This is a case of aortic aneurysm, initial investigation US, confirmed by CT.

Incorrect options-

• Abdominal ultrasound- This is a good initial step to look, but is not detailed enough to see aorta clearly.
• Abdominal MRI- More expensive and takes longer than CT.
• Abdominal X-ray- Doesn't give clear enough view of the aorta.

A duplex ultrasound is the preferred method for diagnosing DVT because it's non-invasive, readily available, and provides accurate images of veins and blood flow.

Nifedipine is the best evidence-based treatment in AR. It is a calcium channel blocker and works by relaxing blood vessels which decreases the BP. This improves the blood flow to heart and reduces worklod.

Incorrect options-

• Digoxin- Used to treat heart faliure and atrial fibrillation.
• Verapamil- It's a calcium channel blocker but not as potent as nifedipine in relaxing blood vessels.
• Enalapril- It is an ACE inhibitor benificial in managing heart conditions but is not used as a first-line treatment for delaying AR surgery.

The likely answer is B, but we should pay attention to the patient's hemodynamic status and specifically the bleeding potential.

Left bundle branch block is a condition in which the electrical signals that control the heartbeat are disrupted causing a delay in the contraction of the left ventricle,it is not responsible for increaing the risk of infective endocarditis.

Prophylaxis is not needed as long as there is no a structural abnormality, prosthetic valves, or previous history of endocarditis.

• [Prophylaxis: Adults- Amoxicillin 2 Grams orally, 1hour before procedure].

Atrial fibrillation is a heart rhythm disorder where the upper chambers of heart [atria] beat irregularyly and rapidly. This irregular beating leads to the accumulation of blood in the atria increasing the risk of clot formation. These clots can travel to the brain and cause a stroke.

• Incorrect options- Sudden death, heart attack, MI can occur in patients with atrial fibrillation but it does not directly cause them.

  ---

  Complications of stroke-

• Thromboembolic events- stroke, systemic embolism
• Heart faliure
• Cognitive decline and dementia
• Cardiovascular events- MI, sudden cardiac death
• Bleeding complications due to anticoagulant therapy
• Quality of life impairment

SVT is a rapid heart rate rhythm originating above the ventricles. TSH is the correct choice because if the patient has hyperthyroidism  it can cause an increase in heart rate and can trigger SVT. Checking TSH will rule out hyperthyroidism as a potential cause of SVT.

• Incorrect options--  ECG stress test ,CT scan are not the preferred initial treatment, and ECG is likely already been performed.

DM + HTN = ACE inhibitors.

Incorrect options-

Diuretics (inexpensive and particularly effective in African-Americans) and beta-blockers (beneficial for patients with CAD) have been shown to reduce mortality in ''uncomplicated hypertension''. They are first-line agents unless a co-morbid condition requires another medication. (see table)

Pericarditis is the inflammation of the pericardim, the sac-like membrane surrounding the heart.

ECG findings- 

• Low voltage- The electrical signals from heart have to pass through inflamed pericardium, which acts as an insulator. This reduces the amplitude of the electrical signals.
• Diffuse change- Look for wide ST elevation [not limited to specific reigons like MI]
• PR depression- A hallmark of pericarditis.
• T wave changes- May become inverted in later stage. 

INR is a test used to measure time taken by blood to clot. A normal INR ranges between 0.8-1.2. Warfarin is a blood thinner medication used to prevent stroke in people with atrial fibrillation. An INR of 7 is very high compared to the normal range, so we will stop warfarin dose immediately and repeat the INR test next day.

Anaerobic exercise (endurance): It is the best option for patients with CAD. This type of exercise involves short bursts of intense activity typically lasting for less than 2 minutes.

• Isotonic exercises, like running or swimming can improve cardiovascular health, but might not be suitble for patients with severe symptoms. 
• Weight-bearing exercise (isometric) may build muscle strength, and bone density they can cause spike rise in BP and is bad for CAD patients.
• Yoga may not be enough to prevent cramps, stiffness, and back pain but is not enogh to improve cardivascular health.

Sleep apnea→ Hypoxemia and hypercapnia→ sympathetic activity increased→ increased afterload on heart →worsened CHF →pulmonary congestion→ narrowed upper airway→ increased apnea events →worsened sleep apnea.

Incorrect options-

• MI- it is not a direct complication of sleep apnea.
• Pericarditis- it usually does not occur due to sleep apnea.
• Endocarditis- not a direct complication of sleep apnea.

Quinidine /quinine is an antiarrhythmic medication. However thay can have certain serious side effects like dangerously abnormal heart rhythm, tinnitus, and hearing loss.

Incorrect options-

• Penicillin can cause allergic reaction which do not require hospitalization.
• Diphenhydramine is an antihistamine with no seious complications.
• OCP's have no life threatening side effects.

Alpha-blocker can cause tachycardia and orthostatic hypotension.

ACE inhibitors Increase survival and decreases mortality. ACE inhibitors inhibit aldosterone which if present in high concentrations causes modification of the cardiac myocytes in the long term.

Fruits and vegetables contain nutrients.and are stongly recommended to prevent IHD. They contain vitamins, minerals, antioxidants and fiber which help lower the blood cholestrol levels, that improves the overall health.

[Tricky question] Here we have symptoms of both left ventricular failure (SOB, Rales) & right ventricular failure (High JVP & LL edema). So, more commonly left ventricular failure leads to right ventricular failure due to overload and not vice versa. So the most correct option is left ventricular dilatation.

The combination of symptoms in the given scenario strongly indicate towards bacterial endocarditis.

Arteries are blood vessels that carry oxygenated blood away from the heart. Oxygen content gives the arterial blood bright red color. The high pressure in arteries causes the blood to spurt out in a pulsatile manner with each heartbeat. 

Statins cause myopathy which leads to muscle weakness. Atorvastatin is a statin medication, used to lower cholesterol. A side effect of which can be muscle weakness and fatigue.

HDL is also called ''good cholesterol''. HDL cholesterol plays a crucial role in removing excess cholesterol from the bloodstream and transporting it to the liver for processing and removal from the body.

Systolic hypertension is defined as an elevated systolic BP while the diastolic pressure remains within a normal range.

