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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3017_Библиотеки_им_академика_М_И_Перельмана
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202 Diagnostic EMQs
2. A 25-year-old woman presents for antenatal care. She is currently at 18 weeks’
gestation and this is her rst appointment with a doctor. She has a history of
bipolar disorder and is currently being treated with lithium. You arrange for a
fetal ultrasound which reveals a grossly enlarged right atrium, the septal leaet
of the tricuspid valve is displaced apically with a sail-like elongation.
3. A 29-year-old woman presents with her 4-week-old child who has had progres-
sive cyanosis. She explains that today he appears blue in colour, she is also very
concerned as he has been feeding poorly and appears to be breathing rapidly. She
had an uneventful home delivery and has not attended routine antenatal care. On
examination the child appears cyanosed and on auscultation of the praecordium
you hear a harsh pansystolic murmur at the left lower sternal edge which is louder
on expiration. You arrange a chest X-ray which reveals a boot-shaped heart.
4. A 29-year-old woman attends at 20 weeks’ gestation and has so far had an
uneventful pregnancy. You arrange for her 20-week fetal ultrasound which
reveals a poorly developed left ventricle, a small left atrium, enlargement of the
right side of the heart, a prominent pulmonary trunk and signicant narrowing
of the rst part of the aorta.
5. A 68-year-old male presents with shortness of breath and postural hypotension.
On examination you note that he has periorbital purpura, peripheral edema to
the level of his knees, hepatomegaly and a pleural effusion on the left. Echocar-
diography reveals atrial thickening, bi-atrial enlargement, a sparkling appear-
ance of the left ventricular myocardium and thickening of the left ventricular
wall with decreased compliance.
See page 210 for answers.
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Cardiology 203
ANSWERS
Chest pain 1
1. J. Pulmonary embolism
This is a condition in which a blood clot, usually from the lower limbs, travels to
the lungs and occludes blood ow. Asignicant pulmonary embolism can lead
to cardiac arrest.
2. E. Angina pectoris
Angina is by denition retrosternal chest pain or tightness which lasts for less
than ten minutes in duration and is relieved by rest and is caused by myocardial
ischaemia.
3. I. Pneumothorax
This patient has presented with a spontaneous pneumothorax. The chest pain is
usually pleuritic in nature.
4. F. Oesophageal spasm
These are painful contractions within the muscular layer of the oesophagus,
they can sometimes be precipitated by gastro-oesophageal reux disease
(GORD). Treatment initially involves drinking warm water, if this is unsuc-
cessful sublingual nitrates can be used.
Chest pain 2
1. H. Pericarditis
Pericarditis is inammation of the pericardium, a thin membrane that sur-
rounds the heart. Viral infections are the most common cause of pericarditis.
2. C. Dissecting thoracic aortic aneurysm
Patients typically present with sudden onset chest pain with radiation to the
back, classically described as “tearing” or “ripping”. They may also present
with shortness of breath and unilateral diminished or absent pulses.
3. K. Slipping rib syndrome
In this condition the cartilage in the lower ribs slips causing signicant dis-
comfort for the individual. There is usually a specic point of tenderness at the
costal margin.
4. G. Myocardial infarction
This patient presents with the classic features for acute myocardial infarction, cen-
tral chest pain lasting greater than ten minutes radiating to the left side and associ-
ated diaphoresis. He also has several risk factors for myocardial infarction. ECG
changes in this case reect those of an inferior STelevation myocardial infarction.
Cardiac vessels
1. D. Left circumex artery
This patient has had a lateral myocardial infarction.
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204 Diagnostic EMQs
2. C. Left anterior descending artery
This patient has had an anterior myocardial infarction.
3. H. Right coronary artery
This patient has had an inferior myocardial infarction.
Collapse 1
1. C. Diabetic neuropathy
This patient has poorly controlled diabetes as evidenced by repeated elevation
of HbA1c measurements. This patient also has evidence of peripheral neu-
ropathy and postural hypotension (a hallmark feature of diabetic autonomic
neuropathy).
2. H. Pulmonary embolism
This is a condition in which a blood clot, usually from the legs, travels to the
lungs and occludes blood ow. Asignicant pulmonary embolism can lead to
cardiac arrest.
3. F. Hypoglycaemic episode
This patient has recently changed her diabetic medications and has not yet had
breakfast. She has symptoms consistent with hypoglycaemia.
4. A. Addisonian crisis
This is a life-threatening condition which results in hypotension, hypoglycae-
mia and hyperkalaekmia. This patient requires urgent medical care.
Collapse 2
1. B. Cardiac tamponade
This occurs when the heart is compressed by uid or gas within the pericar-
dium. Metastatic cancer can cause malignant pericardial effusions resulting in
cardiac tamponade.
