A 30-year-old woman collapses in the supermarket. She regains consciousness within 30 seconds. Witnesses report she appeared pale beforehand and was standing in a queue. She reports feeling hot and nauseous prior to the event. There was no tongue biting, incontinence, or post-event confusion. Her cardiovascular examination is normal, and ECG shows normal sinus rhythm. What is the most likely diagnosis?
Q212
A 43-year-old woman presents to the Emergency Department with fever, confusion, and a purpuric rash that appeared over the last 6 hours. Her temperature is 38.9°C, heart rate 125 bpm, blood pressure 85/50 mmHg, respiratory rate 28/min, and oxygen saturation 94% on room air. Blood tests show: WCC 18.5 × 10⁹/L, platelets 85 × 10⁹/L, lactate 4.2 mmol/L. She has received 2 litres of crystalloid fluid. What is the most appropriate immediate antibiotic therapy?
Q213
A 65-year-old man with known atrial fibrillation presents to the Emergency Department with a 4-hour history of central chest pain. He describes it as 'tearing' in nature, radiating to his back between the shoulder blades. His blood pressure is 165/95 mmHg in the right arm and 125/80 mmHg in the left arm. ECG shows left ventricular hypertrophy but no acute ischaemic changes. Chest X-ray demonstrates a widened mediastinum. What is the most appropriate immediate investigation?
Q214
A 76-year-old man presents to the Emergency Department with a 48-hour history of rigors, dysuria, and increasing confusion. He has a history of type 2 diabetes, chronic kidney disease stage 3, and benign prostatic hyperplasia. His observations show: temperature 39.4°C, blood pressure 86/50 mmHg despite 1 litre IV fluid, heart rate 124 bpm, respiratory rate 28 breaths/min, oxygen saturation 94% on 4L oxygen. Blood tests reveal: lactate 5.2 mmol/L, creatinine 312 μmol/L (baseline 154 μmol/L), white cell count 22.1 × 10⁹/L. You have given IV antibiotics, fluids, and oxygen. Blood pressure remains 88/52 mmHg. According to the Surviving Sepsis Campaign guidelines, what is the most appropriate next pharmacological intervention?
Q215
A 31-year-old woman presents 45 minutes after being stung by a bee whilst gardening. She has developed widespread urticaria, lip swelling, and feels nauseated. She appears anxious but is speaking in full sentences. Her observations are: blood pressure 112/74 mmHg, heart rate 98 bpm, respiratory rate 18 breaths/min, oxygen saturation 98% on room air, peak expiratory flow rate 380 L/min (predicted 420 L/min). There is no wheeze or stridor. She has been given intramuscular adrenaline 500 micrograms. What is the most appropriate ongoing management?
Q216
A 54-year-old woman with known alcoholic liver disease presents with haematemesis. She has vomited approximately 500 mL of fresh red blood. Her blood pressure is 94/58 mmHg, heart rate 118 bpm, respiratory rate 22 breaths/min. She appears pale and clammy. IV access is secured and fluid resuscitation commenced. Blood tests show: haemoglobin 78 g/L, platelets 64 × 10⁹/L, INR 2.1, bilirubin 68 μmol/L, albumin 28 g/L. According to current UK guidance, what is the most appropriate transfusion target for this patient?
Q217
A 39-year-old woman attends the Emergency Department with her second episode of anaphylaxis in 3 months. She was successfully treated with intramuscular adrenaline both times. She has undergone extensive allergy testing which has been negative, and she cannot identify any clear trigger. Between episodes she feels well. Blood tests during the second episode showed a tryptase level of 42 mcg/L (normal <11.4 mcg/L). A repeat tryptase measured 2 weeks later was 18 mcg/L. What is the most likely underlying diagnosis?