A continous murmur is defined as a murmur that is audible throughout the cardiac cycle, it is a typical feature of Patent Ductus Arteriosus.

The main pathophysiology behind most cases of HTN is an increase in peripheral resistance.

Peripheral resistance is defined as resistance that blood encounters when it flows through the small blood vessels. When the blood vessels constrict, the resistance to blood flow increases, this increased resistance leads to an elevation in BP.

Adenosine is the drug of choice in supraventricular tachycardia. Its acts by blocking the electrical signals in the heart which allows the SA node to regain control of heart rhythm. 

In severe anaemia the blood volume is significantly reduced leading to decreased BP. Therefore the pulse feels weak and collapses easily when palpated.

Symptoms and vitals go in favour of leaking aortic aneurysm. Aortic aneurysm is a bulge in the wall of aorta, when the wall weakens it can tear or rupture, causing blood to leak into chest cavity. This immense bleeding puts immense preassure on heart, leading to the symptoms being experienced by the patient.

Incorrect option-

• Peptic ulcer- While epigastric discomfort can indicate towards this, other symptoms of dizziness, falling down, and high heart rate are not associated with ulcers.
• GERD- Causes reflux, heart burn but not the above mentioned symptoms.
• Aortic stenosis- Typically doesn't present with above mentioned symptoms.

Decreased volume of blood in vessels→ reduced cardiac output→ drop in BP when standing.

HOCM is a common cause of sudden cardiac death in young athletes. In this condition heart muscle becomes abnormally thick, which can lead to obstruction of blood flow outside heart, leading to aryythmias during sternous exercise.

Hydrochlorothiazide is a thiazide diuretic which is based on the mechanism of removing fluid from the body which can lead to increase in blood gluscose levels making it unsuitable.

Spironolactone is the first-line treatment for ascites due to liver cirrhosis. It's a potassium sparing diuretic that counters the effects of aldosterone, which is elevated in cirrhosis. This reduces fluid retention effectively in patients with liver disease.

Thiazide diuretics are the drug of choice for mild HTN with no other additional comorbidities'.

Metaprolol is a beta blocker that reduces the heart rate and make it beat more steadily, lowering the risk of future complications.

Incorrect options-

• Nitroglycerine is mainly used for symptom relief.
• Thiazide are great for managing high BP.
• Morphine helps in managing pain and anxiety during the attack.

If the patient's BP is well-controlled and they feel good using garlic water, there's no reason to stop it.

Rheumatic fever can damage heart valves, the most common valve involved is the mitral valve. Damage to the mitral valve leads to mitral regurgitation, as the valve is not closing properly and allowing the blood to leak back into the left ventricle. The left venticle has to overcompensate for this leak causing it to enlarge due to hypertrophy. 

While Q waves are a classic sign of a MI, especially in the early stages but sometimes the damage to the heart is not severe enough to create a Q wave.

Epinephrine also known as adrenaline is the only medication specifically recommended in the ACLS protocol for asystole.

• Dose- 1mg given I/V or via the ETT. This dose may be repeated every 3-5 min as needed.

Atherosclerosis is the plaque buildup within blood vessel, narrowing it and making it harder for blood to flow. Diabetes and HTN are major risk factors for the development of atherosclerosis.

• Hypertension- Increased BP →stress on blood vessels→ endothelial damage→ inflammation →cholesterol deposition →Atherosclerosis.
• Diabetes- Increased blood glucose→ glycation of proteins →endothelial dysfunction→ plaque formation→ Atherosclerosis.

VSD is a common acyanotic heart condition. Ventricular enlargement is caused due to strain on the heart as increased amount of blood enters through the VSD. The extra blood is pumped into the lungs leading to high blood pressure in the pulmonary arteries.

Incorrect options-

• ASD can cause similar findings but is comparatively less responsible for ventricular enlargement or pulmonary HTN.
• Truncus arteriosus usually presents with cyanosis.
• Pulmonary stenosis would cause the above mentioned symptoms significantly.

ASD is an acyanotic condition. 

• Increased lung markings is suggestive of increased blood flow to lungs.
• Enlarged pulmonary artery shadow is due to increased blood flow to the lungs putting strain on the pulmonary arteries.

The kidneys play a crucial role in regulating BP. When they are damaged, they can't filter blood properly, leading to buildup of fluids and an increase in BP.

Incorrect options-

• Cushing syndrome can cause HTN but is not a common cause among adolescents.
• Hyperthyroidism can cause HTN but is more likely to occur in older adults.
• Essential HTN also known as primary HTN is most common type of high BP.

According to the age group;

• In pediatrics up to 18 years old it is renal parenchymal disease.
• In young adults it is thyroid disease.
• In middle age adults it is aldosteronism.
• In old adults > 65 it is atherosclerosis.

In the given scenario the patient's systolic BP is low, our priority at the time is to restore fluid volume and increase the blood pressure. For achieving this we will use I/V fluids.

Mitral valve disease is commonly associated with left-sided heart faliure. When this valve is damaged, it can lead to backup of blood in the lungs, causing symptoms like dysnea and PND.

Fluid build up in the lungs is the first sign of LHF, leading to dyspnea on exertion. Left-sided heart faliure impairs the ability of heart to pump blood effectively out of the left ventricle leading to buil-up of blood and fluid in lungs.

Incorrect answers-

• Orthopnea is shortness of breath on lying flat which is later sign of left-sided heart faliure.
• Pedal edema is sighn of righ-sided heart faliure.
• PND is defined as waking from sleep due to shortness of breath, it's a later sign of left-sided heart failure.

• Warfarin should not be given to pregnant lady, especially during the 1st and 3rd trimesters, as it crosses placenta as well as blood-brain barrier, it is usually difficult to reverse warfarin within a short time because it has a long half-life and works on vitamin K factors which take time to reverse.
• Barbiturates decrease the anticoagulant effect of warfarin.

The Jones criteria require the presence of 2 major or 1 major and 2 minor criteria for the diagnosis of rheumatic fever.

