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3,531 questions
A 50-year-old man with long-standing hypertension presents acutely with severe chest pain radiating through to his back. He looks unwell, with a resting tachycardia (110 bpm) and blood pressure of 150/96 mmHg. There are no murmurs and neurological examination is normal. An urgent CT scan of his chest confirms type-A aortic dissection. The local cardiothoracic centre is USMLE IM2e/Management contacted and urgent transfer arranged. He has received appropriate opiate analgesia. What additional drug treatment should be instigated as part of his immediate treatment plan?
A 70-year-old man is referred by his GP for advice regarding optimisation of secondary prevention. He has a history of angina, with excellent control of symptoms on a combination of aspirin, dipyridamole MR, atenolol 50 mg od, simvastatin 40 mg od and isosorbide mononitrate 20 mg bd. His pulse rate is 70 bpm and blood pressure is 144/86 mmHg. The only other relevant past history includes an ischaemic stroke 2 years ago from which he made a complete recovery. What additional therapy would you consider adding?
A 78-year-old woman presents to AE with three episodes of syncope in the last 24 hours. There is no history of chest pain. She is taking frusemide 80 mg od and ramipril 10 mg od for known hypertension. She is conscious with a blood pressure of 100/40 mmHg. Potassium is 5.3 mmol/l. Her ECG shows complete heart block with rate of 40 bpm. QRS duration is 150 ms with a right bundle-branch block configuration. What is the optimum initial management?
A SO-year-old man presents with a 1-hour history of severe central chest pain. There is no significant past medical history. He is haemodynamically stable with pulse rate of 90 bpm and blood pressure of 120/70 mm Hg. ECG shows 5 mm of ST-segment elevation in the anterior leads (V2-V4). He received aspirin 300 mg in the ambulance and 5 mg diamorphine. What would be the next line of treatment?
A 72-year-old Caucasian woman is referred to out-patients for advice regarding her hypertension management. She has been on treatment in the form of perindopril 4 mg od for the past 3 years. However, on repeated measurements, her readings have been> 160 mmHg systolic, with diastolic readings being in the order of 80-85 mmHg. Renal function is normal as is urine dipstick testing. There is no evidence of left ventricular hypertrophy on ECG. She is obese with a BMI of 33. What would you consider adding as your next drug?
A 69-year-old man presents with a 3-hour history of chest pain. ECG shows an inferior wall infarction with ST elevation of 3 mm. There is no history of diabetes mellitus, injury or previous surgery. Blood pressure is 132/70 mmHg with a pulse of 58/min. Which of the following treatments would be most appropriate?
A 60-year-old woman is found to have a systolic murmur at a routine medical. When you see her she is asymptomatic. Electrocardiography (ECG) shows marked left ventricular hypertrophy with strain. Echocardiography shows a peak aortic valve gradient of 90 mmHg, and decreased LV systolic function. What is the correct management?
A 45-year-old man with a strong family history of ischaemic heart disease presents with atypical chest pains. Electrocardiographic (ECG) exercise testing shows J point depression of 1 mm with a heart rate of 120 beats/min (bpm). What is the most appropriate next step?
A 65-year-old male patient with stable angina complains of shortness of breath after walking two flights of stairs. He has normal left ventricular function on the echocardiogram and a positive exercise tolerance test (3 mm ST depression at stage Ill). What is the most appropriate therapy?
A 65-year-old female patient with severe heart failure presents with increasing shortness of breath. Her current pharmacological treatment consists of an angiotensin-converting enzyme (ACE) inhibitor, loop diuretic and b-blocker. What is the most appropriate management?
A 68-year-old man is admitted with syncope. He is known to have ischaemic cardiomyopathy. His medications include: aspirin 75 mg od, frusemide 80 mg bd and lisinopril 10 mg od. An initial ECG shows sinus bradycardia (50 bpm) and RBBB. Results of blood tests are as follows: sodium, 134 mmoln; potassium, 3.5 mmoln; creatinine 124 mmoln. He has recurrent syncopal episodes on the CCU, where monitoring shows episodes of non-sustained torsades de pointes (polymorphic VT). Which of the following would be your initial line of treatment?
