IM paraclinique new* HKS

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 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?

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 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 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 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 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 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 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 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 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.

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 foil owing is the investigation of choice for detecting pulmonary embolism?

You see a 46-year-old man who has presented to accident and emergency with an acute onset of shortness of breath. Your registrar has high clinical suspicion that the patient is suffering from a pulmonary embolism and tells you that the patient's ECG has changes pointing to the suspected diagnosis. From the list below, which of the foil owing ECG changes are classically seen?

You are asked to request imaging for a patient with a suspected pneumothorax who you have just examined in accident and emergency. Which of the following would be the most appropriate first step imaging modality?

A 56-year-old woman who has recently been discharged from your ward, with oral antibiotics for right basal community-acquired pneumonia, is re-admitted with transient pyrexia and shortness of breath. She is found to have a right-sided pleural effusion which is drained and some pleural aspirate sent for analysis. The results reveal an empyema. Which of the following, from the pleural aspirate analysis, would typically be found in a patient with an empyema?

You are told that a patient in clinic has been diagnosed with cystic fibrosis using the sodium chloride sweat test. Which of the following results from the latter test would indicate a positive diagnosis of cystic fibrosis?

You are asked by your registrar to request an imaging investigation for a 49-year- old woman with jaundice and abdominal pain. She has a past medical history of gallstones and you suspect this is a recurrence of the same problem. The most appropriate imaging investigation is:

You see a 56-year-old man in your clinic with suspected alcoholic liver disease. Liver function tests reveal a bilirubin of 36 iu/L, AST of 150 iu/L, ALT 75 iu/L and ALP 100 iu/L. Which of the following blood test parameters would support a diagnosis of alcoholic-related liver disease?

A 56-year-old man, diagnosed with emphysema, presents with a one-month history of jaundice and ascites. Your registrar suspects that this patient may have liver disease secondary to alantitrypsin deficiency. Select the most likely mode of inheritance from the list below:

A patient on your ward is diagnosed with hepatocellular carcinoma. You are asked to perform a tumour marker level on this patient. Which of the following tumour markers are elevated in hepatocellular carcinoma?

A 64-year-old woman attends your clinic with a 2-week history of jaundice. Over the last three months the patient has lost 10 kg. Associated symptoms include decreased appetite, dark urine and pale stools. On examination, the patient is jaundiced, her abdomen is soft and you can palpate a painless mass in the right upper quadrant. From the list of answers below, select the initial most appropriate investigation that you would request for this patient:

A 33-year-old woman presents to accident and emergency with severe right flank pain. The pain started 3 hours ago and is not constant, occasionally moving towards her right iliac fossa. The patient also feels nauseous and has a low-grade fever. The most appropriate investigation is:

A 21-year-old woman complains of urinary frequency, nocturia, constipation and polydipsia. Her symptoms started 2 weeks ago and prior to this she would urinate twice a day and never at night. She has also noticed general malaise and some pain in her left flank. A urine dipstick is normal. The most appropriate investigation is:

A 58-year-old man presents with breathlessness, he reports feeling unwell over the last three months with nausea, vomiting and difficulty breathing. You notice his ankles are swollen and he has bruises on his arms. The patient mentions he has not been urinating as often as normal. The most appropriate investigation is:

A 24-year-old man presents with a four-month history of abdominal pain which has been getting worse. The patient describes the pain as generalized, dull in character and does not radiate but often occurs alongside loin pain. An irregular mass is palpable in both flanks and a mid-systolic click can be auscultated. The most appropriate investigation is:

Which of the following arterial blood gas results, taken on room air, would you expect to see in a 67-year-old patient who has been suffering with COPD for two years and is not on home oxygen?

A 38-year-old woman presents to her GP with a 2-week history of dysuria, haematuria and shortness of breath. She suffers from chronic headaches and has been taking ibuprofen in order to treat them. She has a history of cardiovascular disease in the family and a friend recommended she use aspirin to keep healthy. The most appropriate investigation is:

A 68-year-old obese Asian man is seen in the hypertension clinic. His blood pressure is 151/93 and he suffers from poorly controlled type 2 diabetes. Blood results demonstrate elevated serum urea and creatinine. An ultra.sound scan shows asymmetry between the two kidneys and on examination audible abdominal bruits are auscultated. Urine dipstick did not detect any blood or protein. The best investigation is:

A 63-year-old woman presents in accident and emergency with a 3-day history of worsening abdominal pain and mild flank pain. Examination reveals pain in the suprapubic region, but otherwise the abdomen is soft with no masses. The patient denies any other symptoms, such as dysuria, but mentions she has had difficulty passing urine in the last week and is only able to provide a small urine sample which is odorous and bloody. She has no other medical problems, but admits to being a long-term smoker. An ultrasound scan of renal system is most likely to show:

