Management IM- VTH

A 79-year-old woman is admitted to the coronary care unit (CCU) with unstable angina. She is started on appropriate medication to reduce her cardiac risk. She is hypertensive, fasting glucose is normal and cholesterol is 5.2. She is found to be in atrial fibrillation. What is the most appropriate treatment?

A 49-year-old man is rushed to accident and emergency complaining of a 20-minute history of severe, crushing chest pain. After giving the patient glyceryl trinitrate (GTN) spray, he is able to tell you he suffers from hypertension and type 2 diabetes and is allergic to aspirin. The most appropriate management is:

A 21-year-old man is on his way home from a party when he experiences the sudden onset of rapid palpitations. He feels uncomfortable but not short of breath and has no chest pain. He goes to the nearest accident and emergency department, where he is found to have a supraventricular tachycardia (SVT) at a rate of 170/minute. Carotid sinus massage produced transient reversion to sinus rhythm, after which the tachycardia resumed. What would be the next step in your management?

A previously fit 19-year-old man presents with unusual shortness of breath on exertion. At times, this is also associated with central chest pain. On examination there is a loud mid-systolic murmur at the left sternal edge. Heart rate and blood pressure are normal and there is no oedema. The ECG shows left axis deviation and the voltage criteria for left ventricular hypertrophy and the echocardiogram reveals a significant thickened interventricular septum, with delayed ventricular filling during diastole. There is a family history of sudden death below the age of 50. Which of the following would be your initial therapy?

A 58-year-old man has made an excellent functional recovery after an anterior MI. He is entirely asymptomatic and there is no abnormality on physical examination. His blood pressure is 134/78 mmHg and he is undertaking a cardiac rehabilitation programme. Which of the following would you not recommend as part of his secondary prevention planning?

A 69-year-old woman complains of intermittent palpitations, lasting several hours, which then stop spontaneously. She also suffers from asthma. Holter monitoring confirms paroxysmal atrial fibrillation. Which of the following statements is correct regarding the management of this patient?

A57-year-oldmanisreviewedinahypertensionclinic,whereitisfoundthathisbloodpressure is 165/105 mmHg despite standard doses of amlodipine, perindopril, doxazosin and bendro umethiazide. Electrolytes and physical examination have been, and remain, normal. Which of the following would be your next stage in his management?

A 68-year-old woman has presented with acute onset shortness of breath 24 hours after a long haul ight. Her blood results show a raised D-dimer level and the arterial blood gas shows a P02 of 8.3 kPa and PC02 of 5.4 kPa. Your consultant suspects a pulmonary embolism and the patient needs to be started on treatment while a CT-PA is awaited. From the list below, please select the most appropriate treatment regime?

A 55-year-old man, who has never smoked and with no past medical history, has been diagnosed with right basal community-acquired pneumonia. There are minimal changes on his chest x-ray and bloods reveal a neutrophil count of 8.2 and a C-reactive protein (CRP) of 15. He has no drug allergies. Although he has a productive cough of green sputum, his respiratory rate is 16, oxygen saturations are 97 per cent on room air and his temperature is 37.4°C. You are asked to place him on treatment. Which of the following treatment options would be appropriate for this patient?

A 68-year-old woman is admitted to accident and emergency with shortness of breath and cough. She has been a smoker for 25 years, smoking on average 20 cigarettes a day, and is a known COPD patient with home oxygen. The observations read a pulse rate of 101, blood pressure of 100/60, respiratory rate of 20, oxygen saturations of 88 per cent on air and temperature of 37.2°C. On auscultation you hear bilateral expiratory wheeze. She is prescribed nebulizers (salbutamol 5 mg + ipratropium 500 μg) with oxygen and chest x-ray requested. Intravenous access has been established and bloods sent for analysis. From the list below, select the most appropriate next step in this patient's management plan?

