MBBS QUESTION ANSWER 4 PDF.pdf

Professor DR Md . TOUFIQUR RAHMAN , FCPS, MD
Professor & Head, Cardiology, CMMC, Manikganj
drtoufiq19711@yahoo.com; drtoufiq1971@gmail.com
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 and any other medications they are taking
 The presence of comorbid conditions such as diabetes or kidney disease
 The patient's race, as some antihypertensive drugs may be more effective in certain populations
 Common classes of antihypertensive drugs include ACE inhibitors, angiotensin receptor blockers, beta
blockers, calcium channel blockers, and diuretics. Combination therapy may be necessary in some cases to
achieve adequate blood pressure control.
b. What are the factors affecting the choice of antihypertensive drugs?
There are several factors that can affect the choice of antihypertensive drugs for a patient, including:
 Age: The choice of antihypertensive medication may differ based on the patient's age. For
instance, thiazide diuretics may be preferred in older patients as they are effective and have fewer
side effects.
 Co-morbidities: Patients with comorbidities such as diabetes, chronic kidney disease, or heart
disease may require specific medications or medication combinations that are tailored to their
condition.

 Race: Studies have shown that certain medications may be more effective in treating
hypertension in certain races. For instance, ACE inhibitors may be more effective in reducing
blood pressure in African Americans compared to other races.
 Adverse effects: Certain medications may cause adverse effects in some patients, such as cough
with ACE inhibitors or swelling with calcium channel blockers. In such cases, alternative
medications may be considered.
 Cost: The cost of medications may also affect the choice of antihypertensive drugs. Cheaper
medications may be preferred, especially for patients with limited financial resources.
 Pregnancy: Antihypertensive medications used during pregnancy should be chosen carefully, as
some medications may have adverse effects on the fetus. Generally, medications such as
methyldopa, labetalol, and nifedipine are considered safe for use in pregnant women with
hypertension.
 Lifestyle factors: Lifestyle modifications such as weight loss, dietary changes, and increased
physical activity may also influence the choice of antihypertensive drugs. For instance, a patient
who is overweight may benefit from a medication that also helps with weight loss.
5. A 50 year old man is admitted with long history uncontrolled hypertension.
(DU-15Ju,12Ju)
(a) How do you clinically evaluate the patient to find out target organ damage?
(b) Suggest necessary investigations with expected findings.
a) Target organ damage evaluation in a patient with uncontrolled hypertension includes:
Fundoscopic examination to check for hypertensive retinopathy, including retinal hemorrhages, exudates, cotton
wool spots, and arteriolar narrowing.
Cardiac examination to evaluate for left ventricular hypertrophy (LVH), which can be detected by palpation or by
ECG findings.
Neurological examination to assess for evidence of stroke, transient ischemic attack, or cognitive impairment.
Renal examination to evaluate for renal insufficiency or chronic kidney disease.

b) Necessary investigations for a patient with uncontrolled hypertension and suspected target organ damage
may include:
 ECG to evaluate for LVH, ST-T changes, or evidence of acute coronary syndrome.
 Echocardiography to assess for LVH, valvular abnormalities, or left ventricular systolic or diastolic
dysfunction.
 Renal function tests including serum creatinine and estimated glomerular filtration rate (eGFR).
 Urinalysis to evaluate for proteinuria or hematuria.
 Lipid profile to assess for dyslipidemia and cardiovascular risk.
 Brain imaging such as CT or MRI to assess for evidence of stroke or transient ischemic attack.
 Ophthalmologic examination to further assess for hypertensive retinopathy.
The expected findings may include LVH, abnormalities in cardiac function, evidence of renal insufficiency or
proteinuria, evidence of stroke or transient ischemic attack, and hypertensive retinopathy. These findings may guide
the management of hypertension and the prevention of further target organ damage.
6. A 50 year old man has presented with headache with BP 180/110 mmHg. (DU-14Ju)
a. How do you clinically evaluate his cardiovascular risk?
b. How do you mange him?
a. To clinically evaluate the cardiovascular risk of the patient, the following factors should be considered:
 Age
 Gender
 Blood pressure levels
 Smoking status
 Lipid profile
 Presence of diabetes
 Family history of cardiovascular disease
 Physical activity levels
Based on these factors, the patient's 10-year cardiovascular risk can be estimated using a risk assessment tool such
as the Framingham Risk Score or the QRISK2 calculator.
b. The management of a 50-year-old man presenting with a headache and a BP of 180/110 mmHg involves the
following:
 Confirm the diagnosis: The first step is to confirm the diagnosis of hypertension by taking accurate blood
pressure measurements. Repeat the measurement after a few minutes to rule out white-coat hypertension.

