Medicine solved scenerio based questions (CARDIOVASCULAR SYSTEM)

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 Medicine solved scenerio based questions (RESPIRATORY SYSTEM)

CARDIOVASCULAR MEDICINE


Risk of Cardiovascular Disease

A 53-year-old bank executive comes for routine checkup. He has sedentary lifestyle and smokes on cigar daily. Although asymptomatic, he is worried about his heart because of positive family history. He is 5.5 inches tall and weighs 85 kg, his waist measures 42 inches and sitting BP was recorded as 150/95 after five minutes rest in the clinic.
a) What points in the history & physical examination are relevant to the CVS risk?
b) What investigations should be done to determine his total risk of developing
cardiovascular disease?
c) What medication may be indicated to reduce the risk of CVS disease?



Heart Failure

A 60-year-old diabetic female presents with gradually increasing breathlessness on exertion. According to her, she becomes breathless while changing her clothes and also gives history of breathlessness during sleep which improves with sitting.
a) What six clinical examination findings you will try to look for confirming your provisional diagnosis?
b) What two drug groups must be used in this patient for improvement?
c) What are the two treatment options for patients who do not improve with
maximal lifestyle modification and drug treatment?

A 58-year-old hypertensive male presents with severe dyspnea. He gives history of severe central chest pain occurring in the morning associated with sweating and later followed by breathlessness. On examination, there are bilateral crepitations up
to mid-chest.
a) What investigations are required? Justify it.
b) How you are going to manage this patient?

A 50-year-old man, a known case of ischemic heart disease and Diabetes Mellitus
seen in ER with acute history of shortness of breath & profuse sweating. On
examination, his BP is 170/110 mm Hg, sinus tachycardia, rate is 120/min, his JVP is
not raised and bilateral fine crepitations are present up to mid zone of chest.
a) What is the most likely diagnosis?
b) What investigations are required in ER?
c) Outline the management.

A 65-year-old diabetic for 35 years presents with shortness of breath and orthopnea.
He has got previous history of shortness of breath. On examination, pulse is
100/min, blood pressure is 160/100 mm Hg, respiration rate is 24/min, temperature
is 95 F, pedal edema is present. JVP is raised and fine basal crackles on the base of
both lungs are present. Apex beat is also displaced and S3 is audible on auscultation.
a) What is your provisional diagnosis?
b) What investigations should be advised for this patient?
c) Enlist five drugs to be given in this patient.

A poorly controlled hypertensive patient has come with progressive dyspnea on
exertion. On examination, there is 3rd heart sound and few basal crepitations.
a) What is the most likely cause of his symptoms?
b) How will you confirm the diagnosis?
c) Name four drugs which may be useful for him.

A fifty-year-old person presents in the emergency wad with severe dyspnea. On
physical examination, his pulse is 110/min regular. Lying down BP 110/70 mm Hg. His
chest is full of fine crepitations without any wheeze. Percussion note is dull on both
bases. Heart sounds are normal except gallop without any murmur. His
investigations are as follows: Hb 13.5 gm%, Creatinine 1.1 mg/dl, Ejection fraction
30%. How would you manage this patient?


Angina Pectoris

A 50-year-old hypertensive male presents with pain behind the breastbone occurring
on exertion with radiation to the left arm. What are the three most likely diagnoses?
Name three stress tests which can be used to reach a final diagnosis.

A 50-year-old male smoker presents with pain behind the breastbone. On further
inquiry, he has radiation of pain towards the jaw and left arm with the pain occurring
only on exertion and relieved by taking rest. He has insignificant past history of any
disease and the detailed physical examination is normal.
a) What can be the six most likely causes of breastbone pain?
b) What three investigations can help in confirming the diagnosis and what lifestyle
advice will you give?

A 50-year-old male smoker and diabetic complaining of precordial chest pain usually
precipitated by stress or exertion and relieved by rest, lasts for 5-10 minutes seen in
OPD department for consultation.
CBC: Hb 16 gm/dl, WBC 9×10^9, Platelets 450×10^9. His resting ECG is normal.
a) What is the most likely diagnosis?
b) What further investigations are required?
c) Enlist the various groups of pharmacological drugs used in his management and
other treatment modalities.

A 40-year-old female presented in A&E department with central chest pain which
would usually come at rest. It bothers her intermittently for last one year. You did an
EKG which shows ST segment elevation in precordial leads. You requested for a
cardiac enzyme panel which turned out to be normal. Meanwhile she was given
aspirin and sublingual nitroglycerin to which she responded with improvement in her
chest pain.
a) What is the diagnosis?
b) How would you confirm the diagnosis?
c) How will you treat this patient?