2. G. Panic attack
These are brief episodes of intense anxiety in which patients may experience
physical symptoms such as palpitations, shortness of breath and dizziness.
3. D. Epileptic seizure
This patient has had a tonic-clonic seizure; this type of seizure causes violent
muscle contractions and loss of consciousness. This patient is also suffering
from postictal symptoms.
4. E. Hypertrophic cardiomyopathy
The presentation and associated family history should raise suspicion about
hypertrophic cardiomyopathy (HOCM). This patient has typical praecordial
examination ndings consistent with HOCM.
5. K. Vasovagal syncope
In this condition a patient collapses as a result of a reex bradycardia and
peripheral vasodilation because of exposure to a stressful trigger. In this case
the most likely trigger is the vaccination.
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Cardiology 205
Arrhythmias 1
1. D. Cardiac tamponade
This occurs when the heart is compressed by uid or gas within the pericar-
dium. Electrical alternans is an ECG nding consistent with a large pericardial
effusion and tamponade.
2. Q. Wolff–Parkinson–White syndrome
In this condition an additional electrical pathway between the upper and lower
chambers of the heart causes tachycardia. Typical ECG ndings include short
PR intervals and QRS complexes with associated slurred upstroke (delta waves).
3. E. First-Degree heart block
The patient has an increased PR interval and is otherwise asymptomatic, he
does not require any treatment for his presentation.
4. B. Atrial Fibrillation
This patient has characteristic features of atrial brillation on her ECG, absent
P waves and irregularly irregular QRS complexes.
5. I. Right bundle branch block
This patient has the typical M shaped QRS complex (RSR’ pattern) in leads
V1-V3 and the W pattern in lead V6.
6. K. Second-Degree heart block – Mobitz type 2
This patient presents with second degree AV block (Mobitz type 2). This pre-
sentation requires immediate hospital admission as this may result in haemody-
namic compromise and progression to a third-degree heart block.
Arrhythmias 2
1. A. Acute pericarditis
This condition results from inammation of the pericardium. Typical exam
ndings include pleuritic chest pain and there may be an associated pericar-
dial rub on auscultation. This patient has classic ECG ndings: saddle shaped
STelevation in most limb leads with PR depression in most chest leads and
reciprocal changes in aVR and V1.
2. G. Hypertrophic cardiomyopathy
The presentation and associated family history should raise suspicion about
hypertrophic cardiomyopathy. ECG ndings in this case are typical of this
condition.
3. M. Third-Degree heart block
This patient has presented with a bradyarrhythmia and dissociation between the
atrial and ventricular beats. This patient requires immediate hospital admission
for cardiac pacing.
4. L. Supraventricular tachycardia
This patient has presented with Supraventricular tachycardia (SVT), the best
treatment options initially are non-pharmacological (Valsalva maneuver,
carotid sinus massage).
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206 Diagnostic EMQs
5. H. Pulmonary embolism
This is a condition in which a blood clot, usually from the legs, travels to the
lungs and blocks blood ow. Pulmonary embolism can lead to cardiac arrest.
This patient has typical ECG ndings including the classic S
I
Q
III
T
III
pattern.
Hypertension 1
1. E. Obstructive sleep apnoea
This condition causes multiple lapses in breathing during sleep. During sleep,
patients experience upper airway collapse which results in snoring. Sleep
apnoea can cause autonomic dysfunction which activates the sympathetic ner-
vous system and results in hypertension.
2. H. Primary hyperaldosteronism
Also known as Conn’s syndrome, this involves the over production of aldoste-
rone by the adrenal glands which results in sodium retention and potassium
excretion. Patients usually present with resistant hypertension and hypokalae-
mia (despite supplementation in this case).
3. I. Renal artery stenosis
This patient has uncontrolled hypertension despite the use of three agents,
peripheral vascular disease, a history of ash pulmonary oedema and a bruit on
abdominal examination. All of these features indicate renal artery stenosis as
the most likely cause of her presentation.
4. C. Cushing syndrome
This patient has typical physical ndings of Cushing syndrome. Failure to sup-
press cortisol levels following administration of low dose dexamethasone sup-
ports a diagnosis of Cushing syndrome.
Hypertension 2
1. B. Aortic coarctation
Coarctation of the aorta is narrowing of the aorta that reduces blood ow to
the lower half of the body beyond this area. This condition is usually picked up
during infancy, adults can present with it in later life with severe hypertension.
2. G. Polycystic kidney disease
This is an inherited condition in which cysts form within the kidneys, causing
them to gradually enlarge and lose function. Hypertension and haematuria are
common ndings in this condition.