A 58-year-old man with known COPD, diagnosed eight months ago, attends your clinic with persistent shortness of breath despite stopping smoking and using his salbutamol inhaler (given to him at the time of diagnosis), which he finds he is using more frequently. You assess the patient's lung function tests that have been recorded just before he saw you in clinic on this occasion. His FEVl = 65 per cent of the predicted value. Oxygen saturations are 95 per cent on room air, respiratory rate in 18, and his temperature is 37.1°C. From the list below, select the next most appropriate step in this patient's management?

Your clinic patient has been diagnosed with pulmonary tuberculosis (TB) following a three­ month history of haemoptysis and fever. The patient is due to start on treatment and you are asked by your registrar which of the following regimes is the most suitable. The patient has no known drug allergies and, in addition, liver function tests and urea and electrolytes results are all within normal ranges. From the list below, which of the following answers is the most appropriate and recommended treatment regimen for this patient?

You see a 76-year-old woman in accident and emergency who has been admitted with a 1-day history of shortness of breath and pyrexia (38.4°C). The patient's past medical history includes hypertension, stroke and insulin-dependent diabetes. She has no known drug allergies. The nursing staff report that the patient vomited after her lunchtime meal yesterday. On examination the patient's respiratory rate is 26, oxygen saturations 93 per cent on room air. On auscultation of the chest, you hear right basal crackles. You suspect that this patient is suffering from aspiration pneumonia. From the list below, which is the most appropriate antibiotic regimen for this patient?

A 55-year-old woman is referred by her GP for upper gastrointestinal (GI) endoscopy following a four-month history of epigastric pain despite treatment with antacids and proton pump inhibitors (PPls). The results demonstrate a duodenal ulcer coupled with a positive campylobacter-like organism (CLO) test. The patient has no past medical history and has no known drug allergies. The m ost appropriate treatment is:

A 35-year-old woman presents with a 24-hour history of watery diarrhoea. She has opened her bowels nine times since the onset of her symptoms. You diagnose gastroenteritis after learning that the patient and her family all ate at a new restaurant and the rest of her family have had similar problems. The most appropriate management is:

During your on-call, you are bleeped to see an 80-year-old woman on the ward who has not opened her bowels for the last 4 days. She is not known to have a history of constipation. On examination, her observations are within normal range, the abdomen is soft and there is mild discomfort at the left iliac fossa. Bowel sounds are present and on PR examination, the rectum is empty. You consult your registrar who asks you to prescribe an osmotic laxative. What is the most appropriate treatment?

A 60-year-old man with alcoholic liver disease was admitted with an upper GI bleed secondary to oesophageal varices. The patient undergoes endoscopic variceal banding and is discharged after 2 weeks in-hospital stay. Which of the following medications would act as prophylaxis in preventing are bleed from his oesophageal varices?

You see a 56-year-old woman who presents with a two-month history of jaundice. Associated symptoms include lethargy and polyarthralgia. Her LFTs reveal a bilirubin of 46 iu/L, AST 200, ALT 175, ALP 104. On examination, the patient is jaundiced and has nger clubbing. There are several spider naevi on the front and back of the trunk. Her abdomen is soft and there is a smooth hepatomegaly. Prior to her onset of symptoms, the patient has been fit and well. Viral serology is normal and anti-soluble liver antigen (SLA) is detected. You decide to start this patient on treatment. The most appropriate treatment is:

You are asked to see a 29-year-old woman diagnosed with ulcerative colitis 18 months ago. Over the last 4 days she has been experiencing slight abdominal cramps, opening her bowels approximately 4-5 times a day and has been passing small amounts of blood per rectum. The patient is alert and orientated and on examination her pulse is 67, blood pressure 127/70, temperature 37.3° C and her abdomen is soft with mild central tenderness. PR examination is nil of note. Blood tests reveal haemoglobin of 13.5 g/dL and a CRP of 9 mg/L. The most appropriate management plan for this patient is:

A 65-year-old man attends your clinic with a three-month history of weight loss of approximately 9 kg despite a normal appetite. A full blood count reveals that his haemoglobin is 9.0 g/dL (previous haemoglobin was 13.5 g/dL one year ago) and the MCV is 71 fL. Abdominal examination is unremarkable and per rectum exam is nil of note. The patient states that he has normal bowel habits and has been feeling quite tired lately. The most appropriate management IS:

