BMJ Cases

Question 1

A 65-year-old man presents to his local aneurysm surveillance team for a screening ultrasound scan. He has been feeling well and in his usual state of good health. His medical history is notable for mild hypertension and he has a 100-pack-year tobacco history. On ultrasound an infrarenal AAA is identified.

Answer 1

Abdominal aortic aneurysm

Question 2

A 55-year-old man with a history of hypertension (well controlled with medication) and tobacco use presents to his primary care physician with a 2-day history of constant and gnawing hypogastric pain. The pain has been steadily worsening in intensity.

He says the pain radiates to his lower back and both groins at times. While he cannot identify any aggravating factors (such as movement), he feels the pain improves with his knees flexed.

There is a palpable pulsatile mass just left of midline below the umbilicus. He is immediately referred for definitive management, but during transfer becomes hypotensive and unresponsive.

Answer 2

AAA

Question 3

A 59-year-old man presents to the emergency department with a sudden onset of excruciating chest pain, which he describes as tearing. There is a history of hypertension. On physical examination, his heart rate is 95 beats per minute. Blood pressure is 195/90 mmHg in the right arm and 160/80 mmHg in the left arm. Pulses are absent in the right leg and diminished in the left.

Answer 3

aortic dissection

The pain of aortic dissection usually manifests as acute, tearing chest and back pain (Stanford Type A) or tearing back pain (Stanford Type B)

Question 4

A 55-year-old white man presents with weakness, palpitations, and dyspnoea on exertion. On physical examination, his blood pressure is 148/50 mmHg with a bounding pulse and an early diastolic murmur over the left sternal border.

He denies any history of drug abuse, rheumatic fever, or connective tissue disorder. The patient is taking hydrochlorothiazide for high blood pressure. Echocardiography reveals a left ventricular ejection fraction (LVEF) of 55%, left ventricular end-diastolic diameter of 70 mm, and end-systolic diameter of 50 mm.

Answer 4

Aortic regurgitation

Question 5

A 31-year-old black man presents to clinic for the first time for a routine physical examination. He denies any complaints. On physical examination the only abnormality is a systolic murmur best heard over the second right intercostal space and an early diastolic murmur best heard over the third left sternal border. LVEF is 55% to 60% with mild LVH. Left ventricular end-systolic diameter is 45 mm and aortic root diameter is 3.5 cm.

Answer 5

aortic regurg

Question 6

A 78-year-old man presents to his primary care physician complaining of 2 months of progressive shortness of breath on exertion. He first recognises having to catch his breath while gardening and is now unable to walk up the stairs in his house without stopping.

Previously he was healthy and active without similar complaints. On physical examination there is a loud systolic murmur at the right upper sternal border radiating to the carotid vessels.

Answer 6

aortic stenosis

Question 7

A 78-year-old man with a history of hypertension presents to his primary care physician with 1 episode of dizziness while watching television. On physical examination, his heart rate is measured at about 40 bpm.

A 12-lead ECG is obtained showing sinus rhythm at about 75 bpm and complete heart block with a wide junctional escape rhythm at about 40 bpm.

On further questioning, the patient admits to increasing fatigue and dyspnoea on exertion for past few weeks

Answer 7

3rd degree av block

Question 8

A 60-year-old man with a history of diabetes, hypercholesterolaemia, and heavy smoking for over 20 years presents giving a 3-week history of increasing pain in his left forefoot, which is affecting his ability to walk and is disrupting his sleep.

On examination, his left foot is pale, cold, devoid of hair, and his lateral two toes are dusky and discoloured. No foot pulses are palpable and are only just detectable by Doppler probe.

Answer 8

gangrene

Question 9

A 56-year-old man with history of poorly controlled diabetes mellitus and alcoholism presents with severe scrotal pain and fever for 3 days. He denies perianal tenderness.

His vital signs are blood pressure 125/60 mmHg, heart rate 120 beats per minute, respiratory rate 25 breaths per minute, and temperature is 38.6°C (101.5°F). His scrotum is extremely tender, black, and malodorous. The adjacent perineal and femoral skin is crepitant.

Answer 9

gangrene

Question 10

A 65-year-old woman presents with unilateral leg pain and swelling of 5 days’ duration. There is a history of hypertension, congestive heart failure, and recent hospitalisation for pneumonia. She had been recuperating at home but on beginning to mobilise and walk, the right leg became painful, tender, and swollen.

On examination, the right calf is 4 cm greater in circumference than the left when measured 10 cm below the tibial tuberosity. Superficial veins on the right foot are more dilated than on the left and easily visible. The right leg is slightly redder than the left. There is tenderness on palpation in the popliteal fossa behind the right knee.