The major diagnostic criteria include carditis, polyarthritis, chorea, subcutaneous nodules, and erythema marginatum. The minor diagnostic criteria include fever, arthralgia, prolonged PR interval on the ECG, elevated acute phase reactants “ESR”, presence of C-reactive protein, and leukocytosis.

Additional evidence of previous group A streptococcal pharyngitis is required to diagnose rheumatic fever. One of the following must be present: Positive throat culture or rapid streptococcal antigen test elevated or rising streptococcal antibody titer, history of previous rheumatic fever or rheumatic heart disease.

Cardiac tamponade (influenced by volume and rate of accumulation) includes the following features-

• Beck's triad (jugular venous distention, hypotension, and muffled heart sounds)
• Hypotension and tachycardia without elevated jugular venous distension if the associated hemorrhage is outside pericardial sac
• Pulsus paradoxus
• Cyanosis
• Varying degrees of consciousness

PVCs in young, healthy patients without underlying structural heart disease are usually not associated with any increased rate of mortality. Antiarrhythmic therapy with flecainide and encainide has been shown to increase mortality. After MI, antiarrhythmic - Despite the suppression of ectopy- patients treated with encainide, flecainide, or moricizine had increased rates of sudden death and death from all causes. Amiodarone may be an exception, as it has been shown to reduce post-MI arrhythmia and death.

Aspirin is commonly used blood thinner to reduce the risk of stroke in patients with AF. It's not accurate to say that aspirin is not true in patients with AF.

Indications of stress test are:-

• 1) Diagnosis of CAD in patients with chest pain that is atypical for myocardial ischemia.
• 2) Assessment of functional capacity and prognosis of patients with known CAD.
• 3) Assessment of prognosis and functional capacity of patients with CAD soon after an uncomplicated myocardial infarction (before hospital discharge or early after discharge.
• 4) Evaluation of patients with symptoms consistent with recurrent, exercise-induced cardiac arrhythmia.
• 5) Assessment of functional capacity of selected patients with congenital or valvular heart disease.
• 6) Evaluation of patients with rate-responsive pacemakers.
• 7) Evaluation of asymptomatic men > 40 years with special occupations (airline pilots, bus drivers, etc)
• 8) Evaluation of asymptomatic individuals > 40 years with two or more risk factors for CAD.
• 9) Evaluation of sedentary individuals (men 45 years and women 55 years) with two or more risk factors who plan to enter a vigorous exercise program.
• 10) Assessment of functional capacity and response to therapy in patients with IHD or heart failure.
• 11) Monitoring progress and safety in conjunction with rehabilitation after a cardiac event or surgical procedure.

After MI mitral valve can become weakened or rupture which leads to acute mitral regurgitation, where blood flows backwards from left ventricle to left atrium during systole. This leads fluid to backup into lungs leading to these symptoms.

• Bed rest helps in preventing pulmonary embolism by reducing the risk of clot dislogement.
• Heparin prevents clot from increasing in size.
• Warfarin taken longer to start working but provides long term protection against further clots.

CLI is a condition in which there is a narrowing or blockage of the arteries in the legs, reducing the blood flow. This can cause claudication that worsens with activity and improves with rest. The loss of hair and shiny appearance of skin is due to poor blood circulation.

Incorrect options-

• DVT causes leg pain, swelling, redness and warmth in the affected limb due to precense of clot in deep vein.
• DIC presents with widespread bleeding and not as a isolated leg pain.
• Spinal stenosis is the narrowing of spinal canal that compresses nerves and causes leg pain, however it typically presents as back pain which then radiates to the legs, but other above mentioned symptoms are not present.

Waiting for resuscitation team ensures that the patient receives care from a group of trained people who can initiate an appropriate treatment.

Weak pulse is not an indication to start CPR.

Simvastsin is a hypolipidemic drug used to control elevated cholesterol ‘hypercholesterolemia’

Alpha blockers relax the muscle in bladder neck and prostate, improving urine flow and relieving symptoms of BPH.

Amiodarone works by stabalizing the heart rhythm and reduces the risk of more dangerous arrythmias like ventricular tachycardia.

Incorrect options-

• No treatment might be required in some PVCs but in this scenario an anterior MI and multiple PVCs are dangerous and should be treated appropriately.
• Nifedipine is a calcium channel blocker that is used to treat high BP.
• Spironolactone is a potassium-sparing diuretic used to treat heart faliure and high BP. Not effective in treating arrythmia.

Severe hypokalemia is defined as a level less than 2.5 mEq/L.

Severe hypokalemia is not linked with any symptoms but may cause:

• 1) Myalgia or muscle pain
• 2) Disturbed heart rhythm including ectopy
• 3) Serious arrhythmias (electrical faster or slower than normal)

Sequence of ECG changes in hypokalemia :

1. Appearance of U-wave
2. T-wave flattening; U-wave becomes more prominent; QU interval mistaken as prolonged QT interval
3. T-wave starts inverting; U-wave is upright (looks like biphasic T-wave with proximal negative deflection and distal positive deflection)– but it is not a biphasic T-wave, rather they are 2 separate waves, i.e, inverted T wave and upright U wave.
4. The entire ST segment going down: ST segment depression- looks like Roller-coaster pattern

Other ECG findings in hypokalemia: PR prolongation, BBBs, polymorphic VT.

[ECG changes in hyperkalemia: 1) Peak T wave & Loss of P wave 2) Wide QRS ( in severe cases) 3) PR prolong ( in severe cases)].

Infective endocarditis is the infection of the inner lining of the heart and heart valves. It is often caused by bacteria or fungi that enter the blood stream and form colonies in heart valves forming vegetations.

During CPR, effective ventilation means that air is sucessfully entering the lungs and expanding them. Chest rise is the most direct and visible sign.

When potassium levels are low it can lead to muscle weakness, this in turn can affect the respiratory muscles leading to respiratory acidosis, where the body is unable to remove carbondioxide effectively causing a buildup of acid in blood.

BMI 30 is indicative that the patient is obeses. Obesity is a major risk factor for HTN.

Incorrect options-

• Wine in less amount is unlikely to cause high BP.
• High Na intake is a well established risk factor for HTN. But the patient is also taking K+ which can help counterattack the effect of sodium on blood pressure.

