Ebook Handbook of PLAB (2nd edition): Part 1

(BQ) Part 1 book Handbook of PLAB presents the following contents: Cardiovascular system, respiratory diseases, neurology, hematology, endocrinology, gastroenterology, rheumatology, infectious diseases, oncology, emergencies, ethics, pharmacology.

PLAB

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Handbook of PLAB

© 2003, Kunal Goyal, Seema Mittal

All rights reserved No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopy- ing, recording, or otherwise, without the prior written permission of the authors and the publisher.

This book has been published in good faith that the material provided by authors is original Every effort is made to ensure accuracy of material, but the publisher, printer and authors will not be held responsible for any inadvertent error(s) In case of any dispute, all legal matters to be settled under Delhi jurisdiction only.

First Edition: 2001

Second Edition: 2003

ISBN 81-8061-190-6

Typeset at JPBMP typesetting unit

Printed at Gopsons Papers Ltd., Noida

Handbook of PLAB is an effort to provide its readers an standing of the new pattern of this examination from the year

under-2000 It is the first book of its kind wherein the author has triedhis best to make it easily readable and easy to follow It incor-porates about 3500 extended matching questions (EMQs) cov-ering all the major topics More stress has been laid on the top-ics which are rendered important from the point of view of thePLAB examination First timers (beginner aspirants) as well asthose who have been preparing already will find the Hand-book equally useful The author is quite hopeful that the latterwill find it of immense use for revision and refresh whateverthey have read before

The author got the idea of writing the book when he alongwith his friends and colleagues was preparing for the PLABexamination This new pattern examination was totally new sothe author and his friends had to face a new unknown chal-lenge hence they felt the need of such a book all the more Thisbook has been written with the first hand experience gained bythe author himself

Learning can be self or from the experience of others Theauthor was not lucky enough to learn from the experience ofothers so he had to venture himself in the blind alleys How-ever, the experience had been quite useful and hence this book.The author is quite hopeful that it will meet the needs of thestudents in their preparation of the PLAB Candid commentsfrom the readers are most welcome

Kunal Goyal

Preface to the First Edition

We owe my heartfelt gratitude to:

My brother, Amit, whose unconditional support and ration has helped me to reach where I an today

inspi-Our parents who have stood by me at all times

All the well wishers for all their support and assistance

Mr JP Vij, Chairman and Managing Director of M/s JaypeeBrothers Medical Publishers (P) Ltd., and his team of dedicatedstaff for their untiring efforts

The huge success of the first edition filled me with enthusiasm,

to work hard to update the book When I first wrote the book,being the first one in the field, just after first exam based onnew pattern, I do realize it had questions, which were difficultand not really suitable for PLAB

Over time, we have learnt more about GMC questioningstyle and topics of interest and importance We have tried ourbest to add on the relevant questions and change the previousones to make this book an essential read for all PLAB aspirants.First time (beginner aspirants) as well as those who have beenprepairing already will find the handbook equally useful Weare quite hopeful that the latter will find it of immense use forrevision and refresh whatever they have read before

I do hope all of you enjoy the book, as much as we did ing it We are as always open to candid comments from ourreaders

revis-Kunal Goyal Seema Mittal

Preface to the Second Edition

1 Cardiovascular System 1

2 Respiratory Diseases 55

3 Neurology 96

4 Hematology 168

5 Endocrinology 191

6 Gastroenterology 212

7 Rheumatology 290

8 Infectious Diseases 315

9 Oncology 353

10 Emergencies 366

11 Ethics 386

12 Pharmacology 392

13 Dermatology 412

14 Surgery 440

15 Radiology 531

16 Biochemistry 534

17 Pediatrics 544

18 Orthopedics 600

19 Psychiatry 635

20 Ear, Nose and Throat 662

21 Ophthalmology 682

22 Obstetrics 698

23 Gynecology 736

24 Renal Diseases 779

25 Miscellaneous 816

Answers 829

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Cardiovascular System

THEME: 1 INTERPRETATION OF PULSE RATE

Options

a Regular fast palpitations

b Regular slow palpitations

c Irregular fast palpitations

d Dropped beats

e Regular and pounding

For each of the situations/conditions given below, choosethe one most appropriate/discriminatory option from above.The options may be used once, more than once, or not at all

a Undisplaced, tapping apex

b Displaced, forceful apex

c Undisplaced, heaving apex

d Displaced, hyperdynamic apex

e Dyskinetic

f Double impluse

For each of the situations/conditions given below, choosethe one most appropriate/discriminatory option from above.The options may be used once, more than once, or not at all.

