Cardiology ❤️

A 56 year old male with an established lateral myocardial infarction as seen on ECG is taken to the cardiology department for percutaneous coronary intervention (PCI). While in the catheterisation laboratory, the nurse in charge noted that he became increasingly unwell and pale. He eventually became unresponsive. An ABCDE assessment was immediately carried out and his airway was secured via an oropharyngeal mask and oxygen was administered. His vitals are as follows:

Blood pressure 75/50 mmHg

Heart rate 210 beats per minute

Respiratory rate 4 breaths per min

Another ECG was performed and revealed a broad complex tachycardia. What is the SINGLE next best step in management of this patient?

A 69 year old man was successfully thrombolysed for an inferior myocardial infarction 15 days ago and was discharged 5 days after the thrombolysis. He is now re-admitted as he is hypotensive, tachycardic and with pulmonary oedema. What is the most SINGLE most likely diagnosis?

A 52 year old white British man is seen in the GP surgery for a blood pressure review. He was started on ramipril 4 weeks ago following an ambulatory blood pressure monitoring result of 151/96 mmHg. Since starting ramipril, he has been suffering from a dry cough. His renal function is normal. What is the most appropriate management?

A 75 year old man attends his GP surgery for a review of his blood pressure. Hs blood pressure on two occasions over the previous month shows readings of 160/100 mmHg. 172/98 mmHg. He was sent home with an ambulatory blood pressure monitor (ABPM) and has returned with daytime blood pressure readings of an average of 170/90 mmHg. He has a healthy lifestyle and has no medical problems. Lifestyle advice was given to him. What is the SINGLE most appropriate medication, if required, to start?

A 43 year old man was brought into the A&E after being stabbed in the chest with a knife. His chest is bilaterally clear. He has muffled heart sounds and his neck veins look distended. His systolic blood pressure is 60 mmHg and pulse is 120 bpm. What is the SINGLE most likely diagnosis?

A 71 year old man presents to the GP surgery with 3 episodes of fainting over the past 2 weeks. He has been having worsening shortness of breath over the past 6 months. He also complains of chest pain when he walks a short distance which is relieved after stopping. A systolic murmur is heard at the right sternal border over the second intercostal space. An ECG was performed which shows the following:

What is the SINGLE appropriate investigation?

A 57 year old man in the medical ward starts to feel dizzy with chest pain. Upon further assessment, he has a blood pressure of 75/45 mmHg and a heart rate of 170 beats/minute. An ECG was performed which is seen below.

A close-up of the ECG can be seen here:

What is the most appropriate management?

A 44 year old refugee from Syria presents to the GP with shortness of breath on exertion over the past few months. He is also beginning to feel shortness of breath when lying flat. He moved to the UK 4 years ago. He has an audible diastolic murmur at the apex. What is the SINGLE most likely diagnosis?

A 55 year old man was brought to the emergency department from a shopping mall after collapsing 2 hours ago. He is now fully conscious and answering questions. His ECG shows an irregular rhythm. His blood pressure is 120/80 mmHg. What is the SINGLE most appropriate investigation to carry out?

A 60 year old man attends the Emergency Department with an episode of dizziness and a fall earlier in the day. His blood pressure is 130/95 mmHg. An ECG shows

A larger image of lead II can be seen here:

He is not on any medications. What is the SINGLE most likely diagnosis?

An 18 year old man complains of fatigue and dyspnoea. On examination, he has a left parasternal heave and systolic thrill with a harsh pan-systolic murmur at left parasternal edge. What is the SINGLE most likely diagnosis?

A 44 year old man has been suffering from palpitations over the past 6 months. They occur several times a day and only last a few minutes. They can occur even at rest. He has not fainted before. He is not short of breath. He smokes around 40 cigarettes a day and he drinks around 40 units of alcohol a week. On examination, his cardiac examination is unremarkable. He had a recent 24-hour ECG, which was unremarkable. What is the SINGLE most appropriate action?

A 66 year old man is brought in by the paramedics after developing chest pain that started 6 hours ago. He was given 300 mg of aspirin, intravenous morphine and sublingual glyceryl trinitrate by the paramedics after performing an ECG which is shown below:

He is uncomfortable and sweating. He has a blood pressure of 110/70 mmHg, respiratory rate of 21 breaths/minute, heart rate of 90 beats/minute, and an oxygen saturation of 949%. What is the SINGLE most appropriate management?

A 66 year old man presents to the hospital with palpitations. A portion of the ECG taken

in the hospital is seen below:

He has no history of any ischaemic heart disease. His blood pressure is 110/70 mmHg, heart rate is 148 beats/minute and respiratory rate is 20 breaths/minute. He looks sweaty on examination. His chest is clear clinically on auscultation. What is the SINGLE most appropriate management?

A 67 year old woman had just had a proctosigmoidectomy a few hours ago. She suddenly becomes very dizzy and feels palpitations. She has no previous cardiac disease. Her heart rate is 148 beats/minute and her blood pressure is 87/51 mmHg. Her respiratory rate is 25 breaths/minute. Her ECG shows evidence of atrial fibrillation. What is the SINGLE most appropriate management?

A 55 year old man presents to the Emergency Department with palpitations, chest pain and dizziness. An ECG was performed is shown below. What is the SINGLE most likely diagnosis?

A 68 year old man is seen in the GP surgery for his medication review. He has a history of an ischaemic stroke 5 years ago. He also has a medical history of type 2 diabetes meliitus, atrial fibrillation and hypertension. His regular medications include lercanidipine, metformin, warfarin and atorvastatin. His blood pressure is 167/101 mmHg. His ECG is seen below:

A zoomed-in image of lead II can be seen below:

What is the most appropriate action to prevent further strokes?

A 55 year old man has central chest pain that radiates to his shoulders and arm. It is relieved by sitting up and leaning forward. Pericardial friction rub is heard. A widespread ‘saddle-shaped’ ST elevation is seen on an ECG. The cardiac shadow is not enlarged on a chest X-ray. What is the SINGLE most likely diagnosis?

A 62 year old woman with longstanding anxiety is seen in the outpatient department. She complains of her heart skipping a beat quite often. This particularly occurs when she is trying to get to sleep. The palpitations are never sustained. What is the SINGLE most likely rhythm disturbance?

A 69 year old man is brought in by ambulance to the Emergency Department with central crushing chest pain which radiates to his left arm. On reporting the ECG, he was diagnosed with an acute myocardial infarction. What is the SINGLE most likely ECG findings that would lead to this diagnosis?

A 65 year old man has chest pain. On initial assessment, he is noted to be pale. An ECG reveals no connection between P waves and QRS complexes with a rate of 42 beats/minute. What is the SINGLE most likely diagnosis?

A 48 year old woman has a sudden painful swollen left arm that started several hours ago. She has been having a fever for the past few days with malaise. She reports having breathlessness. On examination, a loud S1 is heard with a mid-diastolic murmur. She has no left radial pulse. An ECG reveals a sinus rhythm. An echocardiogram was arranged which reveals a left atrial myxoma. What is the SINGLE most appropriate action?

A 6 week old baby presents with the following features of progressive cyanosis, poor feeding, tachypnoea during the first two weeks of life. A holosystolic murmur is heard. What is the SINGLE most likely diagnosis?