Q218
A 66-year-old woman presents with a 24-hour history of fever, productive cough, and increasing confusion. Her daughter reports she has been less responsive today. Observations: temperature 38.9°C, blood pressure 102/68 mmHg, heart rate 108 bpm, respiratory rate 28 breaths/min, oxygen saturation 91% on room air, AVPU = V. Blood tests show: white cell count 19.2 × 10⁹/L, C-reactive protein 245 mg/L, urea 12.4 mmol/L, creatinine 136 μmol/L. Chest X-ray confirms right lower lobe consolidation. What is her CURB-65 score and recommended management setting?
Q219
A 27-year-old man is brought to the Emergency Department by ambulance after collapsing during a half-marathon. He reported feeling dizzy and short of breath before collapsing. On examination, he is alert, heart rate 110 bpm, blood pressure 118/76 mmHg, respiratory rate 20 breaths/min, oxygen saturation 98% on room air. Cardiovascular examination reveals a harsh ejection systolic murmur that decreases with squatting. ECG shows left ventricular hypertrophy with deep T wave inversion in the lateral leads. What is the most appropriate immediate management?
Q220
A 59-year-old man with hypertension and hyperlipidaemia presents with 4 hours of central crushing chest pain. His initial ECG shows widespread ST depression in leads V2-V6, I, and aVL, with ST elevation in aVR. His troponin I is 1240 ng/L (normal <26 ng/L). Blood pressure is 98/62 mmHg, heart rate 96 bpm. He appears clammy and short of breath. Chest auscultation reveals bibasal crackles. What is the most likely underlying diagnosis?
Acute Medical Presentations UK Medical PG Practice Questions and MCQs
Question 211: A 30-year-old woman collapses in the supermarket. She regains consciousness within 30 seconds. Witnesses report she appeared pale beforehand and was standing in a queue. She reports feeling hot and nauseous prior to the event. There was no tongue biting, incontinence, or post-event confusion. Her cardiovascular examination is normal, and ECG shows normal sinus rhythm. What is the most likely diagnosis?
A. Vasovagal syncope (Correct Answer)
B. Cardiac arrhythmia
C. Postural hypotension
D. Hypoglycaemia
E. Epileptic seizure
Explanation: ***Vasovagal syncope***
- This is characterized by a **prodrome** of nausea, pallor, and feeling hot, often triggered by **prolonged standing** or emotional stress.
- The rapid recovery of consciousness within seconds and the **absence of post-ictal confusion** are classic features of neurocardiogenic syncope.
*Cardiac arrhythmia*
- Typically presents with a **sudden onset** of collapse without a preceding prodrome, often referred to as a **Stokes-Adams attack**.
- The **normal ECG** and lack of palpitation history make a primary electrical cardiac cause less likely in this patient.
*Postural hypotension*
- Occurs specifically upon **standing up from a sitting or lying position**, rather than after prolonged standing in a queue.
- It is defined by a significant **drop in blood pressure** (systolic >20mmHg) within three minutes of standing, which is not suggested by the scenario.
*Hypoglycaemia*
- Presentation is usually more gradual and associated with **sweating, tremors, and hunger**, often resolving only with glucose administration.
- It typically results in **prolonged confusion** or altered mental status rather than a brief, self-limiting loss of consciousness.
*Epileptic seizure*
- Characterized by distinct features such as **lateral tongue biting**, urinary incontinence, and a **post-ictal period** of drowsiness or confusion.
- Clonic movements are usually rhythmic and sustained, whereas brief myoclonic jerks can sometimes occur in simple syncope but without the post-event recovery delay.
Question 212: A 43-year-old woman presents to the Emergency Department with fever, confusion, and a purpuric rash that appeared over the last 6 hours. Her temperature is 38.9°C, heart rate 125 bpm, blood pressure 85/50 mmHg, respiratory rate 28/min, and oxygen saturation 94% on room air. Blood tests show: WCC 18.5 × 10⁹/L, platelets 85 × 10⁹/L, lactate 4.2 mmol/L. She has received 2 litres of crystalloid fluid. What is the most appropriate immediate antibiotic therapy?