There are many causes of premature ventricular contractions, which include:

• 1) Heart attack, High blood pressure
• 2) Cardiomyopathy, including congestive heart failure, disease of heart valves such as mitral valve prolapse
• 3) Hypokalemia and hypomagnesaemia
• 4) Hypoxia for example, hypoxia occurs with lung diseases such as emphysema or COPD
• 5) Medications such as digoxin, aminophylline, tricyclic antidepressants& ephedrine containing, decongestant
• 6) Excessive intake of alcohol, excess caffeine intake
• 7) Stimulant drug use such as cocaine, and amphetamines
• 8) Myocarditis (heart muscle inflammation) and cardiac contusion (heart muscle injury)
• 9) Premature ventricular contractions also occur in healthy individuals without heart diseases.

Cardiac syncope is a sudden breif loss of consiousness caused by a temporary decrease in blood flow to the brain. The characterstick feature of cardiac syncope is fast recovery.

Patients with HOCM are not considered at high risk of infective endocarditis during routine dental procedure. Therefore, they typically do not require antibiotic prophylaxis before dental procedure.

Adenosine is a medication used to treat SVT. One of the contraindications of adenosine is LHF. Adenosine can cause a significant drop in BP which can further compromise blood flow in patients with LHF, worsening their symptoms and even causing cardiac arrest.

RHD is the most likely diagnosis according to the given scenario.

The patient is likely experiencing digoxin toxicity, which can cause visual disturbance.

Features of digoxin toxicity-

• Cardiac- Bradycardia, arrythmias
• GI- Nausea,  vomitting
• CNS- Confusion, visual disturbance
• ECG- Prolonged PR, slooping depression in ST segment

Stroke volume determines the amount of blood ejected with each heartbeat ensuring better perfusion of heart muscles.

The best way to treat this patient is through weight reduction and physical activity. This lifestyle modification is essential for managing prehypertension, which is a condition where bloodpressure is higher than normal but not yet in the hypertensive range.

Meat and diary are high in unsaturated fats, and increase the risk of CAD. Reducing their intake can help lower cholesterol and reduce the risk of heart disease.

LDL cholesterol is often referred to as bad cholesterol. High LDL levels are a major risk factor for atherosclerosis.

The above mentioned features of pulselessness and different shape QRS complexes, indicates that the electrical activity is originating from different areas in heart suggesting disorganized electrical system. This pattern is commonly seen in ventricular dysfunction.

Pulse-less VT is treated by unsynchronized shock (not cardioversion) and CPR.

The first thing to be given is the shock, then CPR then drugs (epinephrine & amiodarone).

Angina with ST segment depression 1-2mm is a classic finding in ischemic heart block. The ST segment depression indicates that the heart is not getting enough blood flow.

The defining characterstic of syncope is that it has an abrupt onset.

Incorrect options-

• Rapid recovery is present but irt is not typically the defining characterstic.
• When turn neck to one side is not a trigger for syncope to occur.
• Bradycardia can be a symptom but not a defining characterstic of syncope.

As the patient has a history of MI, it can indiacate that the patients electrical system can get disrupted which can inturn lead to abnormal rhythms like re-enterant tachycardias. The precense of cBatman ''a'' wave wave suggests that the atria are contracting against a closed mitral valve, which is a sign of AV nodal re-enterant tachycardia.

These leads are specifically placed to record the readings of inferior portion of heart

ST elevation in leads V1-V4 is the hallmark of an anterior wall myocardial infarction. Reciprocal depression in the inferior leads is a common finding associated with anterior wall MI. 

The combination of  ST elevation in V4 with a significant Q wave, and ST depression in the inferior leads strongly points towards an anterior wall MI.

Incorrect options-

• Inferior MI presents with ST depression in inferior leads but the precense of ST elevation and a significant Q wave makes it less likely.
• Pericarditis presents as diffuse ST segment elevation and PR segment depression.
• Posterior MI present as ST depression in V1-V4 [anterior leads] and reciprocal ST elevation in inferior leads.

Propanolol is a beta-blocker that is effective in both preventing migraines and lowering blood preassure. It blocks the effects of adrenline which will effectively address both her migraine and hypertension.

Warfarin is primarily used to prevent  the formation of blood clots in people who are at an increased risk of stroke or heart attack. In the above mentioned option elderly male who has a normal heart has no risk of formation of blood clots so warfarin is not needed for this patient. 

• All the other options have heart condition that can lead to clot formation.

Coronary arteries supply blood to the cardiac muscle. When they dialate there is an increased flow of blood through them which will increase the oxygen and nutrient delivery to the cardiac muscle when there is an increased load on heart.

Interstitial renal disease is a disorder characterized by damage to the filtering units of kidney that leads to impairement in the kidneys ability of regulating BP, leading to choronic HTN.

Incorrect options-

• DM is a significant risk factor for causing HTN, but its not the most common cause.
• HTN is condition itself not cause.
• Amyloidosis can cause HTN but is less common as compared to interstitial renal disease.

These murmurs are usually heard best during standing or sitting positions, as these positions increase the blood flow to heart, making the murmur more audible. The supine position may not be the best for hearing these type of murmurs.

Other options-

• Supine position is best to hear venous hum.
• AR murmurs are typically heard louder when the patient is in sitting position.
• Pericardial rub is best heard when the patient is sitting up and leaning forward.

Hypotension is a major concern in elderly patients taking antihypertensive drugs. These drugs lead to hypotension and cause lightheadedness, dizziness, falls, and even unconsiousness.

Morphine is a strong pain reliever which will help relieving severe chest pain, also it helps in tackling the anxiety faced by the patient during this period and will improve the overall well-being of this patient. Administering morphine via the IV route ensures rapid onset of action, whcih is crucial in time-sensitive situation like this.

Amiodarone is an antiarrhythmic medication that is widely used to treat and prevent dangerous heart rhythms like ventricular tachycardia. The scenario also mentions precense of ST segment elevation suggestive of MI which can also be a cause of the ventricular tachycardia. Amiodarone will help by stabilizing the heart rhythm and reduce the risk of further detoriation and complication.