THEME: 4 INTERPRETATION OF JVP Options

a Raised JVP with normal waveform

b Raised JVP with absent pulsation

c Large ‘a’ wave

a ST depression and inverted T–wave in V5–6

b Small T waves, prominent ‘V’ waves, ventricular bigemini

c Tall tended T waves, ST segment depression

For each of the situations/conditions given below choosethe one most appropriate/discriminatory option from above.The options may be used once, more than once, or not at all.

37 A teenage boy with dyspnoea and chest pain is broughtinto A&E He has a history of rheumatic fever An ECGdemonstrates LAH and LVH It also demonstrates Qwaves and raised ST segments

38 An elderly woman is found unconscious at home An ECGdemonstrates sinus bradycardia, J waves, ST depressionand flattened T waves

39 A patients ECG shows a biphasic P wave

40 A patients ECG shows T waves inversion and ST sion

depres-41 A 35-year-old woman complains of tiredness and aise Her T waves are widespread and deep

mal-THEME: 7 INTERPRETATION OF ABNORMAL ECG

Questions

42 A 60-year-old woman taking frusemide is noted to have

U waves in V3 and V4

43 A 50-year-old man presents with fever and chest pain.

He has a history of angina His ECG reveals concave evations of the ST segments in leads II, V5 and V6

el-44 A 55-year-old presents with chest pain and dyspnoea HisECG reveals Q waves in leads III and aVF and inverted Twaves in leads V1-3

45 A 55-year-old woman who has undergone thyroidectomy

is noted to have an ECG with a QT interval of 0.5 sec

46 A 60-year-old woman presents with hoarseness She is asmoker and is on prozac Her pulse rate is 44/min andthe ECG is noted for sinus bradycardia and reduced am-plitude of P, QRS and T waves in all leads

THEME: 8 INTERPRETATION OF ECG Options

k 2nd degree block (mobitz type 2)

For each of the situations/conditions given below, choosethe one most appropriate/discriminatory option from above.The option may be used once, more than once, or not at all

49 One P wave per QRS complex, constant PR interval andprogressive beat to beat change in the RR interval.

50 Dominant R in V1 and inverted T in the anterior chestleads

51 Peaked P waves, right axis deviation, inverted T waves

in leads V1 to V3 and tall R waves in V1

52 Dominant R waves in V1, inverted T waves in leads V1-3and deep S waves in V6

THEME: 9 INTERPRETATION OF ECG ABNORMALITIES Options

Questions

53 J waves, bradycardia and first degree heart block

54 Prolonged QT, all ST segments elevated and show acteristic saddle shape

char-55 Shortened QT interval

56 Tall QRS complexes with LVH pattern

57 Atrial fibrillation, self-resolving

THEME: 10 DIAGNOSIS OF CHEST PAIN Options

Questions

58 A 48-year-old man complains of chest pain He describes

it as gripping and crushing and involving whole chest

He says he has had to give up exercise because it vates the pain and makes both hands numb

aggra-59 A middle-aged lady complains of chest pain, ness and fainting On examination there is a prominent awave in JVP, a right ventricular heave and a loud P2

breathless-60 A 53-year-old man is brought to A&E with crushing chestpain and pallor He cannot breathe and his heart is rac-ing His sputum is blood stained; he has a pleural ruband pyrexia

61 A young man brought to hospital in a state of collapse

He was at his desk saw the value of his stocks fall and felt

a constricting pain in the chest A few moments later hewoke up in the ambulance

62 A 50-year-old lady complains of chest pain radiatingacross the chest She says her muscles are very tender.Breathing aggravates the pain and coughing brings tears

to her eyes She thinks she has had a heart attack

THEME: 11 DIAGNOSIS OF CHEST COMPLAINTS

Questions

63 A 38-year-old woman complains of feeling bloated andrecurrent chest infections She says she bruises easily andhas missed periods On examination you find her BP to

be high

64 A 40-year-old man presents with sweating, headaches andhypertension He also complains of joint pain muscleweakness and numbness in both hands Over the past fewmonths he has become increasingly breathless and hisankles have swollen up

65 A 48-year-old woman presents with fever, malaise, weightloss and joint pains She has high blood pressure and largefeet She complains of persistent chest pain She has pur-puric rash and skin nodules.

