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Try a card Cardiology · Day 1 of revision
In acute coronary syndrome, the first-line antiplatelet given on arrival is type your answer , followed by a second antiplatelet.
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Question
1 / 5
Cardiology Emergency Blackouts and faints

A 78-year-old man is brought to the emergency department after two episodes of sudden collapse without warning today. He is pale and lightheaded. His heart rate is 40 bpm and blood pressure 92/54 mmHg. His ECG is shown.

12-lead ECG showing regular P waves at about 100 per minute marching through a slow, regular ventricular rhythm of about 40 per minute, with no relationship between P waves and QRS complexes

What does the ECG show?

Why this is wrong First-degree AV block is a fixed, prolonged PR interval (over 200 ms) with every P wave followed by a QRS. Here many P waves are not followed by a QRS at all.
Why this is wrong Mobitz I (Wenckebach) shows a PR interval that lengthens progressively until a P wave is dropped, then the cycle repeats. Here there is no consistent PR interval because the P waves and QRS complexes are unrelated.
Why this is wrong Mobitz II has a constant PR interval in the conducted beats with occasional P waves suddenly not conducted. Here the PR interval varies randomly because no P waves are being conducted.
Correct The P waves are regular at about 100 per minute and the QRS complexes are regular at about 40 per minute, but they bear no relationship to each other: complete AV dissociation. Collapse without warning (Stokes-Adams attacks), bradycardia and hypotension make this an emergency. Treat adverse features with IV atropine, then pacing if there is no response, and refer for a permanent pacemaker.
Why this is wrong In sinus bradycardia every P wave is followed by a QRS with a constant PR interval, just at a slow rate. Here the atrial rate is faster than the ventricular rate.
Key learning point

In complete heart block the P waves and QRS complexes are completely unrelated, with a slow, regular escape rhythm. Treat instability with IV atropine then pacing, and arrange a permanent pacemaker.

Reference Resuscitation Council UK Adult advanced life support guidelines ↗
Respiratory Infectious disease Cough Fever

A 67-year-old man presents with a 3-day history of productive cough, fever and right-sided pleuritic chest pain. He is alert and orientated. Temperature 38.6°C, respiratory rate 24/min, heart rate 102 bpm, blood pressure 128/76 mmHg, SpO₂ 95% on air. Urea is 6.1 mmol/L. He has no allergies. His chest X-ray is shown.

PA chest X-ray showing dense consolidation with air bronchograms in the right lower zone, with a preserved right heart border, consistent with right lower lobe pneumonia

What is the most appropriate management?

Correct His CURB-65 score is 1: he scores only for age (65 or over). He is not confused, his urea is below 7 mmol/L, his respiratory rate is below 30 and his blood pressure is normal. That is low-severity community-acquired pneumonia, so NICE recommends oral amoxicillin 500 mg three times a day for 5 days, with home treatment if there are no other concerns and clear safety-netting advice.
Why this is wrong Dual IV antibiotics are for high-severity pneumonia (CURB-65 of 3 or more). With a score of 1 he does not need IV treatment or, on these figures, admission.
Why this is wrong Clarithromycin (or doxycycline) is the alternative for low-severity pneumonia when the patient is allergic to penicillin. He has no allergies, so amoxicillin is first line.
Why this is wrong Antibiotics should start as soon as pneumonia is diagnosed, ideally within 4 hours of presentation. A follow-up X-ray is only offered at around 6 weeks if symptoms persist or there is a higher risk of underlying malignancy, such as in smokers over 50.
Why this is wrong Fever, focal signs and lobar consolidation on the X-ray point to bacterial community-acquired pneumonia, which needs antibiotics.
Key learning point

Score community-acquired pneumonia with CURB-65 (Confusion, Urea >7 mmol/L, RR ≥30, BP <90/≤60, age ≥65). A score of 0–1 is low severity and is treated at home with 5 days of oral amoxicillin.

Reference NICE NG138 · Pneumonia (community-acquired): antimicrobial prescribing ↗
Paediatrics Infectious disease Fever Acute rash

A 6-year-old presents with a 3-day history of fever, sore throat, and a sandpaper-like rash that started on the trunk. The cheeks are flushed with a pale ring around the mouth. The tongue appears as shown.

Bright red tongue with prominent papillae, characteristic of strawberry tongue

What is the most likely causative organism?