 Evaluate for end-organ damage: Assess the patient for any signs of end-organ damage, such as
retinopathy, left ventricular hypertrophy, or renal impairment.
 Start treatment: If the patient has no signs of end-organ damage, lifestyle modifications such as weight
loss, exercise, and dietary changes should be initiated. If the BP remains elevated, pharmacological
treatment should be started.
 Select the antihypertensive agent: Select the antihypertensive agent based on the patient's comorbidities
and contraindications, including ACE inhibitors, ARBs, diuretics, beta-blockers, or calcium channel
blockers.
 Monitor the response to treatment: Monitor the patient's response to treatment by measuring blood
pressure at regular intervals. Adjust the medication dosage if necessary.
 Educate the patient: Educate the patient about hypertension, its complications, and the importance of
adhering to the treatment regimen.
 Follow up: Schedule regular follow-up visits to monitor the patient's blood pressure, assess for any adverse
effects of treatment, and evaluate for any signs of end-organ damage.
7. A 20 year old male recently detected as hypertension. (DU-17/14Ja, 10Ju)
a. Make a check list history and physical sign to find out the causes of hypertension if any.
b. Write down an investigation plan for him.
a. Check list history and physical signs to find out the causes of hypertension in a 20-year-old male:
 Family history of hypertension or cardiovascular diseases
 Obesity or overweight
 Sedentary lifestyle
 Smoking or tobacco use
 Excessive alcohol intake
 Drug abuse or use of certain medications (e.g. non-steroidal anti-inflammatory drugs, oral contraceptives,
steroids)
 Sleep apnea or other sleep disorders

 Endocrine disorders such as hyperthyroidism or Cushing's syndrome
 Renal diseases such as glomerulonephritis or polycystic kidney disease
 Coarctation of the aorta or other congenital heart defects
b. Investigation plan for a 20-year-old male with hypertension may include:
 Blood tests: complete blood count, electrolytes, renal function tests, lipid profile, fasting glucose
 Urine tests: urinalysis, urine protein-to-creatinine ratio, urine culture
 Electrocardiogram (ECG) to evaluate for left ventricular hypertrophy or other cardiac abnormalities
 Ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension and assess
blood pressure variability over 24 hours
 Imaging studies such as renal ultrasound or computed tomography (CT) angiography of the abdomen and
pelvis to evaluate for renal artery stenosis or other structural abnormalities of the kidneys and urinary tract.
Depending on the clinical findings, further investigations such as thyroid function tests or sleep studies may be
indicated.
*** 8. A 30 years old male with no family history of HTN presented with a BP of 200/110
mmHg . (DU-12Ja)
a. What could be the secondary causes?
b. How will you plan to investigate him?
a. In a young patient with no family history of hypertension, secondary causes of hypertension
should be considered. Some of the possible causes include:
 Renal artery stenosis
 Endocrine disorders such as pheochromocytoma, Cushing's syndrome, hyperaldosteronism
 Coarctation of the aorta
 Sleep apnea
 Drug-induced hypertension
b. To investigate this patient, the following tests may be considered:
 Renal function tests, including serum creatinine, blood urea nitrogen, and estimated glomerular
filtration rate (eGFR)
 Urinalysis for proteinuria and hematuria
 Renal ultrasound or CT angiography to evaluate for renal artery stenosis

 Plasma aldosterone/renin ratio to assess for hyperaldosteronism
 24-hour urine collection for metanephrines to evaluate for pheochromocytoma
 Hormone evaluation (e.g. cortisol) to assess for Cushing's syndrome
 Chest X-ray or echocardiogram to evaluate for coarctation of the aorta
 Polysomnography to assess for sleep apnea
The specific investigations may vary depending on the patient's history, physical exam, and initial
laboratory findings.
9. Write down the causes of secondary hypertension. (DU-12Ja)
Secondary hypertension can be caused by various underlying medical conditions, such as:
 Renal causes: Chronic kidney disease, renal artery stenosis, renal parenchymal disease, polycystic kidney
disease, glomerulonephritis.
 Endocrine causes: Primary aldosteronism, Cushing's syndrome, pheochromocytoma, hyperthyroidism,
hypothyroidism, acromegaly, hyperparathyroidism.
 Cardiovascular causes: Coarctation of the aorta, aortic regurgitation, aortic stenosis.
 Medication-induced: Steroids, contraceptive pills, nonsteroidal anti-inflammatory drugs (NSAIDs),
cyclosporine, erythropoietin.
 Others: Obstructive sleep apnea, pregnancy-induced hypertension, drug or alcohol abuse,
neurofibromatosis.
10. Write down clinical sing you will search in case of secondary hypertension. (DU-18Nov)
In case of secondary hypertension, the following clinical signs may be searched for:
Signs of chronic kidney disease such as anemia, proteinuria, and elevated creatinine levels.
Abdominal bruits, which may indicate renal artery stenosis.
Palpable thyroid gland enlargement, which may suggest hyperthyroidism.
Abdominal masses or bruits, which may suggest pheochromocytoma or renal artery stenosis.
Signs of Cushing's syndrome, such as obesity, moon facies, and hirsutism.
Signs of obstructive sleep apnea, such as snoring, daytime sleepiness, and obesity.
Signs of primary aldosteronism, such as hypokalemia, metabolic alkalosis, and muscle weakness.
11. a) A 53 years old patient with hypertension. Write down clinical information you would
search for identification of underlying causes of secondary hypertension.

