Cairo University – Faculty of Medicine

Master Degree In

Cardiovascular Diseases

 November,  2005.

Part II . Paper II.

Answer all questions

Time: 3 hours

(1) A 34-year-old man presented with chest pain and dyspnea on exertion. He was in his usual state of health until one week before admission. He developed mid-sternal diffuse chest and right shoulder ache which increases with deep inspiration, fever, chills, sweats, severe dyspnea on exertion, and an attack of syncope.
Past History: No significant past medical history. He uses alcohol, smokes cigarettes, and has a history of cocaine abuse.
Physical examination: Mild respiratory distress and diaphoretic, temperature of 38.5° C, pulse of 129 bpm, PB 122/81 mm Hg. Oropharynx was clear without thrush. There was no cervical lymphadenopathy; the trachea was midline. There was no jugular venous distention. The breath sounds were diminished at the bases with crackles at the right base without wheezing or rhonchi. Cardiac examination revealed distant heart sounds; tachycardic; normal S1 and S2 with no murmurs, rubs, or gallops. The abdomen was not tender on palpation with normal organ sizes. The extremities were warm, without edema or clubbing.
Oxygen saturation: 96% on room air.
Diagnostic Tests: ECG showed non-specific T-wave changes. A chest CT (Figure 1) and echo (Figure 2) were obtained.
Labs: Serologic evaluation revealed a creatine kinase 68 U, troponin I <0.05 ng/ml, negative antinuclear antibody and rheumatoid factor, C-reactive protein 21 mg/dl, and ferritin 1348 ng/ml. The pericardial fluid had 37,000 white blood cell count (many neutrophils, lymphocytes, and reactive mesothelial cells).
Hospital Course: Initial ER pericardiocentesis was performed and 550 ml of serosanguineous fluid was drained. The patient was empirically started on a multidrug tuberculosis regimen and broad-spectrum antibiotics. Despite this, the patient remained tachycardic and had a persistent pericardial effusion. A surgical subxiphoid pericardial window was performed the next hospital day. Another 500 ml of pericardial fluid was drained.

The provisional diagnosis at this stage was either;
          A. Infectious pericarditis.
          B. Bacterial endocarditis.
          C. Tuberculosis.
          D. Sarcoidosis.
          E. HIV-infection.

 

Comment on the 5 marked points. Figure-1; CT-scan of the chest.	Comment on the 3 marked points. Figure-2; Apical 4-chamber echo.

(1) Discuss the following:
          a. Describe the findings in Figure 1 and 2.

(10 Marks)

          b. Possible diagnosis.

(10 Marks)

          c. Investigations needed to rule out other possibilities.

(10 Marks)

(2) Give a short account on the mode of action, indications and side effects of:
          a. Agiotensin receptor blockers.

(10 Marks)

          b. Glycoprotein IIb/IIIa inhibitors.

(10 Marks)

          c. Fenoldopam.

(10 Marks)

(3) Discuss the emergency room evaluation of a diabetic patient with acute lower limb pain.

(20 Marks)

(4) Discuss the clinical presentation, diagnosis and management of ASD at the age of 30 years.

(20 Marks)

Good Luck.