A 67 year old man attends the Emergency Department following pain shooting down the left arm that started earlier today. He feels clammy and nauseous. His pulse rate is 112 beats/minute, respiratory rate is 24 breaths/minute, blood pressure 110/85 mmHg, and oxygen saturation is 96%. He was started on intravenous morphine for pain. An ECG done in the department shows the following:

What is the SINGLE most likely diagnosis?

A 60 year old man was seen by his GP with symptoms of his heart racing and feeling light-headed persisting for the past 3 days. His medical history includes hypertension and is non-compliant with his medication. His pulse rate was 125 beats/minute and was irregularly-irregular. Additionally, a mid-diastolic murmur was audible at the apex. An ECG performed at the time, showed no P waves, narrow and irregular QRS complexes. He was prescribed metoprolol and was booked for follow up. 5 days later during his follow-up. normal sinus rhythm is seen on ECG. Which of the following is the SINGLE most likely diagnosis?

A 53 year old man with chronic heart failure, develops a red, swollen and acutely tender right large toe. He is subsequently diagnosed with gout and started on a new medication. A few days later his symptoms of gout have significantly improved however, he is now short of breath and complaining of orthopnoea. What is the likely medication that he was started on?

A 52 year old man underwent a hemicolectomy. A few days after his operation he develops chest pain and a temperature of 38.8°C. He is having rigors and night sweats. On auscultation, a systolic murmur is heard. What is the next SINGLE most appropriate investigation?

A 48 year old man attends the clinic to perform a baseline ECG as a requirement before he is started on Modafinil. An ECG shows

A larger image of lead II can be seen here: 

He is not on any medications at present. What is the SINGLE most appropriate

management?

A 59 year old African-Caribbean man takes amlodipine daily for his hypertension for the past 5 years. His home blood pressure readings over the past week show an average of 165/100 mmHg. A urine dipstick shows a trace of protein. Which of the following is the most appropriate antihypertensive to add?

A 58 year old man attends the GP surgery for the results of his cholesterol levels. His recent blood test shows the following:

HDL cholesterol 1.7 mmol/L (0.9-1.93)

LDL cholesterol 2.1 mmol/L ( < 2)

Triglycerides 1.5 mmol/L (0.55-1.90)

Total cholesterol 5.3 mmol/L < 5)

He is a smoker and has a BMI of 33 m/kg2. His blood pressure is 130/84 mmHg. His QRISK3 score is calculated at 14%. He has no other medical conditions and does not take any regular medications. What is the SINGLE most appropriate management to reduce his risk of cardiovascular disease?

A 60 year old man had a myocardial infarction 2 weeks ago. He now presents with dyspnoea and pleuritic chest pain. A pericardial friction rub was noticed on examination. ECG shows widespread ST elevation. A chest X-ray shows an enlarged, globular heart. His pulse rate is 95 beats/minute and his respiratory rate is 24 breaths/minute. What is the SINGLE most likely cause of his symptoms?

A 69 year old woman was seen in the pre-assessment clinic for her elective left knee replacement surgery. During the assessment, her blood pressure was measured at 168/103 mmHg. She was asked to recheck her blood pressure with her GP. When she was reviewed by her GP 2 weeks later, her blood pressure in clinic was 148/87 mmHg and 143/86 mmHg. She is not on any medications. What is the SINGLE most appropriate action?

A 74 year old man started having chest pain. He has a blood pressure of 70/50 mmHg. His level of consciousness is decreased. A radial pulse is felt. An ECG shows the following rhythm. What is the SINGLE most appropriate management?

A 66 year old type 2 diabetic man is seen in the cardiology clinic as he has been having worsening shortness of breath over the past 8 weeks. He has a history of left ventricular failure with reduced ejection volume seen on an echocardiogram. His regular medication includes captopril, carvedilol, spironolactone, sitagliptin and metformin. He has a body mass index of 29 kg/m2.On examination, he has bilateral pulmonary crackles. His heart rate is 53 beats/minute. His last HbA1c was 59 mmol/mol (<48). What is the SINGLE most appropriate medication to prescribe?

A 68 year old man is found collapsed at a shopping mall. An ECG reveals no connection between P waves and QRS complexes with a rate of 35 beats/minute. What is the SINGLE most likely diagnosis?

An 80 year old woman complains of feeling light-headed and weak for the past 8 hours. She was diagnosed with heart failure 6 months ago and is taking ramipril 5 mg and bisoprolol 5 mg daily. She is currently on a cardiac monitor and based on her ECG findings; the medical team concluded that a permanent pacemaker is the best course of management. Her ECG is seen below:

Which of the following is the SINGLE most likely diagnosis?

A 76 year old diabetic man was recently admitted after being found to be in atrial fibrillation. He has no other medical conditions and takes Metformin regularly. His fibrillation was managed in hospital and he was deemed safe for discharge. He has normal renal function and has a normal BMI. On discharge, what is the SINGLE most appropriate long term medication for this patient?

A 58 year old man suddenly becomes shocked several days after suffering an acute myocardial infarction. His chest X-ray shows a large globular shaped heart and clear lung fields. His neck veins look distended. What is the SINGLE most likely diagnosis?

A 77 year old woman who lives alone was found by her neighbour on her kitchen floor. She was found confused but conscious. It is estimated that she has been lying on the floor for the past 20 hours after a fall. An ECG was performed, which is seen below:

Zoomed-in images can be seen below:

Which investigation would likely be abnormal, taking into account the ECG findings?

A 51 year old woman with a recent diagnosis of renal carcinoma presents with bilateral, pitting oedema of her legs and ankles. The oedema started 4 months ago. She was started on amlodipine for her high blood pressure 6 months ago. Her blood pressure in the clinic is 145/88 mmHg. She does not have ascites or shortness of breath. There are no heart murmurs on auscultation. What is the SINGLE most likely cause for her symptoms?

A 40 year old man was brought into the A&E after being hit by a vehicle. He sustained trauma to the chest. His neck veins look distended and his heart sounds are faint. He has a blood pressure of 80/45 mmHg and pulse is 120 bpm. His trachea is central. What is the SINGLE most appropriate management?

A 44 year old woman in the postnatal ward develops sudden onset chest pain and shortness of breath. She had an emergency C-section for fetal distress two days ago. She feels the breathlessness worsen when she lies down. She has a respiratory rate of 32 breaths/minute and a blood pressure of 100/60 mmHg. Her oxygen saturation is 89% on room air and temperature is 36.9°C. On examination, she looks pale and sweaty. Auscultation reveals widespread crepitations over both lung fields. An ECG was performed which shows sinus tachycardia. Oxygen by face mask was commenced. A chest X-ray confirms the diagnosis. Which SINGLE medication is used as part of the management?

A 64 year old man presents with palpitations, chest pain and shortness of breath. His blood pressure was 82/40 mmHg. He appeared confused and drowsy. ECG performed showed a narrow complex, regular tachycardia with an approximate rate of 210 beats per minute. p waves were not visible. What is the most appropriate management step?

A 71 year old man attends the GP surgery after having three syncopal attacks over the past month. He was walking uphill on all three events. There was no associated tongue biting or incontinence. His wife says he only lost consciousness for a few seconds followed by complete recovery. He reports becoming short of breath and having mild chest pain when he walks a short distance. He has a medical history of hypertension. He takes ramipril and amlodipine. His blood pressure is 110/80 mmHg in the clinic. He has a heart rate of 80 beats/minute and respiratory rate is 20 breaths/minute. An ejection systolic murmur is heard on auscultation. What is the SINGLE most appropriate investigation to perform for this patient?