3. A. Acromegaly
This is a condition in adulthood in which excess growth hormone (GH) is pro-
duced by the pituitary gland. It causes overgrowth of the bones in the face,
feet and hands. This condition can cause hypertension as it is associated with
hyperinsulinemia, which stimulates reabsorption of sodium in the kidneys and
sympathetic nervous system activity.
4. D. Hypothyroidism
This patient has classic physical features of hypothyroidism. Hypothyroidism
can cause diastolic hypertension due to vascular endothelial dysfunction.
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Cardiology 207
Murmurs 1
1. A. Aortic regurgitation
This condition occurs when the aortic valve does not close adequately, the result is
retrograde ow of blood from the aorta into the left ventricle during systole. The
murmur is best heard at Erb’s point (the left sternal border at the level of the 3rd
intercostal space). Clinical ndings can include a water-hammer pulse (bounding
pulse at the wrist), Corrigan’s pulse (bounding pulse in the carotids), de Musset’s
sign (bobbing of the head in synchrony with the heart) and a wide pulse pressure.
2. C. Atrial myxoma
Myxomas are the most common primary cardiac neoplasm, they are most
commonly found in the left atrium. The “tumor plop”, which is a high-pitched
sound usually heard in early diastole, occurs from either; 1) the mass on a stalk
impacting against the myocardium, 2) tumour obstructing out ow or 3) tumour
tensing.
3. E. Mitral regurgitation
This is when the mitral valve (between left atrium and left ventricle) is incom-
petent and blood ows from the left ventricle to the left atrium in retrograde
manner during systole. With progressive regurgitation patients can develop
shortness of breath especially on exertion and peripheral oedema. This patient
has typical examination ndings.
4. F. Mitral stenosis
This valve pathology is most commonly associated with rheumatic fever, usu-
ally in childhood. It presents with a diastolic murmur which is heard best at the
5th intercostal space on the mid-clavicular line. Following S2 (closure of the
aortic valve) the opening snap of the stenotic mitral valve is heard followed by
a low-pitched mid-diastolic murmur.
Murmurs 2
1. J. Tricuspid regurgitation
This patient presents with classical examination ndings. Examination also typi-
cally reveals Carvallo’s sign (murmur gets louder with deep inspiration), patients
with severe tricuspid regurgitation may present with an accentuated jugular CV
wave (Lancisi sign) and may also have congestive hepatopathy with a pulsatile liver.
2. I. Pulmonary regurgitation
This condition is most commonly found in association with pulmonary hyper-
tension. This type of murmur is very similar to that seen with aortic regurgita-
tion. The difference between the two being the location of where it is heard
loudest; this murmur being heard loudest at the upper left sternal edge and that
of aortic regurgitation being at the lower left sternal edge. Abounding pulse is
also absent with pulmonary regurgitation.
3. H. Pericarditis
This condition results from inammation of the pericardium. Typical exam nd-
ings include pleuritic chest pain and there may be an associated pericardial rub on
auscultation. There is typically widespread STsegment changes on the ECG.
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208 Diagnostic EMQs
4. K. Tricuspid stenosis
This is narrowing of the tricuspid valve which blocks blood ow from the right
atrium entering the right ventricle. This patient presents with classical clinical
features of this condition.
CHA2DS2-VAScScoring
1. E. CHA2DS2-VAScscore 4
The correct answer is CHA2DS2-VAScscore 4. He has scored
one point for congestive cardiac failure, one point for hypertension and two
points for age of 75 and above.
2. D. CHA2DS2-VAScscore 3
The correct answer is CHA2DS2-VAScscore 3. She has scored
one point for hypertension, one point for age between 65 and 74 and one point
for biological female sex.
3. B. CHA2DS2-VAScscore 1
The correct answer is CHA2DS2-VAScscore 1. He has scored
one point for diabetes mellitus.
4. C. CHA2DS2-VAScscore 2
The correct answer is CHA2DS2-VAScscore 2. She has scored
one point for vascular disease (peripheral arterial disease) and one point for
biological female sex.
5. G. CHA2DS2-VAScscore 6
The correct answer is CHA2DS2-VAScscore 6. He has scored
one point for hypertension, two points for age of 75 and above, two points for a
history of thromboembolism and one point for biological female sex.
Hypertension grading
1. D. Grade 1 (mild) hypertension
Patients with a systolic BP of 140–159 mmHg and/or diastolic BP of 90–99
mmHg are classed as having grade 1 (mild) hypertension. See Australian heart
foundation hypertension guidelines.
2. A. Optimal
Patients with a systolic BP of < 120 mmHg and diastolic BP of < 80 mmHg are
classed as having an optimal blood pressure. See Australian heart foundation
hypertension guidelines.