Incorrect options-

• Digoxin is used to treat heart faliure not ventricular arrythmias.
• Lidocaine can be used, but is not the first-line treatment in the precense of ST segment elevation.
• Plavix and morphine are antiplatelet and pain relievers, both of which don't help in managing the abnormal rhythm.

When the VF waves have a larger amplitude [>3mm] and are more irregular, it generally indicates that the VF is of recent onset. It indicates better chances of sucessful defibrillation because it is suggestive of some residual myocardial energy.

Treatment- 

• Start CPR.
• Defibrillate [120-200J biphasic or 360J monophasic].
• Give epinephrine 1mg every 3-5 min.
• Give amiodarone 300mg, then 150mg if needed.
• Treat reversible causes [hypoxia, acidosis, thrombosis].

MS, AS, AR, MR all increased by squatting, diastolic murmur at apex is MS & at left sternal border is AR.

The above mentioned clinical features are strongly suggestive of heart faliure. Valvular heart disease is a common cause of heart faliure.

All these are features of mitral stenosis. Atrial fibrillation occurs secondary to left atrial enlargement, the fibrillation increases the risk of thromboembolism. There’s more blood in the left atrium, so more is flowing back to the lungs causing pulmonary congestion and edema, when the lungs get congested they try to protect itself from this excess fluid by constricting the pulmonary arteries, so more constriction leads to more resistance and therefore results in pulmonary hypertension.

• The option left ventricular failure doesn’t occur. On the contrary, the LV is very relaxed since less blood is passing through the stenosed valve to the ventricle, so the requirements on the LV are less, the stress is less and ejection fraction is normal.

The combination of narrow QRS complex and rapid pulse are strongly indicating towards atrial flutter. Atrial flutter is a rapid heart rhythm originating from atria.  Amiodarone is an antiarrythmic medication that is effective in slowing down the rapid heart rate associated with atrial flutter.  

Incorrect option-

Nifedipine is a calcium channel blocker which is mainly used for treating high BP. It can be used to slow the heart rate but is not the first-line treatment for atrial flutter.

No electrical activity and QRS oscillation is a characterstic feature of pulseless electrical activity [PEA]. In this condition the heart's electrical function is still intact but the heart muscle is itself not contracting effectively to pump blood. This inability is a sign of ventricular dysfunction. 

50% of infective endocarditis occurs on normal valves.

Predisposing cardiac lesions:

• 1) Aortic/mitral valve disease
• 2) IV drug users in tricuspid valves
• 3) Coarctation
• 4) PDA
• 5) VSD ( Fallot's tetrad included )
• 6) Prosthetic valves

Carotid massage is the simplest non-invasive way to potentially distinguish between these two heart conditions.

Gently massaging the carotid artery stimulates the vagus nerve, which can slow the heart rate in atrial flutter. It can reveal the typical ''sawtooth'' rhythm on ECG, making it easier to tell apart from sinus tachycardia.

MI occurs when blood flow to heart muscle is reduced or blocked due to plaque buildup and disruption in coronary arteries. This narrowing restricts oxygen supply, leading to heart muscle damage.

Syncope from aortic valve stenosis is usually exertional. In the setting of heart failure, it increases the risk of death. In patients with syncope, the 3-year mortality rate is 50%, if the aortic valve is not replaced.

• One popular theory is that severe AS produces a nearly fixed cardiac output. When the patient exercises, their peripheral vascular resistance will decrease as the blood vessels of the skeletal muscles dilate to allow the muscles to receive more blood to allow them to do more work.
• This decrease in peripheral vascular resistance is normally compensated by an increase in the cardiac output. Since patients with severe AS cannot increase their cardiac output, the blood pressure falls and the patient will syncope due to decreased blood perfusion to the brain.
• A second theory as to why syncope may occur in AS is that during exercise, the high pressures generated in the hypertrophied LV cause a vasodepressor response, which causes a secondary peripheral vasodilation that, in turn, causes decreased blood flow to the brain.
• Indeed, in aortic stenosis, because of the fixed obstruction to blood flow out from the heart, it may be impossible for the heart to increase its output to offset peripheral vasodilation. A third mechanism may sometimes be operative. Due to the hypertrophy of the left ventricle in aortic stenosis, including the consequent inability of the coronary arteries to adequately supply blood to the myocardium (see "Angina" below), arrhythmias may develop. These can lead to syncope. Finally, in calcific aortic stenosis at least, the calcification in and around the aortic valve can progress and extend to involve the electrical conduction system of the heart. If that occurs, the result may be heart block a potentially lethal condition of which syncope may be a symptom.

Physiological 3rd heart sound is a filling sound that results from rapid diastolic filling as occurs in healthy young adults, children, athletes, pregnancy, and fever.

Pathological 3rd heart sound is a mid-diastolic sound that results from reduced ventricular compliance and if it's associated with tachycardia, it is called gallop rhythm.

• Left ventricular S3 It's louder at the apex and expiration. It is a sign of left ventricular failure and may occur in AR, MR, VSD, and PDA.
• Right ventricular S3 It's louder at the left sternal edge and with inspiration. Occurs with right ventricular failure or constrictive pericarditis.

[If the obstruction is more than 70 % go for surgery].

Carotid endarterectomy is a surgical procedure that removes the palque buildup from inside the carotid artery. This helps to restore normal blood flow to the brain and reduce the risk of stroke.

[After symptoms subside].

An exercise stress test is a simple and non-invasive way to assess how the heart responds to physical exertion by monitoring ECG, heart rate, and blood pressure. 

[NOTE- In this scenario even though the patient is a known case we want to perform the test to - Assess blood flow during exertion, stratify high risk patients who might need further evaluation, and decide between medical management or invasive procedures].

In chronic atrial fibrillation, cardioversion is contra-indicated due to the risk of thrombus dislodgement.

• When AF is due to an acute precipitating event such as alcohol toxicity, chest infection, or hyperthyroidism, the provoking cause should be treated.
• Strategies for acute management of AF - ventricular rate control or cardioversion (+/- anticoagulation). Ventricular control rate is achieved by drugs that block the AV node, while cardioversion is achieved electrically with DC shock or medically with anti-arrhythmic.

