Cases in cardiology

Cases in cardiologyLIBYAN MEDICAL BOARD FIRST PART REVISIONDR.MAGDI AWAD SASI2016

LIBYAN MEDICAL BOARD 3RD PART 28.3.2016

55yr old female presented with 2month history of Lt. hypochondrial discomfort, early satiety associated with Wt. loss, night sweat, fever and vomting. no bleeding tendency. past history remarkable for type 2 DM on OHA .examination: under weight, pallor, no LN . Abdomen: spleen hugely enlarged. other system normal. lab data: WBC =199X10*3/ul PBF= leucocytosis ,basophilia ,immature RBC =5.5X10*3/ul myeloid precursor (blast 2%)Hb = 10gm% LDH= 600( high), UA= 10mg Hct = 33% RFT,LFT normal MCV=90flMCH= 31pgMCHC= 32gmPLT=1125x10*3/ulESR= 123The first line of management is:BM aspiration for diagnostic abrovalBM for t(8;21)Prognostic approach for Jak-2 mutation by BM aspirationHydroxyurea ,fluids NS ,allopurinolSearch for BCR / ABL

Is a reciprocal translocation between the long arms of chromosome 9 and 22.A large portion of 22q is translocated to 9q ;smaller piece of 9q is moved to 22q .The portion of 9q that is traslocated contains abl ,a porto-oncogen that is the cellular homologue of the ableson murine leukemia virus.The abl gene is recived at a specific site on 22q ,the break point cluster ( bcr ).The fusion gene bcrabl produces novel protein that differs from the normal transcript of abl gene in that it passes tyrosine gene activity ((characteristic activity for transforming genes)).At time of diagnosis, Philadelphia chromosome positive clone dominates.

60yr old male presented with swelling Rt. Side of neck progressive over 3month duration associated with Wt. loss, generalized fatigue, poor appetite. he noted history recurrent infection during last 3month. past history remarkable for hypertension on nifidipine. Examination: pallor ,generalized lymphadenopathy ,spleen 3fbcm,liver 2fbcm. lab data :WBC =90X10*3/ul Lymphocytes 80% LDH= 678 IU/L( high ),UA= 6mg Hb = 8gm% RFT, LFT normal .combs test ve Hct =30% MCV=90flMCH= 33pgMCHC= 32gmPLT=234x10*3/ulESR= 125 PBF= absolute lymphocytsis ,smear (smudge cell ) The following are poor prognostic factors except:Age > 70yearMale sexHigh LDHCD 38Lymphocyte doubling >2 years

Autoimmune warm hemolytic anemia is caused by except:A. SLEB. LymphomaC. Mycoplasma pneumonia D. CLL E. Penicillin

60 year female with CLL presented with fever and confusion . She started on ceftrixone and vancomycin but 2 days later she is deteriorating with no improvement.LP ---2600 WBC ,605 PMN ,gram negative rodsYou would recommend:Add ampicillinAdd clindamycinAdd levofloxacinChange to impenamCeftriaxone.

1. A 62 year old male with a history of mitral valve prolapse, rhematoid arhtritis, and colon cancer presents to the emergency room with increased dyspnea on exertion, lower extremity swelling, and fevers slowly worsning over the past month. His temperature is 38.0 C, blood pressure 95/65, heart rate 80, respirations 20, and oxygen saturation 92% on room air. Physical examination reveals normal breath sounds, a II/VI holosystolic murmur at the apex, and 1+ bilateral lower extremity pitting edema. Laboratory studies show a WBC count of 20 thousand and an ESR of 100. Echocardiogram reveals an 8 mm mobile vegitation on the anterior leaflet of the mitral valve.

Which of the following is the most likely pathogen?

A) Staphalococcus aureusB) Pseudomonas auriginosaC) Candida albicansD) Streptococcus bovis

Answer: D - Streptococcus bovis

This case is a classic presentation of subacute endocarditis. Some pathogens are more agressive than others and can actually present with septic shock such as Staph aureus and Pseudomonas auriginosa.