Acute Coronary Syndrome

A 58-year-old hypertensive male presents with severe dyspnea. He gives history of
severe central chest pain occurring in the morning associated with sweating and
later followed by breathlessness. On examination, there are bilateral crepitations up
to mid-chest.
a) What investigations are required? Justify it.
b) How you are going to manage this patient?

A 50-year-old male presented in the emergency with severe central constricting
chest pain radiating to left arm and lower jaw. There is associated profuse sweating.
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His blood pressure is 90/60 mm Hg. Pulse is 90/min regular. His ECG shows ST
segment elevation in leads II, III and aVF.
a) What is your diagnosis?
b) Which coronary artery is involved?
c) What are other acute coronary syndromes?
d) Enlist the main steps of treatment.

A 55-year-old smoker presented to emergency room with a complain of severe
central chest pain along with sweating and vomiting. On examination, his BP is
160/100 mm Hg and the pulse is 100/min regular. His chest is clear. His father had
died a sudden death at the age of 40 years. ECG showed ST segment elevation in
leads V1-V6.
a) What is the diagnosis?
b) What are the risk factors in this patient?
c) How will you manage this patient in Emergency Room?

A 60-year-old jeweler develops severe retrosternal chest pain with profuse sweating
at 6 am on a cold winter morning. On presentation at 8 am in the emergency, his
pulse rate was 110/min with BP of 150/100 mm Hg and a fourth heart sound is heard
in the left parasternal area without any other significant clinical finding.
a) Give three possible diagnoses in the order of the priority.
b) What four investigations should be done immediately?
c) Enumerate four most important management steps that you will take in the 1st
hour of hospitalization.

A 50-year-old male known diabetic complained of pain in the epigastrium radiating
to the back along with syncopial attack. He had one episode of vomiting and gave
history of similar attack on week back as well. His pulse is 75/min, regular and good
volume. BP on admission was 160/100 mm Hg. His ECG strip show ST elevation in II,
III and aVF leads along with prolonged PR interval.
a) What is the diagnosis?
b) Outline the acute management plan of this patient.

A 58-year-old male smoker complained of pain in the epigastrium radiating to the
back accompanied by pallor and cold sweats. He had one episode of vomiting and
gave history of similar attack of pain, though of lesser duration while walking back
from his work one day. His BP on admission was 160/100 mm Hg and ECG showed ST
elevation in I, aVL, V4, V6.
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a) What is the diagnosis?
b) Enlist the acute management of this patient.
c) Enlist four common complications of condition along with their management.

Hypertension

A 45-year-old male non-smoker seen in OPD, who has been first time diagnosed as a
case of hypertension. His blood pressure 160/100 mm Hg, pulse 80/min regular, JVP
is not raised, CVS normal first and second heart sounds, no gallop, chest is normal on
percussion and auscultation. There is no family history of diabetes mellitus,
hypertension and dyslipidemia.
a) What are the various pharmacological steps in controlling his BP according to UK
hypertension guidelines?
b) If this patient is above age of 55, what will be main difference of treatment?
c) What basic routine tests are required while patient is on treatment?

An 18-year-old asymptomatic cade is found to have a blood pressure of 180/110 mm
Hg on a routine medical examination. His pulse rate is 74/min, regular and has no
other significant clinical findings.
a) Give four most likely causes of hypertension.
b) Enumerate four most useful investigations in this case.
c) Give two bedside clinical signs to evaluate target organ involvement/damage in
this case.

Give four surgical remediable causes of hypertension.

A 17-year-old boy presents with BP of 190/110 mm Hg.
a) How will you investigate him for secondary hypertension?
b) Enumerate four classes of antihypertensive drugs.

A 35-year-old male comes to you with frequent occipital headache. Both his parents
were hypertensive and have died. O/E his BP is 170/150 mm Hg. Rest of examination
is normal.
a) Name five investigations to rule out a secondary cause.
b) Enlist lifestyle changes this patient should follow.
c) Enlist five classes of antihypertensive drugs.


Rheumatic Fever/Rheumatic Heart Disease

A 15-year-old boy presented with 1 week history of sore throat followed by joint
pains mainly involving large joints in migratory sequence. His mother also noticed a
macular rash with clear center on his trunk. On examination, his pulse is 80/min
regular, BP is 110/70 mm Hg and a short mid-diastolic murmur is heard on
auscultation.
a) What is the most likely diagnosis?
b) Enlist the criteria to diagnose this illness.
c) Outline the medical treatment.

