Cairo University – Faculty of Medicine

Cardiology Department

Examination of the Master Degree in

Cardiology Disease

November,  2001. Paper II

Answer all questions

Time: 3 hours

A 67 year old obese female patient who is diabetic and heavy smoker received treatment for coronary artery disease over the past 11 years because of an ECG diagnosis of myocardial infarction (ECG (1), 1990).

There was no history of angina pectoris although her activities were always limited by shortness of breath. In 1990, the chest x-ray was normal and the echocardiogram showed the following measurements in (mm): LVEDD 53, LVESD 28, posterior wall thickness 11, septum 19, left atrium 42.

The ejection fraction was 78%. Other findings included moderate mitral regurgitation and absence of segmental wall motion abnormalities.

In 2001, the patient was admitted to hospital because of recent rapid deterioration in effort tolerance, orthopnea and chest tightness. She was still smoking. Examination showed a rapid irregular pulse at 120 beats/min, jugular venous pressure elevation 10 cm, blood pressure 100/70 mmHg.

The chest showed bilateral diffuse sibilant bronchi. Cardiac auscultation revealed an ejection systolic murmur at the left sternal border, and a longer and softer systolic murmur over the apex. There was no S₃ gallop. The ECG is provided (ECG (2), 2001). Chest x-ray showed generalized cardiomegaly, dilated upper lobe vessel and veiling of the lower lung fields.

a- Discuss the diagnosis and differential diagnosis of this case.

(20 marks)

b- Comment on the pathogenesis of the electrocardiographic findings in ECG.s (1) and (2).

(5 marks)