A 19-year-old man is recently diagnosed with type 1 diabetes and attends your clinic to ask about possible complications in the future. He mentions an uncle who has end-stage renal disease due to poorly controlled diabetes and specifically enquires about testing for early signs of renal impairment. The most appropriate investigation is:

A 60-year-old man visits his GP complaining of tiredness. He has noticed weight loss over the last six months and irritation of the tip of his penis which appears inflamed on examination. He mentions he has been visiting the toilet more often than usual and feeling thirsty. The most appropriate investigation would be:

A 28-year-old woman has noticed a change in her appearance; most notably her clothes do not fit properly and are especially tight around the waist. Her face appears flushed and more rounded than usual, despite exercising regularly and eating healthily her weight has steadily increased over the last 3 weeks. On visiting her GP, he notices her blood pressure has increased since her last visit and she has bruises on her arm. She is especially worried about a brain tumour. The most appropriate investigation would be:

A 22-year-old woman complains of dizziness and feeling light-headed. She works in an office and most frequently experiences this when standing up to visit the toilet. She has never fainted. The patient has lost 5 kg, but attributes this to eating more healthily. She has noticed a recent scar on the back of her hand which has started to turn very dark. The most appropriate investigation is:

A 29-year-old man presents with a 4-week history of polyuria and extreme thirst. The patient denies difficulty voiding, hesitancy or haematuria, although the urine is very dilute. The patient does not believe he has lost any weight and maintains a good diet. No fmdings are found on urine dipstick. The most appropriate investigation is:

A 39-year-old man presents with a three-month history of depression. The patient recently lost a family member and around the same period began to feel unwell with constipation and a depressed mood. He has started taking analgesia for a sharp pain in his right lower back that often radiates towards his front. The most appropriate investigation is:

A 47-year-old woman presents to clinic after being referred from her GP for consistently elevated blood pressure. Her last reading was 147/93. The female does not report any symptoms but recently lost her job and attributes the elevated reading to stress. Her blood tests are a.s follows: Sodium 146, Potassium 3.4, Glucose (random) 7.7, Urea 4. The most appropriate investigation is:

A 49-year-old man has recently been diagnosed with type 2 diabetes and is being carefully monitored. He has been advised to maintain a healthier diet and lifestyle, he attends a follow-up clinic and claims to have been following the diet stringently since his last appointment three months ago. The most appropriate investigation is:

A 33-year-old man complains of a tingling sensation in his hands for several months which occasionally awakens him during sleep. The patient has noticed he has gained weight and no longer wears his wedding ring as it has become too tight. You notice the patient is sweating while speaking to you and has quite a large jaw, furrowed tongue and large hands. His blood pressure reading is 142/91 mmHg. The most appropriate investigation would be:

A 29-year-old man presents to his GP complaining of being constantly thirsty, tired and visiting the toilet more often than usual during the last 4 days. He has noticed his clothes have become more baggy and he now needs to tighten his belt. His parents both have diabetes requiring insulin therapy. A fasting plasma glucose result is most likely to be:

A 45-year-old woman presents to the rheumatology outpatient clinic with a three- month history of stiff hands and wrists. She mentions that the pain is particularly bad first thing in the morning. On examination, the wrists, metacarpophalangeal joints and proximal interphalyngeal joints are swollen and warm. A diagnosis of rheumatoid arthritis is suspected. Which of the following investigations is most specific for confirming the diagnosis?

A 79-year-old woman presents to her GP with pain in the left knee. This is particularly bad in the evenings and is stopping her from sleeping. The GP explains that her discomfort is most likely due to osteoarthritis and arranges for her to have an x-ray of the knee. Which of the following descriptions are most likely to describe the x-ray?

A 32-year-old man presents to the minor injuries walk-in clinic, complaining of back pain. This had started suddenly that morning after he had lifted a heavy box at home. He mentions that the pain has been shooting down his left leg and he cannot walk without the support of his friend. He has not passed urine since the onset of pain. On neurological examination of the lower limbs, tone and power cannot be assessed due to pain but there are decreased ankle reflexes and a sacral anaesthesia. What is the most appropriate next step?

A 70-year-old woman with a history of vertebral crush fractures presents to the osteoporosis outpatient clinic. Which of the following investigations is most useful to assess the extent of her osteoporosis?

A 27-year-old woman presents to accident and emergency complaining of sudden onset shortness of breath and right-sided pleuritic chest pain. She has a past medical history of three miscarriages and a deep venous thrombosis in the right leg. On examination, pulse is 110 bpm, respiratory rate is 24 bpm, oxygen saturation is 88 per cent on room air. An arterial blood gas shows pH 7.40, P02 8.0, PC02 3.1. What is the diagnostic investigation of choice?