A 58-year-old African man presents with pitting oedema of his ankles. He su ers from recently diagnosed hypertension, but is otherwise healthy. Blood results show low albumin and a urine dipstick is positive for protein. The most appropriate initial treatment is:

A 28-year-old woman patient who is 13 weeks pregnant presents for an antenatal clinic appointment. The patient feels embarrassed when asked to provide a urine sample and produces enough for a urine dipstick test only which is positive for leukocytes and nitrites. The patient denies any symptoms. The most appropriate treatment is:

A 55-year-old woman is seen in clinic, she has a ten-year history of type 2 diabetes treated with glibenclamide. Her blood pressure is 148/93 with new onset proteinuria, her serum results show elevated lipid levels, glycated haemoglobin of 5.5 per cent and fasting glucose of 6.0 mmol/L. A renal biopsy shows the presence of Kimmelstiel-Wilson lesions. The most appropriate management is:

A 21-year-old man presents with lethargy over the last week, he has periorbital oedema and proteinuria. The patient mentions he has been to hospital a number of times in the past due to the same symptoms as well as mild eczema. Light microscopy of a renal biopsy showed normal morphology. Electron microscopy of the renal biopsy reveals the diffuse e acement of the epithelial podocytes. The most appropriate treatment is:

A 65-year-old woman complains of panic attacks. She has recently retired as a school teacher, but 2-3 times a week she suffers extreme anxiety, becomes short of breath and sweats excessively. Elevated catecholamines are detected in the urine. The most appropriate medical treatment is:

A SO-year-old Asian man is referred to the diabetes clinic after presenting with polyuria and polydipsia. He has a BMI of 30, a blood pressure measurement of 137/88 and a fasting plasma glucose of 7.7 mmol/L. The most appropriate rst-line treatment is:

A 41-year-old man has been recently diagnosed with type 2 diabetes and has been following a plan of lifestyle measures to improve his diet and increase his level of exercise. On returning to clinic, his BMI is 23, fasting plasma glucose 9.0 mmol/L, blood pressure 133/84 mmHg and HbAlc of 7.1 per cent. The most appropriate treatment option is:

A 19-year-old woman presents with concerns about changes to her facial appearance, in particular her nose and jaw seem quite large, she is also quite sweaty and despite using antiperspirants is nding it di cult to control and is afraid of embarrassment at university. A glucose tolerance test is performed and found to be raised. The most appropriate management would be:

A 40-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 rst thing in the morning. On examination, the wrists, metacarpophalangeal joints and proximal interphalangeal joints are swollen and warm. A diagnosis of rheumatoid arthritis is suspected. Blood tests for rheumatoid factor return as positive. What is the most appropriate management?

A 76-year-old man presents to accident and emergency with pain in his knees. It is worse in the right knee. He describes the pain as being worse in the evening and after exertion. On examination, bony nodules are palpable on the distal interphalangeal joints of both his hands. The right knee is swollen and there is a reduced range of active movement. X-rays show reduction in the joint space, subchondral sclerosis and osteophyte formation. What is the most appropriate treatment?

A 23-year-old man presents to the rheumatology clinic with lower back and hip pain. These have been occurring every day for the past two months. Pain and sti ness are worse in the mornings. He also mentions that his right heel has been hurting. He is previously t and well, but had occasions of lower back pain when he was a teenager. His symptoms have stopped him from playing tennis. Recent blood tests organized by his GP have shown a raised C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). What is the most appropriate treatment?

A 24-year-old woman presents to her GP complaining of cold hands and feet. This has been ongoing for the past three months and is especially bad when she goes out in the mornings and may last for hours. On further questioning, she mentions that her hands sometimes turn blue or red and that gloves are unhelpful. She has otherwise been feeling well and has no past medical history. What is the most appropriate treatment?

