Cases in cardiology

Cases in cardiologyLIBYAN MEDICAL BOARD FIRST PART REVISIONDR.MAGDI AWAD SASI2016

LIBYAN MEDICAL BOARD 2ND PART

1. 45yo man, 6 hours of palpitations, SOB, chest pain and sweating. BP 90/60. ECG broad complex tachycardia. What is the best management?Amiodarone IVSotalol IVDigoxin IVDC cardioversionOverdrive pacing

DC cardioversion

GM2 . 50 year female DM with ESRD presented with sever chest pain of gradual onset left sided persistent for 4 days disturbing her sleep and causing chest discomfort with decreased urine out put for last week with dyspnea and sweating with nauseaO/E: drowzy ,sitting , dyspnic ,nauseating BP 180/110PR 110/min Febrile CHEST BL basal crepitationCVS high pitched systolic sound LBS ,ECG ST up all overECHO ---HTN HD To release her pain:A. IndomethacinB. AngisedC. ThrombolysisD. AntibioticsE. Dialysis

DONT MISS THE INDICATION OF URGENT DIALYSIS IN ESRD PATIENTS

Indications of urgent dialysis:Uremic encephalopathyAcute pulmonary edemaover load in ESRDUremic pericarditisUremic sensory neuropathyUremic gastritisMetabolic acidosis non responding to treatmentHyperkalemia non responding to treatmentUrea->250mgAnuric patient in ESRD

3. A 24-year-old patient is admitted after falling asleep drunk in a toilet cubicle. On examination his BP 130/70, pulse 98 bpm and there is no pericardial rub. There is boggy tenderness of his right calf and both thigh muscles.Biochemistry reveals urea 38 mmol/l, creatinine 410 mol/l, bicarbonate 15 mmol/l, pH 7.1, potassium 7.8 mmol/l and creatine kinase 17 000 IU/l.What is the most appropriate form of treatment?Haemodialysis High-dose diuretic therapy Continuous ambulatory peritoneal dialysis Steroids with Ca gluconate and insulin with dextrose 50%Forced alkaline diuresis

Haemodialysis

4. A 25-year-old lady with known systemic lupus erythematosus (SLE) presents with the nephrotic syndrome. A renal biopsy is performed and this confirms diffuse proliferative glomeronephritis (WHO Class IV). Which of the following treatment regimens would you advise? a. Azathioprine alone b. Prednisolone alone c. Azathioprine and prednisolone d. Prednisolone and intravenous cyclophosphamide e. Prednisolone and methotrexate

Nephrotic syndrome:Generalised anasarcaAlbuminurai proteinuriaHypoalbuminemiaHypercholestremiaLipiduria Minimal change GNMembranous GNIgA GN

Nephritic syndrome:HaematuriaHypertensionHigh power microscope ---WBC casts ,RBC castsPost streptococcal GNMembranous proliferative GNFocal / Diffuse segmental GN

ISN /RPS 2003 CLSSIFICATION OF LUPUS NEPHRITIS [L.P.] Class I;minimal mesangial LN.Class II;mesangial LN.ClassIII; focal LN.[proliferative&sclerosing]ClassIV;Diffuse LN.[segmental/global proliferative OR sclerosing.]ClassV; membranous LN.ClassVI; advanced sclerosis LN.

5. 45 yo woman with Hx of longstanding SLE has haematuria and proteinuria. Creat 500, urea 38. Biopsy described as 60% crescents, interstitial scarring and thickened membrane. Normal C3, low C4. Anti dsDNA>50. Strongest indication for treatment of this pt with an alkylating agent?low C3 and C4High level of dsDNACrescentsInterstitial scarringProteinuria

Those are the criteria for deteriorating LN:Persistent proteinuriaPersistent castsWBC ,RBCHigh creatinine levelUncontrolled HTNFailure to respond to medical therapy

6. A 25-year Libyan male patient, known case of nephrotic syndrome presents with acute, diffuse right abdominal pain. He is tachycardiac, BP 100/75 mmHg and afebrile. He notices urine color change and reduction in urine volume. The following managements are required, EXCEPT:Dopplar abdominal ultrasound.Therapeutic dose of s/c heparin.IV fluid challenge.Urine protein- creatinine ratio.IVP study.

This is a seario of Acute renal artery thrombosis as NS increased the risk of thrombosis thats why heparin of prophylactic dose is mandatory in NS.Acute dyspnea ,chest pain in NS == PEAcute calf pain and swelling == DVTAcute loin pain in NS == Renal artery thrombosis

There is no rule of IVP

7. 14. A 30 yr.old female presented to dermatologist with hyperpigmentation and skin dryness before 2 years . She was seeking medical advice for sever heart burn and dysphagia for last year . She saw Orthopedician for arthralgia and coldness of hands . She was refered to chest hospital for progressive exertional dyspnea with sever headache and visual disturbance.O/E: Dyspnic , BP 180/130 ,PR 120/min , Tighten skin with hyperpigmentation all over the body ,cold blue hands , atrophy of distal pulps FundiHTN retinopathy , Urea 100mg ,creat 7.6mg ,k 4.2mmol , HB 8gm , D bili 3 mg /dl Pulmonary auscultation;bibasilar crakles PBF MHA

all are true except:A. The hypertension is almost always severe with a diastolic BP over 100 mmHg in 90% of patientsB. There is hypertensive retinopathy in about 85% of patients with exudates and haemorrhages and if severe, papilledema.C.Urgent dialysis is mandatory D. Some are asymptomatic and normotensive with aprupt rise of creatinine.E.Acute renal failure with raise creatinine and increase renin level.