Why this is wrong Staph aureus can cause toxic shock syndrome with strawberry tongue and rash, but the clinical picture there is shock and multi-organ involvement, not the classic scarlet fever syndrome described here.
Why this is wrong EBV causes glandular fever. Features are exudative tonsillitis, posterior cervical lymphadenopathy, splenomegaly, and a rash if amoxicillin is given. No strawberry tongue or sandpaper rash.
Correct This is scarlet fever, caused by Group A Strep exotoxin. The classic picture is sore throat plus sandpaper rash plus strawberry tongue plus circumoral pallor plus Pastia's lines. Treatment is 10 days of phenoxymethylpenicillin. Notifiable in the UK.
Why this is wrong Measles presents with the 3 C's (cough, coryza, conjunctivitis), Koplik spots on buccal mucosa, then a head-to-toe maculopapular rash. Different oral sign entirely.
Why this is wrong Parvovirus B19 causes slapped cheek syndrome: bright red cheeks followed by a lacy, reticular rash on the limbs. Fever is usually mild, and there is no sore throat, strawberry tongue or sandpaper rash.
Key learning point

Sandpaper rash, strawberry tongue and circumoral pallor mean scarlet fever from Group A Strep. Treat with 10 days of phenoxymethylpenicillin and notify public health.

Reference NICE CKS Scarlet fever ↗
Rheumatology Dermatology Limb weakness Chronic rash

A 52-year-old woman presents with proximal muscle weakness, difficulty climbing stairs, and the facial appearance shown. Examination reveals violaceous plaques over the MCP and PIP joints of her hands.

Violaceous discolouration of the upper eyelids with periorbital oedema

Which antibody is most likely to be positive?

Why this is wrong Anti-CCP is highly specific for rheumatoid arthritis, not myositis. RA affects MCPs and PIPs but causes synovitis with ulnar deviation, not violaceous plaques.
Why this is wrong Anti-dsDNA is highly specific for SLE and correlates with disease activity (especially lupus nephritis). The clinical picture here is myositis, not lupus.
Why this is wrong Anti-Ro is associated with Sjögren's syndrome and neonatal lupus. Sometimes seen in SLE but not the most likely antibody in dermatomyositis.
Why this is wrong Anti-centromere antibodies point to limited cutaneous systemic sclerosis (CREST: calcinosis, Raynaud’s, oesophageal dysmotility, sclerodactyly, telangiectasia). It does not cause a heliotrope rash or proximal myositis.
Correct This is dermatomyositis. The heliotrope rash plus Gottron's papules plus proximal weakness is classic. Anti-Jo-1 is the most likely specific antibody, associated with anti-synthetase syndrome (myositis plus ILD plus polyarthritis plus mechanic's hands). Always screen for underlying malignancy in patients over 40.
Key learning point

Heliotrope rash, Gottron’s papules and proximal weakness mean dermatomyositis, classically with anti-Jo-1 antibodies. Always screen for an underlying malignancy.

Reference BMJ Best Practice Dermatomyositis ↗
Cardiology Palpitations

A 72-year-old woman presents with two days of palpitations and mild breathlessness. She has hypertension and type 2 diabetes. She is alert, with a blood pressure of 134/80 mmHg and no chest pain. Her ECG is shown.

12-lead ECG showing an irregularly irregular narrow-complex rhythm at about 120 per minute with no discernible P waves

What is the most appropriate first-line drug to control her heart rate?

Why this is wrong Amiodarone is used for rhythm control or in haemodynamic instability and heart failure, not as first-line rate control in a stable patient. It also has significant long-term toxicity (thyroid, lung, liver).
Correct The ECG shows atrial fibrillation: an irregularly irregular rhythm with no P waves, at about 120 bpm. She is haemodynamically stable, so NICE recommends rate control first, with a standard beta-blocker such as bisoprolol (or a rate-limiting calcium channel blocker such as diltiazem). Assess stroke risk with CHA₂DS₂-VASc and bleeding risk before anticoagulating.
Why this is wrong Digoxin is only considered as monotherapy in people with non-paroxysmal AF who are sedentary. It controls the rate at rest but not on exertion, so it is not first line for most patients.
Why this is wrong Adenosine is used to terminate re-entrant SVTs. In AF it only causes brief AV block and does not control the rate.
Why this is wrong Flecainide is a rhythm-control drug (pharmacological cardioversion or pill-in-the-pocket). It is not a rate-control drug and is contraindicated in structural or ischaemic heart disease.
Key learning point

An irregularly irregular rhythm with no P waves is atrial fibrillation. In a stable patient, start rate control with a beta-blocker or rate-limiting calcium channel blocker, and use CHA₂DS₂-VASc to guide anticoagulation.

Reference NICE NG196 · Atrial fibrillation ↗

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Endocrine Renal Acute med
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Paediatrics

A 6-year-old with fever, sandpaper rash and a strawberry tongue. Causative organism?

A Staph aureus
B Group A Strep
C Epstein-Barr virus
D Measles virus
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Scarlet fever. The sandpaper rash plus strawberry tongue is the giveaway. Want to chat about why you nearly picked C?

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