A 14-year-old girl presented with complaints of joint pain and swelling which first
involved the left elbow and then involving the right knee joint over a period of 14
days (migratory). She also complained of slight shortness of breath on exertion.
There is history of sore throat infection 3 weeks back. Her vitals are following: Pulse
110/min, BP 110/80 mm Hg, temperature 102 F and respiratory rate 18/min. JVP is
not raised, no pedal edema is present. Auscultation reveals a soft mid-diastolic
murmur at mitral area.
a) What is your provisional diagnosis?
b) What investigations should be advised in this case?
c) List down causes of diastolic murmur at apex.

A 12-year-old boy presents with complaints of joint pain with swellings in the left
elbow and then the right knee joint over a period of 10 days. He also complains of
mild breathlessness while playing. There is history of sore throat infection 3 weeks
back. His vitals are: Pulse 110/min, BP 110/80 mm Hg, Temperature 102 F,
respiratory rate 18/min. JVP is not raised. No pedal edema is present. Auscultation
reveals a soft mid-diastolic murmur at mitral area.
a) What is your provisional diagnosis?
b) What investigations should be advised in this case?
c) Write down steps of management.

An 18-year-old girl presents with a history of weakness of right half of her body for 6
hours. Examination reveals irregularly irregular pulse. She has history of joint pains
and fever off and on.
a) What is the likely diagnosis?
b) What is the likely cause of her joint pains?
c) How can fever be prevented in the future?

A 12-year-old boy is brought to you with swollen and painful right knee joint. Few
days earlier he had similar swelling of the left wrist joint which is improving. Rest of
the physical examination including CNS, CVS and skin is unremarkable.
a) What is the most likely diagnosis?
b) What criteria are applied to establish the diagnosis?
c) What may be chronic complications of this disease?
d) How can you prevent it in future?

A 16-year-old young girl from a village gave history of low-grade fever of four weeks
duration with weakness, breathlessness, palpitations and joint swelling. On
examination, she looks sick, has temperature 100.5 F, her pulse is 102/min, irregular,
BP 100/60 mm Hg and cardiac auscultation reveals Grade 3 diastolic murmur at
cardiac apex. She has small nodules along the extensor surface of the shin and arm
and painful tender swelling of the right and left knee joints. Chest X-ray shows
cardiomegaly.
a) What is the diagnosis?
b) How you confirm the diagnosis?


Mitral Valve Disease

A 23-year-old married female with a single child, presented in cardiology clinic with
complaints of shortness of breath. She is diagnosed case of rheumatic heart disease
and receiving prophylaxis with benzathine penicillin. She is on digoxin and diuretic
therapy. On examination, she has a pansystolic murmur at apical area radiating to
axilla.
a) What is the valvular lesion?
b) What investigations will you advise?
c) What is the treatment of choice in this patient?

A 28-year-old pregnant female in her third trimester is brought to the medical
emergency markedly short of breath and having hemoptysis. Her pulse is 102/min,
regular and small volume, BP 90/60, neck veins distended with prominent ‘a’ wave,
apex beat in left 6th intercostal space in midaxillary line, her first and second heart
sounds are prominent. There is faint long diastolic murmur increasing in intensity
towards the ed. She also has bilateral basal crackles.
a) What is the complete clinical diagnosis?
b) Give four findings likely to be seen on her chest x-ray?
c) What four treatment options are available for such a lesion?

Aortic Valve Disease

A 46-year-old man with progressive dyspnea with exertion is found to have
tachycardia with a large volume pulse. Early diastolic murmur at the base of the
heart and a BP of 140/50 mm Hg.
a) What three peripheral signs will you look for in cardiovascular system/
b) What is the most likely diagnosis?

A 65-year-old diabetic and hypertensive male patient presents with complaints of
chest pain which occurs on exertion and is associated with feeling of shortness of
breath. Pain is relieved at rest. He also gives history of several episodes of giddiness
while working. On examination, apex beat is in 5th intercostal space in anterior
axillary line. An ejection systolic murmur of grade III is present in aortic area with
radiation towards the carotids. ECG shows left ventricular hypertrophy and cardiac
enzymes are normal.
a) What is your diagnosis?
b) Enumerate two important investigations that you will order in this patient.
c) What is the management of choice in this patient?


Infective Endocarditis

A 20-year-old male diagnosed as Rheumatic Heart Disease developed high grade
fever. On examination, vitals are pulse 120/min, temperature 103 F, respiratory rate
22/min and BP 130/80 mm Hg. Patient looks toxic and tachypneic. There are macular
reddish lesions on the palmer surface of the hands. Abdominal examination shows
splenomegaly. Auscultation reveals a mid-diastolic murmur in mitral area.
a) What is your diagnosis?
b) What are the investigations of choice?
c) Write down management.