A 59-year-old man presents to his GP with sudden onset severe pain, tenderness and swelling of the first metatarsophalangeal joint. He is known to suffer from acute gout and has had several previous similar episodes. What is the most appropriate treatment?

A 70-year-old woman complains of tiredness, fatigue and weight loss. Blood tests reveal an elevated WCC and on examination splenomegaly is palpated. Cytogenetics are positive for the Philadelphia chromosome and the patient is diagnosed with chronic myeloid leukaemia. The most appropriate treatment is:

A SO-year-old woman with T2N2Ml squamous cell carcinoma of the tongue has been electively admitted for her third cycle of palliative cisplatin/5- uorouracil chemotherapy. She has known metastasis to the T3 vertebrae and the ribs. Since her last cycle of chemotherapy she has been very lethargic and constipated. Upon checking her bloods you discover that her corrected calcium levels are 2.95 mmol . The most appropriate treatment is:

A 22-year-old man with testicular cancer has undergone an inguinal orchidectomy. Histology has con rmed teratoma. A preoperative CT staging scan has shown involvement of the para­ aortic lymph nodes. Which of the following treatments is the best post-operative option?

A 51-year-old man with a recent diagnosis of pancreatic carcinoma with metastases to the liver and omentum is about to commence gemcitabine chemotherapy. Prior to his rst cycle he mentions that he is getting increasing severe abdominal pains. He is currently taking paracetemol for this, which eases the pain but is now becoming less effective. The most appropriate analgesia for this patient is:

A 57-year-old man with metastatic adenocarcinoma of the lung is attending for cycle three of his palliative pemetrexed/cisplatin chemotherapy. During his cisplatin infusion, he noticed his arm becoming painful, swollen and red at the cannula site. The most likely cause of this is:

A 55-year-old woman with metastatic pancreatic cancer attends the oncology clinic prior to her second cycle of chemotherapy. She tolerated her first cycle well, but her husband mentions that there have been occasions where she has been confused. Her urea and electrolytes on this occasion reveal a serum sodium of 116 mmol/L. All other results were within the normal range. The chemotherapy is delayed and a urine specimen is sent off. This confirms a diagnosis of syndrome of inappropriate ADH (SIADH). The most appropriate treatment is:

A 56-year-old man, diagnosed with psoriasis three years ago, presents to your clinic with pruritus. His symptoms are not improving despite being prescribed conventional therapy. On examination, you note the presence of erythematous scaly plaques on the extensor surfaces of the knee and elbows. There is no evidence of exural involvement. The most appropriate treatment 1s:

A 68-year-old man is diagnosed with right forearm cellulitis. You are asked to start the patient on treatment and he has no known drug allergies. Which one of the following antibiotics would be the most appropriate choice in this scenario?

A 56-year-old man presents with two lesions on his neck which have been increasing in size over the last three months. On examination you notice two firm brown-coloured nodular lesions on the anterior aspect of the neck. The nodules give an 'apple-jelly' appearance on diascopy. The patient is systemically well. The most appropriate treatment is:

An 18-year-old man presents to you with an itchy scalp which has been present for 2 weeks following a visit at the barber shop. On examination, you notice a 3 x 3 cm oval area of patchy hair loss in the crown area of the scalp with a ring of erythema. You suspect that the patient has a dermatophytic infection. Which one of the foilowing options would be the most appropriate in treating this condition?

A 16-year-old male presents to you with multiple comedones on his face and back. On examination you notice the presence of multiple comedones on the patient's forehead, cheeks and back with peri-lesional erythema. There are no nodules or cysts in these areas. You diagnose the patient with moderate acne. The most appropriate treatment is:

A 47-year-old woman patient presents with a facial, macular 'butterfly rash'. Rheumatological investigations do not reveal that the patient has SLE. You suspect drug-induced SLE-like syndrome and assess her medication history. Which one of the following drugs is most likely to be responsible for this condition?