A. Intravenous ceftriaxone 2g (Correct Answer)
B. Intravenous benzylpenicillin 2.4g
C. Intravenous co-amoxiclav 1.2g
D. Intravenous meropenem 1g
E. Intravenous vancomycin 1g and ceftriaxone 2g
Explanation: ***Intravenous ceftriaxone 2g***
- The patient presents with classic clinical features of **meningococcal septicaemia**, including **fever**, **confusion**, a rapidly progressing **purpuric rash**, and signs of **septic shock** (hypotension, tachycardia, high lactate).
- **Ceftriaxone** is the first-line empirical antibiotic for suspected meningococcal disease in the hospital setting due to its excellent activity against ***Neisseria meningitidis*** and high **CSF penetration**, making it effective for both septicaemia and potential meningitis.
*Intravenous benzylpenicillin 2.4g*
- **Benzylpenicillin** is primarily recommended for **pre-hospital administration** by emergency personnel or general practitioners when meningococcal disease is highly suspected and there may be a delay in hospital transfer.
- In the Emergency Department, a **third-generation cephalosporin** like ceftriaxone is generally preferred for its broader coverage and established efficacy in this severe presentation.
*Intravenous co-amoxiclav 1.2g*
- **Co-amoxiclav** does not provide adequate or standard empirical coverage for the suspected pathogens in **meningococcal sepsis** or meningitis, particularly *Neisseria meningitidis*.
- It is more commonly used for infections like **aspiration pneumonia**, urinary tract infections, or skin and soft tissue infections, which do not fit this critical clinical picture.
*Intravenous meropenem 1g*
- **Meropenem** is a broad-spectrum carbapenem typically reserved for severe infections with suspected **multi-drug resistant organisms** or in patients with a severe **beta-lactam allergy**.
- It is considered **overly broad** for initial empirical treatment of suspected meningococcal disease without specific risk factors for resistant pathogens.
*Intravenous vancomycin 1g and ceftriaxone 2g*
- This combination is standard empirical therapy for **bacterial meningitis** when there is a concern for **penicillin-resistant Streptococcus pneumoniae**, especially in high-risk patients.
- While ceftriaxone is appropriate, the addition of **vancomycin** is usually unnecessary for suspected **meningococcal septicaemia** alone, as ceftriaxone provides sufficient coverage for *Neisseria meningitidis*.
Question 213: A 65-year-old man with known atrial fibrillation presents to the Emergency Department with a 4-hour history of central chest pain. He describes it as 'tearing' in nature, radiating to his back between the shoulder blades. His blood pressure is 165/95 mmHg in the right arm and 125/80 mmHg in the left arm. ECG shows left ventricular hypertrophy but no acute ischaemic changes. Chest X-ray demonstrates a widened mediastinum. What is the most appropriate immediate investigation?
A. Transthoracic echocardiography
B. CT pulmonary angiography
C. CT aortography with contrast (Correct Answer)
D. Coronary angiography
E. Ventilation-perfusion scan
Explanation: ***CT aortography with contrast***- This patient presents with classic signs of **acute aortic dissection**, including **tearing chest pain** radiating to the back, a **significant blood pressure differential** (>20 mmHg) between arms, and a **widened mediastinum** on Chest X-ray.- **CT aortography** is the gold standard immediate investigation due to its high sensitivity and specificity in identifying the **intimal flap**, the extent of the dissection, and involvement of arterial branches, making it crucial for urgent management.*Transthoracic echocardiography*- While useful for detecting **aortic regurgitation** or **pericardial effusion**, it has poor sensitivity for visualizing the **descending aorta** and the full extent of the dissection.- It is generally insufficient as a standalone investigation to definitively rule out or map an **aortic dissection**, particularly in emergent situations.*CT pulmonary angiography*- This is the primary investigation used to diagnose **pulmonary embolism**, which typically presents with **pleuritic chest pain** and shortness of breath, distinct from the patient's tearing pain.- Although it uses contrast, the timing of the bolus is optimized for the **pulmonary arteries** rather than the **aortic arch** and descending aorta, limiting its diagnostic value for aortic pathology.*Coronary angiography*- This invasive procedure is traditionally used to diagnose **coronary artery disease** or acute MI, but it carries a high risk of worsening a dissection if the catheter enters the **false lumen**.- It is not indicated here as the **ECG** shows no acute ischaemic changes and the clinical features strongly point toward a **vascular catastrophe** of the aorta.*Ventilation-perfusion scan*- A **V/Q scan** is used to evaluate for **pulmonary embolism** in patients where CT contrast is contraindicated, such as those with severe **renal failure**.- It provides no information regarding the structural integrity of the **aorta** and is not relevant to the diagnosis of **aortic dissection**.