A 27-year-old woman presents to accident and emergency complaining of sudden onset shortness of breath, right-sided pleuritic chest pain and haemoptysis. She has a past medical history of three miscarriages and a deep venous thrombosis in the right leg. CTP A confirms a large pulmonary embolism. A diagnosis of anti-phospholipid syndrome is suspected and a full autoantibody screen is sent. Which of the following auto-antibodies would confirm the diagnosis if detected?

A 29-year-old woman complains of a 1-week history of weakness and malaise, she has recently become a vegetarian and eats mostly green vegetables and drinks lots of tea during the day. She is apyrexial and has a C-reactive protein (CRP) < 5. You suspect an abnormality of the patient's iron stores. What is the most appropriate investigation to determine iron store levels?

A 29-year-old woman complains of tiredness, especially during activity. On examination the patient appears pale. Auer rods and schistocytes can be seen on peripheral blood smear. The patient is ref erred for a bone marrow biopsy and the extracted cells are sent for cytogenetic analysis. The most likely results are:

An 18-year-old African man presents with worries about his general health stating that hypertension and sickle cell anaemia are present in his family history. The patient denies any shortness of breath, chest pain, digit or limb changes. Blood pressure is 124/77 mmHg. What test would be appropriate to investigate sickle cell anaemia?

A 47-year-old woman presents complaining of dark stools and painful fingers on both hands. She appears plethoric and complains of severe itching, often when she is washing. A large liver and spleen is palpable. You suspect features of polycythaemia rubra vera and measure red cell mass and erythropoietin levels among other tests. Which of the following is likely to be most accurate in this patient?

A 44-year-old woman presents with recurrent fever, pallor, malaise and shortness of breath. She has noticed a petechial rash on her skin and small bruises on her arms. A blood test reveals a pancytopenia. During examination, you palpate a large spleen. Which investigation would differentiate between hypersplenism and a plastic anaemia?

A 66-year-old man presents complaining of a three-month history of weakness, tingling in the limbs and a sore tongue. The patient notes an undesired 5 kg weight loss over 2 weeks. A peripheral blood smear shows a macrocytic anaemia, a Schilling test shows impaired vitamin B 12 absorption and a diagnosis of pernicious anaemia is made. Which of the following antibodies is most closely associated with pernicious anaemia?

A 5-year-old girl presents with her parents who have become concerned about the small petechiae and ecchymoses on her skin. An abdominal examination reveals hepatosplenomegaly. You suspect an acute leukaemia. The most appropriate initial investigation for diagnosis is:

A 77-year-old woman is admitted to hospital with a urinary tract infection. She receives antibiotics and seems to be responding well. On the fourth day she is eating her lunch when she suddenly drops her fork. She calls for the nurse who notices the left side of her face is drooping. What is the best next course of action?

A 62-year-old woman presents to accident and emergency with a 1-day history of sudden onset back pain and difficulty walking. She has not opened her bowels or passed urine for the previous day. She has a past medical history of breast cancer, diagnosed two years earlier and staged as T2N1MO disease with oestrogen receptor positive status. She has been treated for her cancer with a wide local excision and axillary node clearance, followed by radiotherapy, chemotherapy and tamoxif en. On examination, there is reduced tone in the lower limbs. Power is diminished throughout the lower limbs, but especially on hip flexion. There is reduced sensation below the Ll dermatome. What is the most appropriate diagnostic investigation?

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 fever and lethargy. On examination, he is pyrexial with a temperature of 38.8°C. What is the most appropriate next step?

A 57-year-old woman with adenocarcinoma of the sigmoid colon with liver metastasis is attending for cycle six of her palliative FOLFOX chemotherapy. Which tumour marker can be measured in the blood test to indicate the effect of the chemotherapy?

A 58-year-old male with known small cell lung cancer presents to accident and emergency with a 5-day history of severe headache and recurrent vomiting. He has recently commenced chemotherapy for small cell carcinoma of the lung. On examination of the visual fields, there is a left inferior homonymous quadrantinopia. The most important diagnostic investigation is:

A 64-year-old man presents to accident and emergency following a collapse. He describes a blackout, subsequently regaining consciousness when on the floor. He presently feels well and describes no other symptoms. However, he mentions that he has unintentionally lost some weight over the past few months. There is no past medical history. Blood tests reveal a haemoglobin level of 9 g/dL with a mean cell volume on 71 fL. The most appropriate next investigation of this patient is:

A 39-year-old Indian man presents to his GP with a 5-week history of haemoptysis, night sweats and weight loss. Which of the following investigations can be used to confirm the diagnosis of tuberculosis?