A 20 year old man comes to the Emergency Department complaining of palpitations that began when he woke up earlier today. The palpitations have been continuous and are still ongoing. He denies chest pain, shortness of breath or dizziness. His blood pressure is 120/80 mmHg. He has a respiratory rate of 23 breaths/minute. He is completely conscious throughout. Below is his ECG taken in the Emergency Department.

What is the SINGLE most appropriate initial management?

A 72 year old man is found to be unresponsive. You are on the ward and are called to the patient’s bedside by one of the patient’s relative. He is not breathing and has no detectable pulse. Which is the SINGLE most appropriate initial step?

The A 66 year old man is referred by the GP for an echocardiogram as he complains of dyspnoea for the past few months. He has had two episodes of dizziness followed by syncope over the past 4 weeks after getting out of a chair. He feels extremely short of breath after walking up 2 flights of stairs. He takes isosorbide dinitrate for prophylaxis of angina. He is also on long term treatment with low-dose aspirin and a statin for stable angina due to atherosclerotic disease. On examination, there is a systolic murmur at the right parasternal edge on auscultation. What is the SINGLE most likely diagnosis?

A 54 year old man has a temperature of 39°C, a new murmur and symptoms of cardiac failure. He had a dental extraction several days ago. What is the SINGLE most likely reason for his symptoms?

A 59 year old man who is on multiple medications for ischaemic heart disease, hypertension and diabetes finds it difficult to mobilize as he feels dizzy when trying to stand up. What is the SINGLE most appropriate investigation for him?

A 62 year old man who attends the Emergency Department feeling chest discomfort, and nausea. His medical history includes hypertension which he takes antihypertensives for. An ECG was quickly taken which is seen below:

What is the SINGLE most likely diagnosis? 

A 56 year old man presents to the emergency department with chest pain. The following was taken.

What is the SINGLE most likely diagnosis?

A 79 year old man with a past history of ischemic heart disease presents with yellow haloes, nausea and vomiting. His ECG reveals an arrhythmia. Which of the following medication is most likely responsible for his symptoms?

A 22 year old man is seen in the cardiology clinic following investigations for his recurrent fainting episodes while exercising. His ECG recently shows the following:

Rate 80 beats/minute

Normal QRS

Normal PR interval

Prolonged QT interval

He has had similar findings on his ECG since he was 9 years old. What is the SINGLE arrhythmia associated with his condition?

A 60 year old woman with a history of ischaemic heart disease presents to A&E with progressive dyspnoea. She has had previous admissions with heart failure in the past year. She has a respiratory rate of 34 breaths/minute and a systolic blood pressure of 90 mmHg. Her oxygen saturation is 88% on room air. On examination, she looks pale and sweaty, and has widespread crepitations over both lung fields. Oxygen by face mask was commenced. What is the SINGLE most appropriate next step in management?

A 69 year old man has sudden onset chest pain radiating to his left arm while watching television. An ambulance was rushed to the scene and. An electrocardiogram shows ST elevation in II, III and aVF. What is the SINGLE most appropriate analgesia to administer to him while in the ambulance?

A 59 year old male is rushed to Accident & Emergency (A&E) by an ambulance with the complaint of dyspnoea and tachypnoea following a road traffic accident. He looks acutely unwell with an altered mental status. Which of the following are features of cardiac tamponade?

A 30 year old man with type 1 diabetes mellitus presents to the Emergency Department with increased thirst, urinary frequency, lethargy and abdominal pain. His breath has a fruity smell. His ECG was performed and is seen below:

Zoomed-in images can be seen below:

What is the SINGLE most likely electrolyte abnormality?

A 52 year old man has a suspected diagnosis of a patent foramen ovale while undergoing a transthoracic echocardiography. What is the SINGLE next most appropriate investigation to confirm the diagnosis?

A 6 week old baby has a pansystolic murmur at sternal border. He feeds poorly and has poor weight gain. The baby is acyanotic. What is the SINGLE most likely diagnosis?

A 61 year old man presents to the Emergency Department with retrosternal chest pain which started 3 hours ago while he was sitting down. The pain has not eased over the past 3 hours. He had a similar episode 12 hours ago which he took aspirin and a GTN spray which relieved the chest pain. His blood pressure is 120/80 mmHg and his heart rate is 70 beats/minute. His oxygen saturation is 98%. What is the SINGLE most appropriate initial investigation?

A 72 year old man presents to the GP surgery with palpitations for the past 2 weeks. He has no chest pain, dizziness, shortness of breath or history of syncope. He has no history of ischaemic heart disease. He does not drink alcohol or caffeine. His blood pressure is 140/95 mmHg. On examination, he has an irregularly irregular pulse. On auscultation, his lung fields are clear clinically and he has normal heart sounds. An ECG requested in clinic shows atrial fibrillation at a rate of 100 beats/minute. What is the most appropriate management?

A 58 year old woman presents to A&E with the complaint of a fall. Her medical records reveal that she has been in attendance to A&E quite frequently over the last few months because of recurrent falls. On examination, she looks slightly pale and she jokes that she is clumsier nowadays. Her past medical history includes asthma, hypertension and a previous myocardial infarction three years ago. She is on a salbutamol inhaler, a beclomethasone inhaler, amlodipine, aspirin, atenolol and bendroflumethiazide. What is the SINGLE most appropriate investigation to be carried out for this patient?

A 74 year old lady presents to the Emergency Department following a fall at home. On admission to the Emergency Department, she is confused and unable to give a useful history. On examination, she is noted to be pale, pulse irregularly irregular in rhythm and she is noted to have cold peripheries. Her observations include a blood pressure of 80/50, respiratory rate 24 breaths/minute, temperature 36.9° and saturations of 97% on air. A 12-lead ECG is performed and shows narrow QRS complexes, variable R-R intervals with absent P waves at a rate of 150 beats per minute. Given the likely diagnosis, what is the most appropriate next step in management?

A 55 year old carpenter presents with a history of sudden chest pain which radiates to his jaw accompanied by shortness of breath which started 2 hours ago. An ECG was done which shows a normal sinus rhythm without ST elevation. What is the SINGLE most appropriate investigation?

A 58 year old white English man with a past history of myocardial infarction and type 2 diabetes mellitus has a new diagnosis of hypertension. He is currently taking aspirin, atorvastatin and metformin. What is the SINGLE most appropriate medication to be added?

A 52 year old man presents to the Emergency Department after being told by his GP that he needs to go to the hospital urgently because his routine blood test done earlier in the day show a potassium level of 6.6 mmol/L (3.5-5.0). His eGFR and creatinine were within normal limits. He has recently started on ramipril 10 days ago for the management of his high blood pressure. A 12-lead ECG was performed which shows sinus rhythm without hyperkalemic changes. An urgent blood gas was performed, and the report shows.

Potassium 6.7mmol/L (3.5-5.0)

Which of the following is the most appropriate next step in the management of this patient?

An 82 year old male was walking in his garden when he suddenly fell to the ground and was unconscious. He recovered completely within a few minutes however, he described feeling very hot and flushed after the episode. He remembers the events prior to the fall and confidently says he did not trip. He denies feeling sweaty or dizzy prior to the fall. What is the SINGLE best investigation to diagnose his problem?

