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3,531 questions
You are discussing a patient with your registrar who has become acutely short of breath on the ward. After performing an arterial blood gas, you have high clinical suspicion that the patient has a pulmonary embolism. Which of the following is the investigation of choice for detecting pulmonary embolism?
A 29-year-old woman goes to see her GP complaining of fatigue and palpitations. She says she has also lost weight, though without dieting. On examination, her pulse rate is approximately 120/min and irregularly irregular. Her blood pressure is 142/89 mmHg and her body mass index is 19. There are no added cardiac sounds. The ECG confirms the diagnosis of atrial fibrillation. What would you suggest as the most useful next investigation.
A 30-year-old woman presents with pleuritic chest pain and haemoptysis. Her blood pressure is stable at 130/80 mmHg. A ventilation/perfusion scan shows minor mismatch at the lung bases. There is no evidence of RV dysfunction, clinically and on echocardiography. In addition to oxygen, which of the following is the appropriate management for this patient?
A 25-year-old woman with known mitral valve prolapse develops a low grade fever, malaise and night sweats within a couple of weeks of a major dental procedure. Examination reveals a pulse USMLE IM2e/Paraclinic rate of 110/minute, which is regular, tender vasculitic lesions on the finger pulps and microscopic haematuria. Which investigation is most likely to provide a defmitive diagnosis?
A 44-year-old woman presents with episodes of headaches, associated with anxiety, sweating and a slow pulse rate. At the time of her initial consultation, her blood pressure was 150/95 mmHg seated, but 24 hour ambulatory monitoring shows a peak of 215/130 mmHg, associated with the symptoms described above. Which of the following would be your initial diagnostic procedure?
A 70-year-old man, previously fit and well, is referred to out-patients with exertional chest pain that comes on at around 0.8 km (0.5 mile) on the flat. Examination reveals him to be in sinus rhythm at 80 bpm, blood pressure 100/70 mmHg, a diminished carotid upstroke and a loud ejection systolic murmur over the aortic area. Echo confirms left ventricular hypertrophy, preserved systolic function with peak aortic valve gradients of 80 mmHg. Subsequent coronary angiography reveals significant disease in the left anterior descending artery. What is the optimal treatment strategy?
A 32-year-old woman attends her GP for a routine medical examination and is noted to have a mid-diastolic murmur with an opening snap. Her blood pressure is 118/71 mmHg and the pulse is regular at 66 beats per minute. She is entirely asymptomatic and chest x-ray and ECG are normal. What would be the most appropriate investigation at this point?
A 41-year-old woman is referred for assessment after suffering a second pulmonary embolus within a year. She has not been travelling recently, has not had any surgery, does not smoke and does not take the oral contraceptive pill. She is not currently on any medication as the diagnosis is retrospective and she is now asymptomatic. What should be the next step in her management?
A 52 year-old woman has been treated for several years with amlodipine and lisinopril for what has been presumed to be primary hypertension. She is seen by her GP having complained of persistent left loin pain. Her BP is 150/95 mmHg. She is tender in the left loin and both kidneys appear to be enlarged. On urine dipstick testing, there is microscopic haematuria. Which of the following is likely to be the most appropriate investigation at this point?
A 56-year-old man presents to your clinic with symptoms of exertional chest tightness which is relieved by rest. You request an ECG which reveals that the patient has first degree heart block. Which of the following ECG abnormalities is typically seen in first degree heart block?
A 60-year-old man with metastatic adenocarcinoma of the lung, who has finished two cycles of palliative cisplatin/pemetrexed chemotherapy, presents with a 2-day history of nausea and vomiting. On examination, he is tachycardic with a blood pressure of 105/60 mmHg. Blood tests show a urea of 15 mmol/L and a creatinine of 180 µmol/L. Results from a week earlier showed a urea of 4.0 mmol/L and a creatinine of 90 µmol/L. All other blood tests and arterial blood gas results are within the normal range. What is the most appropriate initial management of this patient?
A 52-year-old woman, with a prior history of rheumatic fever, presents with shortness of breath on strenuous exertion while working as a landscape gardener. She is in permanent atrial fibrillation and is on long-term warfarin and digoxin (125 mg once daily). Clinical examination reveals her to be in atrial fibrillation at a rate of around 150 bpm. Echo demonstrates preserved left ventricular function, a heavily calcified mitral valve with moderate mitral stenosis (mitral valve area 1.5 cm2) and moderate mitral regurgitation. Her left atrium is dilated. What is the most appropriate initial treatment option?
A 78-year-old woman is admitted to your ward following a 3-day history of shortness of breath and a productive cough of white frothy sputum. On auscultation of the lungs, you hear bilateral basal coarse inspiratory crackles. You suspect that the patient is in congestive cardiac failure. You request a chest x-ray. Which of the following signs is not typically seen on chest x-ray in patients with congestive cardiac failure?
A 67-year-old man presents to accident and emergency with a 3-day history of shortness of breath. On examination you palpate the radial pulse and notice that the patient has an irregular heart beat with an overall rate of 140 bpm. You request an electrocardiogram (ECG) which reveals that the patient is in atrial fibrillation. Which of the following would you expect to see when assessing the JVP?
You review a 26-year-old woman who attends the cardiology clinic with her husband. They wish to start a family, but they have been referred by the GP as he is worried that she has a history of heart disease. Which of the following cardiovascular conditions is an absolute contra-indication to pregnancy?
A 65-year-old man presents with central crushing chest pain for the first time. He is transferred immediately to the closest cardiac unit to undergo a primary percutaneous coronary intervention. There is thrombosis of the left circumflex artery only. Angioplasty is carried out and a drug-eluding stent is inserted. What are the most likely changes to have occurred on ECG during admission?
A 30-year-old man, who has recently returned from holiday in Africa, presents to accident and emergency with a 7-day history of fever, sweats, malaise and lethargy. Thick and thin blood films detect Plasmodium falciparum. What is the most appropriate treatment?
You see a 19-year-old Caucasian man in your clinic who presents with a history of transient jaundice. On direct questioning, you ascertain that the jaundice is noticeable after periods of increased physical activity and subsides after a few days. The patient bas no other symptoms and physical examination is 11nremarkable. Full blood count is normal (with a normal reticulocyte count) and liver function tests reveal a bilirubin of 37 µmol/L. The most appropriate management is:
A 26-year-old woman is being evaluated for dyspnea, which she experiences when she engages in physical activity. She has been having these symptoms for the past 4 months. She denies having chest pain, orthopnea, or paroxysmal nocturnal dyspnea. The patient's medical history is significant for her having one episode of atrial fibrillation 1 month ago. Her physical examination shows fixed splitting of S2 and a 2/6 systolic murmur in the pulmonic area. An electrocardiogram shows mild right ans deviation and an rSR' pattern in Vl. A chest x-ray reveals an enlarged right atrium and main pulmonary artery. Which of the following is tl1e most likely diagnosis for this patient?
A 16-year-old male becomes unresponsive immediately after being hit in the chest by a baseball in a local game. A family member reports that the patient has a ''heart murmur.'' He takes no medications. The emergency medical service is called and finds the patient to be pulseless. Resuscitation attempts are started and are unfortunately unsuccessful. Which of the following is the most likely mechanism behind tbjs patient's cardiac arrest?