Clinically important kidney disease occur in minority of patients.SCR develops in 10% of patients.SCR occurs early in the course of diffuse scleroderma 23 years of onset ,more often in the fall and winter months.SYMPTOMS:--Symptoms are HEADACHE ,VISUAL CHANGES AND SEIZURES.The clinical presentation is typically with the symptoms of malignant hypertension: Headaches, Hypertensive retinopathy associated with visual disturbances, Seizures, Heart failure and pulmonary oedema. Renal failure may present as acute renal crisis , after prolonged HTN ,less commonly as normotensive renal failure

SCR is the abrupt onset of HTN ,appearance of flame shaped haemorrhage ,cotton wall exudates , grade III/IV retinopathy papillodema and rapid deterioration of renal function over a month.The hypertension is almost always severe with a diastolic BP over 100 mmHg in 90% of patients. There is hypertensive retinopathy in about 85% of patients with exudates and haemorrhages and if severe, papilledema.If malignant HTN left untreated ,it can lead to renal failure Some are asymptomatic and normotensive with aprupt rise of creatinine

There may also be microangiopathic haemolytic anaemia ( Hb with blood film shows schistocytes and helmet cells), thrombocytopenia and raised renin levels. Renal function is impaired and usually rapidly deteriorates.

TREATMENTScleroderma renal crisis is a medical emergency. Aggressive treatment is required to prevent the occurrence ofirreversible vascular injury. ACE-I is the treatment of choice First line treatment is a gradual reduction in blood pressure (10-15 mmHg per day) with an oral ACEIs until the diastolic pressure reaches 85-90 mmHg. ACEI will improve hypertension and slow further renal impairment. This approach leads to a response in 90% of patients by reversing the angiotensin II mediated vasoconstriction. An abrupt fall in BP should be avoided as it can further diminish renal perfusion and increase the risk of ATN. Therefore, parenteral antihypertensive agents (for example, IV nitroprusside or IV labetalol) should be avoided.

CCBs, usually nifedipine, may be added where there is inadequate reduction of BP with ACEI alone. Additional oral hypotensive agents (for example, labetalol) can be used if required, and if pulmonary oedema is present a nitrate infusion may be indicated.High dose of steroids increased the risk of renal failure in SS.There is anecdotal evidence that IV prostacyclin helps the microvascular lesion without precipitating hypotension, and this is used in some UK centres.

There is no rule of urgent dialysis in scleroderma renal crisis as the priorty in the management is to start ACE I.It is mandatory to start ACE Icaptopril up to 400mg/D

8. A 70-year-old farmer is admitted with a 4-day history of feeling increasingly short of breath. He tells you he was kicked by a cow and was laid up with a swollen leg before the symptoms started.

On examination there is extensive bruising and haematoma around the left knee, the leg is more swollen than the right. He has bilateral basal crackles and occasional wheezes on inspiration, blood pressure (BP) 110/80; pulse is 105 and regular, saturations 8991% on pulse oximetry. Chest X-ray reveals nil of note Which of the following represents the best treatment choice for this man? Anticoagulation Oral prednisolone Intravenous furosemide Penicillin iv Nebulised salbutamol

Principal markers useful for risk stratification in acute pulmonary embolism are except:A. Systolic blood pressure < 90mmHgB. Pansystolic M in TA increased by inspiration with right parasternal heave ,S3 confirmed by ECHOC. Positive tropinin T /ID. Sever dyspnea with O2 saturation 88%E. Disturbance of conscious level with UOP < 10ml/hr

9. Which one of the following statements regarding minimal change glomerulonephritis is incorrect? Haematuria is rare Hypertension is found in approximately 25% of patients Has a good prognosis Is a common cause of nephrotic syndrome The majority of cases are steroid responsive

CARDIAC10. 55y female DM patient presented with progresive dyspnea and fatigue on exertion of raising steps of first floor with recent onset of palpitation of a day.Clinically ,weak irregular irregular PR 120/min BP 90/70 ,malar flushCVS loud S1 with DRM and audible opening snap ECG AF /RVRECHO revealed MVA 1.6 cm2 ,LA 50mmThe following is true except:

1. She need valve replacement2. You have to repeat the ECHO3. Cardioversion should be done with heparin4. CCB and BB have rule in treatment5. Warfarin should be given.

Mitral StenosisManagement GuidelinesIndications for MVR (class I and IIa)

Symptomatic pts (NYHA class III and IV) with MVA < 1.5 cm2 unsuitable for PMBV

NYHA class I and II pts with MVA < 1.0 cm2 and PASP >60 at rest unsuitable for PMBV

37Lumper.

Three invasive options are available for patients with MS: PMBC, surgical mitral commissurotomy, and mitral valve replacement (MVR).