Cases in cardiology

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

LIBYAN MEDICAL BOARD 5TH PART

A 43-year-old woman presents for the evaluation of bleeding gums. The patient reports that for the past 2 months, her gums have bled more easily when she brushes her teeth. Physical examination reveals palatal petechiae and scattered petechiae over the lower extremities bilaterally. Which of the following laboratory tests is most likely to identify the abnormality responsible for this patient's bleeding disorder? A. Prothrombin time (PT) and international normalized ratio (INR) B. Complete blood count (CBC) C. Partial thromboplastin time (PTT) D. A mixing study E. Renal function test

SUBCUTANEOUS BLEEDING AND MUCOSAL IN THE FORM OF PETECHEAPLATELET DISORDER.To investigate ----CBC , BLEEDING TIME ,CLOTTING TIMT

TISSUE AND ORGAN BLEEDING ---CLOTTING FACTOR DEF.To investigate -----PT ,INR ,APTT

Bleeding occurs as a consequence of thrombocytopenia, deficiencies of coagulation factors, or both. Thrombocytopenia usually presents as petechial bleeding that is first observed in the lower extremities. Deficiencies in coagulation factor more often cause bleeding into the gastrointestinal tract or joints. Intracranial bleeding, however, can occur with a deficiency of platelets or coagulation factors and can be catastrophic. CBCs are routinely performed in most laboratories through the use of an electronic particle counter, which determines the total white blood cell and platelet counts and calculates the hematocrit and hemoglobin from the erythrocyte count and the dimensions of the red cells. For this patient, a CBC would likely disclose a decreased platelet count (thrombocytopenia). Impaired hepatic synthetic function and vitamin K deficiency would result in prolongation of the PT and INR. Coagulation factor deficiencies and coagulation factor inhibitors would result in prolongation of the PTT. A mixing study is obtained to differentiate between a coagulation factor deficiency and a coagulation factor inhibitor by mixing patient plasma with normal plasma in the laboratory. (Answer: BComplete blood count [CBC])

Regarding erythrpioetin ,all true except: A. The peritubular interstitial cells located in the inner cortex and outer medulla of the kidney are the primary sites for erythropoietin production.

B. Erythropoietin treatment decreases the severity of anemia and improves the quality of life for these patients.

C. Treatment is maximally effective when the marrow has a generous supply of iron and other nutrients, such as cobalamin and folic acid.

D. The most easily monitored immediate effect of increased endogenous or exogenous erythropoietin is an increase in the blood reticulocyte count.

E.There is no benefit of it in In patients with anemia caused by cancer and cancer chemotherapy

Erythropoietin shortens the transit time through the marrow, leading to an increase in the number and proportion of blood reticulocytes within a few days. In some conditions, particularly chronic inflammatory diseases, the effectiveness of erythropoietin can be predicted from measurement of the serum erythropoietin level by immunoassay. It may be cost-effective to measure the level before initiating treatment in patients with anemia attributable to suppressed erythropoietin production, such as patients with HIV infection, cancer, and chronic inflammatory diseases. Several studies have shown that erythropoietin treatment decreases the severity of anemia and improves the quality of life for these patients. In patients with anemia caused by cancer and cancer chemotherapy, current guidelines recommend erythropoietin treatment if the hemoglobin level is less than 10 g/dl

For this patient, which of the following statements regarding iron deficiency anemia is true? A. In men and postmenopausal women, pica and a poor supply of dietary iron are the most common causes of iron deficiency anemia B. Pagophagia, or pica with ice, is a symptom that is believed to be specific for iron deficiency C. Measurement of the serum iron concentration is the most useful test in the detection of iron deficiency D. The preferred method of iron replacement for this patient is parenteral therapy E. In older children, men, and postmenopausal women, a poor supply of dietary iron is almost the only factor responsible for iron deficiency.

