1. Masterclass Cardiology Semesters 8-9 Prof Yean Lim Semester 9 2010

2. Paper 2 39 A 32 year old man presents with a 6 hour history of chest pain. The pain is better when he leans forward and worse coughing and sneezing. He has had a sore throat for 2 days. An ECG performed on his arrival shows saddle type ST elevation in the anterior, lateral and inferior leads. The most appropriate treatment is a) Intravenous streptokinase b) Topical nitroglycerin c) Oral paracetamol d) Subcutaneous fractionated heparin

3. Paper 2 contd 42A 49 year old man presents to the RMH Emergency Department with a 2 hour history of severe of central crushing chest pain radiating to the jaw and left arm. He rates the pain at 8/10. Examination reveals a mild tachycardia and profuse sweating. An ECG reveals 3mm of ST elevation in leads V1, V2, V3 and V4. After commencing O2, aspirin and inserting an IV cannula the most appropriate treatment is – Commence IV nitroglycerin – Commence IV streptokinase – Commence IV heparin – Commence a beta blocker – Commence a ACE inhibitor

4. Paper 3 34Mrs Cardia walks into the Emergency Department with chest discomfort. She is 30 years old. What is your first action? a) Take her pulse and sit her down. b) Take her history. c) Take an ECG. d) Do a rapid assessment of her airway, breathing and circulation.

5. Paper 3 contd 35Mrs Cardia now reports these clinical features: chest tightness, palpitations, diaphoresis, mild dyspnoea and is slightly lightheaded. Your immediate clinical priority now is to: a) take a history b) Defibrillate c) Lie her on a trolley, apply oxygen and continuous cardiac monitoring d) Give her a sub-lingual glyceryl trinitrate tablet.

6. Paper 3 contd 36You decide the appropriate mode of oxygen delivery based upon: a) how the patient looks b) Mrs Cardia’s respiratory rate c) It should always be delivered by closed face mask at 10 litres/minute for chest tightness. d) Rapid respiratory assessment, including pulse oximetry monitoring.

7. Paper 3 contd 374) You take an ECG. Mrs Cardia is diaphoretic and the electrode dots do not adhere to the skin. Initial troubleshooting will be? a) shaving the chest b) wiping the skin dry with a towel. c) Wiping the skin with an alcohol swab d) Using surgical tape to stick the electrodes to the skin

8. Paper 3 contd 38 Her ECG is below (atrial fibrillation, rate approx 130). Please select the most correct diagnosis. a) atrial fibrillation b) rapid atrial fibrillation c) sinus tachycardia d) idioventricular rhythm

9. Paper 3 contd 39 Which of these cardiac rhythms are most likely to cause the sensation of palpitations? a) sinus rhythm b) ventricular fibrillation c) sinus tachycardia d) junctional bradycardia

10. Paper 3 contd 40On questioning, Mrs Cardia denies taking any prescription or non- presciption drugs. She has an unremarkable past history and has never felt like this before. She reports flu-like symptoms in the past two weeks. Her current blood pressure is 85/60 mmHg, her respiratory rate is 28 / min. Chest auscultation demonstrates bibasal fine crackles and a systolic murmur over the mitral valve region. The most correct immediate management of Mrs Cardia is: a) Sedation, Cardioversion and admission to CCU b) Intravenous fluids, digoxin and admission to CCU c) Anti-arrythmic medication and admission to a medical ward. d) Continuous cardiac monitoring, CXR, IV cannula and blood tests.

11. Paper 3 contd 42 The immediate aim of management at this time is to: a) optimize hydration, revert arrhythmia b) control arrhythmia rate, normalize blood pressure and urine output c) control arrhythmia rate, optimize respiratory and cardiac function d) refer immediately to surgeons with a view to urgent valve replacement

12. Paper 4 19An 82 year old Great Grandmother has extensive complications related to her 32 year history of type 2 diabetes including ischaemic heart disease, peripheral vascular disease and retinopathy. She presents with a 0.5 x 0.5 cm ulcer of her heel with extensive cellulitis tracking up her leg. A popliteal pulse is palpable on the affected limb but there are no other distal pulses felt. Because of her exstensive co morbidities the patient is assessed as being unsuitable for vascular bypass. The best test to determine if the wound is likely to heal with conservative therapy is a) Doppler ultrasound b) Toe pressures c) Angiography d) CT Angiogram e) Plain Xray