A 43-year-old woman presents to accident and emergency with epigastric pain that started 4 hours ago. The woman describes the pain as being sharp and radiating to her back. She feels nauseous but has not vomited and is fully alert and orientated. The patient responds well to IV fluids and analgesia. Biochemical blood results show: Bilirubin 8 μmol/L, ALT 38 IU/L, AST 34 IU/L, ALP 421 IU/L, Amylase 1850 U/L. The most appropriate investigation would be:

A 42-year-old man presents with a 2-day history of severe chest pain. The patient reports a sudden ripping sensation at the front of the chest that occasionally radiates to the back. The patient has tried paracetamol and ibuprofen to alleviate the pain, but has had no success. The patient suffers from poorly controlled hypertension and at the last GP appointment his blood pressure was 167/95 mmHg. The most definitive investigation is:

A 19-year-old woman presents with an acute episode of feeling unwell. While in the middle of moving to a new house, she experienced an extremely severe pain near the back of her bead. She denies any recent travelling, fever or neck stiffness. The most defmitive investigation is:

A 35-year-old woman complains of a sharp central chest that is acutely exacerbated each time she moves, breathes in or lies flat. The pain tends to stay in the centre of the chest but occasionally moves towards her neck and shoulders. The pain is relieved by sitting forward. Thepatient does not drink alcohol, is not diabetic and does not smoke. A pericardial rub is heard on auscultation. The most appropriate diagnostic investigation is:

A 45-year-old man with a strong family history of dilated cardiomyopathy presents with peripheral oedema, finger clubbing, jugular venous distension and pulmonary rales. A gallop rhythm is heard on auscultation Which investigation would not be useful in dilated cardiomyopathy?

A 64-year-old man presents with a 2-day history of abdominal pain which he describes as constant, dull and around his umbilicus and occasionally migrating to his groin. He has a body mass index (BMI) of 27 and a past medical history of poorly controlled hypertension. Abdominal examination reveals a pulsatile and expansile mass just below the umbilicus. The most appropriate screening investigation is:

A 71-year old woman presents to accident and emergency with pain in the right knee. This has been ongoing for the past five months but she is now finding it difficult to walk. Pain is usually worse after exertion. On examination, the right knee is swollen. There is a reduced range of active movement and palpable crepitus. What are the most likely findings on x-ray?

A 60-year-old man presents to his GP with gradually increasing fatigue and some exertional dyspnoea. Blood pressure is 118/74 mmHg and pulse rate is 81/minute. There are no abnormal physical findings and on echocardiography the ejection fraction is 0.47. However, the clinical impression remains one of early heart failure. Which of the foil owing circulating biomarkers would lend support to that conclusion?

A SO-year-old man with type 2 diabetes undergoes a prosthetic aortic valve replacement after suffering from congestive heart failure due to native valve endocarditis. Following the operation, he presents with fever, janeway lesions, splinter haemorrhages and night sweats. The most definitive investigation for prosthetic valve endocarditis is:

You are informed that one of your ward patients has been breathless over the last hour and has been quite anxious since her relatives left after visiting. The patient is a 67-year-old woman who was admitted 6 days ago for a left basal pneumonia which has responded well with intravenous antibiotics. Her past medical history includes dementia and hypertension. You are asked by your registrar to interpret the patient's arterial blood gas (ABG) measurements taken during her tachypnoea: pH 7.49 kPa, P02 14.1, PC02 3.1 kPa, HC03 24. From the list of answers below, choose the most appropriate ABG interpretation:

A 59-year-old man, who has completed five cycles of chemotherapy for metastatic colorectal carcinoma, presents to accident and emergency complaining of feeling generally unwell. On examination, he is pyrexial at 38.9°C and there are crepitations in the right lung base. What is the most urgent investigation?

A 39-year-old Indian man presents to accident and emergency with a 6-week history of haemoptysis, night sweats and weight loss. Chest x-ray reveals some shadowing in the left upper zone. What is the most appropriate diagnostic investigation?

A 52-year-old woman who has recently finished a course of chemotherapy for metastatic adenocarcinoma of the lung presents to accident and emergency following a fall at home. She mentions that her legs have been feeling heavy for 2 days. On examination there is reduced power through the lower limbs. Her lower limb reflexes are brisk and she has upgoing plantars. On examination of the abdomen, there is a palpable bladder. There is a sensory level below Ll. What is the most important diagnostic investigation?

A seven-year-old girl is brought to accident and emergency by her mother because of a nose bleed that keeps on bleeding despite pressure and ice-packs. Petechiae and ecchymoses can be seen on examination and the mother reports the child has recently recovered from a throat infection. You suspect the patient is suffering from immune thrombocytopenic purpura and organize tests to measure platelets (Pit), bleeding time (BT), prothrombin time (PT) and partial thromboplastin time (PTT). Which of the foil owing is the most appropriate result?