Answer 10

dvt

Question 11

An otherwise healthy 30-year-old man presents with a several-day history of progressive, severe, retrosternal chest pain that is sharp and pleuritic in nature. The pain is worse on lying down and improved with sitting forward.

There is radiation to the neck and shoulders and specifically to the trapezius muscle ridges. The pain is constant and unrelated to exertion. On physical examination, a pericardial friction rub is heard at end-expiration with the patient leaning forward.

Answer 11

pericarditis

Question 12

A 67-year-old woman presents to her primary care physician complaining of increasing shortness of breath, especially when trying to sleep. She has a history of hypertension and hyperlipidaemia, and is being treated with a beta-blocker and statin therapy.

She does not smoke and drinks alcohol in moderation. On examination, her blood pressure is 148/83 mmHg and heart rate is 126 beats per minute. There is an audible S4 and the jugular venous pressure is elevated 3 cm above normal.

Answer 12

chronic congestive heart failure

Question 13

A 60-year-old man presents to the accident and emergency department. He reports being progressively short of breath. He has a history of uncontrolled hypertension, non-insulin-dependent diabetes mellitus, and has been a heavy smoker for more than 40 years.

He underwent a successful primary angioplasty for a large acute anterior myocardial infarction 2 months ago. His blood pressure is 75/40 mmHg, his heart rate 110 beats per minute, and his respiratory rate 30.

He has elevated neck veins and a prominent S3. His ECG shows sinus tachycardia, and a transthoracic echocardiogram performed in the A&E department reveals impaired systolic function, with an ejection fraction of 20%.

Answer 13

chronic congestive heart failure

Question 14

A 70-year-old woman with a history of hypertension, hyperlipidaemia, 40 pack-years of cigarette smoking, and remote percutaneous transluminal coronary angioplasty is witnessed falling to the ground while brushing her pavement. She has not complained of any preceding symptoms.

The emergency medical personnel who respond to the scene find her unconscious, pale, and without a pulse. After the pads from an automated external defibrillator are attached, the patient is noted to be in ventricular fibrillation.

Answer 14

cardiac arrest

Question 15

A 65-year-old man with a history of hypertension, diabetes mellitus, and hyperlipidaemia presents to the accident and emergency department with the first episode of rapid palpitations, shortness of breath, and discomfort in his chest.

These symptoms started acutely and have been present for 4 hours. Physical examination shows an irregularly irregular radial pulse at rate between 90 and 110 bpm, BP 110/70 mmHg, and respiratory rate of 20 breaths per minute. Heart sounds are irregular, but no S3 or S4 gallop or murmurs are audible. There are no other abnormalities on examination.

Answer 15

new onset atrial fib

Question 16

A 56-year-old woman with a 6- week history of weight loss, anxiety, and insomnia presents with palpitation and dyspnoea. Her pulse rate is irregular at 140 to 150 bpm. Her BP is 95/55 mmHg. She looks thin, frail, and rather anxious and jittery. Her palms are sweaty and have fine tremors. She has a palpable smooth goitre. Examination of the eyes shows bilateral exophthalmoses

Answer 16

new onset atrial fib

Question 17

A 77-year-old man presents with complaints of palpitations and new shortness of breath, especially with exertion. He has a history of rheumatic fever in childhood. He has been told he has a murmur but does not recall having had an echocardiogram. He is otherwise healthy.

Answer 17

atrial flutter

Question 18

A 76-year-old man presents with progressive symptoms of dyspnoea and increasing peripheral oedema. He denies palpitations. He has a history of CHF from hypertensive heart disease. He reports that he is taking his medications as directed and has had no recent medication or dietary changes.

Answer 18

atrial flutter

Question 19

A 40-year-old woman presents with dyspnoea that is worse when she lies on her left side. About 1 week ago she had an episode of unexplained loss of consciousness. Clinical examination shows a diastolic murmur, which is prominent when the patient lies on her left side.

Jugular venous distention is present, and chest examination reveals fine crackles that do not clear with coughing. CXR shows pulmonary congestion, and echocardiogram shows a mass in the left atrium attached to the atrial septum.

Answer 19

atrial myxoma

Question 20

A 58-year-old man presents with dyspnoea. CXR shows small pleural effusion and enlarged pulmonary arteries. Echocardiogram shows large right atrial mass.

Answer 20

atrial myxoma

Question 21

A 31-year-old woman presents with a 1-week history of fever, chills, fatigue, and unilateral ankle pain. Her past medical history includes mitral valve prolapse and hypothyroidism. She admits to infrequent intravenous heroin use and has a 10-pack-year history of smoking.