Question 214: A 76-year-old man presents to the Emergency Department with a 48-hour history of rigors, dysuria, and increasing confusion. He has a history of type 2 diabetes, chronic kidney disease stage 3, and benign prostatic hyperplasia. His observations show: temperature 39.4°C, blood pressure 86/50 mmHg despite 1 litre IV fluid, heart rate 124 bpm, respiratory rate 28 breaths/min, oxygen saturation 94% on 4L oxygen. Blood tests reveal: lactate 5.2 mmol/L, creatinine 312 μmol/L (baseline 154 μmol/L), white cell count 22.1 × 10⁹/L. You have given IV antibiotics, fluids, and oxygen. Blood pressure remains 88/52 mmHg. According to the Surviving Sepsis Campaign guidelines, what is the most appropriate next pharmacological intervention?
A. Noradrenaline infusion via peripheral line targeting MAP ≥65 mmHg (Correct Answer)
B. Commence inotropic support with dobutamine
C. Give further 500 mL fluid bolus and reassess before considering vasopressors
D. Commence vasopressin infusion
E. Administer hydrocortisone 50 mg IV six-hourly
Explanation: ***Noradrenaline infusion via peripheral line targeting MAP ≥65 mmHg***- This patient meets the criteria for **septic shock**, defined by persistent hypotension and a **lactate >2 mmol/L** despite initial fluid resuscitation (1 litre given with no response).- The **Surviving Sepsis Campaign** guidelines recommend **noradrenaline** as the first-line vasopressor, and it can be safely initiated through a **peripheral line** to avoid delays in achieving a **MAP ≥65 mmHg**.*Commence inotropic support with dobutamine*- **Dobutamine** is primarily used in cases of **myocardial dysfunction** or ongoing hypoperfusion despite achieving an adequate MAP with vasopressors.- It is not a first-line treatment for **distributive shock** as it does not address the primary issue of systemic vasodilation.*Give further 500 mL fluid bolus and reassess before considering vasopressors*- While fluid resuscitation is vital, continuing fluids alone in a patient who remains hypotensive with a **lactate of 5.2 mmol/L** delays life-saving vasopressor therapy.- Modern guidelines emphasize the **early initiation of vasopressors** (within the first hour) rather than exhaustive fluid loading to limit the risks of **fluid overload**.*Commence vasopressin infusion*- **Vasopressin** is classified as a **second-line vasopressor** and is typically added to noradrenaline if the MAP remains inadequate.- It is not recommended as a **monotherapy** or first-line agent in the initial management of septic shock.*Administer hydrocortisone 50 mg IV six-hourly*- **Intravenous corticosteroids** are only indicated for patients with septic shock who remain **hemodynamically unstable** despite adequate fluid resuscitation and high-dose vasopressor therapy.- They serve as an adjunctive treatment for **refractory shock** and are not part of the initial stabilization phase.
Question 215: A 31-year-old woman presents 45 minutes after being stung by a bee whilst gardening. She has developed widespread urticaria, lip swelling, and feels nauseated. She appears anxious but is speaking in full sentences. Her observations are: blood pressure 112/74 mmHg, heart rate 98 bpm, respiratory rate 18 breaths/min, oxygen saturation 98% on room air, peak expiratory flow rate 380 L/min (predicted 420 L/min). There is no wheeze or stridor. She has been given intramuscular adrenaline 500 micrograms. What is the most appropriate ongoing management?