A 60-year-old man presents with a history of recurrent dizzy spells for the past 4 months, which occur daily. The dizzy spells last a few minutes and seem to occur if he moves his head, as a result of which he keeps his head as still as possible. The attacks are not associated with any deafness or tinnitus and a neurological examination is entirely normal. You favour a diagnosis of benign paroxysmal positional vertigo. Which of the following descriptions of findings on Hallpike's manoeuvre would confirm this diagnosis?

A 21-year-old student on an internship with The Guardian travel section has recently returned from a backpacking holiday in West Africa. For the last few days he has been having headaches, flu-like symptoms and muscle aches, and now he has started rigoring. Which investigation should be performed to rule out malaria?

A 35-year-old homeless man presents to the emergency department in a state of unconsciousness. He was fitting when the ambulance crew got to him 20 minutes ago, and a friend at the scene estimated that he had started fitting ''around 15 minutes before''. His friend informed the ambulance crew that he is a known epileptic and you find a pack of phenytoin on him. He looks dishevelled and smells of alcohol. He has a blood pressure of 170/95 mm.Hg and temperature 37.9°C. On examination there is a quiet systolic murmur, though it is difficult to fully characterise. Which of the following investigations will be most useful at this stage?

A 45-year-old man presents with intermittent difficulty in swallowing for the last 4 months. This is associated with severe retrosternal pain and regurgitation. He has no risk factors or sinister signs for malignancy. What is the most important investigation in this case?

A 69-year-old man recently diagnosed with metastatic prostate cancer presents with weakness in his legs and urinary retention. He has had back pain for years but in the last 24 hours this has become very severe in his lower back. On examination he has a sensory deficit, loss of anal tone and poor sensation in the skin around the anus. When catheterised he has a residual volume of 1.5 L. Which of the following is the most informative initial investigation?

A 52-year-old man with hyperthyroidism, vitiligo and a 30 pack/year smoking history, presents to hospital with an acute clumsiness of his right hand. Neurological examination reveals normal cranial nerves, and the only abnormal feature on the limb examination is some past pointing and dysdiadochokinesis in the right hand. Diffusion-weighted magnetic resonance imaging (MRI) reveals a small right-sided cerebellar infarct. Which of the following investigations is unlikely to be helpful?

A 59-year-old woman with known polycythaemia vera presents to the emergency department with right upper quadrant pain, tender hepatomegaly and gross ascites, which has come on suddenly. There is no jaundice. What is the next most appropriate investigation?

A 65-year-old man with a longstanding diagnosis of chronic obstructive pulmonary disease has been reviewed by his GP for deteriorating liver function tests and clinical signs and symptoms of cirrhosis. What investigation should the GP arrange?

A 22-year-old-woman presents to AE with a 4-day history of chest pain. She has been unwell with an influenza-like illness for the last week. The ECG shows widespread ST elevation in the inferior, anterior and lateral leads. What ECG changes would you expect to see in the next week or two?

A 53-year-old bus driver presents with a history of chest pain at rest. Initial ECG shows minor ST-segment depression in the lateral leads. Cardiac enzymes, including troponin, are normal. He has known angina, with angiography 3 years previously demonstrating minor right coronary artery disease. He is commenced on aspirin, a b-blocker and a statin. His symptoms settle over 24 hours, 12 hr troponin is normal, and following mobilisation he is discharged home. He needs to know how this episode might affect his future employment. Assuming his condition remains stable with no further symptoms, what would be hte next stage of investigation?

A 69-year-old man has been admitted to the emergency department with syncope. He felt hot, complained of nausea and then fainted. His electrocardiogram (ECG) was normal. His brother suffers from adult onset epilepsy. What is the most appropriate investigation?

A 75-year-old man is referred for total hip replacement. He has a history of hypertension and angina and has suffered a myocardial infarction some 8 years earlier. Current medication includes atenolol 50 mg daily, ramipril 10 mg daily, aspirin 75 mg daily and isosorbide dinitrate 60 mg. Blood pressure at the preoperative assessment was 160/80 mmHg but he maintains that his readings with the general practitioner have been normal. He last had an exercise test some 3 years earlier and managed 8 min with no significant electrocardiogram (ECG) changes. Which one of the foil owing investigations in addition to standard assessment would be most appropriate for the preoperative assessment of this patient?

A 70-year-old woman presents to the pre-operative orthopaedic clinic prior to hip replacement. She has suffered a myocardial infarction 4 years earlier and is managed with aspirin 75mg daily, ramipril 10mg daily and atorvastatin 40mg daily. There is no history of angina but she is only able to walk around 50 yards. On examination she looks well, her BP is 145/80 mmHg with a pulse of 75/minute. Bloods; Hb 14.0 g/dl, WCC 5.9 x109/l, PLT 180 x109/l, Na+ 140 mmol/1, K+ 5.0 mmol/1, Creatinine 130 μmol/1. Which of the following is the most appropriate investigation to assess her suitability for surgery from the point of view of her cardiovascular status?