Physical examination reveals temperature of 39°C (102°F), regular heart rate 110 beats per minute, blood pressure 110/70 mmHg, and respiration rate of 16 breaths per minute. Her cardiovascular examination reveals a grade 2/4 holosystolic murmur that is loudest at the right upper sternal border. Her right ankle appears red and warm, and is very painful on dorsiflexion.

Answer 21

infective endocarditis

Question 22

A 52-year-old woman presents with dyspnoea on exertion, fatigue, and occasional palpitations. She has no prior cardiac history. She denies chest pain, orthopnoea, paroxysmal nocturnal dyspnoea, or lower extremity oedema.

On physical examination her jugular venous distension is around 12 cm and her lungs are clear to auscultation. Cardiac examination reveals a slightly displaced apical impulse with a palpable P2. Cardiac auscultation reveals III/VI holosystolic murmur at the apex that radiates to the axilla with diminished S1 and P2 greater than A2.

Answer 22

mitral regurg

Question 23

A 52-year-old woman presents with gradually increasing dyspnoea on exertion over the past 2 years. Recently she has required 2 pillows at night to alleviate recumbent dyspnoea. On examination, she has an apical diastolic murmur.

Answer 23

mitral stenosis

Question 24

A 36-year-old prima gravida presents with dyspnoea on exertion and 2 pillow orthopnoea during her second trimester. Previous physical examinations had disclosed no cardiac abnormalities. On current physical examination, she has a loud S1 and a 2/6 diastolic rumble.

Answer 24

mitral stenosis

Question 25

An otherwise healthy 30-year-old man presents with a several-day history of progressive, severe, retrosternal chest pain that is sharp and pleuritic in nature. The pain is worse on lying down and improved with sitting forward.

There is radiation to the neck and shoulders and specifically to the trapezius muscle ridges. The pain is constant and unrelated to exertion. On physical examination, a pericardial friction rub is heard at end-expiration with the patient leaning forward

Answer 25

pericarditis

Question 26

A 50-year-old male diabetic smoker presents complaining of leg pain with exertion for 6 months. He notices that he has bilateral calf cramping with walking. He states that it is worse on his right calf than his left and that it goes away when he stops walking. He has noticed that he is able to walk less and less before the onset of symptoms.

Answer 26

peripheral artery disease

Question 27

A 75-year-old woman with hypertension and hyperlipidaemia presents with abnormal ankle brachial index on a routine screening. She is able to walk without any discomfort and is active.

Answer 27

peripheral artery disease

Question 28

A 36-year-old woman presents with a 6-month history of gradually progressive dyspnoea on exertion and fatigue. On physical examination, her vital signs are normal and she appears not to be in any distress. Her lungs are clear to auscultation.

Her cardiac examination shows a prominent jugular V wave, an accentuated pulmonic component to the second heart sound (P2), and a high-pitched holosystolic murmur best heard at the left sternal border.

Answer 28

Idiopathic pulmonary arterial hypertension

Question 29

An 88-year-old woman with a history of dilated cardiomyopathy presents with nausea, light-headedness, and a racing heart. She is taking digoxin and recently her diuretic dosage has been increased. On examination she is alert but weak.

Her BP is 108/88 mmHg, and pulse 88 bpm and regular. The lungs are clear. An ECG shows a sustained atrial tachycardia at 180 bpm with 2:1 AV block. Serum potassium is 2.8 mmol/L (2.8 mEq/L).

Answer 29

atrial tachycardia ( svt? )

the digoxin therapy is contributory?

ecg on bmjbest

Question 30

A previously healthy 35-year-old man presents after an all-night binge that included alcohol and cocaine. He is feeling weak and shaky with reduced exercise tolerance.

His BP is 110/70 mmHg and heart rate 160 bpm and regular. An ECG shows a narrow complex atrial tachycardia. He is given adenosine 6 mg IV. There is abrupt slowing of the ventricular response rate with no effect on the atrial rate.

Answer 30

atrial tachycardia ( svt? )

Question 31

A 78-year-old man was diagnosed with left-sided systolic heart failure 14 years ago. He was subsequently found to have atrial fibrillation, and underwent AV node ablation and pacemaker placement 10 years ago that resulted in an improvement in his left ventricular ejection fraction from 35% to 50%.

He did extremely well over the years and was extremely active; 3 years ago he completed a 210-mile bike ride across the Netherlands. Four months ago, however, he started developing chest tightness and back tightness when pulling his cart during golfing sessions. In addition, he developed significant dyspnoea with activity and his symptoms have worsened.

Now, he says his quality of life is extremely poor. He has problems walking up one flight of stairs where he experiences significant shortness of breath; even walking half a block causes shortness of breath and chest tightness. He has also noticed increased abdominal girth, early satiety, and easy fatigue.