B. Pagophagia, or pica with ice, is a symptom that is believed to be specific for iron deficiency

Measurement of the serum ferritin concentration is the most useful test for the detection of iron deficiency, because serum ferritin concentrations decrease as body iron stores decline. A serum ferritin concentration below 12 mg/L is virtually diagnostic of absent iron stores. In contrast, a normal serum ferritin concentration does not confirm the presence of storage iron, because serum ferritin may be increased independently of body iron by infection, inflammation, liver disease, malignancy, and other conditions.

Which of the following statements regarding megaloblastic anemia caused by folic acid deficiency is false? A. Serum folic acid levels more accurately reflect tissue stores than do red blood cell folic acid levels B. Folic acid deficiency can be differentiated from cobalamin deficiency by measuring methylmalonic acid and homocysteine levels; both are elevated in cobalamin deficiency, but only homocysteine is elevated in folic acid deficiency C. Megaloblastic anemia caused by folic acid deficiency can be masked by concurrent iron deficiency anemia, but hypersegmented polymorphonuclear cells (PMNs) should still be present on the peripheral smear D. Folinic acid can be used to treat patients with megaloblastosis and bone marrow suppression associated with the use of methotrexate

ASerum folic acid levels more accurately reflect tissue stores than do red blood cell folic acid levels)

1. A 73 year old woman has become progressively kyphotic over the last 3 years. Past history includes colon carcinoma and hysterectomy at age 26 for fibroids. She now presents with acute back pain and localised midthoracic tenderness. CXR and lateral spine xrays are shown (wedged shaped crush fracture in mid thoracic vertebrae and osteopenia, NO lytic or sclerotic lesions) The most likely diagnosis is?A)multiple myelomaB)bone metastasesC)osteoarthritisD)osteoporosisE)hyperparathyroidism

osteoporosis

2. A28-year-old woman complains of a 3-week historyof palpitations and shakiness. She attributes her insomnia to her new baby, born 5 weeks previously. On examination there is increased sweating, a fine tremor of outstretched hands, and a small nontender goiter. Laboratory investigations show TSH 98% specificity; 90% sensitivity

3. Which one of the following would not be considered a high-risk marker for sudden cardiac death in hypertrophic cardiomyopathy?

A. Family history of sudden cardiacdeath B. Non-sustained VT on cardiac monitoring C. LV septal thickness of2.3cm D. Drop in blood pressureonETT E. Syncope

C. A septal thickness of >3cm is considered a high-risk marke

Patients at risk of sudden death:I. HISTORY:Age 29mmHg. 1/3 of patients with HCM fail to increase pressure by exercise , WHY? Possibly ---LV baroreceptors firing off under very high pressue causing vasodilatation peripherally. Occurs in :Young patientF/H of sudden deathPatient with small LV cavityV. PROGNOSTIC GENOTYPING:Identification of the mutation type appears to carry prognostic significance .Troponin T mutation is the worst ((dying 1824age)).

4. Which of the following is NOT an indication for mitral balloon valvotomy?

A. Mild mitral stenosis with the pulmonary artery systolic pressure increasing to greater than 60 mmHg during exercise, favorable valve morphology and New York Heart Association functional class II symptoms

B. Moderate mitral stenosis, favorable valve morphology and New York Heart Association functional class II symptoms

C. Severe mitral stenosis with moderate mitral regurgitation, favorable valve morphology and New York Heart Association functional class III symptoms

D. Severe mitral stenosis, unfavorable valve morphology (Wilkins score > 8), New York Heart Association functional class III symptoms in a patient not a candidate for surgical mitral valve repair/replacement.