A 57 year old man presents to A&E with central abdominal and lower back pain associated with feeling faint and sweaty. The pain started very suddenly and it is very severe. His heart rate is 105 bpm and blood pressure is 88/50 mmHg. On physical examination, there is a tender pulsatile abdominal mass and his left femoral pulse is absent. What is the SINGLE most appropriate initial investigation?

A 25 year old male presents to Accident & Emergency with the complaint of substernal sharp chest pain. The patient claims that the pain is much worse on inspiration. His past medical history is insignificant however, he smokes 20 cigarettes daily and drinks 50 units of alcohol weekly. On examination, his chest is clinically clear and his abdominal examination was found to be normal.

His vitals are noted as:

Temperature 38°C

Respiratory rate 18 breaths/minute

Blood pressure 110/70 mmHg

Oxygen saturation 97%

What is the SINGLE most likely diagnosis for this patient?

A 77 year old woman is seen by the GP surgery with complaints of increasing “water in her legs” and worsening shortness of breath when she lies flat. Her symptoms have gradually worsened over the past few months. She has a history of systolic heart failure diagnosed 2 years ago. She was admitted into the hospital 6 months ago for pulmonary oedema which she was treated with intravenous furosemide. Her medications include furosemide, carvedilol, and ramipril. On examination, she has normal vesicular breath sounds on auscultation. Her heart sounds are normal. She has pitting oedema on both her feet and ankles. She has a temperature of 36.7°C, heart rate of 70 beats/minute, blood pressure of 130/80 mmHg, respiratory rate of 15 breaths/minute and an oxygen saturation of 97%. Her previous renal profile was seen to be normal. What is the SINGLE most appropriate management?

A 59 years old man returns for routine follow up 6 weeks following a myocardial infarction. He complains of breathlessness when walking uphill. His ECG shows ST elevation in leads V1, V2, V3, V4 and V5. What is the SINGLE most likely explanation for the abnormal findings?

A 48 year old man presents with a 3 day history of fever, chest pain and shortness of breath. He suffered a myocardial infarction six months ago. On examination, the patient appears moderately ill with a temperature of 38.1°C, a blood pressure of 141/77 mmHg and a heart rate of 105 beats/minute. Cardiac examination shows a holosystolic murmur over the apex. The ECG shows Q-waves in leads I and aVL. What is the most likely diagnosis?

A 69 year old man has the following ECG. What is the SINGLE most appropriate next step in management?

A 50 year old man attends the Emergency Department with complaints of shortness of breath and palpitations which started 4 hours ago. He denies chest pain. He has a pulse of 160 beats/minute, a blood pressure of 110/80 mmHg and a respiratory rate of 20 breaths/minute. His past medical history includes hypertension, type 2 diabetes mellitus and angina. An ECG was performed which shows regular narrow complexes without P waves. The narrow QRS complexes have a normal shape and there are normal T waves. Carotid sinus massage was attempted but he is still tachycardic. What is the SINGLE most appropriate next management?

A 44 year old man who presently has acute renal failure has an ECG that shows tall tented T waves, flat P waves and a wide QRS complex. What is the SINGLE most likely electrolyte abnormality?

A 66 year old man has presented to the Emergency Department with a facial droop, arm weakness and speech difficulties that started 2 hours ago. A computed tomography scan of the head shows no evidence of an acute haemorrhage. An ECG was performed which shows an atrial fibrillation. There is no history of atrial fibrillation in the past. He was managed by the medical team and was thrombolysed and currently awaiting discharge. He has been informed by the medical team that he suffered from a non-disabling ischaemic stroke. He has a known hypersensitivity to apixaban. What is the SINGLE most appropriate long term prophylactic regimen for stroke prevention for him?

A 68 year old woman is brought into the Emergency Department with palpitations and chest discomfort. She gives a history of left hemiparesis four days ago which has partially resolved after a few hours. She has a blood pressure of 160/95 mmHg, respiratory rate of 22 breaths/minute and a heart rate of 120 beats/minute. A CT scan of the head was organised which shows evidence of a small cortical infarct. An ECG taken in the Emergency Department shows absent P waves and an irregularly irregular rhythm with a variable ventricular rate. Metoprolol was given intravenously and she was discharged once asymptomatic. Her renal profile and liver function test were within normal limits. Which long term medications is she likely to benefit from?

A 65 year old man presents to the emergency department with chest pain, palpitations and shortness of breath. The following ECG was taken.

He was given a glyceryl trinitrate spray and morphine which has improved his chest pain. What is the SINGLE most appropriate action?

A 77 year old man has breathlessness on exertion and fatigue which has worsened over a period of one year. He denies having chest pain, palpitations, or wheezing. His medical history includes hypertension which he is on amlodipine. He is a non-smoker. On examination, he has pitting oedema on his ankles bilaterally. There are no murmurs on auscultation of the heart. His ECG shows normal sinus rhythm. What is the SINGLE most appropriate test to request?

A 58 year old man with a history of type 1 diabetes mellitus and hypertension for 13 years develops sudden central chest pain and abdominal pain for 45 minutes. The pain radiates to his jaw. It started while he was driving and it was associated with cold sweating and dyspnoea. He describes the pain as a burning pain. What is the SINGLE most likely diagnosis?

A 60 year old man with a history of ischaemic heart disease starts having chest pain. He has a heart rate of 170 beats/minute and a blood pressure of 70/45 mmHg. An ECG reveals a broad complex tachycardia with absence of atrial activity. He feels unwell and is now semi conscious. What is the SINGLE most likely diagnosis?

A 55 year old man presents to the hospital with symptoms of increasing breathlessness over the past few days and fatigue. He finds it more difficult to sleep during the nights because he is short of breath. On auscultation of his chest, basal crepitations can be heard. He has a history of chronic heart failure and hypertension of which he takes regular ramipril. Investigations were performed and furosemide infusion is given in the department which rapidly improved his symptoms. The medical team decide to discharge him on furosemide orally with a specialist nurse follow up. What is the SINGLE most appropriate medication to be added on his discharged medication list?

A 65 year old man lost consciousness while seated on his sofa. He slumped sideways and did not injure himself when he fell unconscious. His wife was with him and states that he lost consciousness for 5 minutes. He was watching television when he lost consciousness. There was no shaking of his limbs when it occurred. He has a history of angina which the first episode was recorded 6 months ago. On examination, he has a systolic murmur at the second intercostal space on the right of his sternum. His blood pressure is 120/70 mmHg. His pulse is 70 beats/minute and is regular. What is the most appropriate term to use to describe this event?

A 48 year old man has continuous anterior chest pain which is worse on inspiration. 4 weeks ago, he had a myocardial infarction. He has a temperature of 37.5°C. His blood results show an ESR of 82 mm/h. What is the SINGLE most likely explanation for the abnormal investigation?

A 58 year old man presents to the Emergency Department with a dull chest pain and shortness of breath that started 3 hours ago. He has a history of hypertension and takes medications for it. The following ECG was taken.

Which coronary artery is likely occluded?

A 68 year old woman with a history of type 2 diabetes and hypertension developed central chest pain radiating to the left arm upon waking at 7 am. The pain lasted for 1 hour and resolved by the time she arrived in A&E at 8 am. She had been given 300mg Aspirin in the ambulance. Her vitals are stable. Her ECG shows normal sinus rhythm. Her blood tests which were taken at 8.15 am are seen below:

Troponin (HsTnl) 11 ng/L (<12)

What is the most appropriate next management?