A 74-year-old woman patient, who is being treated for chest infection following an elective gastrectomy, develops profuse diarrhoea. A stool sample is collected and microscopy, culture and sensitivity reveal Clostridium dif cile toxin. What is the most appropriate treatment?

A 30-year-old woman aid worker, who has returned from a trip to Haiti 1 day ago, presents to accident and emergency with profuse watery diarrhoea. This started suddenly and she describes her stool as being profuse and colourless. On examination her pulse is 120 bpm. What is the most appropriate treatment?

A 70-year-old man presents to accident and emergency with a 1-day history of a painful rash across his trunk. He has a past medical history of hypertension and hypercholesterolaemia. On examination, there is a well-demarcated blistering rash on the right side of his trunk. What is the most appropriate treatment?

A 27-year-old investment banker presents to accident and emergency with a 4-day history of painful rash on his penis and testicles. He also reports feeling generally run down with a fever and myalgia. He returned from a trip to New York a week ago. On examination, there is a painful vesicular rash over his penis and testicles. What is the most appropriate treatment?

A 34-year-old man presents to his GP with a painless hard penile ulcer. Venereal Disease Research Laboratory tests and Treponema pallidum haemagglutination assay confirm the diagnosis of primary syphilis. What is the most appropriate treatment for this patient?

A 76-year-old man has a 4-day history of profuse watery diarrhoea coupled with abdominal pain. He was seen by his GP 2 weeks ago and started on oral amoxicillin for a lower respiratory tract infection. Stool sample analysis reveals Clostridium dif cile enterotoxin. His observations are within normal range and the patient is apyrexial. Which of the foilowing is the most appropriate treatment for this patient's condition?

A SO-year-old man is diagnosed with type 2 diabetes and you advise an improved diet alongside exercise. You mention monitoring the patient's HbAlc levels until the glucose becomes more stable. What is the most appropriate HbAlc target?

A 24-year-old woman presents with increasing breathlessness on exertion, which has been developing over several months. There are no abnormal physical signs on examination. On the ECG, there is right axis deviation and an R wave in Vl, with peaked P waves. Chest x-ray showed prominent hilar vessels with sparse vasculature peripherally in the lungs. Doppler echocardiography revealed a pulmonary artery pressure of 60 mmHg and primary pulmonary hypertension was diagnosed. Which of the foilowing medications would not be appropriate in managing this patient?

An 18-year-old man presents with a 3-day history of fever, vomiting and headaches on waking in the morning. He has recently started at university and denies taking any illicit substances prior to or during his time at university. He has tried paracetamol but they have not helped. He decided to see a doctor when his neck became painful and stiff to move. On further examination, a non-blanching petechial rash is discovered. The most appropriate management is:

A 46-year-old woman with atrial fibrillation is seen in clinic following an episode of syncope while shopping. She has a family history of epilepsy and a past medical history of breast cancer. She remembers feeling dizzy for a couple of seconds then waking up on the floor. What is the most useful step in management?

You are told by your registrar that a 66-year-old woman from a residential home has been admitted with a right mid-zone community-acquired pneumonia. She is very drowsy and her CURB-65 score is 4. On admission, the patient's oxygen saturations are 91 92 per cent on room air, respiratory rate of 20, temperature of 37.7°C, P02 7.1 kPa and PC02 4.7 kPa. Her oxygen saturations have improved to 95 per cent on 15 L 02 via a non-rebreather oxygen mask. From the list below, which is the most appropriate management plan for this patient?

A 69-year-old man presents with confusion. His wife reports he has become increasingly depressed and confused in the last month. Prior to this, he had been complaining of pain in his right arm and abdomen but he refused to visit his GP. The patient has brisk reflexes, reduced skin turgor, sunken eyes and an x-ray of his right arm shows lytic lesions. The most appropriate management is:

A type 2 diabetic patient has been taking metformin with good effect for the last four months. He has started to lose weight and maintained good glucose control. In the last two months, however, the patient has been persistently hyperglycaemic despite increased metformin dosage and HbAlc targets have not been achieved. The most appropriate management is:

A 28-year-old junior doctor has been complaining of a headache for the last 6 hours. It started gradually, intensifying slowly and involving the entire cranium but over the last hour she has noticed that turning her head is uncomfortable. She feels generally unwell and prefers to lie in a dark room. Her boyfriend has noticed that she seems irritable. On examination, heart rate is 110, blood pressure is 89/60. She is flushed and has warm extremities. She exhibits photophobia and there is neck stiffness. Close examination of her skin reveals no rashes. Kernig's sign is negative. What is the most important next step in management?