C. Severe mitral stenosis with moderate mitral regurgitation, favorable valve morphology and New York Heart Association functional class III symptoms

C/I:1. MR2. Left atrial thrombus3. Dilated LA

5. A 25-year-old man presents with 4 days of fever, retro-orbital pain and severe myalgia following travel to the Indian subcontinent. He has red eyes and a faint, blanching, maculopapular rash. A peripheral smear for malarial parasites is negative and his white cell count and chest X-ray are normal. What is the most likely diagnosis? A. Malaria B. Typhoid fever C. Bubonic plague D. Dengue fever E. Tuberculosis

Dengue fever is transmitted from the bite of infected Aedes aegypti mosquitoes. It is commonly seen in the tropics where epidemics occur. After an incubation period of 34 days, patients develop fever, severe myalgias and headaches (mainly retro-orbital). Painful red eyes are commonly seen, along with lymphadenopathy. A faint, blanching, maculopapular rash is characteristic. White cell counts are normal and platelets may be low, along with mildly abnormal liver function tests. It can be diagnosed during the fever by detection of the viral genome by reverse transcriptase polymerase chain reaction (RT-PCR). Paired sera can provide a retrospective diagnosis. A small proportion of patients may develop dengue haemorrhagic fever with disseminated intravascular coagulation. Treatment is supportive

6. A 55-year-old man has non-infective, necrotising ulcers on his lower limbs. A diagnosis of pyoderma gangrenosum is made. Which of the following conditions is associated with this disorder?

A. Multiple myeloma B. Haemochromatosis C. Gout D. Non-Hodgkins lymphoma E. Autoimmune thrombocytopenia

Pyoderma gangrenosum start as inflammatory pustules or papules that appear on the limbs and trunk. They enlarge rapidly to produce large necrotic ulcers with a sloughy base, which undermines a raised purplish prominent rim. It is associated with multiple myeloma, acute leukaemia, inflammatory bowel disease, polycythaemia vera and rheumatoid arthritis. No cause can be found in 50% of patients.

7. A 16-year-old man presents with difficulty in walking and foot drop. There is weakness of dorsiflexion and eversion of the right foot, with a small area of sensory loss over the dorsum of that foot. What is the most likely diagnosis?

A. Posterior tibial nerve lesion B. Sciatic nerve lesion C. L5 root lesion D. Common peroneal nerve lesion E. Deep peroneal nerve lesion

The common peroneal (L5, S1) nerve arises from the division of the sciatic nerve in the popliteal fossa. It passes close to the head of the fibula and can be damaged by pressure in this area. It divides into a superficial and a deep branch. The deep peroneal nerve supplies the tibialis anterior, extensor hallucis longus and extensor digitorum longus muscles, which dorsiflex the foot and toes. The superficial nerve supplies the peroneus longus and brevis muscles, which evert the foot. Damage to the posterior tibial nerve produces weakness of planter flexion and inversion of the foot.

8. A 75-year-old man is noted by his family to be increasingly confused. His mental state fluctuates considerably and he appears to be hallucinating at times. His daughter commented that his gait has become abnormal over the preceding months, and that his GP had tried a tablet for the nocturnal confusion that apparently made him much worse. On examination he has a Mini-Mental score of 20/30, has generally increased tone and difficulty in performing rapidly alternating movements. His tendon reflexes are slightly brisk but the plantar responses are normal and no primitive reflexes are detected. Which of the following is the most likely explanation of this clinical scenario?

A. Vascular dementia B. Senile dementia of Alzheimers type C. CreutzfeldtJakob disease D. Temporal variant of frontotemporal dementia E. Dementia with Lewy bodies

The associated extrapyramidal features and variable psychiatric features with complex hallucinations are typical of dementia with Lewy bodies (DLB). This condition is now recognised to be the second most common cause of neurodegenerative disease in older people (after senile dementia of Alzheimers type, SDAT). Typically, standard antipsychotic drugs such as haloperidol worsen DLB, and indeed potentially fatal neuroleptic sensitivity reactions can occur. It is one of a group of conditions caused by abnormal aggregation of the synaptic protein a-synuclein. The cholinesterase inhibitor drugs, initially developed for SDAT, look promising for the treatment of DLB

A 40-year-old male was admitted with sudden onset headache and generalised tonic-clonic convulsion. MRI scan and subsequent MRI venography revealed sagittal sinus thrombosis. He recently recovered from an episode of aplastic anaemia. Investigation reveals anaemia with reticulocytosis. What is the most likely diagnosis?