Candidal endocarditis is rare in immunocompetent persons and the vegitations seen are quite large (usually > 1 cm).

Streptococcus viridins group is the most common cause of endocarditis and presents in a subacute fashion (similar to Enterococcus endocarditis). Specifically, Streptococcus bovis (a type of Strep viridins) is strongly correlated with active colon cancer, thus if blood cultures were indeed positive for this organism, a colonoscopy should be performed.

Remember that the anterior leaflet of the mitral valve is the most common site for endocarditis. The holosystolic murmur at the apex likely represents mitral regurgitation due to valve destruction by the organism.

Empirical therapy

Often antibiotics need to be started before the culture results are available. Be guided by the clinical setting

Choice of antibioticPresentationBenzylpenicillin + gentamicinGradual onset (weeks)Flucloxacillin + gentamicinAcute onset (days) or history of skin traumaVancomycin (or teicoplanin) +gentamicin + rifampicinRecent valve prosthesis (possiblemeticillin-resistant S. aureus (MRSA),diphtheroid, Klebsiella , corynebacterium,or nosocomial staphylococci)VancomycinIV drug user

Treatment includes at least 4-6 weeks of IV antibiotics which include:

Penicillins or a third generation cephalosporin-----Strep viridins The combination ampicillin plus gentamicin ------ Enterococcus Nafcillin or oxacillin for penicillin sensative -------Staph aureus Vancomycin plus gentamicin for ----methacillin resistant Staph aureus ((MRSA))

2. 43 year old women had acute onset of shortness of breath and lightheadness .She had a history of rheumatic fever and subsequent MVR. On physical examination ,she was conscious , alert ,pale and tachycardic .HR was 94bpm and regular with low volume pulse . BP 90/40 mmHg .There were bilateral rales with raised JVP and gaint a wave . PO2 92%The urgent intervention to be done:

Transthoracic ECHO Blood culture 3 times 6 hours apart and start antibioticsDiuretic therapy with high O2 concentration TEE with urgent cardiothoracic consultation Dopamine pump to be started

Class I - There is evidence and/or general agreement that surgery is indicated in patients with NVE with one of the following: Valve stenosis or regurgitation leading to heart failure. Aortic or mitral regurgitation with hemodynamic evidence of elevated left ventricular end-diastolic or atrial pressures such as premature closure of the mitral valve with aortic regurgitation, rapid decelerating mitral regurgitation signal by continuous wave Doppler (v-wave cutoff sign), or moderate to severe pulmonary hypertension. IE due to fungal or other highly resistant organisms. Complications such as heart block, annular or aortic abscess, or destructive penetrating lesions such as fistula from the sinus of Valsalva to the right or left atrium or right ventricle, mitral leaflet perforation with IE of the aortic valve, or infection in annulus fibrosis.

3. 38 year female with H/O fever , sever cough ,colored sputum large in the morning for last 3 days. chronic morning cough with recurrent chest infection and wheezy chest for last 20 years after H/O complicated childhood infectionO/E:Pt sick , dyspnic , use accessory muscles , cyanotic , clubbing , BP110/90 ,PR 120/min , TEP 39cChest rhonchi all over , coarse crepts BL basal , RT BB The ideal antibiotic to be started is:Amoxcillin + Erythromycin Co-amoxiclav + IV clarthromycinCefuroxime + IV clarthromycinCeftizidimeCeftrixone

Ceftriaxone ---- PCN resistant pneumococciDMAge>65yearImmunocompromisedAspleniaRenal diseaseMalignancyCardiopulmonary diseaseAlcoholism

Ceftizidime :BronchiectasisCorticosteroids > 10mg /dMalnutritionHospitilizationBroad spectrum antibiotics

CAPTherapy Risk for resistant pneumococci Macrolide or DoxycyclineAbsent B lactam + Macrolide OR Floroquinolone ((not ciprofloxacine))Present

IN patient Option 1 ----------------- FluroquinoloneOptiion 2 -----------------B lactam ((ceftriaxone /cefotaxime )) + macrolide