b) Mention the comorbidities which influence the selection of antihypertensive medication
with example? (DU-19Nov)
a) In a 53-year-old patient with hypertension, the following clinical information should be searched for the
identification of underlying causes of secondary hypertension:
 History of renal disease, such as chronic kidney disease or polycystic kidney disease
 Endocrine disorders, such as pheochromocytoma, Cushing's syndrome, primary aldosteronism, or
hyperthyroidism
 Obstructive sleep apnea
 Coarctation of the aorta
 Drug-induced hypertension
 Lifestyle factors, such as obesity, excessive alcohol intake, and high salt intake
b) Comorbidities that influence the selection of antihypertensive medication include:
 Diabetes: ACE inhibitors or angiotensin receptor blockers (ARBs) are recommended as first-line agents for
hypertension in patients with diabetes.
 Heart failure: ACE inhibitors, ARBs, and beta-blockers are the preferred agents for hypertension in
patients with heart failure.
 Chronic kidney disease: ACE inhibitors or ARBs are the preferred agents for hypertension in patients
with chronic kidney disease.
 Ischemic heart disease: Beta-blockers are recommended as first-line agents for hypertension in patients
with ischemic heart disease.
 Peripheral artery disease: Calcium channel blockers and ACE inhibitors are preferred agents for
hypertension in patients with peripheral artery disease.
Mention the complications of hypertension. (DU-18Nov, 09Ju)
Hypertension, if left untreated or uncontrolled, can lead to various complications, including:
 Stroke: High blood pressure damages the blood vessels and can lead to a stroke, which is a medical
emergency.
 Heart attack: High blood pressure can damage the arteries supplying blood to the heart muscle, leading to
a heart attack.
 Heart failure: The heart has to work harder to pump blood against high blood pressure, which can weaken
the heart muscles over time, leading to heart failure.

 Kidney damage: The kidneys have tiny blood vessels that can be damaged by high blood pressure. This
can lead to kidney failure or kidney disease.
 Vision loss: High blood pressure can cause damage to the blood vessels in the retina, leading to vision loss
or blindness.
 Peripheral arterial disease: High blood pressure can cause damage to the arteries supplying blood to the
legs and feet, leading to poor circulation and pain.
 Aortic aneurysm: High blood pressure can cause the walls of the aorta (the main artery in the body) to
weaken and bulge, which can lead to an aortic aneurysm. If the aneurysm ruptures, it can be life-
threatening.
 Cognitive impairment: Chronic high blood pressure can cause damage to the blood vessels in the brain,
leading to cognitive impairment, such as memory loss, difficulty concentrating, and dementia.
*** 1. How do you diagnose acute rheumatic fever? (DU-16Ja)
Acute rheumatic fever (ARF) is a clinical diagnosis based on the presence of major and minor criteria. The diagnosis
is usually made based on Jones criteria, which includes the following:
Major criteria:
 Carditis (evidence of inflammation of the heart)
 Polyarthritis (inflammation of more than one joint)
 Chorea (involuntary movements)
 Erythema marginatum (rash with a characteristic "marginated" appearance)
 Subcutaneous nodules
Minor criteria:
 Fever
 Arthralgia (joint pain)
 Elevated acute phase reactants (such as erythrocyte sedimentation rate and C-reactive protein)
 Prolonged PR interval on electrocardiogram
To diagnose ARF, a patient must meet either of the following criteria:
Presence of two major criteria, or