A 45-year-old man presents with a 1-day history of severe, excruciating pain in his right ank, vomiting and fever. He describes the pain as 'needle-like' and it moves towards his groin. He has tried diclofenac which has had little effect. When passing urine, the pain increased and his urine was blood-tinged. He denies any other symptoms or medical problems. The patient's temperature is 38°C and a CT scan shows a renal staghorn calculus. The most appropriate treatment is:

A 40-year-old man patient presents with visible haematuria. He denies any other symptoms such as fever or pain, and suffers from no other medical problems. He does not smoke or drink alcohol and denies any illicit substance abuse. The most appropriate management is:

A 60-year-old man who works for an oil company presents with a lesion on the temple that is bothering him as it is growing. It bled once when he knocked it. On examination, the lesion is 8 mm in diameter and is a at, mildly erythematous patch with a few scales and a larger keratotic horn in the centre. There are no other lesions on inspection of his skin and no personal or family history of skin cancer. Which of the following is the most appropriate management plan?

A 45-year-old man who is a heavy smoker is recently diagnosed with chronic obstructive pulmonary disease (COPD). He has no documented acute exacerbations in the past. Which of the following treatment is NOT suitable in the management of COPD in this patient?

A 35-year-old woman is admitted to hospital with quick-onset shortness of breath. She has a past medical history of asthma. Her observations include a pulse rate 120 bpm, blood pressure 100/72 mmHg, respiratory rate 30/min and Sa02 88% on room air. On examination, she appears to be drowsy and exhausted. Her chest is quiet on auscultation. Arterial blood gases show: pH 7.35, Pa02 5.2 kPa, PaC02 4.9 kPa and bicarbonate 24 mmol . Which of the following would NOT be appropriate in the management of this case?

A 55-year-old overweight pub landlord presents with a several-year history of episodic acute painful joint swelling that started in his left big toe and now affects his knees. Symptoms improve with use of diclofenac. Gout was diagnosed on his rst hospital visit, however this now appears recurrent. He developed an acute attack in his left knee 2 days ago. Which of the following represents the best plan for prophylaxis?

An 83-year-old man who was diagnosed as having Parkinson's disease 3 years ago has been treated with levodopa (L-DOPA). Whilst he initially responded well to therapy, he has started to be increasingly still, and has fallen more in the last 4 months despite no intercurrent illness or change in L-DOPA therapy. Which is the best management option?

A 42-year-old woman with menorrhagia is complaining of tiredness. The GP does some blood tests, which reveal hypochromic microcytic anaemia, a decreased ferritin level and a raised total iron binding capacity. Platelets were slightly raised. Which of the following is the best treatment for this anaemia?

A 35-year-old man presents with a 2-day history of right-sided facial weakness.He is otherwise t and well.There is no past history of neurological symptoms. There is no history of preceding infection. On examination, the middle ear is normal, the salivary glands are not enlarged, and there are no other cranial nerves affected. The forehead is not spared. Neurological examination of the limbs is unremarkable. Routine investigations are all normal. Which of the following represents the most reasonable management plan?

A 55-year-old Asian man with known thalassaemia trait registers with a new GP and is found to have a mild microcytic anaemia on routine testing. He does not complain of any symptoms. What is the most appropriate treatment?

A 40-year-old man, previously t and well, limps in to the emergency department with an acutely red, hot, swollen, exquisitely tender knee, which he holds rigid. He is tachycardic and has a temperature of 38.3°C. Which of the following represents the best approach to diagnosis and management?