66 A middle-aged man presents with abdominal pain andbone pain He has hypertension and a recent history ofrecurrent renal stones

67 At a routine health check up you carry out a fundoscopy

on an apparently healthy man You find he has an olar narrowing and tortuosity and an increased light re-flex

arteri-THEME: 12 DIAGNOSIS OF HEART CONDITIONS

Questions

68 A 60-year-old man presents with chest pain radiatingdown his left arm His 12 lead ECG shows Q waves in II ,III and aVF with T wave changes in V5 and V6

69 A 50-year-old woman presents with a fast heart rate with

an irregular rhythm There are no P waves on the ECG

She states that she has lost weight recently and is vous She also suffers from palpitations.

ner-70 On auscultation a patients is noted to have a rumblingdiastolic murmur at the apex The murmur is accentu-ated during exercise

71 A 60-year-old man on digitalis and diuretics presents with

a raised JVP, hepatomegaly, ankle and sacral oedema

THEME: 13 DIAGNOSIS OF CHEST PAIN Options

Questions

72 A collapsed 34-year-old male patient is brought to theemergency room He was playing basketball, when hecomplained of severe chest pain and collapsed On ex-amination is drowsy but arousable Pulse 126/min regu-lar and not palpable on the left radial/brachial artery ECGand chest X-ray normal

73 A 48-year-old heavy smoker complains of severe chestpain radiating to the left shoulder of 30 minutes dura-tion He has had previous episodes on walking up hill.

On examination he is sweating, has a pulse of 98/min,

BP 150/90 mm Hg and normal heart sounds ECG is stillawaited

74 A 21-year-old student became suddenly breathless andhad left sided chest pain during a cycling trip

75 A well built young man has recurrent chest pain On amination he has jerky pulse and a soft systolic murmur

ex-76 Localized, sharp pain exacerbated by coughing and ration

respi-77 Pain following or accompanying eating and increased bybending, hot drinks or lying supine

78 Central chest pain radiating to jaw and associated withexcitement and feeling of impending doom

79 Central chest pain radiating to back and lower limb pulsesnot felt

80 A 75-year-old lady is on her seventh postoperation dayafter a hip replacement surgery and suddenly complains

of chest pain and is breathless Pulse is 102/min, BP 100/

60 mm Hg Blood gases done have the following results

pH 7.35, PaO2 8.2 kPa, PaCO2 4.2 kPa

81 A 45-year-old smoker comes with a stabbing left sidedchest pain of 6 hours duration He is anxious breathing atthe left base

THEME: 14 DIFFERENTIAL DIAGNOSIS OF ANGINA

82 An obese 34-year-old man complains of epigastric pain,which seems to be exacerbated by eating his favouritemeal, fish and chips He get temporary relief when hun-gry

83 An obese 45-year-old man complains of recurring chestpain which radiates to his neck lasting 20 minutes It co-incides with his weekly executive board meetings

84 An obese 29-year-old woman complains of cough of twoweeks and right upper quadrant pain She is mildly fe-brile There was no abdominal tenderness on examina-tion

THEME: 15 DIAGNOSIS OF CHEST PAIN Options

For each of the situations/conditions given below, choosethe one most appropriate/discriminatory option from above.The option may be used once, more than once, or not at all.

Questions

85 A middle-aged woman with sedentary habits has chestpain aggravated by breathing and coughing She has aslight fever 2 months ago she had pneumonia but recov-ered fully

86 A short overweight middle-aged woman complains ofchest pain below her sternum The pain is worse at nightand always starts up after meals

87 A 48-year-old man presents with acute chest pain in thesubsternal area The pain radiates to the neck and arm

He says that the pain also goes through to the back

88 A 62-year-old housewife complains of central chest painafter a heavy meal The pain goes to her back, she saysand her fingertips on left hand are numb Her serum tran-saminase and LDH are normal

89 A young asthmatic comes to you with chest pain of den onset The pain is on the lower left side He says thepain followed a bout of coughing and has left him breath-less

sud-THEME: 16 CAUSES OF CHEST PAIN Options

a Dissecting aortic aneurysm

k Tension pneumothorax

l Pleurisy

For each of the situations/conditions given below, choosethe one most appropriate/discriminatory option from above.The option may be used once, more than once, or not at all

Questions

90 A 55-year-old man presents with sudden onset of severecentral chest pain radiating to the back Peripheral pulsesare absent There are no ECG changes The CXR shows awidened mediastinum

