A 59-year-old man with a history of hypertension and hyperlipidemia presents with 1 hour of substernal chest pressure

 A 59-year-old man with a history of hypertension and hyperlipidemia presents with 1 hour of substernal chest pressure rated an 8 on a scale of 1 to 10 with radiation down the left arm and associated with diaphoresis. Initial vital signs are notable for a blood pressure (BP) of 92/64 mmHg and a heart rate (HR) of 92 beats/min. His electrocardiogram (ECG) is shown below

What is the most likely diagnosis?

A. Anterior ST-elevation myocardial infarction

B. Inferior ST-elevation myocardial infarction

C. Pericarditis

D. ST changes not meeting specific ischemia criteria; additional ECGs should be obtained.

ANSWER: 

Aortic Regurgitation - History, Examination And Study Questions & Answers

Clinical History
· Patients may be asymptomatic (but may have normal or depressed left ventricular function).

· Dyspnoea and fatigue (due to left ventricular impairment and low cardiac output initially on exertion).
· Symptoms of left ventricular failure in later stages.
· Angina pectoris is less common than in aortic stenosis; it usually indicates coronary artery disease.

Examination

1. Pulse
· Collapsing pulse (large volume, rapid fall with low diastolic pressure).
· Visible carotid pulsation in neck (dancing carotids or Corrigan's sign).

· Capillary pulsation in fingernails (Quincke's sign).
· A booming sound heard over femorals ('pistol-shot' femorals or Traube's sign).
· To and fro systolic and diastolic murmur produced by compression of femorals by stethoscope
(Duroziez's sign or murmur).

2. Heart
· Heart sounds are usually normal.
· Apex beat is displaced outwards and is forceful.
· Third heart sound (in early systole with bicuspid aortic valve).
· Early diastolic, high-pitched murmur is heard at the left sternal edge with the diaphragm - if not
readily apparent, it is important to sit the patient forward and auscultate with the patient's breath held
at the end of expiration. When the ascending aorta is dilated and displaced to the right, the murmur
may be heard along the right sternal border as well.
· An ejection systolic murmur may be heard at the base of the heart in severe aortic regurgitation
(without aortic stenosis). This murmur may be as loud as grade 5 or 6, and underlying organic stenosis can be ruled out only by investigations.
· Ejection click suggests underlying bicuspid aortic valve.
· Mid-diastolic murmur of Austin Flint may be heard at the apex. It is typically low-pitched, similar to the murmur of mitral stenosis but without a preceding opening snap.
· Loud pulmonary component of second sound (suggests pulmonary hypertension).

3. General examination
· Head nodding in time with the heart beat (de Musset's sign) may be present.
· Visible carotid pulsation may be obvious in the neck - dancing carotids or Corrigan's sign.
· Check the blood pressure (wide pulse pressure).
· Look for systolic pulsations of the uvula (Muller's sign).
· Check pupils for Argyll Robertson pupil of syphilis.
· Look for stigmata of Marfan's syndrome - high arched palate, arm span greater than height.
· Check joints for ankylosing spondylitis and rheumatoid arthritis.

QUESTIONS

Regarding the most common ECG finding of pulmonary embolism?

A 42-year-old man develops shortness of breath (SOB) and chest pain 7 days after an open cholecystectomy. His blood pressure is 145/86 mm Hg, pulse is 120/min, respiration 24/min, and oxygen saturation of 97%.  Pulmonary embolism is clinically suspected.

Which of the following is the most common ECG finding of pulmonary embolism?
(A) a deep S wave in lead I
(B) depressed ST segments in leads I and II
(C) prominent Q wave in lead I, and inversion of T wave in lead III
(D) sinus tachycardia
(E) clockwise rotation in the precordial leads

Answer: (D) sinus tachycardia

Discussion: Sinus tachycardia is the most common ECG finding in pulmonary embolism.

The specific ECG signs of pulmonary embolism such as the S1, Q3, T3 are rarely seen except in cases of massive pulmonary embolism.
In submassive pulmonary emboli, the ECG may show nonspecific ST changes and sinus tachycardia.
On occasion, pulmonary embolism can precipitate atrial flutter or fibrillation.

Regarding anatomy of the heart...