In general, each patient deserves at least one cardioversion trial.

• If the patient is unstable and presents in shock, severe hypotension, pulmonary edema, or ongoing myocardial ischemia, DC cardioversion is a must.
• In less unstable patients or those at high risk for emboli due to cardioversion as in mitral stenosis, rate control is adopted (digoxin, b-blocker, or verapamil to reduce the ventricular rate. If it's unsuccessful then cardiovert the patient after anticoagulant him for 4 weeks.

• Hospitalization
• Strict bed rest
• Supplemental oxygen
• Sedation with benzodiazepine if there is anxiety.
• Systolic blood pressure is maintained at 100-120 mmHg and pulse should be lowered to 60/min.
• Heparin, antiplatelet, nitrates and b-blocker.

Sudden asphyxiation is the most common cause of death in Ludwig angina. It is potentially life-threatening cellulitis or connective tissue infection, of the floor of the mouth, usually occurring in adults with concomitant dental infections and if left untreated, may obstruct the airways, necessitating tracheotomy.

Innocent heart murmurs are harmless heart sounds that are common in children and young adults. They are often caused by turbulent blood flow through heart valves and are usually not associated with any underlying heart problems. These murmurs are often position independent.

Furosemide is a powerful diuretic. In CHF heart struggles to pump blood leading to fluid buildup in the lungs causing pulmonary edema. Furosemide helps in quicly removing excess fluid thereby reducing the starin on the heart and improving breathing.

Mitral stenosis, often due to RHD, causes blood backup in the lungs, leading to dysnea, frothy blood-tinged sputum, and atrial fibrillation. The ''malar rash'' supports rheumatic origin.

Incorrect options-

• CHF is not the answer eventhough some features are overlapping as the scenario points to mitral stenosis.
• Endocarditis is less likely without history of infection.
• Pericarditis doesn't explain sputum or AF.

Nitroglycerine-

T1/2: 1-4 min.

Dose: 0.3-0.6 mg SL may be repeated 5 min for 15 min for acute attack.

Action: Increase coronary blood flow→ produce vasodilation→ decrease LVED vol. (preload)→decrease myocardial O2 consumption.

Therapeutic effect:

• 1) Relief or prevention of angina attack
• 2) Increase CO
• 3) Decrease BP

 S/E of Nitroglycerine is Methemoglobinemia.

Treatment of ventricular tachycardia depends on patient stability.

• Unstable patients: electrical cardioversion
• Stable patients: amiodarone, lidocaine, procainamide.

According to CHA2DS2-VASc score- 

 C = recent Congestive heart failure[1], H = Hypertension[1],  A = Age>/=75[2], D = DM[1], S2: = stroke/ TIA [each scores 1],V=vascular disease[1], A= age-65-74[1], Sc= female sex[1].

• If score = 0 (AF with none of these) Aspirin
• If score = 1 Controversial (anticoagulation issue)
• If score >/=2  Warfarin

Loss of consiousness is a serious symptom and is not typically associated with stable angina.

Turner syndrome [45,X0] is a genetic condition affecting females, characterized by the abscence of X chromosome.

Features-

• Physical- Short starure, webbed neck, low hairline, wide-spaced nipple.
• Cardiac- Coarctation of aorta, bicuspid aortic valve.
• Reproductive- Primary amenorrhea, infertility, streak ovary.
• Renal- Horseshoe kidney.
• Endocrine- Hypothyroidism, osteoporosis.
• Other- Lymphedema at birth,learning difficulties.

An acute arterial embolus is a blood clot that forms likely in the heart due to recent MI and then lodges in a smaller artey in the leg. This blockage suddenly cuts off the supply to limb leading to severe pain, numbness, and potentially even tissue death.

Hyperkalemia is characterized by- tall peaked T-waves, wide QRS complex, and cardiac arrest if untreated

• Incorrect option-
•  Chvostek sign is a sign of hypocalcemia (taping over facial nerve causes facial muscles to twitch).

Amoxicillin is the most common antibiotic used for prophylaxis of endocarditis. It's taken usually one hour before the procedure to ensure it's in the blood stream when the procedure starts.

The features are strongly suggestive of stroke. It is caused by blood clot blocking the blood flow to brain. Heparin is an anticoagulant that activates antithrombin III, inhibiting thrombin and factor Xa, preventing clot formation.. Starting heparin quickly is a crucial step in managing stroke and improving outcome.

Organ meat like liver, kidney, and brain are very rich in cholesterol. People with hypercholesterolemia should therefore limit their intake.

Unstable angina is characterized by chest pain that occurs at rest or with minimal exertion.

Mitral stenosis causes increased pressure in the left atrium, leading to hypertrophy and dilation to handle the blood backup.

The patient's current symptoms are most concerning at this point. The ER needs to focus on stabalizing the patient and determining the cause of chest pain. Past medical history is of no relevance and value at the movement.

Digoxin is contraindicated as it increases the force of heart contractions, worsening obstruction and symptoms.

Incorrect option-

• Beta-blockers are the first-line treatment as they slow heart rate and improve blood flow.
• Alpha-blockers reduce the resistance of heart to pump against.
• Morphine is not contraindicated but has to be used with precaution.

The fick method measures cardiac output by using oxygen saturation in blood to determine how much oxygen is delivered and consumed by tissues. It compares oxygen levels in arterial and venous blood to calculate oxygen consumption and cardiac output.

CPK is an enzyme found primarily in heart, brain, and skeletal muscle. When there's damage to these tissues, such as heart attack, CPK levels in the blood rise.

Mitral stenosis is a mid-diastolic rumbling murmur that's low pitched and occurs as blood struggles to flow through the narrowed mitral valve during diastole.

Incorrect options-

• Holosystolic and pansystolic murmur occur during systole, not diastole.
• Mid-systolic - Mitral stenosis murmur is not systolic.

Fifty percent of people with unstable angina will have evidence of myocardial necrosis based on elevated cardiac serum markers such as creatine kinase isoenzyme (CK)-MB and troponin T or I, and thus have a diagnosis of non-ST elevation myocardial infarction.