A 52 year old man with history of anterior myocardial infarction 3 weeks ago developed a sudden onset of dyspnoea. He has a blood pressure of 100/60 mmHg, pulse rate of 100 beats/minute, SaO2 = 88%, and his chest is audible for bilateral crackles. What is the SINGLE best investigation to determine the underlying cause?

A 65 year old man attends the GP surgery for a review of his blood pressure. He is known hypertensive and takes regular ramipril. His blood pressure readings in the clinic were 150/95 mmHg. 155/98 mmHg, and 157/91 mmHg. He had previously used amlodipine many years ago but stopped it because of worsening ankle oedema. What is the SINGLE most appropriate medication to add?

A 62 year old man attends the GP surgery after having two syncopal attacks over the past week. He was standing in his garden when he had the syncopal episodes. He did not feel sweaty or have any tremors. There was no associated tongue biting or incontinence. His wife says he only lost consciousness for a few seconds followed by complete recovery. He has a medical history of type 2 diabetes and hypertension. He takes metformin and amlodipine. His blood pressure is 110/80 mmhg on lying and the systolic blood pressure dropped by 25 mmHg when standing. He has a heart rate of 80 beats/minute and respiratory rate is 20 breaths/minute. What is the SINGLE most appropriate initial investigation?

A 28 year old man presents with a 2 hours history of rapid palpitations. He feels light headed but is otherwise well. On examination he has a pulse of 170 beats/minute, regular. His blood pressure is 100/68 mmHg. He had 2 similar episodes of feeling palpitations in the past 3 months. What is the SINGLE most likely rhythm disturbance?

A 65 year old man had chest pain and suddenly collapsed in the park. When the paramedics arrived, he had gained consciousness. He describes having palpitations and a dull ache in his chest before passing out. His blood pressure assessed by the paramedics was 110/80 mmHg and his Glasgow Coma Scale was 15. On arrival at the Emergency Department, he starts feeling palpitations, lightheadedness and short of breath. His blood pressure is 100/60 mmHg. An ECG was performed which is seen below:

What is the SINGLE most likely diagnosis?

A 2 week old baby has developed dyspnoea. His oxygen saturation is 70% on air. He is cyanosed and has an ejection systolic murmur. What is the SINGLE most likely diagnosis?

A 60 year old man has had a recent inferior myocardial infarction. He recovered well in the ward, but on the 4th day, he became unwell with an episode of his blood pressure dropping to 80/50 mmHg. On auscultation, a pan-systolic murmur can be heard along the lower left sternal border. What is the SINGLE most appropriate diagnosis?

Which is the SINGLE most likely artery that has artery dominance in 85% of the general population?

A 57 year old man is found to have a clinic blood pressure of 160/90, 167/99 and 162/85 mmHg. He was given an ambulatory blood pressure machine (ABPM) to take home. He returned the following week with an average reading of 155/91 mmHg. He has no significant medical history. What is the SINGLE most appropriate action?

A 72 year old woman was seen in primary care with ongoing chest discomfort that started earlier in the day. She has a history of hypertension and hypercholesterolaemia. She has normal heart sounds. An ECG was performed which is seen below. 

What is the SINGLE most likely diagnosis?

A 58 year old man develops sudden onset shortness of breath and collapses to the ground after playing football with his friends. The ambulance crew arrives and finds him conscious but drowsy and confused. His blood pressure was 78/42 mmHg. His ECG shows an irregularly irregular narrow-complex rhythm with a rate greater than 200 beats per minute. The paramedic administers two round of electrical cardioversion using the defibrillator. The rate and rhythm do not change, and his blood pressure is now 68/36 mmHg. What is the most appropriate management step for the ambulance crew?

A 70 year old man was successfully thrombolysed for an inferior myocardial infarction 12 days ago. He was discharged a few days ago but has re-attended the Emergency Department because of new-onset shortness of breath. He has bi-basal crackles and a pansystolic murmur at the cardiac apex. His respiratory rate is 28 breaths/minute and heart rate is 100 beats/minute. What is the SINGLE most appropriate investigation to determine the underlying cause?

A 65 year old man continues to experience chest pain 2 days after an acute myocardial infarction. He has a temperature of 37.8°C. His ECG shows widespread ST elevation with upward concavity. What is the SINGLE most likely diagnosis?

A 65 year old man attends the Emergency Department with an episode of collapse. He has a pulse rate of 58 beats/minute. His blood pressure is 120/95 mmHg. An ECG shows 

A larger image of V6 can be seen here:

He is not on any medications. What is the SINGLE most appropriate definitive management?

A 46 year old African-Caribbean man is found to have a blood pressure of 160/90 mmHg on 3 separate occasions in the clinic. He was given an ambulatory blood pressure machine to take home. He returned the following week with an average reading of 163/95 mmHg. What is the SINGLE most appropriate initial treatment?

A 62 year old man had chest pain and suddenly collapsed in the restaurant. When the paramedics arrived, he had gained consciousness. He describes having palpitations and a dull ache in his chest before passing out. His blood pressure assessed by the paramedics was 110/80 mmHg and his Glasgow Coma Scale was 14. On arrival at the Emergency Department, he becomes unconscious. He has a respiratory rate of 4 breaths/minute. His oxygen saturation is 93%. His blood pressure is 60/30 mmHg. An ECG shows a broad complex tachycardia. His Glasgow Coma Scale has dropped to 9. He is being ventilated with an Ambu bag mask and 100% oxygen. What is the SINGLE most appropriate management?

A 55 year old man has sudden onset of central chest pain and shortness of breath 3 hours ago. He looks pale and sweaty. An ECG was done in the Emergency Department and is seen below:

What is the SINGLE most likely diagnosis based on this ECG?

A 72 year old man is found not breathing in the CCU with the following rhythm. His pulse can not be felt. What is the SINGLE most likely diagnosis?

A 28 year old man complains of heart racing. He is completely conscious throughout. He has a pulse of 132 beats/minute, a blood pressure of 120/70 mmHg and a respiratory rate of 21 breaths/minute. An ECG was taken which shows supraventricular tachycardia. What is the SINGLE most appropriate immediate management?

A 63 year old man has had a recent anterior myocardial infarction. On the sixth day, he had an episode of increasing dyspnoea, and chest pain followed by collapse. His blood pressure was measured at 79/50 mmHg. Auscultation reveals a pansystolic murmur throughout the precordium but more audible at the left sternal border, associated with a palpable thrill. There is evidence of raised jugular venous pressure. What is the SINGLE most appropriate diagnosis?

A 65 year old woman comes in to the Emergency Department with complains of leg cramps and feeling weak. She takes bendroflumethiazide for hypertension. Her blood test show the following:

Sodium 134 mmol/l

Potassium 2.1 mmol/l

Urea 4.1 mmol/l

Creatinine 66 μmol/l

Glucose 4.8 mmol/l

What is the SINGLE most likely ECG features to be seen?

A 69 year old woman had sudden burning chest pain and shortness of breath that started 4 hours ago. The pain was associated with nausea, vomiting and diaphoresis. Her ECG on admission shows ST elevation in leads II, III and aVF. Oxygen has been started and she was given sublingual GTN which has improved her chest pain. She was given aspirin 300 mg by the ambulance crew. Her heart rate is 70 bpm and respiratory rate is 18/min. What is the SINGLE most appropriate next step in management?