Which of the following regarding the anatomy of the heart is true?
A) The aortic valve is tricuspid.
B) The ascending aorta is entirely outside the pericardial sac.
C) The left atrial appendage is identified readily by transthoracic echocardiography.
D) The pulmonary trunk lies anterior to the ascending aorta.
E) The right atrium is posterior to the left atrium.

Answer:

Elevated blood pressure in the setting of acute ischemic stroke needs to be judiciously treated because:

Elevated blood pressure in the setting of acute ischemic stroke needs to be judiciously treated because:

A. High blood pressure needs to be treated aggressively in order to decrease the incidence of intracranial bleeding.
B. Acute elevations in blood pressure usually do not spontaneously decline.
C. Blood pressures above 160 mmHg systolic or 100 mmHg diastolic are immediately life-threatening.
D. Areas of ischemic brain lose autoregulation and may be dependent on elevated mean arterial pressure to maintain perfusion.
E. Aggressive lowering of blood pressure with acute ischemic stroke improves outcome.

Answer :

Tetralogy Of Fallot - Long Case Study

Presenting Complains:
- Breathlessness for … months
- Bluish discoloration of the lips and fingers during exertion for … months
- Weakness for … months
- Palpitation for … months
- Chest pain for … months
- Cough for … months.

History of Presenting Complains: According to the patient’s statement, she has been suffering from
breathlessness since her childhood. Her breathlessness was less marked in earlier stage, only felt
during moderate to severe activity. But for the last few months, it is progressively increasing, even
during mild exertion. There is no seasonal variation of breathlessness and it is not associated with
exposure to dust, pollen or fume. There is no history suggestive of paroxysmal nocturnal dyspnea or
orthopnea. The patient also noticed bluish discoloration of skin, finger nail, toes and lips for the last
… months, which is more marked during exercise and less by taking squatting position. She also
experiences diffuse chest pain, usually following any activity or after eating, which radiates to left
shoulder and subsides after taking rest. She also complains of palpitation, weakness and occasional
dry cough. Her bowel and bladder habits are normal. Her mother mentioned that the patient used to
become bluish and breathless while feeding or crying during the first few years of life.

On General Physical Examination:
- The patient is emaciated and short in stature
- Dyspneic
- Central cyanosis (involving tongue, lips, fingers and toes) is present
- There is generalized clubbing (involving all fingers and toes)
- Pulse: 112/min, low volume, regular in rhythm and normal character
- BP: 100/60 mm Hg
- Temperature: 98ºF
- Respiratory rate: 28/min
- No anemia, leukonychia, koilonychia, edema, jaundice, lymphadenopathy or thyromegaly

Cardiovascular system
- Pulse: 112/min, low volume, regular in rhythm and normal character
- BP: 100/60 mm Hg
- JVP: prominent “a” wave
- Visible cardiac impulse in apical and epigastric region
- Apex beat—palpable in the left … intercostal space, … cm from midline, normal in character
- Left parasternal lift and epigastric pulsation—present
- Systolic thrill—present in pulmonary area.
- First heart sound—normal in all the areas
- Second heart sound—P2 is soft (or absent) in pulmonary area, A2 is normal
- There is a harsh ejection systolic murmur in the pulmonary area, which radiates to the neck, more
on inspiration.

Examination of other systems reveals normal findings.

What is the Provisional Diagnosis? 
Tetralogy Of Fallot (TOF)

Mention some cyanotic congenital heart disease.
As follows:

• Tricuspid atresia
• Transposition of great vessels
• Pulmonary atresia
• Ebstein’s anomaly.

What investigations are done in TOF?
As follows:

• Chest x-ray- shows boot-shaped heart, pulmonary conus is concave (small pulmonary artery), right ventricle enlarged (prominent elevated apex), oligemic lung, right-sided aortic arch in 25% cases.
• 2D echocardiography and color Doppler (diagnostic—it shows that the aorta is not continuous with the anterior ventricular septum).
• Other investigations: ECG (RVH), cardiac catheterization in some cases.

A woman with high BP reading recorded at her routine clinic visit...

A 71-year-old woman is reviewed in her local GP clinic. She has recently changed practices and is having a routine new patient medical. Her blood pressure is 146/94 mmHg. This is confirmed on a second reading. In line with recent NICE guidance, what is the most appropriate management?