91 A 20-year-old man recently returned from a holiday inthe caribbean presents with a left sided chest discomfortand dyspnoea On CXR there is a small area devoid oflung markings in the apex of the left lung

92 A 50-year-old man recently back from business trip inHong Kong presents with sudden onset of breathlessnesshaemoptysis and chest pain He is bought to A&E in shock.His CXR is normal The ECG shows sinus tachycardia

93 A 40-year-old man presents with a central crushing chestpain that radiates to the jaw The pain occurred while jog-ging The pain was relieved by rest The ECG is normal

94 A 50-year-old woman with ovarian cancer presents withright-sided chest pain The CXR shows obliteration of theright costophrenic angle

THEME: 17 INVESTIGATION OF CHEST PAIN

e Treadmill exercise test

f Seek immediate expert advice

g Endoscopy

h CXR

97 Epigastric pain and anaemia in a 50-year-old overweightwoman on treatment for joint disease.

98 A 20-year-old man presents with sudden onset of ritic chest pain and dyspnoea He is 182 cm tall and hassmoked for 6 years There is no other medical history

pleu-99 A 58-year-old chronically hypertensive man is admittedwith shearing central chest pain radiating through to theinterscapular region

THEME: 18 DIAGNOSIS OF CARDIAC LESIONS

j Pulmonary stenosis

k VSD

For each of the situations/conditions given below, choosethe one most appropriate/discriminatory option from above.The option may be used once, more than once, or not at all

102 Jerky carotid pulse, dominant ‘a’ wave in the JVP, doubleapical impulse, ejection systolic murmur at the base andPSM at the apex

103 Elevated JVP, early diastolic opening snap MDM at theapex and loud S1

104 Elevated JVP displaced apex, PSM at the apex and 3rdheart sound

105 Loud PSM at the left lower sternal area Mid-diastolic flowmurmur at the apex and loud S2

THEME: 19 MANAGEMENT OF CHEST PAIN

106 A young officer complains of palpitation for 2 months

He says that when he mounts stairs he can feel his heartbeating His health history is unremarkable

107 A 40-year-old man complains of swollen legs and lessness Examination reveals hepatosplenomegaly CXRshows a normal but dense heart shadow and clear lungfields

breath-108 A middle-aged man complains of severe chest pain ating to the neck The pain came on after dinner as hewas retiring for the night His wife called out a locum at 3am

radi-109 An elderly housewife was operating on for gallstones and

at operation a gangrenous gallbladder was removed Acouple of days later she complained of nausea and feel-ing unwell

110 A 60-year-old warehouse man has been acutely less for last week He is a smoker and has a chronic pro-ductive cough for last 14 years

breath-THEME: 20 MANAGEMENT OF ACUTE CHEST PAIN

Options

a Glyceryl trinitrate (0.5 mg) Sublingually

b IV 50 ml of 50% dextrose

c High flow O2 and Ramipril 2.5 mg 12 hr PO

d High flow O2 10 mg IV morphine –anticoagulation

e Crossmatch blood and inform surgeons

f Insert a 16 G cannula in second intercostal space

g IV heparin 5000-10,000 i.u over 5 min.

h Underwater seal drainage

i 10 mg IV diamorphine

j Nifedipine

For each of the situations/conditions given below, choosethe one most appropriate/discriminatory option from above.The options may be used once, more than once, or not at all

Questions

111 A tall young woman developed sharp pain on one side

of his chest two days ago Since then he has been short ofbreath on exertion

112 After a heavy bout of drinking a 56-year-old man vomitsseveral times and develops chest pain When you exam-ine him , he has a crackling feeling under the skin aroundhis neck

113 A 23-year-old woman on the oral contraceptive pill denly gets tightness in her chest and becomes very breath-less

sud-114 A 30-year-old man with Marfan‘s syndrome has suddencentral chest pain going through to the back

115 A 57-year-old man develops crushing pain in the chestassociated with nausea and profuse sweating The pain

is still present when he arrives in hospital an hour later

THEME: 21 DIAGNOSTIC TEST FOR PATIENT

PRESENTING WITH CHEST PAIN

h Full blood count

Questions

116 A 68-year-old man has had malaise for five days and ver for two days He has a cough and you find dullness

fe-at the left lung base

117 A 50-year-old woman returned by air to the UK fromAustralia Three days later she presents with sharp chestpain and breathlessness Her chest X-ray and ECG arenormal

118 A tall, thin, young man presents with a sudden pain inthe chest and left shoulder and breathlessness while cy-cling

119 A 45-year-old manual worker presents with a two hourhistory of chest pain radiating into left arm His ECG isnormal

120 A 52-year-old obese man has had episodic anterior chestpain, particularly at night, for three weeks Chest X-rayand ECG are normal

THEME: 22 INVESTIGATIONS Options

124 A 45-year-old male with an anterior wall infarction,thrombolysed three days ago develops chest pain and anirregular pulse on the third day in intensive care not re-sponding to nitrates.

