to carotids)
- pulmonary stenosis
- aortic sclerosis; hypertrophic obstructive cardiomyopathy (does not radiate)
A 37-year-old lady presents to the Emergency Department with palpitations. She
appears very anxious. On examination: she is thin; her heart rate is 100 BPM and the
*rhythm is irregularly irregular*. She has a smooth, midline mass in the anterior triangle
of the neck and in addition, she has a lid lag.
What is the most likely underlying cause of her palpitations?
rheumatic fever
ischaemic heart disease
anxiety
thyrotoxicosis
congenital heart disease - ✔️✔️Thyrotoxicosis
Irregularly irregular = atrial fibrillation
A 42-year-old woman has her blood pressure checked by her general practitioner. It is
measured as 140/85 mmHg.
What is the next most appropriate step?
, recheck BP in clinic and take the best of 3 readings
refer for specialist investigations
ambulatory blood pressure monitoring
start on amlodipine
do nothing - ✔️✔️*Ambulatory blood pressure monitoring*
Should offer *ABPM for patients with BP between 140/90 and 180/120* to confirm the
diagnosis of hypertension
Confirm diagnosis of hypertension when clinic blood pressure is 140/90mmHg or higher,
and ABPM average is 135/85mmHg or higher
If 140/90 offer antihypertensives if sign of end organ damage, CVD, renal disease,
diabetes
If 160/100 start on antihypertensives
A 70-year-old man with a *history of angina* presents to the Emergency Department
with a *2 hour history of chest pain*. There are *no dynamic changes seen on ECG*.
Which one of the following investigations is most useful in assessing for myocardial
damage in this patient?
myoglobin
troponin T
aspartate transaminase (AST)
creatinine kinase (CK-MB)
lactate dehydrogenase (LDH) - ✔️✔️Troponin T
Myoglobin = not specific but rises in MI
*Troponins I & T = markers of myocardial damage*
AST = liver enzyme
CK-MB = subtype of CK, more heart specific. Rises 4-6h after MI, returns to normal in a
few days.
LDH = marker of tissue damage, not specific
A 20-year-old medical student is being examined by one of his colleagues who notes a
*systolic murmur*. A cardiologist confirms the existence of a *pansystolic murmur, heard
loudest at the lower left sternal edge*. The student has no symptoms and has no known
medical conditions.
A 55-year-old man presents to the ED with *central crushing chest pain*. He has no co-
morbidities and is not currently taking any medication. On systems enquiry, he mentions
that he has *very itchy skin* and that he occasionally gets *painful, discoloured fingers
and toes*.
Blood tests are as follows:
Haemoglobin 18.0 g/dL (12.5 - 16.5 g/dL)
White cell count 10.9 × 109/L (4.0 - 11 × 109/L)
Platelets 390 × 109/L (150 - 400 × 109/L)
Troponin T 0.32 ng/mL (<0.105 ng/mL)
He is commenced on treatment for ACS and referred to haematology with a likely
diagnosis of which of the following?
myelodysplasia
chronic myeloid leukaemia
essential thrombocythaemia
myelofibrosis
polycythaemia rubra vera - ✔️✔️Polycythaemia rubra vera
Myeloproliferative condition where too many RBCs are made (JAK2 mutation)
Symptoms:
- *itching, burning pain in hands and feet*
- *red/blue discolouration*
- *Post-bath pruritis*/aquagenic pruritis
- Splenomegaly -- early satiety, LUQ pain
- gout
- headache blurred vision
- thrombosis (central crushing chest pain)
He has a high haemoglobin level and is approaching a raised WCC.
Would have *elevated HCT and RCM*
A 77-year-old man presents to the Emergency Department complaining of chest pain
that started one hour ago.
Electrocardiogram shows *ST elevation in leads V2, V3 and V4*. He undergoes
percutaneous coronary intervention.