A. Ask her to come back in 6 months for a blood pressure check
B. Arrange 3 blood pressure checks with the practice nurse over the next 2 weeks with medical review following
C. Arrange ambulatory blood pressure monitoring
D. Reassure her this is acceptable for her age
E. Start treatment with a calcium channel blocker

Answer:

Case Discussion - Cardiac Failure Developing On 3rd day Postpartum

A 27 year old female para 2 (h/o of both LSCSs), on the 3rd postoperative day of caesarean develops sudden cardiac failure.
– She has weakness, shortness of breath, palpitation, nocturnal dyspnea and cough.
– O/E- Tachycardia, arrhythmia, peripheral edema, pulmonary rales are present. S3 is present but no murmur is heard.
– She had been a booked patient with regular antenatal checkups and with no prior heart problem and uneventful prior obstetric history.

What is the probable diagnosis?

Case Discussion:
The diagnosis of peripartum cardiomyopathy should be kept in mind in all such cases.

The criteria for diagnosis are:
1. Cardiac failure within last month of pregnancy or within 5 month postpartum.
2. No determinable cause for failure (may be immunological or nutritional).
3. No previous heart disease.
4. Left ventricular dysfunction (Echocardiography) as evidenced by ejection fraction < 45%
5. Left ventricular end-diastolic dimension > 2.7 cm/m2.

Regarding Pacemaker Function...

A 72-year-old woman had a pacemaker inserted 4 years ago for symptomatic bradycardia because of AV nodal disease. She is clinically feeling well and her ECG shows normal sinus rhythm at a rate of 68/min but no pacemaker spikes. Her pacemaker only functions when the ventricular rate falls below a preset interval.
Which of the following best describes her pacemaker function?
(A) asynchronous
(B) atrial synchronous
(C) ventricular synchronous
(D) ventricular inhibited
(E) atrial sequential

Answer: (D) ventricular inhibited

Discussion: The ventricular inhibited (VVI) pacemaker functions when the heart rate falls below a preset interval. If a QRS is detected, the pacemaker is inhibited. If a QRS is not sensed, the pacing stimulus is not inhibited and the ventricle is stimulated

Interventions associated with improved mortality in patients with heart failure. ..

A 70-year-old man, known to have ischemic heart disease and who has had a coronary artery bypass
graft in the past, presents with progressive breathlessness. He is haemodynamically stable but has
clinical signs of congestion and a Chest X Ray confirms pulmonary edema.
An ECG shows sinus rhythm with anterior Q waves, QRS complex of 180 ms duration (normal <120 ms) with a left bundle-branch block pattern.
Transthoracic echocardiography shows systolic left ventricular dysfunction with an ejection fraction of 25% (normal 50–60%).

Question
Which two of the following interventions would not be associated with an improved mortality in this patient?

A Loop diuretic
B Lisinopril
C Statin
D Implantable cardioverter
defibrillator
E Eplerenone
F Biventricular pacing
G Carvedilol
H Spironolactone
I Bisoprolol
J Diltiazem

Answer:

Eisenmenger’s syndrome - Questions & Answers For A Long Case

Eisenmenger syndrome refers to any untreated congenital cardiac defect with intracardiac communication that leads to pulmonary hypertension, reversal of flow, and cyanosis. The previous left-to-right shunt is converted into a right-to-left shunt secondary to elevated pulmonary artery pressures and associated pulmonary vascular disease.

What are your differential diagnoses?

 As follows:

• Congestive cardiac failure
• Chronic cor pulmonale.

Q. What investigations would you suggest ?

 As follows:

1. X-ray chest (enlargement of central pulmonary arteries with peripheral pruning of pulmonary vessels).

2. ECG (RVH, RAH, right axis deviation).

3. Echocardiography.

Q. What are the clinical features of Eisenmenger’s syndrome?

As follows:

• Dyspnea
• Fatigue
• Syncope
• Angina
• Hemoptysis
• Features of CCF.

On examination:

• Central cyanosis (not corrected by giving 100% oxygen. Differential cyanosis (cyanosis in toes, not in the hand) occurs in PDA.
• Clubbing (differential clubbing—clubbing in toes, not in the hand, occurs in PDA).
• Pulse—low volume.
• Prominent “a” wave in JVP.
• Other signs of pulmonary hypertension – palpable P2, left parasternal lift, epigastric pulsation due to RVH. Ejection click and ejection systolic murmur may be present.
• Tricuspic regurgitation may occur (in such case, prominent V wave in JVP, also there may be a pansystolic murmur in left lower parasternal area).
• Polycythemia.
• Original murmur of VSD, ASD or PDA—decrease in intensity, even may disappear.

