Final Exam on the Whole Course

Morphine improves cardiac asthma but is contraindicated in bronchial asthma. Cardiac asthma has inspiratory dyspnea, the patient is never free between attacks, and adrenaline is contraindicated.

Warming improves peripheral cyanosis but has no effect on central cyanosis. Clubbing, secondary polycythaemia and low arterial PO2 belong to central cyanosis.

In heart failure the pulse is weak because of the low COP, so a large volume pulse is not a feature. Tachycardia, oliguria and an enlarged tender liver are all features of H.F..

Malignant hypertension is systemic HPN, a pressure overload on the left ventricle. Pulm. HPN, tricuspid incompetence and right ventricular myocardial disease (the same like Lt. v., e.g. infarction) are causes of right ventricular failure.

Bilateral basal crepitations are a backwards sign of left-sided H.F., due to pulmonary congestion. Oedema of the lower limbs, ascites and pain in the Rt. hypochondrium are systemic congestion features of right-sided H.F..

Hypercalcaemia is listed only with thiazides. Hypokalaemia, hyperglycaemia and hyperuricemia are side effects of both loop diuretics and thiazides.

At 2-4 µg/kg/min dopamine acts on dopaminergic receptors to increase renal blood flow. B1 receptors are reached at 5-10 µg/kg/min and alpha receptors at 10 µg/kg/min, while Na-K ATPase inhibition is the action of digitalis.

Ventricular tachycardia is a contraindication to digitalis for fear of changing it to V.F.. AF, atrial flutter and P.S.V.T. are indications of digitalis.

Secondary prevention lasts till age 40 years or lifelong in patients with severe valvular disease or after valvular replacement. Without carditis it is till age 21 (at least 5 years) and with mild regurgitant lesion till age 25 (at least 10 years), so a, b and c mix up the groups.

Mitral valve is commonly involved, followed by aortic valve then tricuspid valve.

Fever is a minor criterion. Erythema marginatum and carditis are major criteria, and a raised ASO titre is evidence of recent streptococcal infection.

Sydenham's chorea gives hypotonia and hyporeflexia, not hypertonia and hyperreflexia. It is more common in girls over 8 years, gives emotional instability and interrupted speech, and could occur alone weeks or months after the streptococcal infection.

Carditis is treated with corticosteroids. Arthritis is treated with salicylates, chorea with haloperidol, and penicillin allergic patients take daily erythromycin.

In recurrent attacks, 3 minor criteria are enough, but evidence of recent streptococcal infection is still required. One major criterion needs 2 minor criteria.

The handout calls TOF one of the most common CHDs, and it is one of the two cyanotic CHDs it studies, with reduced pulmonary blood flow. The answer is inferred from these lines; the handout does not rank the cyanotic lesions.

For cyanotic spells the handout gives the knee-chest position, oxygen, IV morphine and IV propranolol; hydrocortisone is not among them. Sodium bicarbonate is used to correct the acidosis of a severe spell.

The RV impulse is also increased in ASD, but wide and fixed splitting of S2 is the most characteristic sign of ASD. There is no audible murmur because of flow across the ASD, so a pansystolic murmur is not expected.

The most common associated defect is a secundum ASD or PFO, in over 50% of patients. The displaced leaflet is the septal leaflet of the tricuspid valve, the atrialized RV works as RA, and the ECG shows huge P waves.

RV volume overload on echo with Qp:Qs above 1.5 is the main indication for ASD closure, even without symptoms. Ostium primum and sinus venosus defects are not amenable to transcatheter closure.

Coarctation typically lies just distal to the left subclavian at the site of the ductal attachment. A bicuspid aortic valve is the most common coexisting anomaly, true claudication is rare, and surgery is more hazardous in adults than in children.

Trans-thoracic and trans-esophageal echo and coronary angiography before open heart surgery are the investigations used. CT chest is not one of them; only a CT aortogram is used, in patients with aortic aneurysm.

Quincke's sign is capillary pulsation seen at the root of the nail when pressure is applied to the tip. Head nodding is de Musset sign, higher lower limb pressure is Hill's sign and pistol-shot sounds are Traube's sign.

In acute AR, beta-blockers are avoided as they reduce the cardiac output and the slower rate allows more time for diastolic filling of the LV. Oxygen, diuretics (if no hypotension) and inotropes such as dobutamine are used.

A dilated left atrium > 50 mm is an indication for oral anticoagulation in mitral stenosis. The MS murmur increases on lying on the left lateral position, AF is a common finding, and surgery is for anatomy not suitable for balloon valvotomy.

Invasive coronary angiography is recommended in patients with positive stress test, while CT coronary angiography is a good negative test in patients less likely to have coronary artery disease. So a high-risk patient goes on to invasive testing; retesting later and non-invasive testing suit lower risk, and folic acid has no role.