A 16-year-old young girl from a remote village gives history of low-grade fever of 3
weeks duration with weight loss, weakness, breathlessness and palpitations. On
examination, she looks sick, has temperature of 100.5 F, her pulse is 102/min
irregular. BP 100/60 mm Hg and cardiac auscultation received grade 3 diastolic
murmur at cardiac apex. She has mild splenomegaly as well. Chest x-ray shows
straight left border only.
a) What is the diagnosis?
b) How will you confirm the diagnosis?

A 22-year-old female who underwent an aortic wall replacement some 10 years ago
for rheumatic heart disease now presents with low grade fever for the last six weeks
which partially responds to antibiotics and antipyretics.
a) Enumerate three clinical findings that will help to reach the diagnosis.
b) Give five most relevant investigations.
c) List two most important steps in the management of this lady.

A 10-year-old boy has fever for last three months. He also has pain in left
hypochondrium. His examination shows a diastolic murmur in the precordium and
soft tender spleen.
a) What is the likely diagnosis and why?
b) How will you manage her?


Cardiomyopathy

A 20-year-old male presented with complaints of exertional chest pain and dyspnea
on walking. He has no previous history of cardiac disease. His father had a heart
condition and died. His pulse is 100/min, jerky in character, BP 100/60 mm Hg and
respiratory rate 20/min. Double apical impulse is palpable which is not displaced.
There is a short systolic murmur at base of heart and a pansystolic murmur at apical
area. S4 is also audible. Rest of systemic examination is normal.
a) What is your provisional diagnosis?
b) What investigations will you advise?
c) Write down any two worse prognostic factors in this condition.

Pericardial Diseases

A 50-year-old hypertensive male patient presents with pain behind the breastbone
occurring on exertion with radiation to the left arm. After few days the patient’s pain
becomes constant which increases on bending forward and coughing. He also
develops low grade fever. On auscultation of precordium, three is systolic additional
sound. What is now the most likely diagnosis? What two medicines can be used for
the relief of pain?

A patient presented with slow onset of progressive dyspnea, fatigue and weakness.
On examination, you find mild ankle edema and soft hepatomegaly with ascites. An
echo was done which revealed pericardial constriction.
a) What is the characteristic sign in JVP?
b) Enumerate a few causes.

A 20-year-old boy had fever, central dull chest pain which worsened on deep
breathing and improved on leaning forward. He also had progressive dyspnea for the
last one month. There were no joint symptoms. On examination, his temperature
was 38.5 C, pulse 130/min and BP 110/70 mm Hg. Apex beat was not palpable. On
auscultation, heart sound was soft and a rough scratchy sound was audible all over
the precordium. The respiratory exam was normal. X-ray chest showed enlarged
globular shadows.
a) What is the most likely clinical diagnosis?
b) Enumerate three investigations of this patient.
c) What is the management, if patient develops raised JVP, pulsus paradoxus and hypotension

A 57-year-old man being managed conservatively for chronic renal failure with urea
of 245 mg/dl and creatinine of 4.5 mg/dl, develops sharp sub-sternal chest pain for
two days. He is not obviously dyspneic. His pulse is 90/min regular and of small
volume becoming even smaller during inspiration. BP 105/75 mm Hg, distended neck
veins, apex beat could not be localized and he has very faint heart sounds. Chest is
clear on auscultation.
a) What is the likely diagnosis?
b) What is the single most useful investigation?
c) What is required for the long-term relief of his problem?


Miscellaneous

A 50-year-old man was admitted with left sided chest pain of one hour duration 48
hours ago. On admission, his blood pressure was 130/80 mm Hg and CVS
examination was normal. ECG showed ST segment elevation. Myocardial Infarction
and Q waves in anterior chest lead. On 7th day of admission while going to
washroom, he developed sudden severe dyspnea. On examination, his blood
pressure was 110/80 mm Hg. Jugular Venous Pressure (JVP) was raised. On
auscultation of the heart, a new pansystolic murmur was heard over the precordium.
Chest examination revealed bilateral basal crepitations.
a) Enumerate three causes of pansystolic murmur in this patient.
b) Enumerate the steps of management of acute pulmonary edema.

Write short notes on:
a) ECG changes in acute anterior inferior myocardial infarction.
b) Use of B-blockers in medicine

A 14-year-old presented at OPD with fever, cough and left lower chest pain of three
days duration. Clinical examination shows temperature 100 F, pulse 100/min, BP
160/110 mm Hg. A radio-femoral delay in pulse was noted. Respiratory system
examination showed trachea central, percussion note dull and bronchial breathing at
left lower chest.
a) What is the clinical diagnosis?
b) How will you convince the parents that their boy will need operation in future?

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