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Cairo University
Faculty of Medicine |
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Department of Cardiovascular Medicine
November, 2004 |
Doctorate
Degree in
Cardiovascular
Diseases
Paper I
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Answer all questions |
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Time: 3
hours
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1) A: Discuss the
value and limitations of serum cardiac troponins in the evaluation and
management of heart disease.
B:
Outline the advances in the development of biomarkers for the diagnosis of
myocardial ischemia.
2) Write a critical
appraisal of each of the following:
A:
Examination of the pericardial fluid for the diagnosis of pericardities.
B: The
genetic basis of thrombophilia.
C: The
etiology and differential diagnosis of coronary artery aneurysms.
3) Discuss the current guidelines for the management of non-sustained
ventricular tachycardia
4- A 72 year old female who has diabetes mellitus, hypertension and a
history of angina pectoris for 5 years presented with acute pulmonary edema and
recurrent angina at rest. She was hospitalized and given parentral diuretic,
nitroglycerine, Angiotensin converting enzyme inhibitor, antithrombotic therapy
and insulin control of diabetes. She gave a history of transient left sided
weakness one month earlier.
Examination revealed normal jugular venous pulse, regular sinus rhythm and BP
140/90 mmHg. The popliteal and distal leg pulses were absent bilaterally. The
femoral pulses were 3+. The chest showed bilateral crepitations. The abdomen was
free. Cardiac auscultation revealed normal S1, loud A2, variable wide splitting
of S2, S4 and S3 were heard over the apex. Neurological examination was
unremarkable.
The chest X-Ray showed pulmonary interstitial edema. The ECG
showed complete right bundle branch block with primary ST segment depression in
anterolateral leads. The echocardiogram showed LVED 4.6 (CM), LVES 2.8, Septum
1.1, Posterior wall 1.0, fractional shortening 35%, LA 4.6, Aorta 2.9, Right
ventricle 1.9. The left ventricle showed apical hypokinesis, with normal global
systolic function.
Lab data: Fasting plasma glucose 196 (mg/dl). Creatinine 1.6,
hemoglobin 9.3, and total leukocytic count 5600/mm3 Duplex
ultrasound of the carotid arteries showed a plaque causing 70% diameter stenosis
at the origin of the right internal carotid artery and minor changes on the left
side. Coronary angiography showed 3 vessel disease; a proximal 90%
stenosis of the left anterior descending coronary artery, 70% focal stenosis in
the obtuse marginal branch, and severe stenosis of ht right coronary artery.
A: Discuss the possible management strategies in this case.
B: Discuss the current concepts of myocardial revascularization in
patients with diabetes mellitus and coronary artery disease.
GOOD LUCK
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Cairo University
Faculty of Medicine |
|
Department of Cardiovascular Medicine
November, 2004 |
Doctorate
Degree in
Cardiovascular
Diseases
Paper II
|
Answer all questions |
|
Time: 3
hours
|
1) Discuss the definition, pathophysiology, cardiovascular risk, and
management of the metabolic syndrome.
(20 marks)
2) Outline the cardiovascular manifestations of each of the following:
a-
Human immunodeficiency virus infection
(10 marks)
b-
Behcet's disease
(10 marks)
c-
Depression
(10 marks)
3) Outline the cardiovascular actions and interactions of each of the
following:
a- Peroxisome proliferators activator receptor (PPAR) agonists
(10 marks)
b- Erytheropoitein
(10 marks)
c- Cyclo-oxygenase (COX) 2 inhibitors
(10 marks)
4) Discuss the indications, results and complications of percutaneous
device therapy for congenital cardiac left-to-right shunt.
GOOD LUCK
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|
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Cairo University
Faculty of Medicine |
|
Department of Cardiovascular Medicine
November, 2004 |
Doctorate
Degree in
Cardiovascular
Diseases
Commentary
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Answer all questions |
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Time: 3
hours
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- A 33 year old male patient was admitted in January 2002 to the
department of internal medicine complaining of fever, cough, blood tinged
septum, vomiting, deterioration in effort tolerance, leg oedema and abdominal
swelling which developed over the previous 3 months. There was no past history
of rheumatic fever, tuberculosis, bilharziasis or other chronic medical illness.
The patient used to smoke cigarettes and hashish for 13 years. There was no
report of the diagnosis during that admission. The available investigations
showed hemoglobin 8.1 gm/dL, TLC 12300/mm3, staff 0, poly 73, :19, M 3, Eos 5, B
0%. ESR was 65 mm/1 h and 105 mm/2 h. serum bilirubin was 0.5 mg/dL, serum
albumin 2.9 gm/dL, serum creatinine 1.2 mg/dL, INR 1.6. ANA, and HIV were
negative.
The patient was transferred to the National Heart Institute where he received
medical treatment and underwent tricuspid valve replacement using a porcine
tissue valve. There was no report of the investigations performed at this stage.
Following surgery that symptoms improved, abdominal selling disappeared and the
patient resumed normal activities for one year.
In March 2..3 the patient was readmitted with a picture of cachexia, wasting,
abdominal swelling, oedema and pigmentation of both lower limbs. The jugular
venous pressure was elevated to the lobule of the ear showing an "a" wave. The
chest was clear. The abdomen showed hepatomegaly, splenomegaly and ascites.
Cardiac examination revealed a quiet precordium, soft S1 and normal S2.
auscultation at the left sternal border showed a soft systolic murmur, and a
long rumbling diastolic murmur increasing with inspiration. The patient received
frusemide and spironolactone.
The ECG showed biphasic p wave, incomplete right bundle branch block an diffuse
flat T waves.
Combined TTE and TEE showed (in cm), LVEDD 4.5, LVESDD 2.8, S 1.0, PW 0.9, LA
3.9, Ao 3.0 and RV 2.3, LVEF was 0.76. The mean diastolic gradient across the
tricuspid valve was 20 mmHg and there was 2-3/4 + tricuspid regurgitation. There
was mild anterior pericardial effusion. (A TEE frame is provided). Abdominal
ultrasound showed an enlarged liver displaying slightly coarse texture,
undulated border and dilated hepatic veins and inferior vena cava. The portal
vein was 12 mm in diameter. There were no focal lesions or bile duct dilatation.
The spleen was homogenous and enlarged. There was marked ascites.
Other laboratory findings were hemoglobin 11.3 gm/dL; TLC 9600/mm3, serum
albumin 2.0 gm/dL, and INR 2.4. The serum was positive for hepatitis C virus.
1) Discuss the investigations, diagnosis and differential diagnosis of
this case.
(70 marks)
2) Describe subsequent management of the patient.
(30 marks)
GOOD LUCK
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