Cardiorespiratory

A 66-year-old man has an abdominal aortic aneurysm of 5.8 cm diameter found on his NHS screening ultrasound. He has no abdominal or back pain and is well. Pulse 72, blood pressure 136/80 mmHg. What is the most appropriate next step?

A 76-year-old man has newly diagnosed persistent atrial fibrillation, now rate controlled on bisoprolol. He has hypertension and type 2 diabetes. He has no history of bleeding, his haemoglobin is 141 g/L and eGFR is 68 mL/min/1.73m². Which is the most appropriate treatment to reduce his risk of stroke?

A 79-year-old man has had two episodes of light-headedness on climbing stairs and exertional chest tightness. He has a slow-rising pulse, blood pressure 118/90 mmHg, and an ejection systolic murmur at the right upper sternal edge radiating to both carotids, with a soft second heart sound. What is the most likely diagnosis?

A 55-year-old man has had 2 months of central chest tightness brought on by walking uphill and relieved within 3 minutes by rest. He smokes and has hypertension. Examination is normal and his resting 12-lead ECG is normal. Which is the most appropriate first-line diagnostic investigation?

A 69-year-old man who smokes has 6 months of cramping pain in his left calf after walking about 200 metres, relieved within minutes by standing still. His foot pulses are weak on the left. He has no rest pain and no ulcers. Which is the most appropriate initial investigation?

An 81-year-old man with diabetes has had pain in his left forefoot at night for 4 weeks. It wakes him and is eased by hanging his foot over the side of the bed. The foot is cool and pale on elevation and turns red when dependent. Foot pulses are absent. Ankle pressure is 45 mmHg. What is the most likely diagnosis?

A 59-year-old man with poorly controlled hypertension has sudden severe tearing chest pain radiating between his shoulder blades. Pulse 98, blood pressure 172/96 mmHg in the right arm and 138/80 mmHg in the left. ECG shows left ventricular hypertrophy without ST elevation. He is alert. Which is the most appropriate investigation to confirm the diagnosis?

A 67-year-old man has heart failure with a left ventricular ejection fraction of 30% on echocardiography. He is breathless on moderate exertion. He takes furosemide 40 mg daily, which has relieved his oedema. Pulse 84 sinus rhythm, blood pressure 128/76 mmHg, potassium 4.3 mmol/L, eGFR 72 mL/min/1.73m². What is the most appropriate next step in his drug treatment?

A 47-year-old man has a clinic blood pressure of 156/96 mmHg, and 152/94 mmHg on a second reading in the same consultation. He has no symptoms. Fundoscopy is normal, urine dipstick is negative and he has no cardiovascular disease. What is the most appropriate next step?

A 44-year-old man attends his GP with headaches and blurred vision for a week. Blood pressure is 214/128 mmHg on repeated readings. Fundoscopy shows bilateral swollen optic discs and flame haemorrhages. He is alert with no focal neurological signs. What is the most appropriate next step?

A 77-year-old woman has had profuse watery diarrhoea and vomiting for 3 days. She is drowsy with cool peripheries. Pulse 126, blood pressure 82/48 mmHg, capillary refill 4 seconds. Lactate is 4.4 mmol/L. Her chest is clear, JVP is not visible and she has no history of heart failure. What is the most appropriate initial treatment?

A 31-year-old man has 2 days of sharp central chest pain that is worse on lying flat and on deep breathing, and eased by sitting forward. He had a cold a week ago. Temperature 37.8C, pulse 96, blood pressure 124/78 mmHg. ECG shows concave ST elevation in most leads with PR depression. Troponin is normal. What is the most likely diagnosis?

A 59-year-old man is ready for discharge 4 days after an NSTEMI treated with a coronary stent. He was not previously taking a statin. Total cholesterol is 5.9 mmol/L, ALT 28 U/L, eGFR 80 mL/min/1.73m². He has no drug interactions. Which lipid-lowering treatment is most appropriate?

An 82-year-old man has had several episodes of dizziness on getting out of bed or standing up from his chair. He has hypertension and benign prostatic hyperplasia and takes amlodipine, doxazosin and tamsulosin. He has not lost consciousness. Heart sounds and ECG are normal. Which is the most appropriate initial investigation?

A 58-year-old man has had central crushing chest pain for 90 minutes. He is sweaty, pulse 96, blood pressure 128/80 mmHg. ECG shows 3 mm ST elevation in V1 to V4. He has already been given aspirin 300 mg. The nearest centre offering primary percutaneous coronary intervention (PCI) can treat him within 60 minutes. What is the most appropriate reperfusion strategy?

A 29-year-old woman has had sudden-onset palpitations for 40 minutes. She is alert with no chest pain or breathlessness. Pulse 186 regular, blood pressure 118/74 mmHg. ECG shows a regular narrow-complex tachycardia with no visible P waves. What is the most appropriate first treatment?

A 38-year-old woman who injects drugs has ankle swelling and fatigue after a hospital admission with endocarditis last year. She has a raised JVP with large systolic waves, a pansystolic murmur at the left lower sternal edge that is louder on inspiration, and a pulsatile, enlarged liver. What is the most likely valve lesion?