,Coronary angiography is likely to show a blockage in which blood vessel?
great cardiac vein
left anterior descending artery
right coronary artery
left circumflex artery
left coronary artery - ✔️✔️Left anterior descending
Elevation in V1-V4 = anterior-septal MI
Most likely *left anterior descending artery*
An 85-year-old woman visits her general practitioner (GP) as she has been short of
breath recently. On examination, the GP notices a *third heart sound*
What does a third heart sound represent?
a) the atria contracting against a stiff ventricle
b) the oscillation of blood in a dilated ventricle
c) the ventricles filling rapidly in diastole
d) the opening of the pulmonary valve
e) the closing of the aortic valve - ✔️✔️The ventricles filling rapidly in diastole
_____________________________________
S1 = closure of mitral and tricuspid valves
S2 = closure of aortic and pulmonary valves
S3 = *ventricular filling* (ventricular gallop)
large volume of blood striking a compliant LV
cordae tendinae
(normal in children, if heard in adults associated with *ventricular dilatation - systolic
failure*)
S4 = oscillation of ventricular wall, due to stiffened (non-complicant) ventricle e.g.
hypertropy, ischaemia, old age
ALWAYS ABNORMAL (atrial gallop)
Third heart sound - ✔️✔️Produced by passive filling of the LV --> large volume of blood
*striking very compliant LV wall*
Heard just after S2, is low-pitched
Can be a normal finding in children, pregnant women, athletes.
In older adults often indicates *systolic heart failure* - overly compliant dilated LV
,Fourth heart sound - ✔️✔️S4 atrial gallop sound - heard during filling when atria
contract to force blood into *non-compliant, stiff left ventricle*. The sound is the blood
striking the still ventricle wall.
ALWAYS ABNORMAL - noncompliant LV
Heard just before S1
Sign of diastolic heart failure (LVH) or ischaemia
An 80-year-old man present to his general practitioner (GP) complaining of some chest
pain and shortness of breath over the past three months. On examination, the GP
notices an *ejection systolic murmur*.
Which of the following is most likely to be causing this murmur?
aortic stenosis
hypertrophic obstructive cardiomyopathy
tricuspid stenosis
aortic regurgitation
mitral regurgitation - ✔️✔️Aortic stenosis
*Ejection systolic murmur*
- aortic stenosis (radiates to carotids)
- pulmonary stenosis
- aortic sclerosis; hypertrophic obstructive cardiomyopathy (does not radiate)
A 37-year-old lady presents to the Emergency Department with palpitations. She
appears very anxious. On examination: she is thin; her heart rate is 100 BPM and the
*rhythm is irregularly irregular*. She has a smooth, midline mass in the anterior triangle
of the neck and in addition, she has a lid lag.
What is the most likely underlying cause of her palpitations?
rheumatic fever
ischaemic heart disease
anxiety
thyrotoxicosis
congenital heart disease - ✔️✔️Thyrotoxicosis
Irregularly irregular = atrial fibrillation
A 42-year-old woman has her blood pressure checked by her general practitioner. It is
measured as 140/85 mmHg.
What is the next most appropriate step?
, recheck BP in clinic and take the best of 3 readings
refer for specialist investigations
ambulatory blood pressure monitoring
start on amlodipine
do nothing - ✔️✔️*Ambulatory blood pressure monitoring*
Should offer *ABPM for patients with BP between 140/90 and 180/120* to confirm the
diagnosis of hypertension
Confirm diagnosis of hypertension when clinic blood pressure is 140/90mmHg or higher,
and ABPM average is 135/85mmHg or higher
If 140/90 offer antihypertensives if sign of end organ damage, CVD, renal disease,
diabetes
If 160/100 start on antihypertensives
A 70-year-old man with a *history of angina* presents to the Emergency Department
with a *2 hour history of chest pain*. There are *no dynamic changes seen on ECG*.
Which one of the following investigations is most useful in assessing for myocardial
damage in this patient?
myoglobin
troponin T
aspartate transaminase (AST)
creatinine kinase (CK-MB)
lactate dehydrogenase (LDH) - ✔️✔️Troponin T
Myoglobin = not specific but rises in MI
*Troponins I & T = markers of myocardial damage*
AST = liver enzyme
CK-MB = subtype of CK, more heart specific. Rises 4-6h after MI, returns to normal in a
few days.
LDH = marker of tissue damage, not specific
A 20-year-old medical student is being examined by one of his colleagues who notes a
*systolic murmur*. A cardiologist confirms the existence of a *pansystolic murmur, heard
loudest at the lower left sternal edge*. The student has no symptoms and has no known
medical conditions.