Answer 31

tricuspid regurg

Question 32

A 73-year-old woman presented for the first time 5 years ago with worsening shortness of breath and lower extremity oedema. On clinical examination, she has a laterally displaced apical impulse, with a loud 3/6 holosystolic murmur at the apex.

Jugular veins are distended to the angle of the jaw. Lung examination shows some bibasilar crackles. There is 2-3+ pitting edema in both lower extremities. Echocardiography shows a reduced left ventricular ejection fraction (40%), hypokinesis of the inferior and lateral walls, ischaemic mitral regurgitation (severe), and mild tricuspid regurgitation (TR).

Answer 32

tricuspid regurg

Question 33

A 45-year-old woman presents with complaints of heaviness and fatigue in her legs. She does not experience the symptoms when she first awakens, but they become more noticeable and prominent as the day progresses and with prolonged standing.

When she is standing for most of the day she notes swelling in both legs. The symptoms are concentrated over her medial calf, where she has prominent tortuous veins. She first noted dilated veins about 20 years ago when she was pregnant.

Initially they did not cause her any discomfort but they have progressively enlarged and over the past 10 years have become increasingly painful. She recalls that her mother had similar veins in her legs

Answer 33

varicose veins

Question 34

An 18-year-old man presents to a clinic reporting 2 episodes of loss of consciousness. The first episode occurred 1 year earlier while playing dodge ball in gym class. He recalls diving to the ground to avoid being hit. On getting up quickly, he noticed feeling lightheaded, sweaty, and nauseated.

Apparently, he fell to the ground but does not recall having done so. He later recalls waking up in an accident and emergency (A&E) department. Witnesses reported shaking and clenching of both hands after he had fallen.

In the A&E department he was given phenytoin intravenously because of concern that he may have had a seizure. After a negative work-up in the hospital he was prescribed carbamazepine, despite no abnormalities on an electroencephalogram.

A year later he had a second episode of loss of consciousness while doing bicep curls. He denies palpitations, tongue biting, or incontinence. He experienced a similar prodrome of warmth and lightheadedness. He has no history of seizures outside of these 2 episodes

Answer 34

vasovagal syncope

Question 35

A 60-year-old man presents with syncope while walking outside with his wife. His wife recalls the patient looking at the sky to point out an aeroplane. He then appeared pale and collapsed to the ground, suffering a head laceration in the process.

The history suggested the possibility of carotid sinus syndrome (CSS). In the laboratory, carotid sinus massage was undertaken while the patient was in the upright posture on a tilt table. The massage induced 10 seconds of asystole with near loss of consciousness.

A dual-chamber pacemaker was implanted on the basis of a presumptive diagnosis of CSS; there was no recurrence of syncope during the next year. This patient has had no further faints but occasionally becomes dizzy when turning his head abruptly

Answer 35

vasovagal syncope

Question 36

A 65-year-old obese man presents with a crushing substernal chest pain for the past 3 hours and is hospitalised for an acute anterior wall MI. His medical history includes hypertension and hyperlipidaemia.

He is also a smoker. Primary angioplasty reveals an occluded right coronary artery, which is successfully stented. He is found to have a left ventricular function of 45% with reduced contractility (hypokinesis) of the inferior wall.

On the third day of hospitalisation, telemetry reveals a 5-beat run of wide QRS complexes with a rate of 136 bpm. The patient is asymptomatic during this event.

Answer 36

non sustained ventricular tachy

Question 37

A previously well 45-year-old man presents to the clinic with a 3-week history of progressive shortness of breath. He is able to perform activities of daily living independently but becomes short of breath with mild-to-moderate exertion.

Echocardiogram reveals a reduced left ventricular ejection fraction of 30%. Cardiac catheterisation demonstrates normal coronary arteries. A 24-hour ambulatory ECG shows several episodes of NSVT.

Answer 37

non sustained ventricular tachy

Question 38

A 42-year-old man complains of palpitations followed by dizziness and brief loss of consciousness. His wife reports that he is pale and short of breath. Emergency medical services were called and found him pulseless. The ECG revealed a rapid, irregular wide complex tachycardia. Later he was successfully resuscitated with two successive direct-current shocks.

Answer 38

wolff parkinson white

Question 39

A 35-year-old man presents to an accident and emergency department with palpitations, shortness of breath, dizziness, and chest pain of 4 hours’ duration. An ECG demonstrated narrow-complex short RP tachycardia that responded to intravenous adenosine. The ECG during sinus rhythm revealed ventricular pre-excitation.

Answer 39

wolff parkinson white