A. Observe for 2 hours; if stable and symptoms resolving, discharge with oral antihistamines and advice
B. Observe for at least 6 hours; prescribe adrenaline auto-injector and arrange allergy clinic follow-up before discharge (Correct Answer)
C. Observe for 4 hours; if stable, discharge with oral prednisolone course and GP follow-up
D. Admit overnight for observation due to risk of biphasic reaction
E. Discharge immediately with adrenaline auto-injector and allergy clinic follow-up
Explanation: ***Observe for at least 6 hours; prescribe adrenaline auto-injector and arrange allergy clinic follow-up before discharge***- According to **Resuscitation Council (UK)** and **NICE** guidelines, cases of anaphylaxis treated with **adrenaline** require a minimum observation period of **6-12 hours** due to the risk of **biphasic reactions**.- High-quality discharge planning must include providing two **adrenaline auto-injectors**, education on their use, and a mandatory referral to an **allergy clinic** for follow-up.*Observe for 2 hours; if stable and symptoms resolving, discharge with oral antihistamines and advice*- A **2-hour observation** period is insufficient as **biphasic reactions** can occur several hours after the initial resolution of symptoms.- Discharge without an **adrenaline auto-injector** or **allergy specialist referral** is unsafe for a patient who has experienced a systemic reaction.*Observe for 4 hours; if stable, discharge with oral prednisolone course and GP follow-up*- While **corticosteroids** may be used, a **4-hour observation** period still falls short of the recommended window for monitoring potential late-phase responses.- Follow-up must be with a specialist **allergy clinic** rather than just a general GP to facilitate targeted **IgE testing** and specialized management.*Admit overnight for observation due to risk of biphasic reaction*- Routine **overnight admission** is generally not required if the patient remains stable during the **6-12 hour observation** window and has no high-risk features.- This patient's symptoms are currently stable (speaking in full sentences, normal BP), making a **shorter observation window** followed by discharge more appropriate than an inpatient stay.*Discharge immediately with adrenaline auto-injector and allergy clinic follow-up*- **Immediate discharge** is dangerous because life-threatening clinical deterioration can occur as the initial dose of **intramuscular adrenaline** wears off.- Patients must be monitored to ensure the **inflammatory response** has fully subsided before they leave the clinical setting.
Question 216: A 54-year-old woman with known alcoholic liver disease presents with haematemesis. She has vomited approximately 500 mL of fresh red blood. Her blood pressure is 94/58 mmHg, heart rate 118 bpm, respiratory rate 22 breaths/min. She appears pale and clammy. IV access is secured and fluid resuscitation commenced. Blood tests show: haemoglobin 78 g/L, platelets 64 × 10⁹/L, INR 2.1, bilirubin 68 μmol/L, albumin 28 g/L. According to current UK guidance, what is the most appropriate transfusion target for this patient?
A. Haemoglobin 100 g/L
B. Haemoglobin 90 g/L
C. Haemoglobin 80 g/L
D. Haemoglobin 70 g/L (Correct Answer)
E. Haemoglobin 60 g/L
Explanation: ***Haemoglobin 70 g/L***
- For patients with **acute upper gastrointestinal bleeding** due to **varices** in the context of liver disease, current UK guidance (NICE, **Baveno VI**) recommends a **restrictive transfusion strategy**.
- A target haemoglobin of **70 g/L** is the threshold for initiating transfusion to avoid increasing **portal pressure**, which can exacerbate the risk of **rebleeding** and worsen outcomes.
*Haemoglobin 100 g/L*
- This represents a **liberal transfusion strategy**, which has been shown to be associated with poorer outcomes in patients with **cirrhosis** and **portal hypertension** due to increased **portal pressure**.
- Such a high target is generally reserved for patients with massive, active exsanguination or specific, severe **comorbidities** like **acute coronary syndrome**.
*Haemoglobin 90 g/L*
- While once common, studies like the **Villanueva trial** demonstrated that a **restrictive target** is superior for survival in patients with **variceal bleeding** compared to a liberal target of 90 g/L.
