A 61-year-old man comes to his General Practitioner complaining of increasing exertional dyspnoea accompanied by bilateral peripheral oedema. He reports feeling extremely fatigued lately. During the physical examination, his lungs are clear, but he has ascites. On auscultation of his heart sounds, you detect a holosystolic murmur with a high pitch at the left sternal edge, extending to the right sternal edge. What is the probable reason for this patient’s symptoms?
A 55-year-old man was brought to the Emergency Department following a car accident. Upon examination, there are no visible signs of external bleeding, but his blood pressure is 90/40 mmHg and his heart rate is 120 bpm. He presents with distended neck veins and muffled heart sounds.
What is the most probable echocardiogram finding in this case?
A 50-year-old woman presents with shortness of breath on exertion, and reports that she sleeps on three pillows at night to avoid shortness of breath. Past medical history of note includes two recent transient ischaemic attacks which have resulted in transient speech disturbance and minor right arm weakness. Other non-specific symptoms include fever and gradual weight loss over the past few months. On auscultation of the heart you notice a loud first heart sound, and a plopping sound in early diastole. General examination also reveals that she is clubbed.
Investigations:
Investigation Result Normal value
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Urea 6.1 mmol/l 2.5–6.5 mmol/l
Creatinine 100 μmol/l 50–120 µmol/l
Haemoglobin 101 g/dl
(normochromic normocytic) 115–155 g/l
Platelets 195 × 109/l 150–400 × 109/l
White cell count (WCC) 11.2 × 109/l 4–11 × 109/l
Erythrocyte sedimentation rate (ESR) 85 mm/h 0–10mm in the 1st hour
Chest X-ray Unusual intra-cardiac calcification
within the left atrium
Which of the following fits best with the likely diagnosis in this case?
An 82-year-old woman is brought to the Emergency Department after experiencing a sudden loss of consciousness while shopping. Upon examination, she is fully alert and appears to be in good health.
Her temperature is normal, and her blood glucose level is 5.8 mmol/l. Her cardiovascular system shows an irregular heart rate of 89 beats per minute with low volume, and her blood pressure is 145/120 mmHg while lying down and standing up. Her jugular venous pressure is not elevated, and her apex beat is forceful but undisplaced. Heart sounds include a soft S2 and a soft ejection systolic murmur that is loudest in the right second intercostal space, with a possible fourth heart sound heard. Her chest reveals occasional bibasal crackles that clear with coughing, and there is no peripheral edema. Based on these clinical findings, what is the most likely cause of her collapse?
An 82-year-old woman presents to her general practitioner with increasing shortness of breath on exertion and swelling of her ankles and lower legs. During examination, she appears alert and oriented, but has significant erythema of her malar area. Her cardiovascular system shows an irregular heart rate of 92-104 beats per minute with low volume, and a blood pressure of 145/90 mmHg lying and standing. Her jugular venous pressure is raised with a single waveform, and her apex beat is undisplaced and forceful in character. There is a soft mid-diastolic murmur heard during heart sounds 1 + 2. Bibasal crackles are present in her chest, and she has pitting peripheral edema to the mid-calf. Based on these findings, what is the most likely cause of her collapse?
An 82-year-old woman is brought to the Emergency Department after experiencing a sudden loss of consciousness while grocery shopping. Upon examination, she is fully alert and appears to be in good health.
Her vital signs are normal, with a CBG of 5.8 mmol/l. However, her cardiovascular system shows an irregular, low volume heart rate of 90-110 beats per minute, and her blood pressure is 145/120 mmHg while lying down and standing up. Her JVP is raised by 5 cm, and her apex beat is displaced to the mid-axillary line, with diffuse heart sounds. A loud pansystolic murmur is heard at the apex, radiating to the axilla and at the lower left sternal edge, along with a mid-diastolic rumble best heard at the apex. There are occasional bibasal crackles in her chest, which clear up with coughing. Additionally, she has mild peripheral edema up to the mid-calf.
Based on these clinical findings, what is the most likely cause of her collapse?
A 42-year-old man presents with central chest pain which is worse unless sitting forward. He says that the pain gets worse when he takes a deep breath in. There is no previous cardiac history and he is a non-smoker. Over the past few days, he has had a fever with cold and flu type symptoms.
On examination, his blood pressure is 130/80 mmHg, and he has an audible pericardial rub.
Investigations:
Investigation Result Normal value
Haemoglobin 135 g/l 135–175 g/l
Erythrocyte sedimentation rate (ESR) 40 mm/h 0–10mm in the 1st hour
White cell count (WCC) 8.5 × 109/l 4–11 × 109/l
Platelets 320 × 109/l 150–400 × 109/l
Creatine kinase (CK) 190 IU/l 23–175 IU/l
Total cholesterol 4.9 mmol/l < 5.2 mmol/l
Electrocardiogram – saddle-shaped ST elevation across all leads.
Which of the following diagnoses fits best with this clinical picture?
A 20-year-old female patient visited her doctor complaining of general malaise, lethargy, and fatigue. She couldn’t pinpoint when the symptoms started but felt that they had been gradually developing for a few months. During the physical examination, the doctor detected a murmur and referred her to a cardiologist based on the findings. The cardiac catheterization results are as follows:
Anatomical site Oxygen saturation (%) Pressure (mmHg)
End systolic/End diastolic
Superior vena cava 77 –
Right atrium (mean) 79 7
Right ventricle 78 –
Pulmonary artery 87 52/17
Pulmonary capillary wedge pressure – 16
Left ventricle 96 120/11
Aorta 97 120/60
What is the most accurate description of the murmur heard during the chest auscultation of this 20-year-old woman?
You are asked to see a 63-year-old man who has been admitted overnight following a road traffic accident. He sustained extensive bruising to his chest from the steering wheel. The nurses are concerned as he has become hypotensive and tachycardic. There is a history of a previous inferior myocardial infarction some 7 years ago, but nil else of note. On examination his BP is 90/50 mmHg, pulse is 95/min and regular. He looks peripherally shut down. There are muffled heart sounds and pulsus paradoxus.
Investigations – arterial blood gas – reveal:
Investigation Result Normal Value
pH 7.29 7.35–7.45
pO2 11.9 kPa 11.2–14.0 kPa
pCO2 6.1 kPa 4.7–6.0 kPa
ECG Widespread anterior T wave inversion
Which of the following is the most likely diagnosis?
An 85-year-old woman attends her general practice for a medication review. She is currently taking aspirin, simvastatin, atenolol, captopril and furosemide. The general practitioner (GP) performs an examination and notes an irregular pulse with a rate of 100 bpm. The GP makes a referral to the Cardiology Department with a view to establishing whether this woman’s atrial fibrillation (AF) is permanent or paroxysmal and to obtaining the appropriate treatment for her.
Which of the following is the most recognised risk factor for the development of AF?