THEME: 23 MATCH THE PATHOPHYSICAL FEATURES WITH THE

CONGENITAL DEFECTS BELOW

Options

a Hypoplastic left heart syndrome

b Persistent truncus arteriosus

c Tricuspid atresia

d Pulmonary atresia with VSD

e Critical aortic stenosis

For each of the situations/conditions given below, choosethe one most appropriate/discriminatory option from above.The options may be used once, more than once, or not at all

Questions

125 An obligatory right to left atrial shunt

126 Symptoms are primarily related to pulmonary vascularresistance and size of pulmonary arteries

127 Ductus dependent systemic flow with an obligatory left

to right atrial shunt

128 Ductus dependent pulmonary flow with an obligatoryright to left ventricular shunt

THEME: 24 MATCH THE FOLLOWING X-RAY FINDINGS WITH

CONGENITAL HEART DISEASE

Questions

129 Coarctation of aorta

130 Tetralogy of Fallot

131 Dextra position of great vessels

132 Levo-transposition of the great arteries

133 Total anomalous pulmonary venous return

THEME: 25 DIAGNOSIS OF CHEST COMPLAINTS

m Cholecystitis

n Pancreatitis

For each of the situations/conditions given below, choosethe one most appropriate/discriminatory option from above.The option may be used once, more than once, or not at all

middle-136 A young woman complains of acute chest pain It is bing and makes her breathless It involves her whole chestand lips and feet have gone numb

stab-137 A 52-year-old man drives himself to A&E with an acutestabbing pain He has had the pain for more than half anhour and is in extreme distress He is pale and sweatyand he vomits

138 A 33-year-old woman complains of chest pain radiatingthrough to the back She is overweight and decided tocome in after taking a cup of hot tea, which brought onthe chest pain She says it is worse on leaning forward

THEME: 26 DIAGNOSIS OF CHEST PAIN Options

a Dissecting aortic aneurysm

139 A 56-year-old man had been operated for fracture neckfemur Six days later he complained of dyspnoea at restand chest pain ECG showed sinus tachycardia and rightaxis deviation

140 A 55-year-old porter collapsed while bending On sion he regained consciousness but started to vomit, wassweating profusely and complained of chest pain CXRshowed widened mediastinum

admis-141 A 69-year-old man is admitted with severe epigastric painand sweating Over the last few weeks he has sufferedfrom chest pain and shortness of breath on moderate ex-ercise On examination his JVP is 10 cm above the sternalangle, pulse 65/min and BP 115/65 and there is bilateralankle oedema

142 A 45-year-old alcoholic is admitted to A&E with severeretrosternal pain and shortness of breath The pain is con-stant and radiates to the neck and interscapular region

On examination his pulse is 120/min, BP is 90/60 andleft lung base is dull on percussion

143 A 25-year-old man presents with shortness of breath andchest tightness His father had collapsed and died sud-denly when he was 33 On examination the cardiac apex

is double and with S4 and a late systolic murmur

144 A 28-year-old man presented to A&E with severe ness of chest, which was worse on exercise He had astrong history of MI On examination his temperature was37.8 Pulse 90 and BP 130/80 Apex was normal Cervicallymphadenopathy, erythematous buccal cavity and poly-morphous rash

tight-THEME: 27 DIAGNOSIS OF CHEST PAIN Options

146 A 50-year-old woman returned by flight to UK from Paris

3 days later she presents to A and E with central chestpain and breathlessness Her CXR and ECG are normal

147 A tall thin 35-year-old man with sudden chest pain ating to the left shoulder and breathlessness while cycling

radi-148 A 50-year-old porter presents with a 3 hours history ofchest pain radiating into the left arm His ECG is normal

149 A 50-year-old obese man has had episodic anterior chestpain; particularly at night for 2 weeks CXR and ECG arenormal

THEME: 28 DIAGNOSIS OF CHEST PAIN Options

Questions

150 A 24-year-old man develops acute pain on the right side

of the chest radiating to the right shoulder associated withfever She has vomiting and has mild yellowing of theskin