A 60 year old lady has severe chest pain. ECG shows changes of inferior wall myocardial infarction. The ECG also shows progressive prolongation of PR interval until a QRS complex is dropped. What is the SINGLE most likely diagnosis?

A 61 year old man is planned to undergo a mitral valve replacement surgery. He has a history of asthma and takes regular inhalers for it. His cardiology team would like to decrease his risk of post-operative atrial fibrillation by starting amiodarone. What is the SINGLE most appropriate test to perform prior to starting amiodarone?

A 51 year old female presents with the complaint of increasing breathlessness and breathlessness on exertion. She has been having difficulty in sleeping lately and she says that she has to use three pillows to sleep at night. On examination, the patient is noted to have bilateral pedal oedema up to the level of her calf and widespread crepitations bilaterally on auscultation. Auscultation of the heart reveals a pansystolic murmur at the cardiac apex. An ECG was done which was significant for a broad P wave. She has no medical problems other than asthma, which was diagnosed when she was 7 years old, and that she had rheumatic fever when she was 14 years old. She does not drink alcohol or smoke. What is the SINGLE most likely cardiac defect that this patient has?

A 42 year old man collapsed and died at home. The GP’s report states that he has type 2 diabetes and has a BMI of 35. What is the SINGLE most likely cause of death?

A 64 year old man presents with palpitations and mild shortness of breath. His blood pressure is 132/80 mmHg. He was talking in full sentences and appeared anxious. ECG is performed and is seen below.

Zoomed-in images can be seen here:

What is the most appropriate management step?

A 38 year old man presents to the Emergency Department feeling unwell and dizzy. He is increasingly short of breath and has mild chest discomfort. He has a heart rate of around 35 beats/minute. His blood pressure is 70/30 mmHg. His ECG shows broad complexes with atrioventricular dissociation. What is the SINGLE most appropriate first-line treatment?

A 76 year old man with no significant medical history presents to the clinic for his annual checkup. His only complaint is mild exercise intolerance that he attributed to his advanced age. His physical examination is only significant for an ejection systolic murmur that is louder upon auscultation with the patient in the upright position. What is the SINGLE most likely cardiac defect that this patient has?

A 71 year old woman is brought in by ambulance to the Emergency Department with sudden chest pain and shortness of breath which started 2 hours ago. The pain radiates to her left arm. An ECG was taken which is shown below:

Oxygen has been started and she was given sublingual GTN which has improved her chest pain. Her heart rate is 100 bpm and respiratory rate is 18/min. What is the SINGLE most appropriate next step in management?

A 68 year old man attended the GP surgery to check his blood pressure. His clinic blood pressure is 158/96 mmHg. He was asked to do home blood pressure measurements after the appointment. The average of 14 readings of his home blood pressure measurements is 145/92 mmHg. His 10-year risk of developing cardiovascular disease is estimated to be 7% using a risk calculator. He is a non-smoker and otherwise completely healthy. What is the SINGLE most appropriate management?

A 50 year old man with diabetes mellitus suddenly develops persistent crushing central chest pain radiating to the neck and arm when he was driving. It was associated with nausea, vomiting, dyspnoea, and palpitations. He has a pulse of 122 beats/minute, a blood pressure of 110/70 mmHg and a respiratory rate of 34 breaths/minute. What is the SINGLE most likely diagnosis?

A 62 year old woman who had a stroke a year ago now reports having increased dyspnoea on exertion. An ECG was performed which showed atrial fibrillation. A chest X- ray shows a straight left heart border. What is the SINGLE most likely diagnosis?

A 66 year old man with a history of hypertension presents to A&E with sudden, severe lower abdominal pain and back pain. A tender pulsatile abdominal mass is palpated lateral and superior to the umbilicus. His heart rate is 110/min and blood pressure is 80/50 mmHg. What is the SINGLE most appropriate investigation?

A 59 year old male with known chronic kidney disease presents to Accident & Emergency (A&E) in an acute confusional state with shortness of breath and a fever of 39.4 °C. His heart rate is 115 beats/minute and his respiratory rate is 28 breaths/minute. Auscultation of his chest reveals a mitral pan-systolic murmur which has not been heard before. An examination is significant for a 1 cm non-tender, haemorrhagic macular lesion on the right sole and petechiae on the upper trunk. What is the SINGLE most appropriate initial investigation to help achieve a diagnosis?

A 58 year old man presents to the Emergency Department after experiencing a fainting spell which lasted for seconds. He reports being lightheaded and tired for the past few weeks. Over the past 2 days, he has been feeling short of breath. He denies having any chest pain. He has a medical history which includes type 2 diabetes mellitus and hypertension. His blood pressure is 131/92 mmHg, pulse rate is 45 beats/minute. respiratory rate is 21 breaths/minute, and temperature is 37.1°C. His ECG is shown below:

A larger image of lead II can be seen here:

What is the most appropriate initial step in the management of this patient?

A 50 year old smoker and heavy drinker presents with complaints of a racing heart. He has no chest pain. The palpitations usually occur when he drinks alcohol or after a meal. He has no significant past medical history. A 24 hours ECG is shown to be normal. What is the SINGLE most appropriate action?

A 52 year old man presents with increased breathlessness when walking. He finds it difficult to sleep at night due to shortness of breath and has to either roll on his side or use a few pillows for his head and upper back to reduce his symptoms. His symptoms have been worsening for the past 5 months. He is currently taking furosemide which gives him some relief. His medical history is significant for diabetes mellitus. An echocardiogram reports an ejection fraction of 36%. On examination, bilateral pedal oedema is noted. What is the SINGLE most appropriate medication to initially start?

A 44 year old man from Mozambique attends the GP surgery with a 6 month history of progressive shortness of breath on exertion. He has recently moved to the UK a year ago. The last chest X-ray he had a week ago shows straightening of the left atrial appendage. A diastolic murmur was audible and he was sent for an echocardiogram. The echocardiogram reveals a severe reduction of the mitral valve area. What is the SINGLE most likely complication associated with his condition?

A 45 year old man has substernal chest pain which radiates to his shoulders which started 4 days ago. He had a myocardial infarction 2 weeks ago but the initial pain had subsided. He claims that the pain is much worse on inspiration and often relieved by sitting forward. The pain is worse when he lies flat. His vitals are noted as:

Temperature 37.5°C

Respiratory rate 20 breaths/minute

Blood pressure 110/70 mmHg

Oxygen saturation 99%

Heart rate 70 beats/minute

Given his clinical symptoms and likely diagnosis, which is a typical finding seen on an ECG?

A 50 year old female presents with shortness of breath and palpitations which has been on going for the past few hours. She has ankle swelling which has been present for more than a year and feels difficulty in breathing while lying down. She is a known alcoholic. A chest radiograph shows evidence of cardiac enlargement. What is the SINGLE most likely cause of her worsening condition?

A 59 year old man attends the Emergency Department following a dull central chest pain that started 4 hours ago. He is still in pain and feels clammy. He has no previously known coronary artery disease. His medical history includes hypertension which he takes amlodipine regularly. His pulse rate is 98 beats/minute, respiratory rate is 20 breaths/minute, blood pressure 150/95 mmHg, and oxygen saturation is 97%. He was started on intravenous morphine for his chest pain. Blood tests have been taken for troponin levels but have not come back yet. An ECG was done which shows the following:

A chest X-ray done in the department is normal. What is the SINGLE most appropriate next step?

A 75 year old man is found to be unresponsive. The ward doctor is called to the patient’s bedside. He is not breathing and has no detectable pulse. Which is the SINGLE most appropriate next step?

