BMJ Cases Flashcards
(39 cards)
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.
Abdominal aortic aneurysm
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.
AAA
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.
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)
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.
Aortic regurgitation
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.
aortic regurg
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.
aortic stenosis
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
3rd degree av block
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.
gangrene
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.
gangrene
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.
dvt
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.
pericarditis
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.
chronic congestive heart failure
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%.
chronic congestive heart failure
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.
cardiac arrest
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.
new onset atrial fib
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
new onset atrial fib
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.
atrial flutter
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.
atrial flutter
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.
atrial myxoma
A 58-year-old man presents with dyspnoea. CXR shows small pleural effusion and enlarged pulmonary arteries. Echocardiogram shows large right atrial mass.
atrial myxoma
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.
infective endocarditis
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.
mitral regurg
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.
mitral stenosis
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.
mitral stenosis
