Fcps cardiology long case

1. FCPS CARDIOLOGY
LONG CASE
DR SHAHID IQBAL
CONSULTANT CARDIOLOGIST

2. WHO YOU ARE?
YOU ARE WHAT YOU
THINK OF YOURSELF TO
BE……

3. FORMAT
 Time Duration : 1 hour.
 Candidate time : 30 Mins.
 Examiner time : 30 Mins.
 Proposed Time Division :
History Taking – 15 Mins Max.
Examination – 10 Mins.
Summary - 05 Mins.

4. TIPS AND TRICKS
 1) Be Confident.
 2) Be Simple.
 3) Make an eye contact with the patient.
 4) Develop repo with the patient (Smiling face)
 5) Communicate with the patient in his/her language.
 6) Time Management is the key.
 7) Be Precise.
 8) Focus only on the positive findings.
 9) Every command should be loud and clear.
 10) Be Gentle with the patient.
 11) Thanks at the end of your long case and redress your patient.
 12) Make a summary in your mind before you face the examiner.

5. FREQUENTLY ASKED LONG CASES
 1) Acute Coronary Syndrome (STEMI, NSTEMI,Unstable
angina)
 2) Stable ischemic Heart disease.
 3) Syncope.
 4) Complete Heart Block.
 5) Pacemaker.
 6) Channelopathies.
 7) Infective Endocarditis.

6. HISTORY TAKING
 Patient Profile :
 Name……….
 S/D/O………..
 Age………
 Residence………..
 Occupation……
 Admitted through ER/OPD on date, time……
with the presenting complaint:
chest pain….01 hour
Shortness of breath…..

7. HISTORY TAKING
He/She is known case of:
HTN-10 years
DM-5 years
NON-SMOKER/SMOKER (PACK YEARS)
IHD (PCI/CABG/STEMI/NSTEMI/UNSTABLE ANGINA)
THYROID PROFILE (CHECKED/NOT CHECKED)

8. HISTORY TAKING
CHEST PAIN DESCRIPTION :
My Patient was in usual state of health 1 hour ago
when he/she developed chest pain while he/she was at
rest, it was retrosternal in location, moderate to severe in
intensity, gradual in onset, squeezing/gripping in nature,
radiating towards both arms and upper jaw, aggravated
on minimal exertion and partially relieved with
sublimngual nitrate/rest.it was progressive and persistent
in nature.

9. HISTORY TAKING
 ASSOCIATED FEATURES :
SHORTNESS OF BREATH.
PALPITATIONS.
SYNCOPE.
NAUSEA/VOMITING/DIARRHEA
FOOD INTAKE.
RESPIRATORY MOVEMENT
CHANGE OF BODY POSTURE.
CHEST TRAUMA
WHEEZ/COUGH/SPUTUM PRODUCTION.
HEMOPTYSIS.
ORTHOPEDIC/PELVIC SURGERY.
PROLONGED IMMOBILITY/AIR TRAVEL
VESICULAR SKIN RASH
LEG/BUTTOCK CLAUDICATION.
PSYCHOLOGICAL DISTURBANCE.
HISTORY OF DRUG ABUSE.

10. HISTORY TAKING
PRE-HOSPITAL COURSE :
WITH THIS PAIN,MY PATIENT
INITIALLY LANDED IN A LOCAL HOSPITAL VIA HIS MOTOR
BIKE/AMBULANCE WHERE ECG WAS DONE AND HE WAS
REFFERED TO A TERTIARY CARE HOSPITAL AFTER HE WAS
GIVEN SOME ORAL/SUBLINGUAL/INTRAVENOUS
MEDICATIONS WHICH PARTIALLY RELIEVED HIS
SYMPTOMS BUT WERE PERSISTENT.

11. HISTORY TAKING
HOSPITAL COURSE :
HE LANDED IN THE EMERGENCY DEPARTMENT OF PIC/TERTIARY
CARE HOSPITAL WITH HISTORY OF CHEST PAIN OF 2 HOURS DURATION WHERE
HIS ECG WAS DONE,SHIFTED TO CCU,CARDIAC MONITOR ATTACHED,IV LINES
SECURED,ELECTRICAL AND HEMODYNAMIC MONITORING STARTED.AFTER BRIEF
HISTORY AND TARGTED PHYSICAL EXAMINATION,HE WAS TOLD BY THE DOCTOR
ON DUTY THAT HE IS SUFFERING FROM MAJOR HEART ATTACK.AFTER TAKING THE
INFORMED CONSENT,CATH LAB TEAM ACTIVATED AND HE WAS IMMEDIATLEY
SHIFTED TO CATH LAB ALONGWITH EMERGENCY TROLLY.CORO ANGIO DONE WAS
DONE THROUGH RIGHT RADIAL APPROACH WHICH SHOWED TIGHT STENOSIS IN
THE MIDCOURSE OF LAD WHICH WAS SUCCESSFULLY STENTED UN THE SAME
SETTINGS.THE WHOLE PROCEDURE WAS UNEVENT FREE/COMPLICATION FREE.