A 65 year old man with a background of hypertension and diabetes is referred to the medical service at his local district general hospital (DGH) by his general practitioner (GP) following the complaint of a 25-minute episode of dull, aching, left-sided chest pain, initially radiating to his jaw, while sitting and watching television. Prior to arrival, he was given 300 mg of aspirin by his GP and complains of no pain on arrival. The patient has no family history of cardiac problems however, he is a heavy smoker and has smoked a pack a day for 30 years.

His vitals are as follows:

Blood pressure 150/90 mmHg

Heart rate 105 beats/minute

Respiratory rate 20 breaths/minute

Oxygen saturation 97% on room air

An ECG done is normal.

His blood was taken approximately three hours from the start of symptoms and the results are as follows:

Troponin T 199 ng/L (less than 5 ng/L)

Sodium 144 mmol/L (135-145 mmol/L)

Potassium 5 mmol/L (3.5-5.0 mmol/L)

Urea 7 mmol/L (2.0-7 mmol/L)

Creatinine 140 μmol/L (70-150 μmol/L)

eGFR 87 (greater than :90)

What is the most appropriate immediate next step in management?

A preterm neonate who was born at 32 weeks has a continuous murmur that disappeared at the time of discharge from the paediatric intensive care unit. What is the SINGLE most likely diagnosis?

A 72 year old woman is brought in by her husband as she has sudden chest discomfort, palpitations and epigastric pain which started 1 hour ago. She has been feeling nauseous. She denies pain radiating to the arms or neck. There are ST elevations seen on leads II, III and aVF on the ECG. Oxygen has been started. She was given sublingual GTN and diamorphine which has improved her chest pain. Her heart rate is 90 beats/minute and respiratory rate is 18 breaths/minute. What is the SINGLE most appropriate next step in management?

A 45 year old lady who was previously fit and well is admitted with breathlessness, palpitations and a history of two episodes of syncope over the past two days. Upon further questioning, she admits to having difficulty breathing when she sits upright. She finds great relief when she lies down flat on her couch. Upon examination, the tips of her fingers are noted to be blue and clubbing is noticed. Auscultation reveals a mid-diastolic rumble which changes when the patient changes position and a loud S1 at the cardiac apex. What is the SINGLE most likely diagnosis?

A 62 year old man has a routine ECG pre-operatively for an elective osteoarthritic knee replacement. He is in sinus rhythm, and the QRS complex is not prolonged. There is a gradual prolongation of the PR interval, followed by a dropped beat every 3 or 4 QRS complexes. The ECG machine is unable to calculate the PR interval. The patient does not complain of any palpitations. What is the SINGLE most likely diagnosis?

A 46 year old man is asked to come in to the GP surgery for the results of an abnormal blood result. His blood test reveals the following:

HDL cholesterol 1.7 mmol/L (0.9-1.93 mmol/L)

LDL cholesterol 4.9 mmol/L ( < 2 mmol/L)

Triglycerides 1.5 mmol/L (0.55-1.90 mmol/L)

Total cholesterol 8.1 mmol/L < 5 mmol/L)

On questioning further, he states that his father died when he was 58 years old from a myocardial infarction. He is a smoker. He drinks an estimate of 10 units of alcohol a week. What is the most likely diagnosis?

A 34 year old man comes to the Emergency Department complaining of palpitations that began when he woke up earlier today. The palpitations have been continuous and are still ongoing. He denies chest pain, shortness of breath or dizziness. His blood pressure is 130/80 mmHg. He has a respiratory rate of 19 breaths/minute. He is completely conscious throughout. Below is his ECG taken in the Emergency Department.

A larger image of lead II can be seen here: 

What is the SINGLE most appropriate medication to administer?

A 55 year old man had a myocardial infarction 3 days ago. He now complains of a shortness of breath and a sharp pain in the chest. The pain increases when he breathes and is relieved when sitting forward. His respiratory rate is 22 breaths/minute and his heart rate is 95 beats/minute. What is the SINGLE most likely diagnosis?

A 53 year old man notices occasional left-sided chest pain for the past few weeks that lasts less than 30 minutes following exercise. The pain is relieved when resting. He smokes 10 cigarettes a day for the past 20 years. What is the SINGLE most likely diagnosis?

A 75 year old man has had several episodes of dizziness in the past month. They mostly occur when he is on his long walks through the forest. He has palpitations with them. Both the palpitations and dizziness resolve after a few minutes. He does not have any chest pain with the episodes. He does not complain of dyspnoea. He is not dizzy at present. His medical history includes hypertension and type 2 diabetes mellitus. His medications include ramipril, indapamide and metformin. He has a blood pressure of 127/84 mmHg on sitting and 120/80 mmHg on standing. An ECG shows normal sinus rhythm with a heart rate of 68 beats/minute. His heart sounds are normal on auscultation. What is the SINGLE most appropriate investigation?

An 81 year old woman presents acutely short of breath and distressed. Her medical history includes chronic heart failure and hypertension. She takes regular amlodipine and candesartan. On examination, she has bilateral course crepitations throughout the lung fields. She has ankle swelling. She has a temperature of 36.5°C, heart rate of 110 beats/minute, blood pressure of 140/95 mmHg, respiratory rate of 28 breaths/minute and an oxygen saturation of 95% on 15 litres of oxygen per minute. Her chest X-ray shows bilateral interstitial shadowing and cardiomegaly. She is started on intravenous furosemide. An echocardiogram was performed, which showed a left ventricular ejection fraction of 349%. Her renal profile is within normal limits. She was stabilised, and her symptoms improved. What is the SINGLE most appropriate management to add on in the hospital?

A 65 year old man attends the Emergency Department with dizziness. He has a pulse rate of 51 beats/minute. His blood pressure is 75/56 mmHg. An ECG shows a 3rd degree heart block. He is not on any medications. He has been given atropine. What is the SINGLE most appropriate next step in management?

A 74 year old man started having chest pain. He has a blood pressure of 70/50 mmHg. He is conscious and a radial pulse is felt. An ECG shows the following rhythm.

What is the SINGLE most likely diagnosis?

A 54 year old female presents with the inability to lie down flat on her bed at night. On examination, she has widespread bibasilar crepitations on auscultation and an irregularly irregular radial pulse. Her past medical history is significant for an anterolateral myocardial infarction a year ago. Auscultation of the heart reveals a 2/6 grade pansystolic murmur at the cardiac apex. She has no other medical problems. She does not drink alcohol or smoke. What is the SINGLE most likely cardiac defect that this patient has?

A 57 year old woman who is suffering from hypertension, presents to the hospital with complaints of recurrent falls when trying to get out of bed or getting up from sitting. She is on a calcium channel blocker and a thiazide diuretic. What is the SINGLE most likely cause of her falls?

A 33 year old woman has sharp stabbing pain in her chest that started 2 days ago. The pain radiates to both shoulders. She has recently recovered from an upper viral respiratory tract infection which started 2 weeks ago. A chest X-ray is seen to be normal.

Her ECG is seen below

This is the same ECG magnified:

What is the SINGLE most likely diagnosis?

A 62 year old man attends the Emergency Department following a dull central chest pain that started earlier today. He feels clammy and nauseous. His pulse rate is 70 beats/minute, respiratory rate is 21 breaths/minute, blood pressure 130/85 mmHg, and oxygen saturation is 97%. He was started on intravenous morphine for pain. An ECG done in the department shows the following:

What is the SINGLE most appropriate next step?