- This target is usually considered for non-variceal GI bleeding in patients with significant concurrent **cardiovascular disease**.
*Haemoglobin 80 g/L*
- Although 80 g/L falls within the commonly cited **restrictive target range** (70-80 g/L), the primary **transfusion trigger** for variceal bleeding in UK guidelines is typically 70 g/L.
- Transfusing to 80 g/L could still unnecessarily elevate **portal pressure** compared to a lower, yet adequate, target, potentially increasing **rebleeding risk**.
*Haemoglobin 60 g/L*
- This target is dangerously low for a patient presenting with active **haematemesis** and signs of **hemodynamic instability** (hypotension, tachycardia).
- Maintaining a **haemoglobin** of **60 g/L** would significantly increase the risk of **tissue hypoxia**, **ischemia**, and multi-organ dysfunction in an acutely bleeding patient.
Question 217: A 39-year-old woman attends the Emergency Department with her second episode of anaphylaxis in 3 months. She was successfully treated with intramuscular adrenaline both times. She has undergone extensive allergy testing which has been negative, and she cannot identify any clear trigger. Between episodes she feels well. Blood tests during the second episode showed a tryptase level of 42 mcg/L (normal <11.4 mcg/L). A repeat tryptase measured 2 weeks later was 18 mcg/L. What is the most likely underlying diagnosis?
A. Idiopathic anaphylaxis
B. Mastocytosis (Correct Answer)
C. Hereditary angioedema
D. Carcinoid syndrome
E. Scombroid food poisoning
Explanation: ***Mastocytosis*** - The key finding is a **persistently elevated baseline tryptase** (18 mcg/L) measured two weeks after the acute event, which indicates an increased total body burden of **mast cells**. - Patients with **systemic mastocytosis** are highly predisposed to recurrent, often severe, **anaphylaxis** that may occur without an identifiable external trigger.*Idiopathic anaphylaxis* - This is a diagnosis of exclusion for recurrent anaphylaxis where **allergy testing** is negative and no cause is found. - It would not explain an **elevated baseline tryptase**, as tryptase levels should return to the normal range (<11.4 mcg/L) within 24 hours of an episode.*Hereditary angioedema* - Presents with episodes of **non-pitting edema** (angioedema) without urticaria or pruritus, and does not typically present as true anaphylaxis. - It is associated with **C1 esterase inhibitor deficiency** and low **C4 levels**, rather than elevated tryptase.*Carcinoid syndrome* - Characterized by **flushing**, diarrhea, and bronchospasm, but symptoms are usually due to **serotonin release** rather than mast cell degranulation. - Diagnosis is confirmed by elevated **urinary 5-HIAA** levels, and it does not cause a rise in serum tryptase.*Scombroid food poisoning* - Occurs after ingesting spoiled fish containing high levels of **histamine**, mimicking an allergic reaction. - This is an **acute, isolated event** associated with specific food intake and would not result in a chronically elevated baseline tryptase.
Question 218: A 66-year-old woman presents with a 24-hour history of fever, productive cough, and increasing confusion. Her daughter reports she has been less responsive today. Observations: temperature 38.9°C, blood pressure 102/68 mmHg, heart rate 108 bpm, respiratory rate 28 breaths/min, oxygen saturation 91% on room air, AVPU = V. Blood tests show: white cell count 19.2 × 10⁹/L, C-reactive protein 245 mg/L, urea 12.4 mmol/L, creatinine 136 μmol/L. Chest X-ray confirms right lower lobe consolidation. What is her CURB-65 score and recommended management setting?
A. CURB-65 score 3; consider hospital admission with consideration for intensive care assessment
B. CURB-65 score 4; urgent intensive care assessment required (Correct Answer)
C. CURB-65 score 2; consider hospital admission for treatment
D. CURB-65 score 3; hospital admission required for treatment
E. CURB-65 score 5; immediate intensive care admission required
Explanation: ***CURB-65 score 4; urgent intensive care assessment required***
- This patient scores 4 points on the **CURB-65 criteria**: **New-onset confusion** (AVPU = V), **Urea > 7 mmol/L** (12.4 mmol/L), **Respiratory rate** (28 breaths/min, often considered significant in the context of severe distress, particularly with other high-risk features), and **Age ≥ 65** (66 years old).