151 A tall young man developed chest pain in the righthemithorax following RTA On palpitation this area istender A CXR shows no lung injury

152 A 22-year-old male prostitute develops severe chest pain.The area of chest pain corresponds to an area with anerythematous rash

153 A 70-year-old man develops crushing central pain ciated with nausea and profuse sweating radiating to theneck By the time he gets to the hospital the pain has gone

asso-154 Minutes after upper GI endoscopy, a 56-year-old man velops chest pain On examination he has a crackling feel-ing under the skin around his upper chest and neck.

de-THEME: 29 DIAGNOSIS OF CHEST COMPLAINTS

Questions

155 A middle-aged man presents with variable heart mur He also complains of fever, malaise and night sweats

mur-On examination you find clubbing and splenomegaly

156 A 43-year-old woman presents with fever and weight loss.She is pale and her spleen is enlarged Her fingers aremildly clubbed with painful lesions on the pulps She isbreathless

157 A young man presents with dyspnoea especially at nightsand wheeze He is exhausted and coughs His sputum isfrothy and contains blood ECHO shows the heart to beglobular in shape and contracting poorly

158 A young man present with dyspnoea, chest pain, ing spells and palpitations On auscultation you find ajerky pulse and a late systolic murmur ECHO demon-strates asymmetrical septal hypertrophy.

faint-159 A 62-year-old man presents with sharp chest pain Hehas had it for 3 days and it radiates down into his abdo-men Breathing deeply and coughing aggravate it On aus-cultation of the chest you hear a scratching sound

THEME: 30 INVESTIGATIONS OF CHEST PAIN

163 A tall young man presents with history of sudden chestpain radiating to the back and the interscapular area

THEME: 31 DIAGNOSIS OF CARDIOVASCULAR

DISEASES IN CHILDREN Options

h Acute rheumatic fever

i Congestive heart failure

Questions

164 A 10-year-old boy presents with stridor He has a history

of recurrent swelling of the hands and feet with nal pain and diarrhoea His sister also suffers from simi-lar attacks

abdomi-165 A 6-year-old girl presents with spiking fevers On nation she has spindle-shaped swellings of her fingerjoints

exami-166 A 12-year-old boy presents with polyarthritis and nal pain He had a sore throat a week ago On examina-tion he is noted to have an early blowing diastolic mur-mur at the left sternal edge

abdomi-167 A 10-year-old boy presents to casualty following a zure while at the gym On examination he has a loud sys-tolic ejection murmur with a thrill

sei-168 A 12-year-old girl presents with pallor, dyspnoea and a

PR of 190 She is noted to have cardiomegaly andhepatomegaly

THEME: 32 DIAGNOSIS OF CONGENITAL HEART DISEASE Options

j Transposition of great arteries

k Congenital aortic stenosis

For each of the situations/conditions given below, choosethe one most appropriate/discriminatory option from above.The option may be used once, more than once, or not at all

Questions

169 A 27-year-old woman presented with headache On amination her BP was 165/115 mmHg, pulse 90 and therewas ejection systolic murmur all over the precordium andback

ex-170 A 39-year-old man presented with progressive ness and palpitations On examination the JVP was el-evated with a prominent ‘a’ wave and there was a pul-monary ejection systolic murmur ECG showed a RBBBwith large P waves

breathless-171 A 12-year-old boy with a history of recurrent chest tions presented with worsening shortness of breath Onexamination there was systolic thrill at the left lower ster-nal edge, PSM and accentuated S2

infec-172 A 21-year-old man presented with worsening shortness

of breath He had been told that he had a murmur since

he was a child On examination there was a continuousmurmur and the pulse was bounding

173 A 5-year-old boy was referred for poor growth and ening shortness of breath On examination he was cy-anosed and there was clubbing There was an ESM singleS1 and parasternal heave CXR showed RVH and a smallpulmonary artery

wors-174 An infant was referred for heart failure and cyanosis Onexamination there was elevated JVP, hepatomegaly, PSM

at the lower left sternal edge and S3 CXR showed a largeglobular heart ECG showed RBBB

THEME: 33 DIAGNOSIS OF CARDIOVASCULAR DISEASE Options

Questions

175 A 35-year-old pregnant woman presents to her GP forher first prenatal check up He notes that her BP differs inboth arms and is lower in the legs