A SO-year-old man presents to the cardiology clinic for review. His brother died suddenly of a cardiac arrest while playing Sunday league soccer, and was found on post-mortem to have an underlying diagnosis of hypertrophic obstructive cardiomyopathy (HOCM). Which of the following is the most appropriate way to screen the patient?

A 42-year-old male from El Salvador complains of several months of dyspnea on exertion. Physical examination reveals an elevated jugular venous pressure, clear lungs, a third heart sound, a pulsatile liver, ascites, and dependent edema. Chest radiography reveals no cardiomegaly and clear lung fields. An echocardiogram demonstrates normal to mildly decreased left ventricular systolic function. The initial diagnostic workup should include all the following except?

A 26-year-old woman presents to the emergency department with an oxygen saturation reading of 80 o/o on air with a background history of increased breathlessness on exertion over the course of a week. She has not travelled abroad recently and does not have a family history of thromboembolism. On examination, there is elevation of the jugular venous pressure and accentuation of the pulmonary component of the second heart sound. A chest examination is unremarkable. A chest X-ray is normal and a subsequent CT angiography demonstrated a pulmonary embolism. Which of the following management is NOT appropriate?

A 66-year-old man with a 10-year history of chronic obstructive pulmonary disease is assessed in the respiratory clinic for eligibility for long-term domiciliary oxygen therapy. Which of the following is NOT a criterion for prescription of long-term oxygen therapy?

A 55-year-old man is being investigated for irregular heart rhythms. He has a medical history of diabetes mellitus. He explains that exercise is difficult for him due to joint pains. During the examination it is noted that he has tan skin pigmentation and hepatomegaly. Which of the following investigations could reveal the aetiology of his symptoms?

A 62-year-old woman presents to the emergency department with collapse. She felt dizzy when she tried to stand up from a sitting position. She did not lose consciousness. She denied any visual disturbances, headache or head injury. She also complained of fatigue over the past month. She takes only omeprazole and paracetamol. An ECG showed normal sinus rhythm. Blood pressure was 102/50 mmHg with a postural systolic drop of 30 mmHg. Blood test showed revealed Na+ 126 mmol/L, K+ 6.5 mmol/L, urea 10.0 mmol/L, creatinine 139 μmol/L. Which of the following will be most useful in establishing the diagnosis?

A 31-year-old man presents with a 1-month history of a growing round, flat, erythematous lesion on the left thigh. The border is slightly more erythematous than the rest of the lesion and has some flakiness of the skin. The lesion itches. The patient also has had long-standing itchy scales between his toes. Which of the following investigations would help confirm the most likely diagnosis?

A 42-year-old woman presents to her GP with a 2-month history of nipple discharge from her left breast. The discharge is milky in colour. No blood is noted. She has a past medical history of hypertension, type 2 diabetes mellitus and depression. She has been taking regular medication for these conditions. She has been amenorrhoeic for 6 months. A provisional diagnosis of hyperprolactinaemia is made. What of the following is NOT appropriate management?

A 52-year-old woman presents to the GP with intermittent palpitations and breathlessness that has occurred over the last few weeks. She denies chest pain. Her electrocardiogram (ECG) shows sinus tachycardia and she does not appear to be anaemic. Which blood test would be of most use in confirming the diagnosis?

The patient in Question 38 receives thrombolytic therapy with streptokinase within 30 minutes of the onset of his chest pain. Soon after administration of streptokinase, the ECG changes revert to baseline. He is monitored on telemetry for 48 hours without any arrhythmias. He is able to walk around the ward without difficulty. Further diagnostic tests during the immediate discharge period should include which of the following?

A previously healthy 52-year-old man presents with complaints of intermittent substernal chest discomfort. The pain does not radiate. The symptoms occur with exercise, and they are not relieved by rest. The patient does not have shortness of breath. The resting ECG is normal. You determine that the patient has an intermediate pretest probability of having significant coronary artery disease, and you elect to have him undergo exercise ECG testing to further evaluate his symptoms. Which of the following fmdings would be most highly suggestive of significant ischemic heart disease (IHD) on exercise ECG testing?

A 56-year-old man with hypertension presents to your clinic for a routine health maintenance visit. He is asymptomatic and takes only hydrochlorothiazide. His blood pressure is 138/78 mm Hg. His total cholesterol level is 190 mg/di, and his high-density liproprotein (HDL) cholesterol level is 36 mg/di. He is a nonsmoker. He tells you he is concerned about IHD and that he has read about new methods to detect early disease, including CT imaging. He is interested in this screening test in hope of detecting any disease he may have before it becomes a problem. How should you advise this patient with regard to electron-beam computed tomography (EBCT)?