A 48-year-old man is admitted to the emergency department vomiting blood. He has a blood pressure of 80/45 mmHg with a heart rate of 135 bpm. He is cool and clammy to the touch. Which of the following should NOT be in your immediate management of this patient?

A 25-year-old man presents with a severe outbreak of a dry erythematous itchy rash that is now widespread, despite having used a steroid cream prescribed by his GP. It appears to be eczema, and along with regular emollients for the dryness, and antihistamines for the itch, you would like to prescribe some very potent topical steroids for a brief period to attempt get on top of the outbreak. Which of the following is classed as a very potent topical steroid?

A 76-year-old man presents with a vesicular eruption on the left side of his forehead only. It is severely painful and the vesicles have started to crust over. On examination, the area affected is well-demarcated. You also note a red eye with apparent conjunctivitis. Given the most likely diagnosis, which of the following treatments is the most appropriate?

A 17-year-old girl shuf es awkwardly into clinic with her mother, who explains that her daughter has suffered from severe acne for the last few years and nothing that the GP has tried has shifted it. On examination, as well as several large pustules on her face and comedones, some scarring is beginning to develop. You would like to start oral isotretinoin (roaccutane). When counselling about side e ects, which of the following would you NOT advise the patient?

A 67-year-old man is discharged from hospital following an incision and drainage of a large abdominal wall abscess. He needs someone to help change his wound packing regularly, however he is immobile and lives alone. Which member of the multidisciplinary team would be most appropriate to help?

A 68-year-old-man with atrial brillation (AF) is admitted electively for DC cardioversion, to be performed as a day-case procedure. However, the procedure is postponed to a later date. Which one of the following reasons could be responsible for the delay?

A 75-year-old man with congestive cardiac failure presents with atrial fibrillation. He is haemodynamically stable with a ventricular rate of 72. He has a good functional state, although ECHO cardiography revealed a dilated left atrium and mild mitral regurgita on. Which drug option would be most beneficial for this patient?

A 32-year-old man with Wol -Parkinson-White syndrome presents with a 2-hour history of palpitations and breathlessness. On examination, his heart rate is 190 beats/min with blood pressure of 100/60 mmHg. ECG shows broad-complex tachycardia. What would be your first line of treatment?

A 45-year-old asthmatic patient presents with palpitations. An ECG shows supraventricular tachycardia, with narrow QRS complexes. Carotid sinus massage is not successful. What would you do next?

A 75-year-old man with isolated systolic hypertension, who also has urinary incontinence, gout and asthma, attends outpatients with a blood pressure reading of 190/86 mmHg. Which of the following drugs would you initiate for this patient?

A SO-year-old man suffers an extensive anterior myocardial infarction but recovers well in hospital. His predischarge ECHO shows him to have an ejection fraction of 35%. He is otherwise asymptomatic. His medications on discharge should include which of the following?

A SO-year-old woman who is already on ramipril, frusemide and bisoprolol for heart failure, decompensates and presents to AE with pulmonary oedema. Her heart rate is 120 bpm and her blood pressure is 100/65 mmHg. She is given oxygen and diamorphine. Which of the following actions is indicated in her further management?

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 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 at. 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 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 calci ed 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 50-year-old man with long-standing hypertension presents acutely with severe chest pain radiating through to his back. He looks t1nwell, 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 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?

An 81-year-old woman is referred to cardiology out-patients with a history of dizzy episodes and one episode of syncope. She is known to have long-standing atrial fibrillation. A 24-hour tape confirms atrial fibrillation, with rates varying from 30 to 140 bpm. There are several daytime pauses of over 3 seconds. She is listed for a permanent pacemaker. Which of the following would be the most appropriate device?

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/1. 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 5O-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 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 bas a ventricular rate of 165/min and a blood pressure of 90/50 mmHg, feeling faint and unwell. Which of the following 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 identi ed 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. Signi cant 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 brillation for which she takes warfarin and amiodarone. Which of her medications is most likely to interact with the cranberry juice?