Older group: Ciprofloxacin, norfloxacin, and ofloxacin

Newer group: Gemifloxacin, levofloxacin, and moxifloxacin

ICUTHEARPYCLINICAL SITUATIONB lactam + Azithromycin /FQMost patients Antipseudomonal B lactam + FQPseudomonas risk factors Add Vancomycin or linezolidMRSA Floroquinolone + AztreonanPCN-- allergic

4. A 50 year old man presents with an acutely swollen knee and fever. His CRP is 200mg/l. Aspiration yields 2mls of turbid fluid that has negatively birefringent needle shaped crystals. Renal function shows a creatinine of 3mg/dl, INR is normal. What is the best course of action?NSAIDS.Start allopurinol and colchicines.Opiate analgesia.Intra-articular steroid injection.Oral steroids.

5. A 23-year-old male with asthma presented to the emergency department with acute breathlessness and wheeze following a coryzal illness. He has been treated with high flow oxygen, regular nebulised bronchodilators and 200 milligrams of intravenous hydrocortisone. On examination he was pale, clammy and unable to record a peak flow reading. His pulse is 140 per min, temperature 37.3C, and had oxygen saturations of 86% on 15L of oxygen. Auscultation of his chest reveals poor breath sounds bilaterally with a faint polyphonic wheeze. His arterial blood gas on 15L of oxygen reveals: pH 7.30 (7.36-7.44) PO2 8.0 kPa (11.3-12.6) pCO2 7.8 kPa (4.7-6.0) HCO3 16 mmol/L (20-28) What is the most appropriate management for this patient? Non-invasive ventilation Intubation and invasive positive pressure ventilation Intravenous magnesium Intravenous aminophylline Intravenous antibiotics

Sine respiratory alkalosis is the usual derangement in asthma ,PaCO2 that is increasing toward normal indicate impending respiratory failure & the need for frequent monitoring of ABG.

Metabolic acidosis is another ominous sign of impending respiratory failure resulting from lactic acidosis due to fatiguing respiratory muscles.

PEFR 20%C/I CVA ,MI ,HTN ,AAA

SEVER PERSISTENTMODEARTE PERSISTENTMILD PERSISTENT INTERMITENT Throughout the daydaily>2 days/wk but not Daily2 days/wkSYMPTOMSOften 7/wk>1/wk but not nightly3-4/mo2/moNIGHT TIME AWAKINGSeveral times per dayDaily>2 days/wk but not daily and not >1 on any day2 days/wkShort-acting 2agonist use for symptom control (not prevention of EIB)Extremely limitedSome limitationMinor limitationNoneInterference with normal activityFEV160% but 80% predictedNormal FEV1 between exacerbationsFEV1>80% predictedLung functionFEV1/FVC reduced >5%FEV1/FVC reduced 5%FEV1/FVC normalFEV1/FVC normal

6. 50 year male C/O chronic cough for years which has got worse recently . Cough is associated with green color with occasional phlegm with occasional blood.No H/O smoking . H/O asthma 20 years not controlled with maximal treatment .HRCT bronchiectatic changes in distal /proximal air ways with no lobar predilectionWhat is the most appropriate diagnostic test?A. bronchoscopyB. PFT with Methacholine challenge test.C. Positron-emission tomography.D. Skin test for Aspergillus fumigates.E. Sweat chloride test.

7. An 85-year-old man is admitted from home because he has become increasingly confused and is not coping. He is known to have metastatic carcinoma of the prostate and takes Zoladex 3 monthly. You note that he has bruising over the left side of his forehead.

Which of the following investigations will not help you diagnose and treat his confusion?A : CT scan of the headB : Midstream urine sampleC : CalciumD : Urea and electrolytesE : Prostatic specific antigen (PSA).

8. A 35-year-old man presents with fatigue and jaundice of 5 days duration. Investigations show AST 2300 U/l, ALT 2540 U/l, GGT 650 U/l, total bilirubin 8.1 mg/dl.

Which of the following is least likely to be performed?Ultrasound examination.Viral serology.Liver auto-antibodies.Liver biopsy.Prothrombin time & INR