A 63-year-old Black man has swelling of his lips and tongue that started 4 hours ago. He has no itching, rash or wheeze and his blood pressure is 146/90 mmHg. He has no stridor. He started ramipril 3 months ago and has no family history of swelling. What is the most likely cause?

A 38-year-old man has had a cough with clear sputum for 9 days after a cold. He feels tired but is eating and drinking. Temperature 37.4C, respiratory rate 16, pulse 82, SpO2 98% on air. His chest is clear apart from occasional wheeze that clears on coughing. He has no long-term conditions. What is the most appropriate management?

A 36-year-old woman develops widespread urticaria, lip swelling, wheeze and hoarseness 5 minutes after starting intravenous co-amoxiclav. Respiratory rate 30, pulse 128, blood pressure 82/50 mmHg, SpO2 90% on air. The infusion has been stopped and she is lying flat with high-flow oxygen. What is the most appropriate next treatment?

A 32-year-old woman with asthma has been increasingly wheezy for 2 days. She cannot complete sentences in one breath. Respiratory rate 28, pulse 118, SpO2 93% on air. Peak flow is 45% of her best. She has widespread wheeze, is alert and is not tiring. What is the most appropriate initial treatment?

A 69-year-old woman with COPD is admitted with an exacerbation. After 1 hour of nebulised salbutamol and ipratropium, oral prednisolone and controlled oxygen at target saturation 88 to 92%, her arterial gas shows pH 7.27 (7.35 to 7.45), PaCO2 8.6 kPa (4.7 to 6.0), PaO2 8.1 kPa. She is alert and wants full treatment. What is the most appropriate next step?

A 57-year-old man who has smoked 30 cigarettes a day for 40 years has had a cough with sputum every winter for years and is now breathless walking up a hill. He has no wheeze at night, no allergies and no weight loss. Chest examination is normal. Which investigation is needed to confirm the most likely diagnosis?

A 29-year-old woman has 2 weeks of fever, painful ankles and tender red nodules on both shins. She has a mild dry cough. Chest X-ray shows bilateral hilar lymphadenopathy with clear lung fields. Adjusted calcium is 2.75 mmol/L (2.2 to 2.6). She has no weight loss or night sweats and has not travelled. What is the most likely diagnosis?

A 55-year-old man with alcohol dependence was found intoxicated on the floor 3 weeks ago. He now has swinging fevers, night sweats and a cough producing foul-smelling sputum. He has poor dentition. Chest X-ray shows a thick-walled cavity with an air-fluid level in the right lower zone. What is the most likely diagnosis?

A 64-year-old woman who smokes sees her GP with a cough of 5 weeks. A chest X-ray shows a 3 cm mass in the right upper lobe. She has lost 4 kg in weight. She is otherwise well and examination is normal. What is the most appropriate next step?

A 74-year-old man who worked in a shipyard fitting insulation in the 1970s has 3 months of dull left-sided chest pain, breathlessness and weight loss. Chest X-ray shows a left pleural effusion. CT shows nodular, irregular thickening encasing the left lung, including the mediastinal pleura. What is the most likely diagnosis?

A 70-year-old woman on the surgical ward is difficult to rouse on the evening after a hip replacement. She is using a morphine patient-controlled analgesia pump. Respiratory rate 6, SpO2 86% on air, pulse 64, blood pressure 118/70 mmHg. Pupils are pinpoint. Her airway is open with a jaw thrust and she is given oxygen. What is the most appropriate treatment?

A 51-year-old man is brought to his GP by his wife, who says he snores loudly and stops breathing for several seconds at night. He falls asleep watching television and once nodded off at traffic lights. BMI 37 kg/m2, blood pressure 148/92 mmHg. His Epworth Sleepiness Scale score is 15. What is the most appropriate next step?

A 39-year-old woman has sudden pleuritic chest pain and breathlessness 10 days after an ankle fracture treated in a cast. Pulse 112, blood pressure 122/78 mmHg, SpO2 93% on air. Her left calf is swollen and tender. Two-level Wells score is 7.5. Renal function is normal, she is not pregnant and has no contrast allergy. What is the most appropriate investigation?

A 62-year-old man with a recently found right hilar mass has 1 week of facial swelling, a headache worse on bending forward and breathlessness lying flat. His face and neck are swollen and plethoric, with distended non-pulsatile neck veins and dilated veins over the upper chest wall. What is the most likely diagnosis?

A 40-year-old woman is admitted with suspected pulmonary tuberculosis. Sputum microscopy is positive for acid-fast bacilli and culture is pending. She asks the doctor not to tell anyone outside the hospital because she is worried about her job. What is the most appropriate action?

A 34-year-old man who moved to the UK from a country with a high TB rate 1 year ago has had a cough for 7 weeks, night sweats and 6 kg weight loss. Chest X-ray shows right upper lobe consolidation with cavitation. He is producing sputum. Which is the most appropriate investigation to confirm the diagnosis?

A 52-year-old man on the ward becomes acutely breathless 20 minutes after a central venous catheter was inserted in his right subclavian vein. Respiratory rate 36, pulse 136, blood pressure 74/40 mmHg, SpO2 82% on 15 L/min oxygen. The trachea is deviated to the left and the right chest is hyperresonant with absent breath sounds. What is the most appropriate immediate step?