Myocardial Infarction: Secondary Prevention

A 55-year-old man is admitted following an anterior myocardial infarction. Which of the following drugs is least likely to reduce mortality in the long-term?
A. Atorvastatin
B. Atenolol
C. Ramipril
D. Aspirin
E. Isosorbide mononitrate

Answer:

Heart Diseases in Pregnancy

Regarding heart diseases in pregnancy answer the following questions:

1. Which cardiovascular change is not physiological in pregnancy:
a. Split 1st heart sound
b. Mid diastolic murmur
c. Shift of apex beat to 4th ICS and outwards
d. Decreased peripheral vascular Resistance.

Answer: b. Mid diastolic murmur

2. Indication for cesarean section in pregnancy is:
a. Mitral stenosis
b. Aortic aneurysm
c. PDA
d. Transposition of great vessels

Answer: b. Aortic aneurysm

3. Surgery for mitral stenosis during pregnancy is done at:
a. 8 wks
b. 10 wks
c. 14 wks
d. 22 wks

Answer: c. 14 wks

4. Which of the following disease has worst prognosis during pregnancy:
a. Pulmonary stenosis
b. Mitral stenosis
c. VSD
d. ASD

Answer: b. Mitral stenosis

5. All of the following are predictors of cardiac event during pregnancy except:
a. NYHA class>3
b. Obstructive lesion of the heart (mitral valve and aortic valve <1 cm2
c. Previous H/O heart failure
d. Ejection fraction <40%.

Answer: a. NYHA class>3

Discussion:

Wenckebach, or type I second-degree AV block

A 62-year-old man with coronary artery disease (CAD) presents with presyncope. His physical examination is normal except for bradycardia (pulse 56 beats/min) and an irregular pulse. The electrocardiogram (ECG) shows Wenckebach’s type atrioventricular (AV) block.

Which of the following are you most likely to see on the ECG?
(A) progressive PR shortening
(B) progressive lengthening of the PR interval
(C) tachycardia
(D) dropped beat after PR lengthening
(E) fixed 2:1 block

Answer: (D) dropped beat after PR lengthening

Discussion:

In the consideration of cardiac tamponade, which of the following statements is most true?

In the consideration of cardiac tamponade, which of the following statements is most true?
A- Bradycardia is common
B- Early diastolic descent (y descent) is exacerbated
C- Pulsus paradoxus is pathognomonic
D- Renal failure is a recognized complication
E- The apex beat is always absent

Answer:

A 45-year-old builder with one episode of unexplained syncope has a transthoracic echocardiogram that is suggestive of hypertrophic cardiomyopathy.,,,

Clinical scenario
A 45-year-old builder with one episode of unexplained syncope has a transthoracic echocardiogram that is suggestive of hypertrophic cardiomyopathy.

Question
Which two of the following features are not associated with a high risk of sudden death?

A History of ventricular tachycardia (VT) or resuscitated ventricular fibrillation
B Recurrent syncope
C Strong family history of sudden death
D Breathlessness on exertion
E Extreme left ventricular hypertrophy (septal thickness >3 cm)
F Non-sustained VT on Holter monitoring
G Syncope while running
H Diagnosis in childhood
I Resting outflow tract gradient >25 mmHg
J BP drops on exercise

Answer:

Rheumatic Fever - Long Case Study

Presenting complains:  18 years old female presents with the complains of:
- Migrating polyarthritis involving bigger joints (knee, ankle, elbow) for … days
-  Fever for … days
- Palpitation, chest pain … for days
- Malaise, weakness, fatigue for … days

History of presenting complains: According to the patient’s statement, she was quite fit and well … days back. Then she suffered from sore throat from which she recovered completely within a few days. After … days, she developed severe joint pain. Initially, it involved the right knee joint, but then sequentially the right ankle, left knee, left ankle and elbow joints were involved. The joints are
swollen, red and very painful, even with mild movement. The smaller joints are not involved. There
was no morning stiffness.
The patient also complains of fever, which is high grade, continued and reduces with antipyretic
drugs. It is not associated with chill and rigor, but there is profuse sweating. She also complains of
palpitation, chest pain, malaise, fatigue, weakness during her disease period. There is no history of
abnormal or involuntary movement (chorea) or skin changes. Her bowel and bladder habits are
normal. She denied any history of diarrhea, sexual exposure, skin rash, mouth ulcer, uveitis or any
urinary complaint.