a) Homocystinuria b) Thrombotic thrombocytopaenic purpura c) Paroxysmal Cold Haemoglobinuria d) Paroxysmal Nocturnal Haemoglobinuria e) Thalassaemia

d)

Paroxysmal Nocturnal Haemoglobinuria (PNH) is an intracorpuscular defect acquired at the stem cell level. Three common manifestations are haemolytic anaemia, venous thrombosis and deficient haematopoiesis. Granulocytopaenia and thrombocytopaenia are common and reflect deficient haematopoiesis. Clinical haemoglobinuria is intermittent in most patients and never occurs in some, but haemosiderinuria is usually present. Venous thrombosis is a common complication of patients of European origin. Thrombosis can occur in cerebral venous sinuses and is a common cause of death in a patient with PNH.

9. Which one of the following disorders is MOS commonly associated with Stevens-Johnson syndrome?

A. Herpes simplex infection B. Sarcoidosis C. Systemic lupus erythematosus D. Herpes zoster infection E. Coeliac disease

Stevens-Johnson syndrome is an immunological reaction in the skin and mucous membrane characterised by iris skin lesion (erythema multiforme) in the skin and extensive bullae formation in the mouth and conjunctivae.

The commonest disease association is with a preceding herpes simplex or Mycoplasma pneumoniae infection.

Other causes include drug sensitivity (e.g. sulfonamides, penicillins, barbiturate, phenytoin and possibly the contraceptive pill).

10. A 65-year-old man, with a history of smoking, presents with chronic cough, haemoptysis and weight loss. His Chest X-Ray shows a cavitating lesion. What is the likely diagnosis? A. adenocarcinoma B. alveolar cell carcinoma C. large cell carcinoma D. small cell carcinoma E. squamous cell carcinoma

11. A patient is brought to the emergency department after a seizure leading to prolonged immobility on a sidewalk. He has dark urine and myalgias. What is the most urgent step in the management of this patient? a. Urinalysis b. Urine myoglobin level c. EKG d. CPK levelE. Creatinine

Answer: C. EKG is the most urgent step in an acute case of rhabdomyolysis. This case tests your knowledge of how people die with rhabdomyolysis. Severe muscle necrosis leads to hyperkalemia, which leads to arrhythmia.A specific diagnosis with urinalysis or urine myoglobin is not as important as detecting and treating potentially life-threatening conditions, such as hyperkalemia with peaked T waves. This condition would be treated with immediate intravenous calcium gluconate, insulin, and glucose

12. A 40-year-old woman presents with progressive confusion and mild neck stiffness with headache of a month . A CT scan showed basal meningeal enhancement. A lumbar puncture showed an opening pressure of 200 mmH2O, a turbid CSF with 500 leucocytes/ml (90% lymphocytes), a glucose concentration of 1 mmol/l and negative results with Gram, Indian ink and ZiehlNeelsen stains. What is the best treatment?

A. Rifampicin + INAH + pyrazinamide + ethambutol B. Ceftriaxone C. Aciclovir D. Corticosteroids E. Liposomal amphotericin B

Rifampicin + INAH (isonicotinic acid hydrazide) + pyrazinamide + ethambutol are used to treat tuberculous meningitis (TBM), which is the most likely diagnosis based on the subacute history, CT findings and the modest lymphocytic lymphocytosis accompanied by severe hypoglycorrhacia.

A negative ZiehlNeelsen stain is not unusual in such cases, except when large volumes of spun CSF are examined.

Almost without exception, patients with bacterial meningitis have a high neutrophil pleocytosis and a few days history at presentation. Apparently, the patient had not been receiving antibiotics, which can modify the CSF in those with bacterial meningitis.

Viral meningitis is unlikely since the cell type is mononuclear and the sugar concentration normal (except in patients with mumps meningitis). There is no reason to suspect fungal meningitis as she has no immunocompromising conditions, although the CSF changes may be indistinguishable from TBM.

