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Chapter 10 Test — Approach to Rhythm Diagnosis: A Systematic Method for Every Arrhythmia
24 questions · 24 min · +4 / -1
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Question 1
Question 1
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A 58-year-old man is brought to casualty with palpitations. The monitor shows a tachycardia at 190/min. Before you look at the tracing in detail, what is the FIRST step in the systematic approach to any arrhythmia?
A.
Measure the QRS width in a lead with a clear onset
B.
Examine lead II and V1 for P waves
C.
Calculate the ventricular rate by the 300 method
D.
Assess whether the patient is haemodynamically stable
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Question 2
Question 2
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On a standard ECG (25 mm/s) the rhythm is regular and there are exactly 4 large squares between two consecutive R waves. What is the ventricular rate?
A.
60 bpm
B.
100 bpm
C.
50 bpm
D.
75 bpm
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Question 3
Question 3
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Work through the rhythm systematically on the ECG shown. The rate is about 75/min, the R–R intervals are constant, every QRS is narrow, and each QRS is preceded by an upright P wave with a constant PR interval. What is the rhythm?
A.
Atrial fibrillation
B.
Atrial flutter
C.
Normal sinus rhythm
D.
Complete heart block
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Question 4
Question 4
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A patient comes to casualty with palpitations. The ECG shows a rapid, regular, narrow-complex (QRS <120 ms) tachycardia at about 180 bpm, with no clearly discernible P waves and no capture or fusion beats. What is the most likely diagnosis?
A.
Ventricular tachycardia
B.
AV dissociation
C.
Supraventricular tachycardia
D.
Sinus tachycardia
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Question 5
Question 5
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A 22-year-old man is brought to casualty with palpitations and dizziness. Heart rate is 160/min and blood pressure 110/80 mmHg. His ECG is shown — a regular narrow-complex tachycardia with no distinct P waves. What is the first line of management?
A.
Adenosine 6 mg IV
B.
Adenosine 12 mg IV
C.
Vagal manoeuvre
D.
Amiodarone 300 mg IV
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Question 6
Question 6
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A 55-year-old woman presents with dizziness and palpitations. She is normotensive. The rhythm strip shown is a regular narrow-complex tachycardia at about 180/min with no visible P waves. Valsalva and carotid sinus massage have already been tried without effect. What is the best next treatment?
A.
Adenosine 6 mg rapid IV push
B.
Amiodarone 150 mg IV
C.
Oral beta-blocker
D.
Repeat the Valsalva manoeuvre
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Question 7
Question 7
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A 38-year-old woman presents with sudden-onset palpitations and a regular narrow-complex tachycardia at 180 bpm. BP is 110/70 mmHg. The physician applies carotid sinus pressure for 5 seconds and the tachycardia terminates abruptly with restoration of sinus rhythm. Which arrhythmia is most likely?
A.
Atrial flutter with 2:1 block
B.
Atrial fibrillation with a rapid ventricular response
C.
Monomorphic ventricular tachycardia
D.
AV nodal re-entrant tachycardia (AVNRT)
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Question 8
Question 8
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Which one of the following responses to intravenous adenosine is correctly matched?
A.
Atrial fibrillation — termination
B.
AV nodal re-entrant tachycardia — termination
C.
Ventricular tachycardia — termination and complete recovery
D.
Atrial flutter — termination and complete recovery
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Question 9
Question 9
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A 26-year-old woman has a regular narrow-complex tachycardia at 200/min. A retrograde P wave is clearly visible AFTER each QRS, with an RP interval of about 110 ms. Which mechanism does this favour?
A.
AVRT using an accessory pathway
B.
AVNRT (AV nodal re-entrant tachycardia)
C.
Sinus tachycardia
D.
Atrial flutter with 2:1 block
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Question 10
Question 10
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The most common form of paroxysmal supraventricular tachycardia is:
A.
Junctional ectopic tachycardia
B.
AV nodal re-entrant tachycardia (AVNRT)
C.
Accessory pathway-mediated tachycardia (AVRT)
D.
Accelerated junctional rhythm
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Question 11
Question 11
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Which of the following correctly describes antidromic conduction in atrioventricular re-entrant tachycardia (AVRT)?
A.
Retrograde conduction through the bundle of Kent with a narrow QRS complex
B.
Anterograde conduction through the bundle of Kent with a broad QRS complex
C.
The treatment of choice is unsynchronised defibrillation
D.
Carotid sinus massage prevents further paroxysmal attacks
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Question 12
Question 12
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All of the following are supraventricular tachycardias EXCEPT:
A.
AV nodal re-entrant tachycardia
B.
Sinus tachycardia
C.
Junctional tachycardia
D.
Premature ventricular beats
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Question 13
Question 13
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A 45-year-old man has palpitations of abrupt onset and termination. The ECG during an episode shows a narrow-complex tachycardia at 180/min without visible P waves, consistent with paroxysmal supraventricular tachycardia (PSVT). Which of the following rhythms is NOT classified under PSVT?
