MBBS QUESTION ANSWER 4 PDF.pdf

Professor DR Md . TOUFIQUR RAHMAN , FCPS, MD
Professor & Head, Cardiology, CMMC, Manikganj
[email protected]; [email protected]
3. A 50 year old male presents with BP-180/100 mmHg. How will you investigate him? (DU-18Ju)
When investigating a patient with high blood pressure, several tests can be done to determine the cause and severity of the hypertension. Some of the tests that can be performed include:

Blood tests: This may include a complete blood count (CBC), kidney function tests, fasting glucose level, and lipid profile.

Urine tests: A urinalysis may be done to check for the presence of protein or blood in the urine, which could indicate kidney damage.

Electrocardiogram (ECG): This test records the electrical activity of the heart and can help detect any abnormalities in heart function.

Echocardiogram: This test uses sound waves to create an image of the heart and can help detect any structural abnormalities or problems with the heart's function.

Ambulatory blood pressure monitoring (ABPM): This is a portable device that measures blood pressure at regular intervals over a 24-hour period, providing a more accurate assessment of blood pressure patterns.

Renal artery ultrasound: This test uses sound waves to create an image of the renal arteries, which supply blood to the kidneys, and can help identify any blockages or narrowing in these arteries.

CT or MRI angiography: These imaging tests can provide detailed images of the blood vessels in the body, including the renal arteries, to help identify any blockages or narrowing.

The specific tests ordered will depend on the individual patient and their medical history, and should be decided by a healthcare professional.



4. A 25 year old woman has presented with repeated recordings of blood pressure above 160/100 mmHg. (DU- 21M)
a. What history and clinical signs you would look for?
b. What are the factors affecting the choice of antihypertensive drugs?
a. When evaluating a young woman with repeated recordings of high blood pressure, it is important to take a detailed history and perform a thorough physical exam to identify any underlying causes or risk factors. Some key points to consider include:

Family history of hypertension or cardiovascular disease
Personal history of kidney disease, diabetes, or other chronic medical conditions
Lifestyle factors such as diet, exercise, and tobacco and alcohol use
Medications or supplements that may contribute to hypertension
Symptoms such as headaches, chest pain, or shortness of breath
Physical exam findings such as enlarged kidneys, abnormal heart sounds, or signs of hormonal imbalances
b. The choice of antihypertensive drugs depends on several factors, including the patient's age, overall health status, and specific blood pressure goals. Some factors to consider when selecting a medication include:

The drug's mechanism of action and potential side effects
The patient's medical history

1. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
3.A50yearoldmalepresentswithBP-180/100mmHg.Howwillyou
investigatehim?(DU-18Ju)
Wheninvestigatingapatientwithhighbloodpressure,severaltestscanbedonetodeterminethecauseandseverity
ofthehypertension.Someoftheteststhatcanbeperformedinclude:
Bloodtests:Thismayincludeacompletebloodcount(CBC),kidneyfunctiontests,fastingglucoselevel,
andlipidprofile.
Urinetests:Aurinalysismaybedonetocheckforthepresenceofproteinorbloodintheurine,which
couldindicatekidneydamage.
Electrocardiogram(ECG):Thistestrecordstheelectricalactivityoftheheartandcanhelpdetectany
abnormalitiesinheartfunction.
Echocardiogram:Thistestusessoundwavestocreateanimageoftheheartandcanhelpdetectany
structuralabnormalitiesorproblemswiththeheart'sfunction.
Ambulatorybloodpressuremonitoring(ABPM):Thisisaportabledevicethatmeasuresbloodpressure
atregularintervalsovera24-hourperiod,providingamoreaccurateassessmentofbloodpressurepatterns.
Renalarteryultrasound:Thistestusessoundwavestocreateanimageoftherenalarteries,whichsupply
bloodtothekidneys,andcanhelpidentifyanyblockagesornarrowinginthesearteries.
CTorMRIangiography:Theseimagingtestscanprovidedetailedimagesofthebloodvesselsinthe
body,includingtherenalarteries,tohelpidentifyanyblockagesornarrowing.
Thespecifictestsorderedwilldependontheindividualpatientandtheirmedicalhistory,andshouldbedecidedbya
healthcareprofessional.
4.A25yearoldwomanhaspresentedwithrepeatedrecordingsofbloodpressure
above 160/100mmHg.(DU-21M)
a.Whathistoryandclinicalsignsyouwouldlookfor?

2. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
b.Whatarethefactorsaffectingthechoiceofantihypertensivedrugs?
a.Whenevaluatingayoungwomanwithrepeatedrecordingsofhighbloodpressure,itisimportanttotakea
detailedhistoryandperformathoroughphysicalexamtoidentifyanyunderlyingcausesorriskfactors.Somekey
pointstoconsiderinclude:
Familyhistoryofhypertensionorcardiovasculardisease
Personalhistoryofkidneydisease,diabetes,orotherchronicmedicalconditions
Lifestylefactorssuchasdiet,exercise,andtobaccoandalcoholuse
Medicationsorsupplementsthatmaycontributetohypertension
Symptomssuchasheadaches,chestpain,orshortnessofbreath
Physicalexamfindingssuchasenlargedkidneys,abnormalheartsounds,orsignsofhormonalimbalances
b.Thechoiceofantihypertensivedrugsdependsonseveralfactors,includingthepatient'sage,overallhealthstatus,
andspecificbloodpressuregoals.Somefactorstoconsiderwhenselectingamedicationinclude:
Thedrug'smechanismofactionandpotentialsideeffects
Thepatient'smedicalhistoryandanyothermedicationstheyaretaking
Thepresenceofcomorbidconditionssuchasdiabetesorkidneydisease
Thepatient'srace,assomeantihypertensivedrugsmaybemoreeffectiveincertainpopulations
CommonclassesofantihypertensivedrugsincludeACEinhibitors,angiotensinreceptorblockers,beta
blockers,calciumchannelblockers,anddiuretics.Combinationtherapymaybenecessaryinsomecasesto
achieveadequatebloodpressurecontrol.
b.Whatarethefactorsaffectingthechoiceofantihypertensivedrugs?
Thereareseveralfactorsthatcanaffectthechoiceofantihypertensivedrugsforapatient,including:
Age:Thechoiceofantihypertensivemedicationmaydifferbasedonthepatient'sage.For
instance,thiazidediureticsmaybepreferredinolderpatientsastheyareeffectiveandhavefewer
sideeffects.
Co-morbidities:Patientswithcomorbiditiessuchasdiabetes,chronickidneydisease,orheart
diseasemayrequirespecificmedicationsormedicationcombinationsthataretailoredtotheir
condition.

3. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
Race:Studieshaveshownthatcertainmedicationsmaybemoreeffectiveintreating
hypertensionincertainraces.Forinstance,ACEinhibitorsmaybemoreeffectiveinreducing
bloodpressureinAfricanAmericanscomparedtootherraces.
Adverseeffects:Certainmedicationsmaycauseadverseeffectsinsomepatients,suchascough
withACEinhibitorsorswellingwithcalciumchannelblockers.Insuchcases,alternative
medicationsmaybeconsidered.
Cost:Thecostofmedicationsmayalsoaffectthechoiceofantihypertensivedrugs.Cheaper
medicationsmaybepreferred,especiallyforpatientswithlimitedfinancialresources.
Pregnancy:Antihypertensivemedicationsusedduringpregnancyshouldbechosencarefully,as
somemedicationsmayhaveadverseeffectsonthefetus.Generally,medicationssuchas
methyldopa,labetalol,andnifedipineareconsideredsafeforuseinpregnantwomenwith
hypertension.
Lifestylefactors:Lifestylemodificationssuchasweightloss,dietarychanges,andincreased
physicalactivitymayalsoinfluencethechoiceofantihypertensivedrugs.Forinstance,apatient
whoisoverweightmaybenefitfromamedicationthatalsohelpswithweightloss.
5.A50yearoldmanisadmittedwithlonghistoryuncontrolledhypertension.
(DU-15Ju,12Ju)
(a)Howdoyouclinicallyevaluatethepatienttofindouttargetorgandamage?
(b)Suggestnecessaryinvestigationswithexpectedfindings.
a)Targetorgandamageevaluationinapatientwithuncontrolledhypertensionincludes:
Fundoscopicexaminationtocheckforhypertensiveretinopathy,includingretinalhemorrhages,exudates,cotton
woolspots,andarteriolarnarrowing.
Cardiacexaminationtoevaluateforleftventricularhypertrophy(LVH),whichcanbedetectedbypalpationorby
ECGfindings.
Neurologicalexaminationtoassessforevidenceofstroke,transientischemicattack,orcognitiveimpairment.
Renalexaminationtoevaluateforrenalinsufficiencyorchronickidneydisease.

4. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
b)Necessaryinvestigationsforapatientwithuncontrolledhypertensionandsuspectedtargetorgandamage
mayinclude:
ECGtoevaluateforLVH,ST-Tchanges,orevidenceofacutecoronarysyndrome.
EchocardiographytoassessforLVH,valvularabnormalities,orleftventricularsystolicordiastolic
dysfunction.
Renalfunctiontestsincludingserumcreatinineandestimatedglomerularfiltrationrate(eGFR).
Urinalysistoevaluateforproteinuriaorhematuria.
Lipidprofiletoassessfordyslipidemiaandcardiovascularrisk.
BrainimagingsuchasCTorMRItoassessforevidenceofstrokeortransientischemicattack.
Ophthalmologicexaminationtofurtherassessforhypertensiveretinopathy.
TheexpectedfindingsmayincludeLVH,abnormalitiesincardiacfunction,evidenceofrenalinsufficiencyor
proteinuria,evidenceofstrokeortransientischemicattack,andhypertensiveretinopathy.Thesefindingsmayguide
themanagementofhypertensionandthepreventionoffurthertargetorgandamage.
6.A50yearoldmanhaspresentedwithheadachewithBP180/110mmHg.(DU-14Ju)
a.Howdoyouclinicallyevaluatehiscardiovascularrisk?
b.Howdoyoumangehim?
a.Toclinicallyevaluatethecardiovascularriskofthepatient,thefollowingfactorsshouldbeconsidered:
Age
Gender
Bloodpressurelevels
Smokingstatus
Lipidprofile
Presenceofdiabetes
Familyhistoryofcardiovasculardisease
Physicalactivitylevels
Basedonthesefactors,thepatient's10-yearcardiovascularriskcanbeestimatedusingariskassessmenttoolsuch
astheFraminghamRiskScoreortheQRISK2calculator.
b.Themanagementofa50-year-oldmanpresentingwithaheadacheandaBPof180/110mmHginvolvesthe
following:
Confirmthediagnosis:Thefirststepistoconfirmthediagnosisofhypertensionbytakingaccurateblood
pressuremeasurements.Repeatthemeasurementafterafewminutestoruleoutwhite-coathypertension.

5. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
Evaluateforend-organdamage:Assessthepatientforanysignsofend-organdamage,suchas
retinopathy,leftventricularhypertrophy,orrenalimpairment.
Starttreatment:Ifthepatienthasnosignsofend-organdamage,lifestylemodificationssuchasweight
loss,exercise,anddietarychangesshouldbeinitiated.IftheBPremainselevated,pharmacological
treatmentshouldbestarted.
Selecttheantihypertensiveagent:Selecttheantihypertensiveagentbasedonthepatient'scomorbidities
andcontraindications,includingACEinhibitors,ARBs,diuretics,beta-blockers,orcalciumchannel
blockers.
Monitortheresponsetotreatment:Monitorthepatient'sresponsetotreatmentbymeasuringblood
pressureatregularintervals.Adjustthemedicationdosageifnecessary.
Educatethepatient:Educatethepatientabouthypertension,itscomplications,andtheimportanceof
adheringtothetreatmentregimen.
Followup:Scheduleregularfollow-upvisitstomonitorthepatient'sbloodpressure,assessforanyadverse
effectsoftreatment,andevaluateforanysignsofend-organdamage.
7.A20yearoldmalerecentlydetectedashypertension.(DU-17/14Ja,10Ju)
a.Makeachecklisthistoryandphysicalsigntofindoutthecausesofhypertensionifany.
b.Writedownaninvestigationplanforhim.
a.Checklisthistoryandphysicalsignstofindoutthecausesofhypertensionina20-year-oldmale:
Familyhistoryofhypertensionorcardiovasculardiseases
Obesityoroverweight
Sedentarylifestyle
Smokingortobaccouse
Excessivealcoholintake
Drugabuseoruseofcertainmedications(e.g.non-steroidalanti-inflammatorydrugs,oralcontraceptives,
steroids)
Sleepapneaorothersleepdisorders

6. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
EndocrinedisorderssuchashyperthyroidismorCushing'ssyndrome
Renaldiseasessuchasglomerulonephritisorpolycystickidneydisease
Coarctationoftheaortaorothercongenitalheartdefects
b.Investigationplanfora20-year-oldmalewithhypertensionmayinclude:
Bloodtests:completebloodcount,electrolytes,renalfunctiontests,lipidprofile,fastingglucose
Urinetests:urinalysis,urineprotein-to-creatinineratio,urineculture
Electrocardiogram(ECG)toevaluateforleftventricularhypertrophyorothercardiacabnormalities
Ambulatorybloodpressuremonitoring(ABPM)toconfirmthediagnosisofhypertensionandassess
bloodpressurevariabilityover24hours
Imagingstudiessuchasrenalultrasoundorcomputedtomography(CT)angiographyoftheabdomenand
pelvistoevaluateforrenalarterystenosisorotherstructuralabnormalitiesofthekidneysandurinarytract.
Dependingontheclinicalfindings,furtherinvestigationssuchasthyroidfunctiontestsorsleepstudiesmaybe
indicated.
***8.A30yearsoldmalewithnofamilyhistoryofHTNpresentedwithaBPof200/110
mmHg.(DU-12Ja)
a.Whatcouldbethesecondarycauses?
b.Howwillyouplantoinvestigatehim?
a.Inayoungpatientwithnofamilyhistoryofhypertension,secondarycausesofhypertension
shouldbeconsidered.Someofthepossiblecausesinclude:
Renalarterystenosis
Endocrinedisorderssuchaspheochromocytoma,Cushing'ssyndrome,hyperaldosteronism
Coarctationoftheaorta
Sleepapnea
Drug-inducedhypertension
b.Toinvestigatethispatient,thefollowingtestsmaybeconsidered:
Renalfunctiontests,includingserumcreatinine,bloodureanitrogen,andestimatedglomerular
filtrationrate(eGFR)
Urinalysisforproteinuriaandhematuria
RenalultrasoundorCTangiographytoevaluateforrenalarterystenosis

7. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
Plasmaaldosterone/reninratiotoassessforhyperaldosteronism
24-hoururinecollectionformetanephrinestoevaluateforpheochromocytoma
Hormoneevaluation(e.g.cortisol)toassessforCushing'ssyndrome
ChestX-rayorechocardiogramtoevaluateforcoarctationoftheaorta
Polysomnographytoassessforsleepapnea
Thespecificinvestigationsmayvarydependingonthepatient'shistory,physicalexam,andinitial
laboratoryfindings.
9.Writedownthecausesofsecondaryhypertension.(DU-12Ja)
Secondaryhypertensioncanbecausedbyvariousunderlyingmedicalconditions,suchas:
Renalcauses:Chronickidneydisease,renalarterystenosis,renalparenchymaldisease,polycystickidney
disease,glomerulonephritis.
Endocrinecauses:Primaryaldosteronism,Cushing'ssyndrome,pheochromocytoma,hyperthyroidism,
hypothyroidism,acromegaly,hyperparathyroidism.
Cardiovascularcauses:Coarctationoftheaorta,aorticregurgitation,aorticstenosis.
Medication-induced:Steroids,contraceptivepills,nonsteroidalanti-inflammatorydrugs(NSAIDs),
cyclosporine,erythropoietin.
Others:Obstructivesleepapnea,pregnancy-inducedhypertension,drugoralcoholabuse,
neurofibromatosis.
10.Writedownclinicalsingyouwillsearchincaseofsecondaryhypertension.(DU-18Nov)
Incaseofsecondaryhypertension,thefollowingclinicalsignsmaybesearchedfor:
Signsofchronickidneydiseasesuchasanemia,proteinuria,andelevatedcreatininelevels.
Abdominalbruits,whichmayindicaterenalarterystenosis.
Palpablethyroidglandenlargement,whichmaysuggesthyperthyroidism.
Abdominalmassesorbruits,whichmaysuggestpheochromocytomaorrenalarterystenosis.
SignsofCushing'ssyndrome,suchasobesity,moonfacies,andhirsutism.
Signsofobstructivesleepapnea,suchassnoring,daytimesleepiness,andobesity.
Signsofprimaryaldosteronism,suchashypokalemia,metabolicalkalosis,andmuscleweakness.
11.a)A53yearsoldpatientwithhypertension.Writedownclinicalinformationyouwould
searchforidentificationofunderlyingcausesofsecondaryhypertension.

8. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
b)Mentionthecomorbiditieswhichinfluencetheselectionofantihypertensivemedication
withexample?(DU-19Nov)
a)Ina53-year-oldpatientwithhypertension,thefollowingclinicalinformationshouldbesearchedforthe
identificationofunderlyingcausesofsecondaryhypertension:
Historyofrenaldisease,suchaschronickidneydiseaseorpolycystickidneydisease
Endocrinedisorders,suchaspheochromocytoma,Cushing'ssyndrome,primaryaldosteronism,or
hyperthyroidism
Obstructivesleepapnea
Coarctationoftheaorta
Drug-inducedhypertension
Lifestylefactors,suchasobesity,excessivealcoholintake,andhighsaltintake
b)Comorbiditiesthatinfluencetheselectionofantihypertensivemedicationinclude:
Diabetes:ACEinhibitorsorangiotensinreceptorblockers(ARBs)arerecommendedasfirst-lineagentsfor
hypertensioninpatientswithdiabetes.
Heartfailure:ACEinhibitors,ARBs,andbeta-blockersarethepreferredagentsforhypertensionin
patientswithheartfailure.
Chronickidneydisease:ACEinhibitorsorARBsarethepreferredagentsforhypertensioninpatients
withchronickidneydisease.
Ischemicheartdisease:Beta-blockersarerecommendedasfirst-lineagentsforhypertensioninpatients
withischemicheartdisease.
Peripheralarterydisease:CalciumchannelblockersandACEinhibitorsarepreferredagentsfor
hypertensioninpatientswithperipheralarterydisease.
Mentionthecomplicationsofhypertension.(DU-18Nov,09Ju)
Hypertension,ifleftuntreatedoruncontrolled,canleadtovariouscomplications,including:
Stroke:Highbloodpressuredamagesthebloodvesselsandcanleadtoastroke,whichisamedical
emergency.
Heartattack:Highbloodpressurecandamagethearteriessupplyingbloodtotheheartmuscle,leadingto
aheartattack.
Heartfailure:Thehearthastoworkhardertopumpbloodagainsthighbloodpressure,whichcanweaken
theheartmusclesovertime,leadingtoheartfailure.

9. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
Kidneydamage:Thekidneyshavetinybloodvesselsthatcanbedamagedbyhighbloodpressure.This
canleadtokidneyfailureorkidneydisease.
Visionloss:Highbloodpressurecancausedamagetothebloodvesselsintheretina,leadingtovisionloss
orblindness.
Peripheralarterialdisease:Highbloodpressurecancausedamagetothearteriessupplyingbloodtothe
legsandfeet,leadingtopoorcirculationandpain.
Aorticaneurysm:Highbloodpressurecancausethewallsoftheaorta(themainarteryinthebody)to
weakenandbulge,whichcanleadtoanaorticaneurysm.Iftheaneurysmruptures,itcanbelife-
threatening.
Cognitiveimpairment:Chronichighbloodpressurecancausedamagetothebloodvesselsinthebrain,
leadingtocognitiveimpairment,suchasmemoryloss,difficultyconcentrating,anddementia.
***1.Howdoyoudiagnoseacuterheumaticfever?(DU-16Ja)
Acuterheumaticfever(ARF)isaclinicaldiagnosisbasedonthepresenceofmajorandminorcriteria.Thediagnosis
isusuallymadebasedonJonescriteria,whichincludesthefollowing:
Majorcriteria:
Carditis(evidenceofinflammationoftheheart)
Polyarthritis(inflammationofmorethanonejoint)
Chorea(involuntarymovements)
Erythemamarginatum(rashwithacharacteristic"marginated"appearance)
Subcutaneousnodules
Minorcriteria:
Fever
Arthralgia(jointpain)
Elevatedacutephasereactants(suchaserythrocytesedimentationrateandC-reactiveprotein)
ProlongedPRintervalonelectrocardiogram
TodiagnoseARF,apatientmustmeeteitherofthefollowingcriteria:
Presenceoftwomajorcriteria,or

10. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
Presenceofonemajorcriterionandtwominorcriteria,alongwithevidenceofapreviousgroupA
streptococcalinfection.
Inadditiontoclinicalcriteria,laboratorytestssuchasthroatculture,antistreptolysinOtiter,andanti-DNaseBtiter
canalsobeusedtosupportthediagnosisofARFandidentifythepreviousgroupAstreptococcalinfection.
*2.Writedownthediagnosticcriteriaofacuterheumaticfever.(DU-10Ja,09Ju)
Thediagnosticcriteriaforacuterheumaticfever(ARF)includethefollowingmajorcriteriaandminorcriteria:
Majorcriteria:
Carditis(inflammationoftheheart):documentedbyclinicalexaminationorechocardiographyand
manifestedbythepresenceofanewmurmur,pericardialrub,orcardiomegaly.
Polyarthritis:involvementoftwoormorejoints,typicallyinvolvinglargejoints(e.g.,knees,ankles,
elbows,wrists)inamigratorypattern.
Chorea(Sydenham'schorea):involuntarypurposelessmovementsofthelimbs,trunk,orface,usually
withoutweakness.
Erythemamarginatum:anon-pruritic,pink,serpiginousrashwithawell-definedborder.
Subcutaneousnodules:small,firm,painlessnoduleslocatedoverbonyprominencesortendons.
Minorcriteria:
Fever(≥38°C).
Arthralgia:paininoneormorejoints.
Elevatedacute-phasereactants:erythrocytesedimentationrate(ESR)and/orC-reactiveprotein(CRP)
levels.
ProlongedPRintervalonelectrocardiogram(ECG).
ThediagnosisofARFrequiresthepresenceoftwomajorcriteria,oronemajorandtwominorcriteria,plus
evidenceofaprecedinggroupAstreptococcalinfection,asdeterminedbyapositivethroatcultureor
elevatedstreptococcalantibodytiter.
3.WhatismodifiedJonescriteriaofrheumaticfeverandpathogenesisofrheumaticfever?
(DU-08M)
ModifiedJonescriteriaisasetofdiagnosticcriteriausedforthediagnosisofacuterheumaticfever.Thecriteria
includemajorcriteriaandminorcriteria.Themajorcriteriaare:
Carditis(inflammationoftheheartmuscle)
Polyarthritis(inflammationofmultiplejoints)
Sydenham'schorea(involuntarymovements)

11. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
Erythemamarginatum(atypeofskinrash)
Subcutaneousnodules
Theminorcriteriaincludefever,arthralgia(jointpain),elevatedacute-phasereactants(suchasC-reactiveprotein
orerythrocytesedimentationrate),andaprolongedPRintervalonanelectrocardiogram.
Thediagnosisofacuterheumaticfeverrequiresthepresenceoftwomajorcriteriaoronemajorcriterion
plustwominorcriteriaandevidenceofaprecedingstreptococcalinfection.Additionally,thediagnosismay
besupportedbyevidenceofarecentstreptococcalinfection,suchasapositivethroatcultureorrapid
streptococcalantigentest.
Pathogenesisofrheumaticfever
RheumaticfeveriscausedbyanautoimmuneresponsetoapreviousinfectionwithgroupAstreptococcus.
ThebacteriapossessMproteinsontheirsurfacethatcantriggertheimmunesystemtoreact.
Theimmunesystemcross-reactswithhumantissue,includingheartvalves,joints,andthecentralnervous
system.
Thiscross-reactivityleadstoinflammationanddamagetothesetissues.
Theresultofthisinflammationanddamageistheclinicalmanifestationsofacuterheumaticfever.
4.A13yearsoldgirlpresentedwithhistoryoffeverandpainfulswellingoflargejoints.
WhataretheD/Ds?Howwillyoutreatifshedevelopscarditis?(DU-07Ja)
Thedifferentialdiagnosis(D/Ds)fora13-year-oldgirlwithfeverandpainfulswellingoflargejointsincludes:
Infectiouscauses:Bacterialinfectionslikeosteomyelitisorsepticarthritis,viralinfectionslikeparvovirus
B19,andotherinfectionslikeLymedisease.
Juvenileidiopathicarthritis(JIA):Agroupofchronicinflammatoryjointdiseasesinchildrenthatcan
causejointpain,swelling,andstiffness.
Reactivearthritis:Jointinflammationthatdevelopsafteraninfectioninanotherpartofthebody,suchas
thegastrointestinaltractorgenitourinarysystem.
Systemiclupuserythematosus(SLE):Achronicautoimmunediseasethatcancausejointpainand
swelling,aswellasfever,skinrashes,andothersymptoms.

12. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
Kawasakidisease:Anacutefebrileillnessthatprimarilyaffectschildrenandcancausejointpainand
swelling,aswellasothersymptomslikerash,redeyes,andswollenlymphnodes.
Rheumaticfever:Acomplicationofuntreatedstreptococcalinfectionthatcancausejointpainand
swelling,aswellasfever,skinrashes,andheartproblems.
Leukemia:Atypeofcancerthatcancausejointpain,swelling,andbonepain.
Thedifferentialdiagnosiscanbenarroweddownbasedonfurtherevaluation,includinglaboratorytestsandimaging
studies.
thefollowingtreatmentapproachescanbeconsidered:
Antibiotictherapy:Treatmentwithantibioticsisthecornerstoneofmanagingrheumaticfeverandcarditis.
Penicillinisthefirst-lineantibioticforpreventingfurtherinfectionwithgroupAstreptococcus,whichcan
triggerarecurrenceoftheautoimmuneresponse.Antibiotictherapyshouldbecontinuedforatleast10
daysoruntiltheacuteinflammationsubsides.
Anti-inflammatorymedications:Anti-inflammatorymedicationssuchasaspirinandcorticosteroidsmay
beprescribedtoreduceinflammationandrelievepain.Aspirincanalsopreventbloodclotsfromforming
ontheheartvalves,whichcancausefurtherdamage.
Bedrest:Patientswithcarditismayrequirebedrestuntiltheacuteinflammationsubsides.Bedrestcan
helpreducetheworkloadontheheartandpreventfurtherdamage.
Monitoring:Patientswithcarditisshouldbecloselymonitoredforanysignsofheartfailure,suchas
shortnessofbreathoredema.Theyshouldalsoundergoregularechocardiographytoassesstheextentof
valvedamageandtomonitorforanychangesinheartfunction.
Surgery:Inseverecasesofrheumaticcarditis,surgerymaybenecessarytorepairorreplacedamaged
heartvalves.Thisisusuallydoneincaseswherethevalvedamageiscausingsignificantimpairmentof
heartfunctionorifthereisahighriskofheartfailure.
Long-termprophylacticantibioticstopreventrecurrenceofARFandreducetheriskofdevelopingrheumatic
heartdisease.
5.A5yearsoldboypresentswithfever&swellingofkneeandanklejointfor3weeks. Writedown3
importantD/D.Discussthetreatmentofacuterheumaticfeverwith carditis.(DU-09Ju)

13. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
Threeimportantdifferentialdiagnosesofa5-year-oldboypresentingwithfeverandjointswellingfor3weeks
include:
Septicarthritis:Thisisanacutebacterialinfectionofajointthatcausessimilarsymptomstorheumatic
feverbutisusuallymonoarticularandassociatedwithmoreseverepain,redness,andtendernessofthe
affectedjoint.Septicarthritisrequiresurgentdrainageandantibiotics.
Juvenileidiopathicarthritis:Thisisagroupofchronicautoimmunedisordersthatcanpresentwithfever,
jointswelling,andstiffness.Thediagnosisisbasedonclinicalfeatures,laboratorytests,andimaging
studies.Thetreatmentmayincludenonsteroidalanti-inflammatorydrugs,disease-modifyingantirheumatic
drugs,andbiologicagents.
Reactivearthritis:Thisisaninflammatoryjointdiseasethatcanoccurafteraninfection,especiallywith
certainbacteriasuchasChlamydia,Salmonella,orShigella.Reactivearthritisusuallyaffectsthelower
limbjoints,suchasknees,ankles,andfeet,andmaybeassociatedwithskinrash,eyeinflammation,or
urethritis.Thetreatmentmayincludeantibiotics,nonsteroidalanti-inflammatorydrugs,andcorticosteroids.
Assumingthediagnosisofacuterheumaticfeverwithcarditis,thetreatmentusuallyinvolvesacombinationof
antibioticsandanti-inflammatorydrugs.Theantibioticsaimtoeradicatethestreptococcalinfectionandprevent
furtherrheumaticfeverrecurrences,whiletheanti-inflammatorydrugsaimtoreducetheinflammationand
symptomsofcarditis.Thespecificregimenmayvarydependingontheseverityofcarditis,thepresenceofother
complications,andthepatient'sageandweight.Ingeneral,thefollowingprinciplesapply:
Antibiotics:A10-daycourseoforalorintramuscularpenicillinisthefirst-lineantibioticforacute
rheumaticfever,asitiseffectiveagainstmoststrainsofstreptococciandhaslowtoxicity.Alternative
antibioticsmaybeusedforpatientswhoareallergictopenicillinorhaverecurrentrheumaticfeverdespite
adequatepenicillintherapy.Long-termprophylaxiswithpenicillinisrecommendedtopreventrecurrences,
usuallyuntiltheageof21yearsorfor10yearsafterthelastepisodeofrheumaticfever,whicheveris
longer.
Anti-inflammatorydrugs:High-doseaspirinornonsteroidalanti-inflammatorydrugs(NSAIDs)suchas
ibuprofenornaproxenareusuallygivenforthefirst2-3weeksofacuterheumaticfevertocontrolfever,
pain,andinflammation.Corticosteroidssuchasprednisoneormethylprednisolonemaybeusedinsevere
casesofcarditisorwhenothertherapiesarenoteffectiveorcontraindicated.Thedurationanddoseofanti-
inflammatorydrugsshouldbetailoredtothepatient'sresponseandadverseeffects,suchasgastricirritation
orbleeding.

14. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
Supportivecare:Patientswithacuterheumaticfeverandcarditismayrequirehospitalizationforclose
monitoringofvitalsigns,fluidbalance,andelectrolytestatus.Theymayalsoneedbedrest,oxygentherapy,
ordiureticstomanageheartfailureorpulmonaryedema.Regularfollow-upwithacardiologistor
rheumatologistisnecessarytomonitortheprogressionofcarditisandadjustthetreatmentaccordingly.
6.A15yearoldboypresentedwitholigoarthritisinvolvinglargejointsfor2week.Hehad
feverabout3weeksbackandsufferedfromsorethroat.(DU-13Ja)
a)Whatisyourprovisionaldiagnosis?Mentiontheotherimportantphysicalfindingsthat
youwilllookforinthiscase.
b)Nameimportantinvestigationthatcanbedonetoestablishthediagnosis.
a)Theprovisionaldiagnosisinthiscasewouldbeacuterheumaticfever.Otherimportantphysicalfindingsthat
shouldbelookedforinclude:
Evidenceofcarditissuchastachycardia,anewmurmurorchangesinexistingmurmurs,pericardialruborsignsof
heartfailure
Skinmanifestationssuchaserythemamarginatum,subcutaneousnodules,oranon-pruriticrash
Sydenham'schorea,whichisadisorderofinvoluntarymovementsandaffectsabout10%ofpatientswith
rheumaticfever
b)Theimportantinvestigationsthatcanbedonetoestablishthediagnosisofacuterheumaticfeverinclude:
ThroatculturetodetectthepresenceofgroupAstreptococcus,thebacteriaresponsibleforstrepthroat,
whichisaprecursortoacuterheumaticfever
BloodteststolookforelevatedlevelsofinflammatorymarkerssuchasC-reactiveprotein(CRP)and
erythrocytesedimentationrate(ESR)
Electrocardiogram(ECG)tolookforevidenceofabnormalheartrhythmsorothercardiacabnormalities
Echocardiographytoassessthestructureandfunctionoftheheart,particularlyifcarditisissuspected
Jointaspirationtoruleoutothercausesofjointpainandswelling
**7.A13yearsoldgirlpresentswithmigratingpolyarthritisfor2weeks.HerPulseis
120beats/minasucultationsrevealsoft1stheartsoundwithpansystolicmurmurat
apex.(DU-11Ju)

15. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
a.Whatisyourmostlikelydiagnosis?
b.Whatothersclinicalmanifestationsyouwilllookforinfavourofyourdiagnosis?
c.Howwillyoutreather?
a.Themostlikelydiagnosisisacuterheumaticfever.
b.Otherclinicalmanifestationsthatmaysupportthediagnosisofacuterheumaticfeverincludeahistoryofrecent
streptococcalinfection,fever,migratorypolyarthritis,andthepresenceofcardiacmurmursorsignsofcarditis.
c)treatment--
Antibioticsareusedtotreattheunderlyingstreptococcalinfectionthatcausedacuterheumaticfever.
Anti-inflammatorymedicationssuchasaspirinornonsteroidalanti-inflammatorydrugs(NSAIDs)are
giventoreduceinflammationandpreventdamagetotheheartvalves.
Bedrestisrecommendedforpatientswithcarditistominimizetheworkloadontheheart.
Corticosteroidsmaybeprescribedinadditiontoanti-inflammatorymedicationstofurtherreduce
inflammationandpreventlong-termdamagetotheheart.
Immunoglobulintherapymaybeconsideredforpatientswithseverecarditisorwhenothertreatmentsare
ineffective.
Surgerymaybenecessaryinsomecasestorepairorreplacedamagedheartvalves.
Prophylacticantibioticsaregiventopreventfurtherepisodesofacuterheumaticfeverandtoprevent
recurrenceofstreptococcalinfections.
*8.A15yearsoldboypresentswithpolyarthritis.(DU-11Ja)
a.Whatdiagnosticcriteriawouldyoulookfortoestablishthediagnosisofrheumaticfever?
b.Giveanoutlineofmanagementofrheumaticfever.
a.Toestablishthediagnosisofrheumaticfever,thediagnosticcriteriathatneedtobelookedforarethemodified
Jonescriteria.Thesecriteriaconsistofmajorandminorcriteria.Themajorcriteriainclude:
Carditis(inflammationoftheheart)
Polyarthritis(inflammationofmultiplejoints)
Chorea(involuntarymovements)
Erythemamarginatum(rash)
Subcutaneousnodules
Theminorcriteriainclude:
Fever
Arthralgia(jointpain)
Elevatedacute-phasereactants(e.g.erythrocytesedimentationrate,C-reactiveprotein)
ProlongedPRintervalonECG

16. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
Thediagnosisofrheumaticfeverrequiresthepresenceofeithertwomajorcriteriaoronemajorandtwo
minorcriteria,inadditiontoevidenceofaprecedinggroupAstreptococcalinfection.
b.Themanagementofrheumaticfeverincludesthefollowing:
Antibiotictherapytoeradicatethestreptococcalinfectionandpreventfurtherepisodesofrheumaticfever.
Symptomatictreatmentofjointpainandinflammationwithnonsteroidalanti-inflammatorydrugs
(NSAIDs)orcorticosteroids.
Treatmentofheartfailure,ifpresent,withdiuretics,angiotensin-convertingenzymeinhibitors,andbeta-
blockers.
Prophylaxisagainstfutureepisodesofrheumaticfeverwithlong-termantibiotictherapy,usuallywith
benzathinepenicillinGinjectionsevery3-4weeks.
Closemonitoringforthedevelopmentofrheumaticheartdisease,whichmayrequiresurgicalintervention
inseverecases.
9.Howwillyoudifferertiaterheumatoidarthritisfromrheumaticfever?(DU-08Ja)
Rheumatoidarthritis(RA)andrheumaticfever(RF)aretwodistinctdiseasesthatcanpresentwithsimilar
symptoms,makingtheirdifferentiationcrucial.Herearesomekeydifferencesbetweenthetwoconditions:
Ageofonset:Rheumaticfevertypicallyaffectschildrenaged5-15years,whileRAusuallypresentsin
adultsover40yearsold.
Jointinvolvement:Inrheumaticfever,thejointsinvolvedareusuallylargejoints(knees,ankles,elbows),
andthearthritisismigratory,meaningitmovesfromonejointtoanother.Incontrast,RAinvolvesthe
smalljointsofthehandsandfeetandisusuallysymmetrical.
Extra-articularmanifestations:Rheumaticfevercancausecarditis(inflammationoftheheart),which
canresultinheartfailure,whileRAdoesnottypicallyinvolvetheheart.
Laboratoryfindings:RFisdiagnosedbasedonthemodifiedJonescriteria,whichincludelaboratorytests
forevidenceofrecentgroupAstreptococcalinfection(suchaselevatedanti-streptolysinOtiterorpositive
throatculture).InRA,therearespecificantibodiespresent,includingrheumatoidfactorandanti-cyclic
citrullinatedpeptideantibodies.

17. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
Responsetotreatment:Treatmentforrheumaticfeverinvolvesantibioticstoeradicatethestreptococcal
infection,aswellasanti-inflammatorymedicationstocontrolinflammationandpreventcomplications.In
contrast,RAistreatedwithdisease-modifyingantirheumaticdrugs(DMARDs)andimmunosuppressants.
Insummary,whilebothRAandRFcanpresentwithjointsymptoms,theageofonset,jointsinvolved,extra-
articularmanifestations,laboratoryfindings,andresponsetotreatmentcanhelpdifferentiatebetweenthetwo
conditions.
Mitralvalvedisease
1.Howwillyouinvestigateacaseofmitralvalvularheartdisease?(DU-08Ja)
Investigationofacaseofmitralvalvediseasemayincludethefollowing:
Medicalhistory:Takingadetailedhistoryisessentialtoidentifyanyriskfactorsforvalvularheartdisease,
suchasahistoryofrheumaticfeverorinfectiveendocarditis.
Physicalexamination:Athoroughphysicalexaminationcanidentifyanyabnormalheartsounds
(murmurs)orrhythmdisturbances.
ECG(electrocardiogram):AnECGcandetectanyabnormalheartrhythmsandevidenceofleft
ventricularhypertrophy.
ChestX-ray:AchestX-raycanshowevidenceofanenlargedheart,pulmonaryedemaorothersignsof
congestiveheartfailure.
Echocardiography:Thisisthemostimportanttestfordiagnosingmitralvalvedisease.Itusesultrasound
wavestocreateimagesoftheheartanditsvalvestoassessthevalveanatomy,function,andseverityof
regurgitationorstenosis.
Cardiaccatheterization:Thisinvasiveprocedureinvolvesinsertingacatheterintothehearttomeasure
pressuresintheheartchambersandtoassessthedegreeofvalvularstenosisorregurgitation.
MRIorCTscan:Thesetestscanprovidemoredetailedimagesoftheheartanditsstructuresandhelp
assessvalvemorphology,function,andcomplicationssuchasthrombusorabscessformation.

18. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
Thechoiceofinvestigationmaydependontheindividualpatient'spresentationandthesuspectedunderlying
etiologyofthevalvedisease.
2.Howwillyoutreatacaseofmitralstenosisclinically?(DU-16Ja,11Ju)
Thetreatmentofmitralstenosisdependsontheseverityofthediseaseandthesymptomsofthepatient.The
followingaresomeoftheclinicaltreatmentoptions:
Medications:Medicationssuchasdiuretics,beta-blockers,andcalciumchannelblockersmaybe
prescribedtomanagesymptomslikeshortnessofbreathandpalpitations.
Anticoagulation:Patientswithmitralstenosisareatincreasedriskfordevelopingbloodclots,whichcan
leadtostrokeorothercomplications.Therefore,anticoagulantmedicationslikewarfarinmaybeprescribed
toreducetheriskofbloodclots.
Balloonvalvuloplasty:Thisisaminimallyinvasiveprocedurethatinvolvesinflatingaballooninthe
mitralvalvetowidentheopeningandimprovebloodflow.Thisprocedureistypicallyrecommendedfor
patientswithmoderatetoseveremitralstenosiswhoaresymptomaticandhavefavorablevalveanatomy.
Surgicalrepairorreplacement:Forpatientswithseveremitralstenosisorthosewhoarenotcandidates
forballoonvalvuloplasty,surgicalrepairorreplacementofthemitralvalvemaybenecessary.Thechoice
ofproceduredependsonthepatient'soverallhealth,theseverityofthevalvedisease,andtheextentof
damagetothevalve.
Antibioticprophylaxis:Patientswithmitralstenosisareatincreasedriskofdevelopinginfective
endocarditis,whichisaninfectionoftheheartvalve.Therefore,patientsmayrequireantibioticprophylaxis
beforedentalorotherinvasiveprocedurestoreducetheriskofinfection.
Thetreatmentofmitralstenosisshouldbetailoredtotheindividualpatientbasedontheirsymptoms,disease
severity,andoverallhealth.
***3.A40yearoldwomanpresentswithpalpitationandexertionalbreathlessnessfortwomonths.
Examinationofprecordiumrevealssoftsecondheartsoundandanearlydiastolicmurmuratthe
aorticarea.(DU-22M)
a.Whatothersignyouwouldlookforduringherclinicalexamination?
b.Mentioninvestigationtoarriveatadiagnosisalongwithexpectedfindings.

19. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
a.Inadditiontothesoftsecondheartsoundandearlydiastolicmurmurattheaorticarea,Iwouldalsolook
for:
Presenceofathrill(avibratorysensationfeltonpalpationovertheaorticarea)
Signsofleftventricularhypertrophy(e.g.heavingapexbeat,displacedandsustainedapicalimpulse)
Signsofheartfailure(e.g.raisedjugularvenouspressure,pulmonarycrackles,peripheraledema)
Corrigan'ssign:Visibleandpalpablecarotidpulsation
DeMusset'ssign:Headnoddingintimewiththeheartbeat
Quincke'ssign:Pulsationsofthenailbed
Hill'ssign:Significantdifferencebetweenbrachialandfemoralarterialbloodpressures
b.Toarriveatadiagnosis,thefollowinginvestigationsmaybeperformed:
Electrocardiogram(ECG):mayshowleftventricularhypertrophyand/oratrialfibrillation
Echocardiogram:thisisthemostusefuldiagnostictoolandcanconfirmthepresenceofaortic
regurgitation,aswellasassesstheseverityandunderlyingcause.Echocardiographymayshowdilatationof
theascendingaorta,bicuspidaorticvalve,orinfectiveendocarditisasunderlyingcauses.
ChestX-ray:mayshowcardiomegaly,pulmonarycongestion,orsignsofaorticdilatationifpresent.
Bloodtests:maybeperformedtoidentifyunderlyingcausesorcomplications,suchaselevated
inflammatorymarkersininfectiveendocarditis,orelevatedB-typenatriureticpeptide(BNP)inheart
failure.
Theexpectedfindingsdependontheunderlyingcauseandseverityoftheaorticregurgitation.Ingeneral,
echocardiographywillshowaretrogradeflowofbloodfromtheaortabackintotheleftventricleduringdiastole,
andmayalsoshowdilatationoftheleftventricleand/oraorticroot.Iftheunderlyingcauseisabicuspidaorticvalve,
echocardiographymayshowfusionoftwooftheaorticvalvecusps.Ifthepatienthasinfectiveendocarditis,blood
culturesmaybepositivefortheinfectingorganism.
4.A30yearoldwomanpresentswithpalpitationandexertionalbreathlessnessforsix
months.Examinationofprecordiumrevealsloudfirstheartsoundandamid-diastolic
murmurattheapex.(DU-20Nov)
a.Mentioninvestigationstosupportyourdiagnosiswithexpectedfindings.
b.Writedowncomplicationsshemightdevelop.
a.Thefollowinginvestigationsmaybehelpfultosupportthediagnosisofthepatient:
Electrocardiogram(ECG)toevaluatetheheartrhythmandelectricalactivity
Echocardiogramtoassesstheheartstructureandfunction,andtovisualizethemitralvalve

20. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
ChestX-raytoevaluatethesizeandshapeoftheheart,andtodetectanyfluidaccumulationinthelungs
Expectedfindingsmayinclude:
ECGmayshowirregularheartrhythm,atrialfibrillation,orotherabnormalities
Echocardiogrammayshowthickeningorenlargementoftheheart,mitralvalveprolapse,ormitral
regurgitation
ChestX-raymayshowenlargedheartorfluidinthelungs.
b.Thepatientmightdevelopthefollowingcomplications:
Pulmonaryedema
Heartfailure
Infectiveendocarditis
Embolism(bloodclotsthatcantraveltootherpartsofthebody)
Arrhythmias(abnormalheartrhythms).
Earlydetectionandmanagementofthesecomplicationsarecrucialtopreventfurthercomplicationsandimprovethe
patient'soutcome.
3.A40yearoldwomanpresentswithpalpitationandexertionalbreathlessnessfortwo months.
Examinationofprecordiumrevealssoftsecondheartsoundandanearlydiastolicmurmurattheaortic
area.(DU-22M)
a.Whatothersignyouwouldlookforduringherclinicalexamination?
Inadditiontothesoftsecondheartsoundandearlydiastolicmurmurattheaorticarea,thereareafewothersigns
thatmightbelookedforduringtheclinicalexaminationofapatientwithsuspectedaorticregurgitation.Someof
thesesignsinclude:
Corrigan'ssign:Visibleandpalpablecarotidpulsation
DeMusset'ssign:Headnoddingintimewiththeheartbeat
Quincke'ssign:Pulsationsofthenailbed
Hill'ssign:Significantdifferencebetweenbrachialandfemoralarterialbloodpressures
Thesesignsmaysuggestthepresenceofaorticregurgitationandcanhelpinmakingadiagnosis.

21. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
5.A26yearsoldladypresentedtoyouwithgraduallydevelopingdyspnoeawithirregularly
irregularpulseandloudfirstheartsoudwithlowpitchedapicalmid-diastolicmurmur.
Howwillyoumanageher?(DU-06Ja)
Theclinicalpresentationdescribedinthescenariosuggeststhepossibilityofatrialfibrillationwithmitralstenosis.
Themanagementofthepatientinvolves:
Confirmationofdiagnosis:Thiscanbedonebyperforminganechocardiogramtoconfirmthepresenceof
mitralstenosisandassesstheseverityofthedisease.A12-leadelectrocardiogram(ECG)shouldalsobe
donetoconfirmthepresenceofatrialfibrillation.
Controlofsymptoms:Thepatient'ssymptomsofdyspneacanbemanagedwithdiureticstoreducefluid
overloadandoxygentherapyasneeded.Anti-arrhythmicmedicationssuchasbeta-blockers,calcium
channelblockers,ordigoxincanbeusedtocontroltheheartrateinatrialfibrillation.
Anticoagulationtherapy:Patientswithatrialfibrillationandmitralstenosisareatahigherriskof
developingbloodclots,whichcancausestrokeorothercomplications.Therefore,anticoagulationtherapy
shouldbeinitiatedwithmedicationssuchaswarfarinordirectoralanticoagulants(DOACs).
Interventionaltherapy:Inseverecasesofmitralstenosis,surgicalinterventionmaybenecessarytorepair
orreplacethedamagedvalve.Inlessseverecases,balloonvalvuloplastymaybeanoption.
Long-termmanagement:Thepatientshouldbemonitoredregularlyforsymptomsandcomplications,
withfollow-upechocardiogramstoassesstheprogressionofthediseaseandtheeffectivenessoftreatment.
Lifestylemodifications,includingsaltandfluidrestrictionandsmokingcessation,canalsobehelpfulin
managingsymptomsandslowingtheprogressionofthedisease.

22. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
6.A40yearsoldladypresentedtoyouwithmitralstenosiswithatrialfibrillation.Howwillyou
managesuchlady(DU-06S)
Themanagementofapatientwithmitralstenosisandatrialfibrillationwouldinvolveseveralaspects,including
medicalmanagement,controlofsymptoms,andpreventionofcomplications.Someofthekeymanagementsteps
are:
Anticoagulationtherapy:Patientswithmitralstenosisandatrialfibrillationareatanincreasedriskof
thromboembolism.Therefore,anticoagulationtherapywithmedicationssuchaswarfarinordirectoral
anticoagulants(DOACs)isnecessarytopreventstrokeandotherthromboembolicevents.
Ratecontrol:Atrialfibrillationcancausearapidheartrate,whichcanworsensymptomsinpatientswith
mitralstenosis.Therefore,controllingtheheartratewithmedicationssuchasbeta-blockers,calcium
channelblockers,ordigoxinmaybenecessarytoimprovesymptomsandreducetheriskofcomplications.
Rhythmcontrol:Insomecases,attemptsmaybemadetorestorenormalsinusrhythmwithmedications
suchasamiodaroneorcardioversion.However,thismaynotbefeasibleoreffectiveinallpatients.
Diuretics:Mitralstenosiscancausefluidbuildupinthelungsandotherpartsofthebody,leadingto
symptomssuchasdyspneaandedema.Diureticssuchasfurosemidemaybeprescribedtorelievethese
symptoms.
Balloonvalvuloplastyorsurgery:Insomecases,mitralstenosismaybesevereenoughtowarrant
invasivetreatmentsuchasballoonvalvuloplastyorsurgerytorepairorreplacethemitralvalve.

23. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
Antibioticprophylaxis:Patientswithmitralstenosisareatincreasedriskofinfectiveendocarditis,and
therefore,antibioticprophylaxisisrecommendedbeforecertaindentalormedicalprocedures.
Overall,themanagementofmitralstenosiswithatrialfibrillationrequiresamultidisciplinaryapproachinvolvinga
cardiologist,electrophysiologist,andcardiacsurgeonasnecessary.Thetreatmentplanshouldbetailoredtothe
individualpatient'sneedsandpreferences,takingintoaccountfactorssuchastheseverityofsymptoms,thepresence
ofcomorbidities,andthepotentialrisksandbenefitsofvarioustreatmentoptions.
InfectiveEndocarditis&PericardialEffusion
1.WriteimportantC/Fofinfectiveendocrditis.Giveinvestigationofthisdisease.(DU-09Ju)
Infectiveendocarditis(IE)isaninfectionoftheendocardialsurfaceoftheheart,includingtheheartvalves,chordae
tendineae,andmuralendocardium.ThefollowingareimportantclinicalfeaturesofIE:
Fever
Neworchangingheartmurmur
Signsofsystemicembolization,suchaspetechiae,splinterhemorrhages,orJanewaylesions
Oslernodes(painfulnodulesonthepadsoffingersandtoes)
Rothspots(retinalhemorrhageswithawhitecenter)
Clubbingoffingers
InvestigationsthatcanbedonetoestablishthediagnosisofIEinclude:
Bloodcultures:Twoorthreesetsofbloodculturesshouldbetakenbeforestartingantibiotics.
Echocardiography:Transthoracicechocardiography(TTE)isusuallydonefirst.Transesophageal
echocardiography(TEE)ismoresensitiveandspecificbutismoreinvasive.
Completebloodcount(CBC):Anemiaandleukocytosismaybepresent.
Erythrocytesedimentationrate(ESR)andC-reactiveprotein(CRP):Thesearemarkersof
inflammationthatmaybeelevatedinIE.
OtherinvestigationsmaybedonetolookforcomplicationsofIE,suchaschestX-rayorcomputedtomography(CT)
scantoevaluateforpulmonaryembolismorsepticemboli,orbrainimagingtoevaluateforstrokeorabscess
formation.TreatmentofIEtypicallyinvolvesaprolongedcourseofantibiotics,oftengivenintravenously,andin
severecases,surgicalinterventionmaybenecessary
2.Givethemanagement&complicationsofinfectiveendocarditis.(DU-04M)

24. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
Managementofinfectiveendocarditisinvolvesamultidisciplinaryapproachandincludesantimicrobialtherapy,
surgicalintervention,andsupportivecare.Thespecifictreatmentregimendependsonthecausativeorganism,the
siteandseverityofinfection,andthepresenceofcomplications.
Antimicrobialtherapy:Antibioticsarethemainstayoftreatmentforinfectiveendocarditis.Thechoiceof
antibioticregimendependsonthecausativeorganismanditsantibioticsusceptibilitypattern.Empiric
therapyshouldbestartedimmediately,andtheregimenshouldbemodifiedoncetheresultsofblood
culturesareavailable.Antibiotictherapyisusuallygivenfor4-6weeks,andthepatient'sclinicalresponse
ismonitoredclosely.
Surgicalintervention:Surgerymaybenecessaryinpatientswithcomplicationssuchasvalvedysfunction,
heartfailure,orpersistentinfectiondespiteadequateantimicrobialtherapy.Surgicaloptionsincludevalve
repairorreplacement,removalofinfectedtissue,anddrainageofabscessesorpericardialeffusion.
Supportivecare:Patientswithinfectiveendocarditisrequireclosemonitoringforcomplicationssuchas
embolicevents,heartfailure,andarrhythmias.Theymayalsorequiresymptomatictreatmentsuchas
antipyretics,analgesics,anddiuretics.
Complicationsofinfectiveendocarditisinclude:
Valvedysfunction:Valvedysfunctioncanresultinheartfailure,arrhythmias,andembolicevents.
Embolicevents:Embolicanoccurinvariousorgans,causinginfarctionandtissuedamage.
Perivalvularabscess:Abscessformationcanleadtovalvularandmyocardialdestruction.
Systemiccomplications:Systemiccomplicationssuchassepticemia,renalfailure,andrespiratoryfailure
canoccurinseverecases.
Neurologicalcomplications:Neurologicalcomplicationssuchasstrokeandtransientischemicattackscan
occurduetoemboliorsepticemia.
Fungalendocarditis:Fungalendocarditisisararebutseriouscomplicationthatcanoccurin
immunocompromisedpatients.
Prostheticvalveendocarditis:Prostheticvalveendocarditisisaseriouscomplicationthatrequiresprompt
surgicalintervention.
3.HowwouldyoudifferentiatechestpainofacuteMIfromacutepericarditis?(DU-05M)

25. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
Chestpainisacommonpresentingsymptomforbothacutemyocardialinfarction(MI)andacutepericarditis.
However,therearesomedifferencesintheirclinicalpresentationsthatcanhelpdifferentiatebetweenthetwo
conditions.
AcuteMItypicallypresentswithsevere,crushing,andpersistentchestpainthatisoftendescribedasapressureor
tightnessinthechest.Thepainmayradiatetotheleftarm,neck,jaw,back,orepigastricregion.Itisusually
associatedwithsweating,shortnessofbreath,nausea,vomiting,andpalpitations.Thepainisnotrelievedbyrestor
nitroglycerinandmaylastforseveralhoursorlonger.
Acutepericarditis,ontheotherhand,presentswithasharp,stabbing,orpleuriticchestpainthatisusuallylocated
retrosternallyorleftprecordialregion.Thepainmayradiatetotheleftshoulderandarm.Thepainisworsenedby
deepbreathing,coughing,swallowing,orlyingflatandisrelievedbysittinguporleaningforward.Thepatientmay
alsohaveafever,malaise,andapericardialfrictionrubonexamination.
Intermsofinvestigations,electrocardiogram(ECG)isausefultooltodifferentiatebetweenacuteMIandacute
pericarditis.InacuteMI,ECGtypicallyshowsST-segmentelevationordepression,T-waveinversion,orQwaves
intheaffectedleads.Inacutepericarditis,ECGmayshowdiffuseST-segmentelevation,PR-segmentdepression,
andPR-segmentelevationinaVRlead.Echocardiographymaybeusefultoconfirmthediagnosisofacute
pericarditisandtoassessforthepresenceofpericardialeffusion.
Insummary,whilebothacuteMIandacutepericarditiscanpresentwithchestpain,theirclinicalpresentationsand
ECGfindingscanhelpdifferentiatebetweenthetwoconditions.
3.HowwouldyoudifferentiatechestpainofacuteMIfromacutepericarditis?(DU-05M)
DistinguishingchestpainbetweenacuteMIandacutepericarditiscanbedonebythefollowing:
ChestPaininAcuteMI:
Typically,chestpaininMIissevere,crushingorsqueezinginnature.
Painusuallystartsinthecenterofthechestandmayradiatetotheleftarm,neck,jaw,orback.
PaininMIoftenlastsformorethan20minutesanddoesnotgetrelievedbyrestornitroglycerin.
Thepatientmayalsoexperienceshortnessofbreath,sweating,nausea,andvomiting.
ChestPaininAcutePericarditis:

26. ProfessorDRMd.TOUFIQURRAHMAN,FCPS,MD
Professor&Head,Cardiology,CMMC,Manikganj
[email protected];[email protected]
Thechestpaininacutepericarditisisusuallysharp,pleuritic,andpositional.
Thepainworsenswithdeepbreathing,coughing,andlyingdown,andimproveswithsittinguporleaning
forward.
Thepaininpericarditisisnotusuallyrelievedbynitroglycerin.
Thepatientmayalsoexperiencefever,malaise,andmyalgias.
Insummary,thekeydifferencesbetweenchestpaininacuteMIandacutepericarditisarethenatureanddurationof
pain,associatedsymptoms,andresponsetonitroglycerin.Itisimportanttodifferentiatebetweenthetwoasthey
requiredifferentmanagementapproaches.