8/4/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 1 of 295 A 54yearold man presents with an irregular tachycardia with a ventricular rate of around 120 bpm. He played in a cricket match the previous day and consumed 28 units of alcohol on the evening of the match. On examination his blood pressure is 95/50 mmHg What is the most likely diagnosis? A Atrial flutter B Paroxysmal atrial fibrillation C Sicksinus syndrome D Sinus tachycardia E Ventricular tachycardia Explanation The answer is Paroxysmal atrial fibrillation – Paroxysmal atrial fibrillation (AF) is the correct answer. Both AF and flutter are associated with alcoholic binges. AF is typically irregular, whereas flutter is typically regular if the AV block is consistent. In flutter, the rates are more typically 150 bpm (2:1 block) or 100 bpm (3:1) block. In some cases there may be subtle fluctuation in the degree of block causing some variability, but it is rarely irregularly irregular. The other conditions listed can be ruled out as they are less associated with alcohol and are more likely to cause a regular tachycardia Paroxysmal atrial fibrillation • Episodes of tachycardia in this condition may occasionally be precipitated by an excess intake of alcohol or caffeine • Other causes may be hypertension thyroid disorder valvular heart disease acute myocardial infarction (less common than often considered) atrial septal defect https://mypastest.pastest.com/Secure/TestMe/Browser/429893 1/3 8/4/2016 MyPastest or preexcitation syndromes such as Wolff–Parkinson–White • Atrial flutter is associated with an absolutely regular rhythm of 150–220 bpm Treatment • Standard therapy for atrial fibrillation of recent onset is electrical cardioversion under anticoagulant cover, provided that there are no contraindications • Patients who present within 48 hours of onset can be anticoagulated with heparin and undergo synchronised direct current cardioversion (DCCV) • Patients who present after 48 hours will need 4–6 weeks of full anticoagulation (INRs > 2.0 if using warfarin) before synchronised DCCV. Alternatively, earlier DCCV can be performed if a transoesophageal echocardiogram (TOE) can be done to exclude clot in the left atrial appendage • Intravenous flecainide may be considered for chemical cardioversion in the absence of a history of ischaemic heart disease; amiodarone is an acceptable alternative • Longterm prophylaxis with agents such as sotalol may be required Atrial flutter (Option A) is incorrect. Atrial flutter is less associated with alcohol and is more likely to cause a regular tachycardia Sicksinus syndrome (Option C) is incorrect. Sicksinus syndrome is less associated with alcohol and is more likely to cause a regular tachycardia Sinus tachycardia (Option D) is incorrect. Sinus tachycardia is less associated with alcohol and is more likely to cause a regular tachycardia Ventricular tachycardia (Option E) is incorrect. Ventricular tachycardia is less associated with alcohol and is more likely to cause a regular tachycardia 42012 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Session Progress Responses Correct: https://mypastest.pastest.com/Secure/TestMe/Browser/429893 2/3 8/4/2016 MyPastest Responses Incorrect: 295 Responses Total: 295 Responses % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/aboutus) Contact Us (https://www.pastest.com/contactus) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 3/3 8/4/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 2 of 295 A previously fit 25yearold man with a history of heavy smoking comes to the Emergency Department complaining of breathlessness and pleuritic pain occurring suddenly in the middle of a pub team football match. On examination, a systolic click is heard over the precordium, and there are decreased breath sounds on the left What is the possible diagnosis? A Pulmonary embolism B Mitral valve prolapse C Unstable angina D Myocardial infarction E Pneumothorax Explanation The answer is Pneumothorax – This is the most likely diagnosis in a young fit man presenting with sudden shortness of breath, a pleuritic pain and decreased breath sounds on one side. Primary spontaneous pneumothorax is usually due to rupture of apical pleural blebs and occurs almost exclusively in smokers.The patient should be assessed for signs of a tension pneumothorax (shift of the trachea to the contralateral side and a deteriorating clinical state with haemodynamic compromise) Other notes: • Such features as tachycardia, dyspnoea or tachypnoea may be absent in patients with even a moderate to large pulmonary embolism • There may be an accentuated pulmonic component of the second heart sound • Breathlessness in those with mitral valve prolapse is insidious and progresses gradually • Ischaemic pain (heavy, crushing or squeezing, which may radiate to the arms, abdomen, back, lower jaw and neck ) could represent unstable angina pectorisor myocardial infarction, but that is unlikely in this case with his young age and other clinical presentation Pulmonary embolism (Option A) is incorrect. A pulmonary embolism would not typically be associated with reduced breath sounds, and is typically associated with a ‘pleural rub’ https://mypastest.pastest.com/Secure/TestMe/Browser/429893 1/2 8/4/2016 MyPastest Mitral valve prolapse (Option B) is incorrect. Pneumothoraces, particularly those on the left side with the trapped air being near the heart, can produce a systolic click as the air trapped between the mediastinal and visceral pleura is shifted by the rhythmic ventricular contractions. Although systolic clicks can be heard with mitral valve prolapse, this answer does not fit the clinical presentation Unstable angina (Option C) is incorrect. The clinical history and physical signs are not classical for unstable angina Myocardial infarction (Option D) is incorrect. The clinical history and physical signs are not classical for a myocardial infarction 41972 Next Question Previous Question Tag Question Feedback End Review Difficulty: Easy Peer Responses Session Progress Responses Correct: Responses Incorrect: 295 Responses Total: 295 Responses % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/aboutus) Contact Us (https://www.pastest.com/contactus) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 2/2 8/4/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 3 of 295 A 40yearold man is referred by his GP for advice with regard to primary prevention of cardiovascular disease. He is a smoker with a strong family history of premature death from ischaemic heart disease. Following a period of lifestyle modification, his fasting cholesterol concentration is 7.2 mmol/litre. On consultation of the local guidelines you find that his estimated 10year risk of a coronary heart disease event is > 30% What would you advise? A Cholestyramine B Dietician advice C Fibrate D Nicotinic acid E Statin Explanation The answer is Statin – Prevention of cardiovascular disease The Joint British Societies (JBS) for the Prevention of Cardiovascular Disease have recently updated their guidelines for managing lipids • Nonfasting blood samples should be taken to measure total cholesterol (TC) and HDLcholesterol. In the past, fast LDLc was used, but a more pragmatic approach of measuring nonHDLc is now being proposed (determined by TC minus HDLc = nonHDLc) • All highrisk people should receive professional lifestyle support to reduce total and LDLc, raise HDLc and lower triglycerides to reduce their CVD risk • Individuals should be offered interventions to address all modifiable risk factors, including dietary advice smoking cessation advice and support moderation of alcohol consumption weight reduction where appropriate https://mypastest.pastest.com/Secure/TestMe/Browser/429893 1/3 8/4/2016 MyPastest • The risk of patients should be determined by levels recommended by NICE: a number of different algorithms and risk predictors are available. NICE currently recommends QRISK2 for all primary prevention up to the age of 84 years. The JBS have also produced risk calculators • Specific cholesterollowering drug therapy is recommended in: patients with established CVD individuals at particularly high risk of CVD: diabetes age > 40 years, patients with CKD stages 3–5, or FH individuals with high 10year CVD risk – from the 2014 guidelines this is considered to be those with ≥10% chance of CVD within the next 10 years (previously this was 30%) individuals with high lifetime CVD risk estimated from heart age and other JBS3 calculator metrics, in whom lifestyle changes alone are considered insufficient by the physician and person concerned • Statins are recommended as they are highly effective at reducing CVD events with evidence of benefit to LDLc levels