However, cryptococcal meningitis occasionally presents in a normal host, but here the Indian-ink stain is usually positive. There is no evidence that the patient has benign intracranial hypertension or collagen vascular disease, so steroids are not indicated and are contraindicated for the treatment of infectious meningitis alone.

Bacterial meningitis is treated with ceftriaxone, viral meningitis with aciclovir and fungal meningitis with liposomal amphotericin B.

REMEMBER:H/O symptoms of headache ,confusion ,cranial nerve palsy with basal meningeal irritation of a month or two in apatient with CSF study of lymphocytosis and hypoglycemis is TB

13. Which is not a paraneoplastic syndrome associated with Lung CancerSIADHLambert-Eaton SyndromeSweets SyndromeDermatomyositisGBS like syndrome

The syndrome was first described in 1964 by Dr.Robert D Sweet. It was also known as Gomm-Button disease in honour of the first two patients diagnosed. It is characterized by erythematous well defined cutaneous papules associates with fever and is associated with haematologic malignancies like leukaemia, Rheumatoid Arthritis, IBD, Behcets Syndrome

14. A 45-year-old male executive comes to your office complaining of epigastric pain for 2 months. His primary physician prescribed him H2-blockers 3 weeks ago, which have produced only partial relief of his symptoms. His weight is stable. His physical exam is normal. An upper endoscopy reveals a 1-cm duodenal ulcer. Which of the following risk factors is not associated with the development of ulcer disease?

A.Daily use of nonsteroidal anti-inflammatory drugs(NSAIDs) B. Gastric infection with H. pylori C. Emotional stress D. Cigarette smoking E. Gastrin-secreting tumors

Although considered a risk factor in the past, several studies showed that emotional stress is not a risk factor for the development of duodenal ulcer. Daily NSAID use significantly increases the risk of ulcer disease (risk ratio, 10- to 20-fold).Gastric infection with H. pylori increases risk about five- to sevenfold. Cigarette smoking doubles the risk of duodenal ulcer. At least 90% of those patients with Zollinger-Ellison syndrome have duodenal ulcer.

15. A 51-year-old woman presents with abdominal pain, weight loss, early satiety, and night sweats. On physical exam she appears cachectic, multiple enlarged lymph nodes are present in her neck (supraclavicular area), and a mass is palpated in the epigastrium. Laboratory data reveal a hemoglobin of 8 g/dL and a normal WBC count. Which of the following is the most appropriate next step in establishing the diagnosis?

A. Upper GI series B. Peripheral blood smear C. CT of the abdomen D. Upper endoscopy with biopsy E. Exploratory laparotomy

This patient has lymphoma of the stomach. Lymphoma of the stomach can resemble superficially spreading carcinoma, linitis plastica, or solitary adenocarcinoma. Gastroscopy with directed biopsy and brush cytology gives a higher yield than was previously appreciated, especially in the presence of exophytic lesions. Lymphoma of the stomach frequently presents radiographically as a bulky mass and less frequently as a diffusely infiltrating tumor-the most common form of secondary lymphoma-giving the appearance of large folds on upper GI series, frequently associated with multiple nodular defects and ulcerations. Although CT may be useful to evaluate the extent of disease, it will not provide a specific diagnosis. Exploratory laparotomy is useful for staging and therapeutic resection where possible.

16. A 49-year-old man presents to the emergency room because of melena of 3 days' duration. He denies abdominal pain. Vital signs reveal a resting pulse of 104 per minute and a 25-mm Hg orthostatic drop in BP. Physical findings include bilateral temporal wasting, pale conjunctivae, spider angiomas on his upper torso, muscle wasting, hepatosplenomegaly, and hyperactive bowel sounds without abdominal tenderness to palpation. His stool is melenic. Nasogastric tube aspiration reveals coffee grounds material. Hematocrit is 31%. The appropriate next step in the management of this man's illness would be to

A. Pass a Sengstaken-Blakemore tube. B. Obtain an upper GI series. C. Insert a transjugular intrahepatic portosystemic shunt (TIPS). D. Obtain immediate visceral angiography. E. Perform upper endoscopy.