A.
Atrial fibrillation
B.
Atrial tachycardia
C.
AV nodal re-entrant tachycardia
D.
AV re-entrant tachycardia
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Question 14
Question 14
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A 62-year-old hypertensive man presents with palpitations and mild breathlessness. His ECG is shown. The rhythm is regular at approximately 150 bpm with narrow QRS complexes, and the baseline between the QRS complexes in the inferior leads shows a regular undulating pattern with no isoelectric line. The most likely diagnosis is:
A.
Sinus tachycardia at 150 bpm
B.
AVNRT with pseudo-S waves
C.
Atrial flutter with 2:1 atrioventricular block
D.
Atrial fibrillation with rapid ventricular response
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Question 15
Question 15
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In a patient with a regular narrow-complex tachycardia at 150/min, carotid sinus massage transiently slows the ventricular rate and reveals sawtooth waves in II, III and aVF. What is the atrial rate in this rhythm?
A.
300/min
B.
450/min
C.
200/min
D.
150/min
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Question 16
Question 16
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A 70-year-old man has palpitations. His ECG is shown: the QRS complexes are narrow, the R–R intervals clearly vary, and regular atrial waves (arrows in V1) march through the tracing at a constant fast rate. Which diagnosis best fits?
A.
Atrial fibrillation
B.
Multifocal atrial tachycardia
C.
Atrial flutter with variable AV block
D.
Sinus arrhythmia
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Question 17
Question 17
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A 68-year-old man with severe COPD and an acute exacerbation has palpitations. The rhythm strip shown is an irregular narrow-complex tachycardia at about 120/min; the arrows mark P waves of at least three different shapes, each with a different PR interval, and the baseline between them is isoelectric. What is the diagnosis, and what is the correct management?
A.
Atrial flutter with variable block — synchronised cardioversion
B.
Multifocal atrial tachycardia — treat the hypoxia and underlying lung disease
C.
Wandering atrial pacemaker — no treatment needed as the rate is normal
D.
Atrial fibrillation — start rate control with diltiazem
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Question 18
Question 18
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A 64-year-old man with a previous anterior myocardial infarction develops palpitations. His ECG is shown: after a few sinus beats there is abrupt onset of a regular, wide, uniform-morphology tachycardia at about 190/min. He is alert with a blood pressure of 105/70 mmHg. What is the safest working assumption?
A.
Assume ventricular tachycardia until proven otherwise
B.
Assume a paced rhythm and check the pacemaker
C.
Assume SVT with aberrancy and give IV verapamil
D.
Assume antidromic AVRT and give IV adenosine
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Question 19
Question 19
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In the wide-complex tachycardia shown, the arrows mark P waves that occur at their own slower rate, completely independent of the QRS complexes. Which statement about this finding is correct?
A.
It indicates Wolff-Parkinson-White pre-excitation
B.
It confirms supraventricular tachycardia with aberrant conduction
C.
It is seen only in atrial flutter with variable block
D.
It is the single most specific ECG sign of ventricular tachycardia
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Question 20
Question 20
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A 74-year-old man with known coronary artery disease presents with palpitations. He is alert and his blood pressure is stable at 120/84 mmHg. His ECG is shown — a regular wide-complex tachycardia with uniform QRS morphology. What is the most appropriate initial treatment?
A.
Oral metoprolol
B.
IV metoprolol
C.
Oral amiodarone
D.
IV amiodarone
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Question 21
Question 21
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A haemodynamically unstable patient presents with supraventricular tachycardia. What is the most appropriate treatment?
A.
IV ibutilide infusion
B.
IV diltiazem bolus
C.
Synchronised cardioversion
D.
IV beta-blocker such as metoprolol
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Question 22
Question 22
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A 24-year-old man presents with palpitations. The ECG shows an irregular tachycardia at over 220/min with wide QRS complexes that vary in width and shape from beat to beat. He is alert with a systolic BP of 105 mmHg. Which drug must be AVOIDED?
A.
None — all listed options are safe
B.
IV adenosine
C.
Intravenous fluids
D.
IV procainamide
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Question 23
Question 23
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A 63-year-old woman on sotalol develops palpitations and near-syncope. Her baseline ECG had shown a prolonged QT interval, and the monitor now shows an irregular wide-complex tachycardia in which the QRS complexes twist around the baseline, changing amplitude and axis. What is the treatment of choice?
A.
IV magnesium sulphate
B.
IV adenosine
C.
IV amiodarone
D.
IV verapamil
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Question 24
Question 24
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A 72-year-old woman presents with dizziness. Her ECG shows a rate of 38/min with a constant PR interval and intermittent sudden non-conducted P waves (Mobitz type II second-degree AV block). What is the most appropriate management?
A.
IV atropine 1 mg, repeated up to a total of 3 mg
B.
Temporary pacing and permanent pacemaker referral
C.
IV adenosine to clarify the level of the conduction block
D.
Observation alone, since this block is benign
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