A 32-year-old woman who is known to be 17 weeks' pregnant presents for review. She has periods of paroxysmal supraventricular tachycardia (SVT) and on this occasion has a ventricular rate of 165/min and a blood pressure of 90/50 mmHg, feeling faint and unwell. Which of the foilowing anti-arrhythmics would be the most appropriate prophylaxis for her?
A 72-year-old man presents for an extraction of three teeth under local anaesthesia. He has a past history of rheumatic heart disease. Mitral stenosis has been identified but the rotten teeth are being removed before valve replacement. He is allergic to penicillin. Which of the following would be the most appropriate antibiotic regime for him?
A 64-year-old woman suffers from frequent and painful urinary tract infections. After her third course of antibiotics in the past 6 months she is advised by the GP to take cranberry juice supplements. Significant past medical history of note includes hypertension for which she takes ramipril and bendroflumethiazide and hypercholesterolaemia for which she takes simvastatin. There is also a history of paroxysmal atrial fibrillation for which she takes warfarin and amiodarone. Which of her medications is most likely to interact with the cranberry juice?
A 25-year-old man was found by his family at home havin.g suffered a cardiac arrest. He was previously well, apart from well controlled Type 1 diabetes controlled with a basal bolus insulin regime. His family followed the ambulance and ask if they can be in the resuscitation room. After 20 mins of repeated resuscitation cycles he has remained in asystole. Blood gases; pH= 7.01, P02= 8.4 kPa, PC02= 3.9 kPa, Bicarb= 10 mmol/1. Which person is the most appropriate person to make the decision to discontinue resuscitation?
A 45-year-old man was diagnosed with new onset AF after visiting his GP complaining of palpitations. An ECG confirmed atrial fibrillation with a ventricular rate of 85/minute, and an ECHO did not reveal any significant structural heart disease. On advice of the hospital he was given low molecular weight heparin and stabilised on warfarin, with an INR of 2.5. Yon arrange for him to be cardioverted a few weeks later and the procedure is successful. For how long is it recommended to continue his warfarin therapy according to current guidelines?
A 58-year-old man with multiple dental problems presents to the Emergency department. Apart from an abscess on his toe for which he has been receiving flucloxacillin he has been relatively well. On examination he has splinter haemorrhages and looks anaemic. You detect an aortic systolic murmur. Echocardiogram is suggestive of aortic valve endocarditis and blood cultures confirm Streptococcus viridans. In addition to IV benzylpenicillin which antibiotic would you prescribe?
A 54-year-old woman with a history of atrial fibrillation presents with left face and arm weakness consistent with a stroke. On examination her BP is 162/82 mm.Hg, with a pulse of 85/min, irregular. Investigations; Hb 12.1 g/dl, WCC 5.4 x109/I, PLT 175 x109/I, Na+ 140 mmol/1,K+ 5.0 mmol/1, Creatinine 105 µmol/1. ECG - Atrial fibrillation, evidence of previous inferior myocardial infarction. CT head - No evidence of intracerebral haemorrhage. 6hrs post stroke you are considering anti-coagulation or anti-platelet therapy, which of the following would be most appropriate?
A 60-year-old woman with a long history of manic depressive psychosis managed with lithium therapy is sent to see you for review. She has a BP of 152/93 mmHg, and the GP is keen to commence anti-hypertensive therapy. Investigations: Hb 12.3 g/dl, WCC 5.4 x109/l, PLT 195 x109/l, Na+ 143 mmol/1, K+ 4.0 mmol/1, Creatinine 145 µmol/1, Total cholesterol 5.9 mmol/1, HDL 0.8 mmol/1. Which antihypertensive would be most appropriate for her to start?
An 18-year-old man.comes to the Emergency room because he has suffered a severe syncopal attack whilst playing a game of squash. His opponent tells you that he collapsed and took a few minutes to recover. Apparently this was the second episode, the first having occurred after a strenuous period of exercise at the swimming pool. Of note is the fact that his father died of a cardiac arrest at the age of 32. On examination he looks fit, his BP is 132/78 mmHg, his pulse is 70/min, sinus rhythm. Investigations; Hb 12.8 g/dl, WCC 5.0 x109/l, PLT 182 x109/l, Na+ 139 mmol/1, K+ 4.8 mmol/1, Creatinine 120 µmol/1. ECG Sinus rhythm but QT interval 0.51s. 24hr tape paroxysmal AF on 2 occasions. Which of the following agents should be given for rhythm control in this case?