After this patient has been hemodynamically stabilized, the next most important step is to perform a diagnostic/therapeutic upper endoscopy. If the source of his bleeding is from esophageal varices, then these can be obliterated with sclerosis or, preferably, endoscopic band ligation. The use of a Sengstaken-Blakemore tube should be reserved for patients in whom upper endoscopy was unsuccessful in controlling the hemorrhage. A TIPS should be considered in patients in whom medical and endoscopic therapy have failed. Barium studies have no role in the evaluation of patients with suspected variceal hemorrhage

17. A 67-year-old man in previously good health is hospitalized because of a 2-day history of fever and diminished consciousness. The patient responds inconsistently to verbal commands. His temperature is 39.5 C (103.1 F); he has tachycardia, and his blood pressure is 80/58 mm Hg. There is no bleeding. His hemoglobin is 12.1 g/dL, leukocyte count is 29,000/L with 80% neutrophils, and platelet count is 20,000/L. Which of the following studies should be obtained in this patient? A. Bone marrow aspiration and biopsy B. Factor VIII level C. Measurement of platelet-associated IgG D. Measurements of fibrin D-dimer and total fibrinogen E. Bleeding time

D. Measurements of fibrin D-dimer and total fibrinogenThis is a case of DIC.

18. A 18 year female was HBsAg positive in health check up,but without symptoms and signs,and the liver functions were normal. In May the following year, she was admitted for fever,weakness,vomiting and jaundice of sclera.ALT 200U/L,Hb 140g/L, anti-HAV IgM(+).Anti-HBc IgG(+) HBsAg(+).The diagnosis may be:A. Acute hepatitis A(icteric type) and HBsAg chronic carrier.B. Chronic hepatitis B(CPH).C. Chronic active hepatitis B.D. Acute hepatitis A and acute hepatitis B.E. Acute hepatitis A and chronic persistent hepatitis B.

19. A 27-year-old man with a history of IV drug use was found to have abnormal liver function tests Further work-up including serologic tests for viral hepatitis show Hepatitis B surface antibody (HBsAb) negative Hepatitis B surface antigen (HBsAg) positive Hepatitis core antibody (HBcAb) positive Hepatitis B e antibody (HBeAb) positive Hepatitis B e antigen (HBeAg) negative Which of the following statements is true regarding this patient?

A. He is a chronic hepatitis B virus (HBV) carrier with high infectivity. B. He is in the incubation period of HBV. C. He is a chronic HBV carrier with low infectivity. D. He has recovered from HBV infection and is immune to HBV E. He had chronic active hepatitis

Answer: C

In the interpretation of results of hepatitis B serologic tests, the following facts should be considered: During the incubation period (i.e., before the onset of clinical manifestations) HbsAg, HbeAg, and HBV DNA become detectable in the serum. At the onset of clinical symptoms (e.g., jaundice), an increase in the serum transaminases antibodies occurs and antibodies to HBc become detectable (HBc antibodies). Initially, the HBc antibodies are IgM and thereafter IgG; these latter antibodies persist for years. HBs antibodies become detectable late in convalescence. A rise in HBs antibodies in combination with a loss of HbsAg, HbeAg, and HBV DNA indicate the presence of immunity to HBV. HbeAg and HBV DNA are markers of active viral replication and thus indicate high infectivity. The loss of HbeAg and appearance of anti-HbeAb indicates a less infective stage.

Acute HBV infection ------IgM anti HBc ABEarly diagnosis of acute HBV infection-------- HBsAg in serumMost reliable indicator of recent HB infection -----IgM anti HBcAfter 15 days of HBsAg --------- HBV DNA by PCR Indicators of HBV replication are:1. HBV DNA2. DNA POLYMERASE 3. Hbe Ag