- A score of 4 indicates **severe pneumonia** with a high predicted mortality, necessitating immediate **hospital admission** and urgent assessment for **Intensive Care Unit (ICU)** management.
*CURB-65 score 3; consider hospital admission with consideration for intensive care assessment*
- While a score of 3 also warrants hospital admission, it underrepresents the severity of a patient presenting with **altered consciousness** and significantly elevated **urea** and **CRP** levels.
- Clinical guidelines recommend that patients scoring 4 or higher are at even greater risk and require more urgent **critical care** review compared to those scoring 3.
*CURB-65 score 2; consider hospital admission for treatment*
- This score is incorrect as it fails to account for at least three positive criteria present in this patient: **confusion**, **elevated urea**, and **age over 65**.
- A score of 2 generally suggests **moderate severity** where hospital-based treatment is considered, but it does not mandate the urgent specialist escalation required for this critically ill patient.
*CURB-65 score 3; hospital admission required for treatment*
- This option correctly identifies the need for hospital admission but misses the critical **age** and **metabolic (urea)** markers that contribute to a higher risk profile.
- It also lacks the necessary recommendation for **intensive care assessment**, which is vital for a patient showing signs of **sepsis** and altered mental status.
*CURB-65 score 5; immediate intensive care admission required*
- This score is an over-calculation; the patient's **blood pressure** (102/68 mmHg) does not meet the criteria for a point (systolic < 90 mmHg or diastolic ≤ 60 mmHg).
- While the patient is very unwell, the **CURB-65 tool** is a specific scoring system, and a score of 5 would require the presence of all five clinical criteria simultaneously.
Question 219: A 27-year-old man is brought to the Emergency Department by ambulance after collapsing during a half-marathon. He reported feeling dizzy and short of breath before collapsing. On examination, he is alert, heart rate 110 bpm, blood pressure 118/76 mmHg, respiratory rate 20 breaths/min, oxygen saturation 98% on room air. Cardiovascular examination reveals a harsh ejection systolic murmur that decreases with squatting. ECG shows left ventricular hypertrophy with deep T wave inversion in the lateral leads. What is the most appropriate immediate management?
A. Discharge with advice to avoid strenuous exercise and arrange urgent cardiology follow-up
B. Administer IV fluids and observe for 4 hours before discharge
C. Admit for echocardiography and consideration of implantable cardioverter-defibrillator (Correct Answer)
D. Arrange exercise tolerance test to assess exercise-induced arrhythmias
E. Commence beta-blocker therapy and arrange cardiology follow-up
Explanation: ***Admit for echocardiography and consideration of implantable cardioverter-defibrillator***
- The patient's presentation with **exertional syncope**, a **harsh ejection systolic murmur that decreases with squatting**, and **ECG findings of LVH with deep T wave inversion** are highly suggestive of **Hypertrophic Cardiomyopathy (HCM)** and represent high-risk features for **Sudden Cardiac Death (SCD)**.
- Immediate admission is critical for **echocardiographic confirmation** of HCM and thorough **risk stratification** to determine the need for an **implantable cardioverter-defibrillator (ICD)**, which is vital in preventing fatal arrhythmias in high-risk HCM patients.
*Discharge with advice to avoid strenuous exercise and arrange urgent cardiology follow-up*
- Discharging a patient who has experienced **exertional syncope** with findings highly suggestive of **Hypertrophic Cardiomyopathy (HCM)** is unsafe due to the significant and immediate risk of **sudden cardiac death (SCD)**.
- While avoiding strenuous exercise is important, it is insufficient as immediate management; the priority is **inpatient evaluation** and **risk assessment** to prevent a recurrence of a life-threatening event.