A 72-year-old man with a history of myocardial infarction 10 years ago and angina presents with complaints of recurrent chest pain, which he has been experiencing over the past 4 months. This pain is retrosternal, is brought on by exertion, and is relieved by rest. The patient has been taking aspirin, long acting diltiazem, simvastatin, atenolol, and isosorbide dinitrate at maximal doses. His blood pressure is 130/80 mm Hg; pulse, 62 beats/min; and respirations, 16 breaths/min. Physical examination is normal. ECG shows normal sinus rhythm, with left bundle branch block. Which of the following tests would be most useful in the evaluation of this patient's angina?

A 70-year-old man presents to his physician with complaints of chest tightness. The sensation is substernal, is brought on by exertion, and is relieved by rest. He is able to walk several blocks before he notes chest pressure. His medical history is remarkable only for hypertension and hyperlipidemia. His medications are hydrochlorothiazide, 25 mg daily, and aspirin, 325 mg daily. Which of the following statements is true for this patient regarding exercise treadmill testing?

A 53-year-old man presents for evaluation of severe chest pain. The pain has been present for 2 hours and is radiating down both arms. He reports no previous similar episodes of chest pain. On examination, he is diaphoretic. His blood pressure is 160/100 mm Hg bilaterally, and his pulse is 100 beats/min. Chest and cardiac examinations are normal. An electrocardiogram shows sinus tachycardia but no ST segment changes. A chest x-ray is unremarkable. What would you recommend as the next step in the workup of this patient?

A 23-year-old man reports a 3-day history of a constant left-sided chest pain, which worsens with inspiration and activity. His symptoms were preceded by several days of fatigue, rhinorrhea, and cough. He is worried that he has broken a rib from coughing. He reports no other symptoms and has no risk factors for cardiovascular disease. On examination, he is comfortable. Other findings on physical examination are as follows: blood pressure, 120/70 mm Hg; pulse, 94 beats/min; respiratory rate, 12 breaths/min; temperature, 100.2° F (37.9° C). His lungs are clear. Cardiovascular examination shows tachycardia, but otherwise the results are normal. Which of the following should be the appropriate step to take next in this patient's workup?

A 15-year-old girl is being evaluated for a heart murmur. She is asymptomatic. On physical examination, her blood pressure is 174/104 mm Hg on her right arm. Her pulses are 2+ on her upper extremities. The femoral pulses are slightly lower in amplitude than the radial pulses. Her cardiac examination reveals a short midsystolic murmur in the left infrascapular area. For this patient, which of the following is most likely to be found on additional studies?

A 28-year-old woman who is 18 weeks pregnant and is G lPO is referred to you by her obstetrician for ad vice regarding management of a possible VTE diathesis. Although she has no personal history of VTE, she reports that her mother and a cousin both had blood clots during pregnancy; she does not know whether they were tested for clotting disorders. She is feeling well, and her physical examination is remarkable only for her pregnancy. Which of the following actions would you take for this patient?

A 32-year-old woman presents to clinic to establish primary care. She has recently relocated from another city. The patient's medical history is significant for psoriasis, for which she has been treated with methotrexate, 20 mg a week for 6 years. Which of the following should NOT be done to monitor for methotrexate toxicity?

A 23-year-old man presents with worsening pain and swelling in his right ankle, which he has had for the past month. He is otherwise healthy, though he admits to an unhealthy lifestyle, including nightshift work, heavy alcohol use on the weekends, and occasional unprotected sex with men, though he has had none in the past 12 months. He denies any history of sexually transmitted disease or intravenous drug use, diarrheal illness, fever, chills, weight loss, dysuria, penile discharge, or other joint pains. On examination, he is in no apparent distress. Removal of his baseball cap reveals a 6 x 15 cm patch of a sharply demarcated, erythematous, scaly rash on his anterior scalp and forehead. Skin and nail examination reveals no further rashes in the groin, gluteal fold, or umbilicus and no nail pitting. A few 1 cm nodes are found in his neck and groin. His right ankle is normal in color but swollen and boggy, with decreased range of motion and mild tenderness to palpation. Biopsy of his scalp suggests psoriasis. What other testing should be performed on this patient?

A 21-year-old man presents to the acute care clinic complaining of itching. He states that since childhood, be has had a recurrent rash characterized by ''red, itchy, dry patches'' of skin. Sometimes the rash is associated with ''little bumps.'' Examination of his skin revealserythematous, scaling plaques on the flexural surfaces of his arms with associated excoriations. You suspect the patient has atopic dermatitis. Of the following findings, which is NOT among the major diagnostic criteria of atopic dermatitis?