Warfarin is the best prevention in the given scenario. It prevents stroke by inhibiting vitamin K- dependent clotting factors [II, VII, IX, X], reducing blood clot formation and embolism risk in atrial fibrillation.

Tetrology of fallot is associated with endocarditis because of the abnormnal blood flow patterns and the presence of a VSD in TOF can create areas of turbulence and increased pressure within the heart. These condition can damage the heart valves, making them more susceptible to bacterial infection, which leads to endocarditis.

Tetrology of fallot is a complex heart defect with four main features-

• VSD
• Pulmonary stenosis
• Overriding of aorta
• Right ventricular hypertrophy

In RBBB the ECG shows-

• Long S wave in lead V1- delayed right ventricle activation.
• Long R wave in lead V6- prolonged electrical signal due to delayed conduction.

Beta-blockers reduce mortality in CHF by blocking adrenaline's effects, slowing heart rate, lowering BP, and decreasing heart strain. This improves heart function and prevents harmful cardiac remodeling over time.

The ST depression seen on the Holter monitor indicates ischemia, even if no chest pain is present. MI occurs when the heart muscle doesn't get enough oxygenated blood.

• Lisinopril is an ACE inhibitor that lowers BP by blocking angiotensin I from converting to angiotensin II, a vasoconstrictor. It increases bradykinin, causing dry cough.
• Losartan is an ARB and blocks angiotensin II at its receptor itself, achieving the same BP lowering effect without affecting bradykinin, not leading to cough.

Incorrect options-

• Nifedipine, minoxidil and thiazide have a different mechanisms.

Atherosclerosis is a process where plaque made of cholesterol, fat and other substances, builds up on the inner wall of arteries. This plaque formation narrows the arteries, restricing blood flow to heart.

Aortic sclerosis is a common age-related condition where the aortic valve becomes thickened and stiffer. This makes it hard for the heart to pump blood out of the left ventricle, leading to a gradual decline in heart function. As the patient has a famliy history, age factor and no symptoms at the moment it is likely pointing towards aortic sclerosis.

Based on the symptoms the most likely diagnosis is stable angina. 

After an inferior MI the papillary muscle that support the mitral valve can rupture. This leads to acute MR where blood leaks back to the left atrium during contraction, causing sudden shortness of breath.

Since the patient in this scenario is allergic to penicillin alternative antibiotics are needed.

• IV vanomycin and IV gentamicin is a common choice for antibiotic prophylaxis in patients with penicillin allergy.

A BP of 180/140mmHg is considered as hypertensive crisis, which is a medical emergency. The goal of treatment here is to rapidly reduce BP to prevent organ damage. We need to ensure a safe reduction as a rapid drop can be dangerous and lead to complication. Therefore the diastolic pressure should be reduced gradually 110-100 mmHg within 12 hours for the above mentioned scenario.

Unstable angina is a condition in which the blood flow to heart is reduced, causing unpredictable chest pain, often at rest. It shows evidence of MI, such as ST-segment depression or T-wave inversion on an ECG.

When patient has no pulse it is indicative of cardiac arrest. CPR is the immediate life saving intervention for cardiac arrest. It involves chest compression to circulate blood and rescue breaths to provide oxygen to the brain and other organs.

Incorrect options-

• Call resuscitation team- While calling resuscitation team is important, it should be done after initiating CPR.
• Admit to hospital- Necessary after sucessful resuscitation.
• Supply oxygen-  Administered after CPR is initiated.

Causes of LBBB: 1) Aortic stenosis 2) Dilated cardiomyopathy 3) Acute myocardial infarction 4) Extensive coronary artery disease 5) Primary disease of the cardiac electrical conduction system 6) Long-standing hypertension leading to aortic root dilatation and subsequent aortic regurgitation.

Causes of RBBB : 1) Coronary artery disease 2) Myocarditis 3) ASD, VSD and Valvular heart disease 4) COPD & pulmonary embolus.

Dressler's syndrome is a secondary form of pericarditis that occurs in the setting of injury to the heart or the pericardium.

ACEI are the first-line treatment as they-

• Lower BP
• Reduce heart workload
• Improve blood flow
• Decrease fluid retention

Buspirone is an anti-anxiety medication that can cause liver related side effects, which may lead to fatigue. A liver function test is the most appropriate investigation in this case.

As the patient has AF there is an increased risk of blood clot formation. When a blood clot travels to arteries supplying intestines, it can cause blockage of the arterial supply to intestines causing tissue damage. This condition is called ischemic mesentery.

Symptoms of ischemic mesentery-

• Nausea/vomitting, severe abdominal pain and bloody stools. 

The combination of these clinical features are strongly indicative of aortic dissection, which is a serious condition in which the inner layer of aorta tears allowing blood to flow between the layers of the vessel wall. Aortic angiogram is a diagnostic imaging test that uses X-rays and contrast dye to visualize the aorta and detect any tears or blockages. It is the most definitive test to diagnose aortic dissection. 

These medications are often the first-line treatment of HTN, especially in older adults. They work by increasing urine output, lowering the amount of fluid in body thereby decreasing BP.

Note: High cholesterol, unhealthy food &sedentary life are modifiable risk factors.

VSD causes a hole in the septum that seprates the ventricles of heart, leading to increased blood flow to the right side, causing right ventricular hypertrophy,overload, and RBBB on ECG.

Incorrect options-

• TGA will be immediately evident after birth.
• Coarctation of aorta is not associated with RVH.
• PDA  increases blood floe to lung but will not lead to RVH.

Hydrochlorothiazide is a thiazide diuretic which can worsen hyperuricemia and gout.

“ Hyperuricemia is a relatively common finding in patients treated with a loop or thiazide diuretic and may sometimes, lead to gouty arthritis”.

Pericarditis patient presents with substernal pleuritic chest pain that is aggravated by lying down and relieved by leaning forward.

ECG - Low voltage diffuse ST segment elevation.

After an MI damage to papillary muscle can cause MR, leading to blood leaking backwards into the left atrium. Symptoms include SOB and lung crepitations due to pulmonary edema.

Incorrect options-

• Pulmonary embolism is less likely as there is no evidence of a clot.
• Pneumonia is not the correct option as the features are more indicative towards MR and not infection.
• AR is not typically a post MI complication.