3. F. Grade 3 (severe) hypertension
Patients with a systolic BP of ≥ 180 mmHg and/or diastolic BP ≥ 110 mmHg are
classed as having grade 3 (severe) hypertension. See Australian heart founda-
tion hypertension guidelines.
4. G. Isolated systolic hypertension
Patients with a systolic BP > 140 mmHg and diastolic BP < 90 mmHg are
classed as having isolated systolic hypertension. See Australian heart founda-
tion hypertension guidelines.
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Cardiology 209
5. B. Normal
Patients with a systolic BP of 120–129 mmHg and/or diastolic BP of 80–84
mmHg are classed as having a normal blood pressure. See Australian heart
foundation hypertension guidelines.
Heart failure grading
1. D. NYHA Class IV
This patient reports that they are symptomatic at rest and with exertion, patients
are graded from class Ito class IV.
2. B. NYHA II
This patient is asymptomatic at rest, and becomes only mildly symptomatic with
exertion, but is able to continue her normal activities of daily living. Patients are
graded from class Ito class IV.
3. C. NYHA III
This patient reports that they are asymptomatic at rest and have marked symp-
toms with exertion. Her symptoms are signicantly impacting her daily activi-
ties. Patients are graded from class Ito class IV.
Cardiac structure 1
1. A. Atrial septal defect
This is a congenital defect of the heart in which there is a persistence of com-
munication in the septum between the atria of the heart. Most patients with a
small atrial septal defect are asymptomatic.
2. M. Ventricular septal defect
This condition is commonly associated with Down syndrome. This patient has
typical ndings on auscultation.
3. I. Peripartum cardiomyopathy
This is weakness of the heart muscles which occur at the advance stages of
pregnancy or after delivery. The heart becomes enlarged as a result and does
not pump blood effectively resulting in heart failure.
4. C. Dilated cardiomyopathy
This is a condition which affects the muscles of the heart causing progressive
dilatation and reduced capacity to pump effectively. It is likely that alcohol is
the causative factor for this patient.
5. L. Transposition of the great arteries
This is a congenital cardiac defect in which the aorta is attached to the right
ventricle of the heart rather than the left and the pulmonary artery is attached to
the left ventricle of the heart rather than the right. Symptoms of this condition
are usually present from birth.
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210 Diagnostic EMQs
Cardiac structure 2
1. G. Mitral valve prolapse
Also known as Barlow syndrome; this involves the bulging of one or both mitral
valve leaets into the left atrium during systole, allowing retrograde blood ow.
The patient is typically asymptomatic.
2. D. Ebstein’s anomaly
The use of lithium during the rst trimester of pregnancy is associated with
an increased risk of cardiac malformation. Apical displacement of the septal
leaet of the tricuspid valve by more than 8mm/m2 with a sail-like elongation
is diagnostic for Ebstein’s anomaly.
3. K. Tetralogy of Fallot
This is a congenital heart condition involving four abnormalities (pulmonary
stenosis, right ventricular hypertrophy, overriding aorta and ventricular septal
defect, pneumonic PROV). Achild with Tetralogy of Fallot usually has a harsh
systolic crescendo decrescendo murmur at the left upper sternal margin which
radiates through to the back (right ventricular outow obstruction).
4. F. Hypoplastic left heart syndrome
This is a congenital heart condition which affects blood ow through the heart.
In this condition the left side of the heart does not pump oxygenated blood
through the body effectively as the left ventricle is too small.
5. J. Restrictive cardiomyopathy
This patient has a history and examination ndings consistent with amyloidosis
and echocardiograph ndings support this. Amyloidosis is the most common
cause of restrictive cardiomyopathy.
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DOI: 10.1201/9781003459941-9 211
9
Respiratory
ARTERIAL BLOOD GAS INTERPRETATION 1
A. Metabolic acidosis – fully compensated
B. Metabolic acidosis – partial compensated
C. Metabolic acidosis – uncompensated
D. Metabolic alkalosis – fully compensated
E. Metabolic alkalosis – partial compensated
F. Metabolic alkalosis – uncompensated
G. Respiratory acidosis – fully compensated
H. Respiratory acidosis – partial compensated
I. Respiratory acidosis – uncompensated
J. Respiratory alkalosis – fully compensated
K. Respiratory alkalosis – partial compensated
L. Respiratory alkalosis – uncompensated
For each of the following, what is the MOST likely diagnosis?
1. pH 7.32, PaCO
2
36 mmHg and HCO
3
19 meq/L
2. pH 7.50, PaCO
2
31 mmHg and HCO
3
24 meq/L
3. pH 7.49, PaCO
2
41 mmHg and HCO
3
30 meq/L
4. pH 7.31, PaCO
2
52 mmHg and HCO
3
27 meq/L
See page 234 for answers.
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