A 42 year old lady had corrective surgery for cyanotic congenital heart disease at the age of 3 after having a palliative operation during infancy. On examination, a parasternal heave and a diastolic murmur at the left upper sternal edge is noted. What is the SINGLE most likely diagnosis?

A 69 year old hypertensive white British man is currently on Indapamide 2.5mg daily but his blood pressure is still high. He suffers with bilateral ankle oedema. Which of the following is the SINGLE best choice to add in order to control his blood pressure?

A 49 year old man was recently diagnosed with hypertension. As part of the workup, an ECG was requested of which a trace is shown below:

What is the SINGLE most likely diagnosis?

A 55 year old woman was found collapsed at home. The paramedics revived her but in the ambulance she had a cardiac arrest and could not be saved. The paramedic’s report states that the woman was immobile lately due to hip pain and that they found ulcer under the metatarsal head. She has a history of diabetes mellitus and was on anti- diabetics. What is the likely cause of her death?

A 22 year old male athlete has been having frequent fainting attacks since childhood. He has no family history of sudden death or arrhythmias. His ECG demonstrates a sinus rhythm with normal P-R and QRS intervals but a prolonged QT interval. What is the cause of his fainting?

A 55 year old man with a history of a myocardial infarction three years ago presents with progressive dyspnoea. He has had two previous admissions with heart failure in the past year and complains of the inability to lie down flat on his bed. He has a respiratory rate of 31 breaths/minute and a systolic blood pressure of 90 mmHg. His oxygen saturation is 90% on room air. On examination, he looks pale and sweaty, and has widespread crepitations over both lung fields. Oxygen by face mask was commenced. What is the SINGLE most appropriate investigation to confirm the diagnosis?

A 55 year old man who suffered a myocardial infarction a few days ago is now ready for discharge from the hospital. His medical history remains insignificant other than the myocardial infarction he had. He has no drug allergies. He has already been put on aspirin, clopidogrel and bisoprolol. Which is the most appropriate additional medication(s) need to be given to him on discharge?

A 50 year old man presents with a stab wound to his left anterior chest at the level of the 4th intercostal space. On physical examination, his neck veins are dilated, heart sounds are faint and trachea is central. He has a systolic blood pressure of 80 mmHg and a pulse rate of 130 bpm. What is the SINGLE most likely diagnosis?

A 71 year old man recently feels breathless on exertion with some palpitations when resting. He finds them difficult to describe. An ECG was performed which as attached below. What is the SINGLE most likely diagnosis?

A 65 year old man attends the Emergency Department with dizziness. He has a pulse rate of 48 beats/minute. His blood pressure is 75/56 mmHg. His respiratory rate is 21 breaths/minute. An ECG shows a 3rd degree heart block. He is not on any medications. What is the SINGLE most appropriate initial management?

A 72 year old woman presents to the emergency department with chest pain. The following ECG was taken.

What is the SINGLE most likely diagnosis?

A 65 year old man presents with recurrent lightheadedness for one month especially when he gets up from bed in the morning. He also has occasional episodes of lightheadedness when standing for prolonged periods of time. He suffers from hypertension and type 2 diabetes. His regular medications include atenolol, amlodipine, bendroflumethiazide and metformin. On physical examination, his blood pressure was 125/85 mmHg taken when he was supine and 101/69 mmHg when standing. What is the SINGLE most likely diagnosis?

A 46 year old man was brought into the A&E after being stabbed in the chest with a knife. His chest is bilaterally clear. He has muffled heart sounds and his neck veins look distended. His blood pressure is 84/40 mmHg and pulse is 110 bpm. What is the SINGLE most appropriate investigation that can lead to a diagnosis?

A 55 year old man is seen by a health care assistant as he would like to live a healthier lifestyle. His elder brother recently died from a myocardial infarction which triggered his awareness to live a healthy lifestyle. He smokes 6 cigarettes a day. He drinks 14 units of alcohol a week but does not drink on Mondays and Thursdays because he plays tennis in the evening on those days. His total salt intake is an estimate of one teaspoon a day. He eats 5 portions of fresh fruit and vegetables a day. He has a BMI of 20 kg/m2. His clinic blood pressure is 139/87 mmHg. He has no previous medical problems. What is the SINGLE most appropriate action?

A 76 year old man presents to the Emergency Department with 3 episodes of fainting over the past day. He has been having worsening shortness of breath over the past 2 weeks. A systolic murmur is heard at the right sternal border over the second intercostal space. An ECG was performed at the department which shows the following:

A zoom in image of the ECG can be seen here:

What is the SINGLE most likely diagnosis?

Which of the following may cause the abnormalities of the QRS axis shown on this ECG?

A 49 year old man with a history of a myocardial infarction complains of chest pain with shortness of breath on exertion over the past few days. His ECG is seen below:

Zoomed images can be seen here:

Echocardiogram shows an ejection fraction of 35% (reduced) and decreased septal wall thickness. What is the SINGLE most likely diagnosis?

A 43 year old woman is admitted with pyrexia, breathlessness and a history of syncope. She was recently diagnosed with a pulmonary embolism. There is an early diastolic sound and a mid-diastolic rumble. Her jugular venous pressure is elevated with prominent A- waves. Her blood tests reveal a raised erythrocyte sedimentation rate (ESR). What is the SINGLE most likely diagnosis?

A 52 year old man with a BMI of 27 is being treated for hypertension. He drinks around 8 units of alcohol per week and smokes 20 cigarettes a day. His lipid profile was done and shows a total cholesterol of 4.2. What is the SINGLE best referral for him?

A 65 year old man presents with fatigue and dyspnoea 3 days after having a myocardial infarction. On auscultation he has a pansystolic murmur at the apex radiating to the axilla. What is the SINGLE most likely diagnosis?

A 58 year old man presents to the Emergency Department with severe, central chest pain that began an hour ago while he was watching television. The pain is still ongoing. The pain radiates to his neck, left shoulder and arm and does not vary with movement or breathing. He feels nauseous, vomited once in the ambulance, and is sweating profusely. Apart from a medical history of hypertension, he was otherwise well. His blood pressure is 110/70mmHg, and heart rate is 120 beats/minute. On examination of the chest, there is no localised tenderness, his lung fields are clear, and heart sounds are normal. An ECG was performed and is normal. His chest X-ray appears normal. His blood results show the following:

Haemoglobin 132 g/L (130-180)

White cell count 11 x 109/L (4-11)

Platelets 250 x 109/L (150-400)

CRP 18 (< 10 mg/L)

Troponin T 60 ng/L (<14)

Which of the following is the SINGLE most likely diagnosis?

A 61 year old man has difficulty in breathing over the past few hours with chest discomfort. He is seen in the Emergency Department with fine inspiratory crepitations which is widespread. The following X-ray was taken.

An ECG shows normal sinus tachycardia. He has a heart rate of 100 beats/minute and respiratory rate is 27 breaths/minute. His oxygen saturation is 90%. His blood pressure is 120/80 mmHg. He was started on high flow oxygen, GTN sublingual and furosemide intravenously. His breathing has improved significantly but he continues to be drowsy. His troponin and renal profile blood results are within normal limits. An echocardiogram reveals left ventricular impairment. His medical history includes asthma. What is the SINGLE most appropriate medication to add on?