12. HISTORY TAKING
HOSPITAL COURSE :
HE LANDED IN THE EMERGENCY DEPARTMENT OF PIC/TERTIARY
CARE HOSPITAL WITH HISTORY OF CHEST PAIN OF 2 HOURS DURATION WHERE
HIS ECG WAS DONE,SHIFTED TO CCU,CARDIAC MONITOR ATTACHED,IV LINES
SECURED,ELECTRICAL AND HEMODYNAMIC MONITORING STARTED.AFTER BRIEF
HISTORY AND TARGTED PHYSICAL EXAMINATION,HE WAS TOLD BY THE DOCTOR
ON DUTY THAT HE IS SUFFERING FROM MAJOR HEART ATTACK.AFTER EXCLUDING
ABSOLUTE CONTRA-INDIACTIONS AND TAKING THE INFORMED CONSENT,HE WAS
SUCCESSFULLY THROMBOLYSED. NEXT DAY CORO ANGIO DONE WAS DONE
THROUGH RIGHT RADIAL APPROACH WHICH WENT COMPLICATIONS FREE AND IT
SHOWED SEVERE TRIPLE VESSEL DISEASE AND WAS ADVISED SURGICAL
CONSULTATION.

13. RISK PROFILE
 KNOWN CASE OF :
HTN -10 YEARS (GOOD CONTROL AND COMPLIANCE)
TAKING ORAL ANTIHYPERTENSIVES.
NO HISTORY OF BLURRING OF VISION.
STROKE/TIA
NEPHROPATHY.
DM – 5 YEARS (GOOD CONTROL AND COMPLIANCE)
TAKING SUBCUT INSULIN AND OHGs.
LAST HBAIC (5.8 etc)
NO NUMBNESS/PARASTHESIA.
POSTURAL DROP.
WOUND/INFECTION.
FROTHY URINE.
SMOKING 10 PACK YEARS.NEVER TRIED TO QUIT. HE IS ALSO HAVING SIGNIFICANT
EXPOSURE TO 2ND HAND SMOKING AT WORKPLACE.
ISCHEMIC HEART DISEASE : TAKING ANTIPLATELETS,PREVIOUS HISTORY OF ANY
EVENT(STEMI/NSTEMI/UNSTABLE ANGINA),PREVIOUS HISTORY OF REVASCULARISATION (PCI,CABG

14. HISTORY TAKING
FAMILY HISTORY :
SUDDEN CARDIAC DEATH.
PREMATURE CAD (MALES<65 YEARS,FEMALES<55 YEARS).
SOCIAL HISTORY :
MARRIED HAVING NO…KIDS..EARNS ALMOST 25000 PKR/MONTH,LIVES IN
2.5 MARLA HOUSE SITUATED AT THE GROUND FLOOR.
PERSONAL HISTORY : NO HISTORY OF SUBSTANCE ABUSE,ADEQUATE SLEEP AND MOOD.LIVES A
SEDENTARY LIFESTYLE AND UNHEALTHY DIETARY BEHAVIOUR.
DRUG HISTORY : NO HISTORY OF DRUG ALLERGY.
PAST MED/SURGICAL HISTORY : UNREMARCABLE.

15. HISTORY TAKING
 SYSTEMIC REVIEW :
No H/O weakness of any part of body.
Any ASOC.
No Hematemesis
No Hematuria.
No Melena.
bowel habits.
Describe if there is any positive finding.
If no positive finding then describe no significant ailment present.

16. PHYSICAL EXAMINATION
 A young male/female lying comfortably on the couch, well co-
operative through out the examination with Pulse rate of…..of
normal volume and character. No radio-radial or radio-femoral
delay. All pulses are palpable or comparable. BP is
130/80mmgh with no postural drop. Patient is currently
afebrile.RR is 16 breaths/min. Regarding CNS Examination,
sensory, motor, cranial nerves and higher mental functions are
intact.No vocal fremitis or vocal resonance.Abdomen is soft
and non-tender. Bowel sounds are audible. No Hepatic or renal
bruit.No vesicular or skin rash. No arthralgias or myalgias.Rest
of the examination is unremarkable.