Zolpidem is a short acting hypnotic. It works by enhancing the effect of GABA, which promotes sleep. It has a rapid onset of action and a short half-life.

[Long acting hypnotics can increase risk of accidents in a patient with MI]. 

Ca channel blockers can lead to negative inotropy which can be life threatening. These medications can lead to hypotension which is dangerous in patients with MI who already may have low BP.

In absence of PCI facility, fibrinolytic therapy like Streptokinase is the next best option to restore blood flow to heart muscle.

Fever is considered a minor criteria as it's a common symptom in many illnesses, it's not specific to any one disease. However when combined with other minor or major criteria, it can help strengthen the diagnosis.

In this scenario, the patient is presenting with AF and has a dangerously low BP - Syncronised cardioversion is the recommended treatment in this case as it delivers a timed electrical shock to heart, aiming to restore a normal heart rhythm. This can quickly improve BP and circulation.

AS causes narrowing of the aortic valve which restricts the blood flow from the heart to the body. This can lead to hypotension, especially during exertion. When the teacher stood up to teach there was decreased blood flow to brain due to hypotension which led him to faint.

One of the precipitants of CHF in HF patients is a high salt diet. Therefore salt restriction is most important advise.

The recurrence rate of endocarditis even after treatment is around 12%.

The above mentionesd sysmptoms are stongly suggestive of constrictive pericarditis, which is a condition in which the pericardium become thickened and scarred restricting the hearts ability to fill properly.

Incorrect options-

• TR typically presents with murmur and symptoms of right sided heart faliure
• TS presents with murmur and features of right sided heart faliure.
• Pulmonary HTN usually doesn't present with low volume pulse and no murmur.

Arotic aneurysm is characterized by pulsatile epigastric mass. 

Rheumatic heart disease can lead to mitral stenosis,which can cause embolic strokes. ECHO identifies valve abnormalities and potential embolic sources.

Incorrect options-

• MR angiography assesses blood vessels not the heart valves.
• Non contrast CT rules out hemorrhagic stroke but doesn't assess valve disease.
• ECG evaluates electrical activity but not structural abnormalities.

Hypertrophic cardiomyopathy causes thickening of cardiac muscle, making it harder to pump blood. Exercise can trigger suddent cardiac death in these individuals, especially with a family history.

Incorrect option-

• PDA, VSD, ASD these are all congenital deformaties that present in early life and rarely cause sudden death in adults during exercise.

TOF is a heart defect with 4 key features, and VSD is one of them.

Features of TOF-

• VSD
• Pulmonary stenosis
• overriding aorta
• Right ventricular hypertrophy

In rheumatic valvular disease with a mitral orifice of 1 cm, the heart compensates by dilation of the left atrium with chamber hypertrophy. This happens because the left atrium has to work harder to push blood through the narrowed valve, causing it to enlarge and thicken.

 Incorrect options-

• Ventricular changes [dilatation or contraction] occur later, not initially.
• The left atrium doesn't decrease contraction pressure- it needs to contract harder.

MS is classified as severe when the mitral valve area is </=1.0cm2. In this case the valve area is 0.7cm2 which is indicative of intervention.

Percutaneous mitral valvuloplasty is the preferred treatment for severe symptomatic MS in patient withot contraindication such as severe MR or left atrial thrombus.

All can cause QT-interval prolongation

The patient has had a anterior wall MI with PVCs and pulmonary edema, indicating the heart isn't pumping effectively. They are already on medications to strengthen the heart, reduce fluid buildup. The next best step is amiodarone, an antiarrythmic drug that stabilizes abnormal heart rhythms and prevents more serious complications.

RHD occurs after an infection with group A streptococcus, which typically causes tonsillitis or pharyngitis. The immune response to this throat infection can mistakenly attack the heart leading to damage.

PDA  is a condition in which the ductus arteriosus, a blood vessel connecting the aorta and pulmonary artery in a fetus, fails to close after birth. This abnormal blood flow creates continous, machinery like murmur that is often heard at the left sternal border.

Incorrect options-

• AS presents with ejection systolic murmur.
• MS presents with diastolic rumble murmur.
• MR presents with holosystolic murmur.

Digoxin is used in heart faliure and ventricular fibrillation to slow the ventricular rate. In AF, the atria beats rapidly and irregularly, which can cause the ventricles to pump too fast. By slowing the ventricular rate, digoxin reduces starin on the heart and improves its efficiency.

Carvedilol is a beta-blocker and is contraindicated with diltiazem, a calcium channel blocker, because their combined action can cause severe bradycardia.

Arterioles are like control valves of the vascular system. They regulate blood pressure by constricting or dilating, which adjusts the blood flow and resistance. This makes them the key regulators in initial BP regulation.

• Obesity worsens HTN, and even small weight loss can lower BP.
• HTN is a major risk factor for heart attacks, strokes, and kidney disease.

So contolling these factors is crucial as they together have the most immediate and long-term benifits.

Syncope on exertion/rest and chestpain are hallmark features of HCM.

Incorrect options-

• AS typically presents with murmur that radiates but doesn't change with change is position.
• Pulmonary stenosis affects the right heart and the murmur is heard at upper left sternal border.
• Constrictive cariomyopathy is more associated with signs of right heart faliure.

Troponin appears 1-6 h after injury, peaks at 24 h, and may remain elevated for 7-10 d in STEMI.

After MI metoprolol [beta-blocker] is commonly used to prevent future arrythmias by slowing the heart rate and reducing the strain on heart.

In sinus arrythmia, carotid massage slows the heart rate because the rhythm is still controlled by the sinus node.

In AF, the irregular rhythm is unaffected by carotid massage since its not controlled by the SA node.

Incorrect options-

• Temporal artery massage isn't relevant
• Amiodarone and Digoxin treat arrythmias but don't help in differentiating them.

A stress ECG is the best initial test. It helps assess wheather coronary artery disease is causing pain, especially since CAD is common in this age group.

Incorrect options-

• Barium study and UGID are for GIT related issues.
• CXR is useful for lung conditions, not for chest pain from potential heart problems.