*Administer IV fluids and observe for 4 hours before discharge*
- Administering **IV fluids** might temporarily improve preload and reduce the **left ventricular outflow tract (LVOT) obstruction** in HCM, but it does not address the underlying pathology or the high risk of **sudden cardiac death (SCD)**.
- A brief observation period without definitive diagnostic imaging like **echocardiography** is inadequate for a patient who has suffered a potentially life-threatening **syncopal event** due to suspected severe cardiac disease.
*Arrange exercise tolerance test to assess exercise-induced arrhythmias*
- An **Exercise Tolerance Test (ETT)** is generally **contraindicated** in patients with suspected or confirmed **obstructive Hypertrophic Cardiomyopathy (HCM)** who have experienced **syncope**, as it can dangerously exacerbate outflow obstruction and trigger lethal **arrhythmias**.
- The immediate priority in this context is to confirm the diagnosis and assess the severity of HCM through non-invasive imaging like **echocardiography**, rather than performing a provocative test.
*Commence beta-blocker therapy and arrange cardiology follow-up*
- While **beta-blockers** are a cornerstone of medical therapy for symptomatic **Hypertrophic Cardiomyopathy (HCM)**, they primarily improve symptoms by reducing heart rate and contractility, but they do not directly prevent the risk of **sudden cardiac death (SCD)**.
- Commencing medication without immediate **inpatient diagnostic confirmation** and comprehensive **risk stratification** for **SCD** (including consideration of an **ICD**) is insufficient given the patient's exertional syncope.
Question 220: A 59-year-old man with hypertension and hyperlipidaemia presents with 4 hours of central crushing chest pain. His initial ECG shows widespread ST depression in leads V2-V6, I, and aVL, with ST elevation in aVR. His troponin I is 1240 ng/L (normal <26 ng/L). Blood pressure is 98/62 mmHg, heart rate 96 bpm. He appears clammy and short of breath. Chest auscultation reveals bibasal crackles. What is the most likely underlying diagnosis?
A. Posterior ST-elevation myocardial infarction
B. Non-ST-elevation myocardial infarction with high-risk features
C. Left main stem or proximal left anterior descending artery occlusion (Correct Answer)
D. Acute pulmonary oedema secondary to hypertensive crisis
E. Acute pericarditis with myocardial involvement
Explanation: ***Left main stem or proximal left anterior descending artery occlusion***
- The ECG pattern of **widespread ST depression** (V2-V6, I, aVL) with **ST elevation in lead aVR** is highly characteristic of severe **left main stem (LMS)** or **proximal LAD** occlusion.
- The patient's presentation with **hypotension** (98/62 mmHg), clamminess, and bibasal crackles indicates **cardiogenic shock** and **acute heart failure**, signifying extensive myocardial damage consistent with a large anterior/anterolateral infarct.
*Posterior ST-elevation myocardial infarction*
- A **posterior MI** typically presents with ST depression in **V1-V3** and **dominant R waves** in these leads, often requiring posterior leads (V7-V9) to confirm ST elevation.
- This ECG pattern differs significantly from the described widespread ST depression and ST elevation in aVR.
*Non-ST-elevation myocardial infarction with high-risk features*
- While the patient has elevated troponin and ST depression, the specific combination of **aVR elevation** with widespread ST depression is a **STEMI-equivalent**.
- This ECG pattern indicates critical coronary artery disease and warrants **immediate revascularization**, distinguishing it from a standard high-risk NSTEMI.
*Acute pulmonary oedema secondary to hypertensive crisis*
- A **hypertensive crisis** would be characterized by significantly **elevated blood pressure**, whereas this patient is **hypotensive** (98/62 mmHg).
- The pulmonary oedema and cardiogenic shock are consequences of severe **myocardial pump failure** due to the extensive infarction, not primarily from high systemic afterload.
*Acute pericarditis with myocardial involvement*
- **Acute pericarditis** typically causes **diffuse concave upward ST elevation** and often **PR segment depression**.
- It does not usually present with severe **hemodynamic instability** like cardiogenic shock or such massive **troponin elevation** (1240 ng/L).