17. NEXT QUESTION
WHAT IS YOUR DIAGNOSIS?

18. HOW TO ANSWER
Sir/ madam, based on the history and
examination my diagnosis is………..
ACS (Most Probably STEMI) under the
risk profile of HTN,DM,Smoking etc.

19. NEXT QUESTION
 DESCRIBE THIS ECG?
OR
 DEFEND YOUR DIAGNOSIS ON THIS ECG?
OR
 THIS IS ECG OF THIS PATIENT,COMMENT ON THIS?

20. HOW TO DESCRIBE ECG?
 THIS IS A 12 LEAD ECG OF PATIENT (XYZ) DONE ON (DATE) AT
NORMAL PAPER SPEED AND CALIBRATIONS WHICH IS
SHOWING……….
1) RHYTHM (SINUS/AFIB/BLOCK etc)
2) ST SEGMENT CHANGES (ELEVATIONS/DEPRESSIONS)
3) RATE.
4) AXIS
5) SPECIFIC FINDINGS.

21. NEXT QUESTION
HOW WOULD YOU PROCEED IN THIS CASE?

22. HOW TO ANSWER
Check list for the management.
1) Admit the patient.
2) Brief History and targeted physical examination.
3) Get a fresh ECG within 10 min of arrival.
4) Oxygen therapy if SO2 is less than 94 percent.
5) Pain management.( IV Morphine)
6) Electrical and hemodynamic monitoring.
7) Secure IV Lines.
8) Load the patient with Dual antiplatelets therapy.
9) Anticoagulation with IV heparin/enoxaparin.
10) Consent.
11) Exculde Contra-indiactions in case of thrombolysis.
12) Activate cath lab team Immediately shift the patient to cath lab with emergency
trolly.

23. NEXT QUESTION
WHICH REVASCULARISATION STRATEGY
WOULD YOU PREFER IN THIS CASE AND
WHY?

24. HOW TO ANSWER
FACTORS FAVOURING THROMBOLYSIS.
a) Non PCI capable centre.
b) Transfer time more than 120 Min,
c) Absolute Contra indications to thrombolysis.
FACTORS FAVOURING PPCI.
a) PCI capable centre.
b) Door to balloon time within 90 Mins.
c) STEMI symptoms within 12 hours presentation.
FACTORS FAVOURING URGENT CABG.
a) STEMI symptoms within 12 hrs, severe LMS disease,high syntax score, anatomy not
amenable to PCI.
b) TVCAD/DVCAD with ostial LAD involvement.
c) Distal LMS disease with bifurcation lesion of LAD and LCX.
d) Refractory angina not responding to medical treatment, high syntax score.

25. CD PRESENTATION
This is a coronary angiography of patient (XYZ),55 years old
male done on 12th December 2021 through right radial
approach. Left system is engaged with JL Catheter which is
showing that LMS (Left Main stem) is normal bifurcating
vessel into LAD and LCX.LAD is good caliber vessel showing
tight stenosis/critical disease involving the proximal part. Left
system is non-dominant. LCX is of small caliber vessel with
TIMI 3 flow. Right Coronary artery is engaged with JR catheter
which is showing a dominant vessel with mild irregularities
involving the mid course.LV Angiogram done/not done.

26. FREQUENTLY ASKED QUESTIONS
 1) TIMI Score (STEMI/NSTEMI)
 2) Grace Score.
 3) Contra indications to thrombolysis.
 4) Revascularization guidelines.
 5) Trials of PCI and thrombolysis.
 6) Types of stents.
 7) Types of thrombolytics.
 8)Pharmacology (Aspirin,BB,CCBs,ARNI,Statins,Digoxin,Diuretics)
 9) Complications of MI and management.
 10) Counselling for the CABG.

27. FREQUENTLY ASKED QUESTIONS
 11) Recent advances in ACS management.
 12) Trials on Statins.
 13) Syntax Score.
 14) Definition of universal 4th MI.
 15) types of MI.
 16) PCI Complications and management.
 17) AHA Lesions classification.
 18) Medina Classification.
 19) Classification of stent thrombosis and ISR.
 20) Classification of Coronary perforation.
 21) Criteria of successful Thrombolysis.
 22) Procedural and angiographic success.

28. ITS NOT OVER
UNTILL
ITS DONE!!!!

29. THANK YOU
BEST OF LUCK 