General Physical Examination: 
- Appearance: Ill looking
-  Built: average
- Nutrition: average
-  Anemia: mildly anemic
- No jaundice, cyanosis, clubbing, leukonychia, koilonychia, edema or dehydration.
-  No lymphadenopathy, thyromegaly, etc

Vitals:
- Pulse: 110/min
-  BP: 130/75 mm Hg
-  Temperature: 39°C
-  Respiratory rate: 24/min

Cardiovascular examination ; Normal with no murmurs audible.

Loco-motor examination: (Knee joint involved)
Swollen and red with increased local temperature. Extremely tender on  palpation and restricted movements due to pain.

Other systemic examination ; Normal

Provisional Diagnosis: Acute Rheumatic Fever

Differential Diagnosis: 

A 32-year-old athlete presents with severe interscapular pain after training....

Clinical scenario
A 32-year-old athlete presents with severe interscapular pain after training. He is of slim build and tall (210 cm). He has a sinus tachycardia and his BP is 180/100 mmHg with no deficit between his right and left arm. There are no murmurs and all his peripheral pulses are palpable.
The rest of his physical examination is normal.
A CXR shows widened mediastinum and a CT confirms an aortic dissection distal to the left subclavian artery that does not involve the aortic arch.

Question
Which of the following is the most appropriate intervention?
A Intravenous calcium antagonist
B Intravenous labetalol
C Urgent cardiothoracic surgical referral
D Transoesophageal echocardiography
E Oral angiotensin-converting enzyme inhibitor

Answer:

Sub acute bacterial Endocarditis(SBE) - Long Case With Questions & Answers

Clinical History:
Mr …, 28-year-old, student, normotensive, nondiabetic, nonsmoker, presented with fever for 1 month, which is low grade, continued, sometimes associated with chills and rigor, also with profuse
sweating, subsides only with paracetamol, highest recorded temperature was 101F. He also complains
of central chest pain, sharp in nature without any radiation, does not aggravate by cough or movement of the chest. He also experiences occasional palpitation, associated with difficulty in breathing after mild to moderate exertion for the last few months, which are relieved by taking rest. There is no history suggestive of orthopnea or paroxysmal nocturnal dyspnea. For the last 2 months, the patient also experiences malaise, generalized weakness, arthralgia, myalgia, anorexia and substantial loss of weight.
There is no history of unconsciousness, hematuria or loin pain (differentiates from embolic phenomena). He does not give any history of dental procedures or cardiac or other surgery or
instrumental procedure (catheterization, colonoscopy, cannula, etc.) or any history of intravenous drug abuse. His bowel and bladder habits are normal.
He has been suffering from some valvular heart disease for several years. There is no family history of such illness. He used to take frusemide, propranolol and vitamins prescribed by the local physicians.

Examination: 
Patient is ill looking, emaciated and toxic, with moderate anemia. There is generalized clubbing: involving all the fingers and toes and there are two splinter hemorrhages in the left index finger.
No cyanosis, jaundice, koilonychia, leukonychia, lymphadenopathy or thyromegaly.
-Pulse: 110/min.
- Blood pressure: 95/75 mm Hg.
- Respiratory rate: 28/min.
- Temperature: 100°F.

On cardiovascular examination a murmur was detected on auscultation.

Provisional Diagnosis: Sub acute bacterial Endocarditis(SBE)

Points supporting the diagnosis:

A 67 Year Old man with Fever After a prosthetic aortic valve replacement...

A 67-year-old man presents with a  6-week history of malaise, low-grade pyrexia and rigors 6 months after having a prosthetic aortic valve replacement.
His C-reactive protein is 150 mg/dL (normal <5 mg/dL) and
his creatinine 150 μmol/L (normal <120 μmol/L).
 A transoesophageal echocardiogram confirms vegetation on the aortic prosthesis.

Question
Which of the following organisms is most likely to be responsible?

A Staphylococcus aureus
B Streptococcus viridans
C Staphylococcus epidermidis
D Escherichia coli
E Candida albicans

Answer: