how to pass medicine exams2

Cardiac dicussion2
Case3/atrial fibrillation
1-history
*palpitation
*syncope
*tiredness
*dyspnea
*history of[ischamic heart disease---hypertension---rheumatic heart disease---congenital heart disease---valvular heart dsisease---thyrotoxicosis]
*history of caffien/digitals/theophylin consumption
2-examination
*irregular irregular pulse
look for * malar flash,mitral valvotomy scar[mitral stenosis]
*warm hands,goitre,pretibial myxedema[thyrotoxicosis]
*check for blood pressure [hypertension]


Q1.what are the commenest causes of atrial fibrillation?
A1.(1)mitral valvular disease in middle and young age
(2)ischaemic heart disease and hypertension in old age
(3)thyrotoxicosis (atrial fibrilltion may be the only clinical feature in old age)
(4)constrictive pericarditis
(5)chronic pulmonary disease


Q2.what are the commenest sites of systemic embolisation?
A2.legs, brain,kideny,spleen , coronary artery , superior mesenteric artery


Q3.how would you investigate this patient?
A3. ECG / echocardiography / thyroid function test


Q4.what are the other causes of irregular irregular pulse?
A4. multiple ventricular ectopics / atrial flutter / complete heart block


Q5.how would you treat such a patient?
1-Attempt to restore ventricular rate
*in hypertensive patient use Ca blockers
*in thyroid patient use beta blockers
*in ischeamic heart patient use beta blockers or Ca blockers
*in heart failure use digoxin or Ca blockers
2-attempt to restore sinus rhythm by cardioversion and drugs
*drugs restore the sinus rhythm are[quinidine/procainamide/amidarone]
3-anticoagulation with warfarin is advised in some patient



case4/aortic stenosis
1-history
*most of patient are asymptomatic
*dyspnea is a common symptom suggest left ventricular dysfunction
*fatigue
*angina in 70%
*syncope in 25%

2-examination
*low volume pulse
*heaving non displaced heart apex
*palpable systolic vibration over the primary aortic area with the patient in sitting position
*systolic thrill over the aortic area
*second soft heart sound
*ejection systolic murmur+ejection click after 1st heart sound
*third heart sound indicate left ventricular dysfunction.

Q1.mention some causes of aortic stenosis?
A1.-under the age of 60[rheumatic,congenital]
-between 60 to 75[cacified bicuspid aortic valve]
-more than 75 [degenerative cacification]


Q2.what do you understand by the term ejection systolic murmur?
A2.it is a crescendo-decrescendo murmur which begins after the 1st heart sound and ends before the second.

Q3.what are the complication of aortic stenosis?
A3.(1)left ventricular failure
(2)arrythmias
(3)systemic embolization
(4)infective endocarditis 10% of cases
(5)heamolytic anemia
(6)sudden death 10-20%


Q4.how would you manage this patient?
A4.valve replacement even in asymptomatic patients
*if the patient presents with signs and symptoms of aortic stenosis with normal aortic valve in echocardigraphy,this cauld be supravalvular or subvalvular aortic stenosis.

Q5.if this patient had a bleeding per rectum what is the unusual cause come to mind?
A5.angiodyplasia of the colon

Q6. if the patient was icteric and had a heamolytic anemia what is the cause?
A6.sever cacified aortic stenosis cause sever heamolysis and jaundice.



Case5/myocardial infarction
1-history
*dyspnea
*palpitation
*syncope
*post infarct angina
*family history of[cardiovascular diease/hyperlipidemia/gout]
*smoking
*past medical history of [DM/hypertension/stroke/myocardial infarction /hyperlipidemia]
*history of cotraceptives in youn women


2-examination
*hands:nicotine staining of the fingers
*pulse:check the rate(keeping in your mind tackycardia or bradycardia),check the rhythm (keeping in your mind atrial fibrillation or ventricular arrythmias)
*check blood pressure
*JVP may be raised
*eyes:look for arcus senilis or xanthelasma
*apex beat: double apical impulse
*auscultate: 4th heart sound,pericardial rub,pansystolic murmur


Q1.what is levien's sign?
A1. in acute myocardial infarction the patient often descibes the pain as cleching fist

Q2.what are the major risk factors for MI ?
A2.*DM
*HTN
*hyperlipidemia
*smoking


Q3.how would you manage a patient with acute MI?
A3.*immediatly(1)chewable non coated aspirin 160-325mg
(2)pain relif
*within 30min after hospital admission:--thrombolysis
*within 12hours from the infarction:--beta blockers if there is no contraindications
*within the 1st 24hours :--ACE inhibitors

Q4. what are the complication of MI?
A4.*arrythmias[early and late complication]
*thromboembolism[early and late complication] *heart failure[early complication]
*circulatory failure:cardiogenic shock:heart block [early complication]
*pericarditis[early complication]
*mitral regurgitation[late complication]
*rupture of ventricular septum[late complication]
*dresseler's syndrome(pyrexia+pericarditis 2 to 12 weeks after the infarction) [late complication]
*ventricular aneurysm[late complication]

Q5.what is a silent MI?
A5.it is a painless infarction ,common in diabetics and in elderly,they may be presents with complication.

reference:Davidson's clinical cases