Typical angina is constricting chest discomfort, brought on by exertion or emotion, and relieved within minutes by rest or nitroglycerin. Pain made worse by deep breathing is pleuritic pain and points to a non-ischemic cause. A duration of about 15 minutes is still consistent with angina, which is short-lived (minutes, not seconds or hours), so it does not exclude typical pain.

Headache is a common side effect of nitrates that could be managed with paracetamol. Nitrates are vasodilators, so they lower rather than raise blood pressure.

Ivabradine may cause visual disturbance (phosphenes) due to retinal side effects. Nicorandil must not be combined with nitrates, ranolazine prolongs QTc, and trimetazidine changes the heart fuel from fatty acids to glucose.

Elevated troponin and dynamic ST or T changes make the patient high risk, so PCI is done within less than 24 hours. The 2 hour window is for hemodynamic or electrical instability or refractory pain, and fibrinolytic therapy is only for STEMI.

Tertiary prevention is reduction in complications or disability, rehabilitation, or restoration of function. Primordial prevents the risk, primary reduces incidence, and secondary reduces prevalence or consequence of disease.

Infective endocarditis is rare in ASD due to the low pressure gradient between the two atria. VSD and PDA are among the congenital lesions where it is common, and pulmonary stenosis is not named as a rare site.

After dental procedures and oral or upper respiratory surgery the organism is usually Strept. viridans. Staph. aureus follows cardiac surgery and catheterization, and Strept. faecalis follows gastrointestinal and genitourinary procedures.

Immunological tests in infective endocarditis show increased gamma globulins and a false positive rheumatoid factor. The ESR is increased but not as high as in rheumatic fever, and blood culture is positive in 80% of cases.

Haemorrhagic pericarditis occurs in malignant infiltration, uraemia, myocardial infarction and T.B.. Right-sided heart failure causes hydropericardium, an accumulation of transudate.

Signs of tamponade include signs of low COP, pulsus paradoxus, congested neck veins and weak distant heart sounds. Pulmonary crepitations are not among them; the chest x-ray shows pulmonary oligaemia.

An early diastolic dip followed by plateau (square root sign) on ventricular pressure tracing is a finding of constrictive pericarditis. A flask-shaped shadow that changes from day to day and Ewart's sign belong to pericardial effusion.

Proteins > 3 gm%, LDH > 200 IU/L and cells > 1000/cmm define an exudate, and T.B. is the most common cause of exudative effusion. Right sided heart failure, liver cell failure and nephrotic syndrome give a transudate.

The HOCM midsystolic murmur increases on standing and decreases with squatting or leg raising, because more venous return fills the ventricle and decreases the obstruction.

Heredity and obesity are predisposing factors of essential HPN, so the young obese woman with a family history fits essential HPN. Sudden development, HPN resistant to treatment and onset after 50 years are clues to renal artery stenosis, a secondary cause.

Only patients with acute target organ damage (emergencies) need hospitalization, preferably in ICU. Urgencies have no acute end organ damage and blood pressure is lowered over 1-2 days.

Severe elevation of blood pressure always needs treatment, never reassurance alone. Without acute end organ damage it is an urgency, lowered over 1-2 days; with acute Lt.v. failure and pulmonary oedema it is an emergency needing hospital and rapid reduction.

ACE inhibitors are on the 'Avoid' list of HPN with pregnancy. Alpha methyl dopa and CCBs (not at labour) are on the 'Use' list, and labetalol is a safe combined alpha and beta blocker.

Grade IV hypertensive retinopathy is papilloedema plus grade III changes. Narrowing is grade I, silver wiring with kinking of veins is grade II, and flame shaped hge with cotton exudate is grade III.

Clonidine causes postural hypotension and rebound hypertension. Hydralazine causes tachycardia, minoxidil causes hirsutism, and reserpine causes depression.

Recurrent pulm. emboli cause obstructive (obliterative) pulmonary hypertension by obstruction of the pulm. arterioles. Chronic thromboembolic pulmonary hypertension is WHO group 4.

The Graham Steell murmur is an early diastolic murmur due to functional PR in pulmonary hypertension. The ejection systolic murmur of relative PS and functional TR are separate findings, and the machinery murmur belongs to PDA.

D-dimer is raised in thromboembolism but is not specific; it is a breakdown product of fibrin, so it points to a clot indirectly.

Colored Doppler and venography are both listed for diagnosis of DVT; duplex ultrasound is preferred because it is accurate and non-invasive. D-dimer is not specific, and CT pulmonary angiography looks for a lung embolus.

A hemodynamically unstable patient, with shock or heart failure, is treated with thrombolytic therapy. Embolectomy is done when thrombolysis is contraindicated, IVC interruption is for stable patients who cannot take anticoagulants, and morphine is avoided.

AF with mitral stenosis or a prosthetic valve needs VKA (warfarin) after bridging with parenteral anticoagulation till INR 2-3. Rivaroxaban and apixaban are used only when there is no mitral stenosis or prosthetic valve.