Two months after returning from an expedition to the Amazon, a 42-year-old archeologist notices a red-brown papule on her nose. On skin examination, she is suntanned. She also has a verrucous nodule with early ulceration where she first noted the papule on the nose. What would you do for this patient at this point?

A 36-year-old man comes to your clinic complaining of lack of energy. He was diagnosed with diabetes 2 years ago. Review of systems is positive for decreased libido and energy for the past several months. He has been married for 3 years. He and his wife have been trying to conceive a child for the past year. Physical examination shows decreased pubic and axillary hair; his testicular vol11me is 15 ml. Total testosterone levels are low; LH and follicle-stimulating hormone (FSH) are in the low-normal range. The prolactin level is normal. Which of the foil owing would be the most appropriate test in the evaluation of this patient?

A 44-year-old African-American woman presents to your clinic with a complaint of weight gain. She reports increasing weight gain over the past year despite any noticeable change in her dietary intake. She notes that most of the added weight is around her abdomen. During the review of symptoms, she notes recent onset of amenorrhea without associated hot flushes. All women in her family experienced menopause after 50 years of age. On physical examination, the patient is hypertensive, with a blood pressure of 152/94 mm Hg. You notice that she has classic moon facies with purple abdominal striae. Which of the foil owing statements regarding the testing for Cushing syndrome is true?

A 23-year-old female patient presents to your office for a routine annual visit. She mentions that her mother tested positive for the ''breast cancer genes.'' She asks you for general information regarding these tests and about the need for her and her family to be tested for these mutations. Which of the following statements is correct regarding BRCAl and BRCA2 testing?

A 22-year-old man comes to your clinic for evaluation of chronic abdominal pain. The patient has been experiencing pain for 1 year. Initially, the pain was episodic, but lately it has become constant. It is felt in the epigastrium and radiates to the back. Sometimes the pain is accompanied by nausea and vomiting. The patient denies having diarrhea. Physical examination is unremarkable. An upper endoscopy and abdominal CT scan are unremarkable. You suspect chronic idiopathic pancreatitis. Which of the following would be the most appropriate test to confirm the diagnosis?

A SO-year-old man comes to your clinic complaining of intermittent upper abdominal pain that radiates to his back and worsens with meals. He has a long history of binge drinking. He notes that lately he has been losing weight and that his stools have been loose. Which of the following should be the first test to determine whether this patient has chronic pancreatitis?

A 49-year-old man presents with right upper quadrant abdominal pain that began 8 hours ago. The pain is constant and is associated with nausea, vomiting, and fever. Over the past few months, he has had intermittent episodes of similar pain, but those were less intense, resolvedspontaneously within 1 or 2 hours, and were never associated with vomiting or fever. Results of physical examination are as follows: temperature, 101.3° F (38.5° C); blood pressu.re, 130/90 mm Hg; pulse, 90 beats/min; and respirations, 16breaths/min. The patient looks tired and moderately uncomfortable. Bowel sounds are present, but he has right upper quadrant tenderness. There is no palpable liver or gallbladder. Laboratory results are remarkable for a white blood cell count of 14,000, with a left shift. Bilirubin, amylase, and alkaline phosphatase levels are normal. Which of the following is the best diagnostic imaging test for this patient?

A 10-year-old boy is evaluated for edema. He developed unilateral left upper and lower extremity edema 1 year ago. On review of systems, abdominal swelling and occasional diarrhea are noted. The physical examination is remarkable for unilateral edema and abdominal shifting dullness to percussion. A complete blood count shows lymphopenia. The serum albumin level is low at 1 g/dl. Urinalysis shows no protein; liver function tests are within normal limits. Which of the following would be the most likely finding on small bowel biopsy for this patient?

A 54-year-old man presents with a 3-day history of left lower quadrant pain. H e reports that his appetite has decreased and that he has been experiencing mild nausea. He denies having any significant change in bowel function, hematochezia, or melena. On examination, his temperature is 101.3° F (38.5° C) and his blood pressure is 145/84 mm Hg. He has significant tenderness in the left lower quadrant, with some mild local fullness. No rebound is appreciated. The white blood cell count is 13,400. What is the most appropriate diagnostic test for this patient?

A 25-year-old woman presents to your clinic complaining of lower abdominal pain and periods of constipation alternating with episodes of diarrhea. Her previous physician diagnosed her with an irritable bowel after an extensive evaluation. She takes a selective serotonin reuptake inhibitor for depression but has no other significant medical history. Which of the following abnormalities is NOT present in patients with functional gastrointestinal disorders?

Three months after liver transplantation for chronic hepatitis C infection, a 45-year-old man develops biochemical abnormalities suggestive of cholestatic hepatitis. Which of the following evaluation strategies is most important for this patient at this time?