Presence of one major criterion and two minor criteria, along with evidence of a previous group A
streptococcal infection.
In addition to clinical criteria, laboratory tests such as throat culture, antistreptolysin O titer, and anti-DNase B titer
can also be used to support the diagnosis of ARF and identify the previous group A streptococcal infection.
* 2. Write down the diagnostic criteria of acute rheumatic fever. (DU-10Ja, 09Ju)
The diagnostic criteria for acute rheumatic fever (ARF) include the following major criteria and minor criteria:
Major criteria:
Carditis (inflammation of the heart): documented by clinical examination or echocardiography and
manifested by the presence of a new murmur, pericardial rub, or cardiomegaly.
Polyarthritis: involvement of two or more joints, typically involving large joints (e.g., knees, ankles,
elbows, wrists) in a migratory pattern.
Chorea (Sydenham's chorea): involuntary purposeless movements of the limbs, trunk, or face, usually
without weakness.
Erythema marginatum: a non-pruritic, pink, serpiginous rash with a well-defined border.
Subcutaneous nodules: small, firm, painless nodules located over bony prominences or tendons.
Minor criteria:
 Fever (≥ 38°C).
 Arthralgia: pain in one or more joints.
 Elevated acute-phase reactants: erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP)
levels.
 Prolonged PR interval on electrocardiogram (ECG).
The diagnosis of ARF requires the presence of two major criteria, or one major and two minor criteria, plus
evidence of a preceding group A streptococcal infection, as determined by a positive throat culture or
elevated streptococcal antibody titer.
3. What is modified Jones criteria of rheumatic fever and pathogenesis of rheumatic fever?
(DU-08M)
Modified Jones criteria is a set of diagnostic criteria used for the diagnosis of acute rheumatic fever. The criteria
include major criteria and minor criteria. The major criteria are:
 Carditis (inflammation of the heart muscle)
 Polyarthritis (inflammation of multiple joints)
 Sydenham's chorea (involuntary movements)

 Erythema marginatum (a type of skin rash)
 Subcutaneous nodules
The minor criteria include fever, arthralgia (joint pain), elevated acute-phase reactants (such as C-reactive protein
or erythrocyte sedimentation rate), and a prolonged PR interval on an electrocardiogram.
The diagnosis of acute rheumatic fever requires the presence of two major criteria or one major criterion
plus two minor criteria and evidence of a preceding streptococcal infection. Additionally, the diagnosis may
be supported by evidence of a recent streptococcal infection, such as a positive throat culture or rapid
streptococcal antigen test.
Pathogenesis of rheumatic fever
 Rheumatic fever is caused by an autoimmune response to a previous infection with group A streptococcus.
 The bacteria possess M proteins on their surface that can trigger the immune system to react.
 The immune system cross-reacts with human tissue, including heart valves, joints, and the central nervous
system.
 This cross-reactivity leads to inflammation and damage to these tissues.
 The result of this inflammation and damage is the clinical manifestations of acute rheumatic fever.
4. A 13 years old girl presented with history of fever and painful swelling of large joints.
What are the D/Ds? How will you treat if she develops carditis? (DU-07Ja)
The differential diagnosis (D/Ds) for a 13-year-old girl with fever and painful swelling of large joints includes:
 Infectious causes: Bacterial infections like osteomyelitis or septic arthritis, viral infections like parvovirus
B19, and other infections like Lyme disease.
 Juvenile idiopathic arthritis (JIA): A group of chronic inflammatory joint diseases in children that can
cause joint pain, swelling, and stiffness.
 Reactive arthritis: Joint inflammation that develops after an infection in another part of the body, such as
the gastrointestinal tract or genitourinary system.
 Systemic lupus erythematosus (SLE): A chronic autoimmune disease that can cause joint pain and
swelling, as well as fever, skin rashes, and other symptoms.

 Kawasaki disease: An acute febrile illness that primarily affects children and can cause joint pain and
swelling, as well as other symptoms like rash, red eyes, and swollen lymph nodes.
 Rheumatic fever: A complication of untreated streptococcal infection that can cause joint pain and
swelling, as well as fever, skin rashes, and heart problems.
 Leukemia: A type of cancer that can cause joint pain, swelling, and bone pain.
The differential diagnosis can be narrowed down based on further evaluation, including laboratory tests and imaging
studies.
the following treatment approaches can be considered:
 Antibiotic therapy: Treatment with antibiotics is the cornerstone of managing rheumatic fever and carditis.
Penicillin is the first-line antibiotic for preventing further infection with group A streptococcus, which can
trigger a recurrence of the autoimmune response. Antibiotic therapy should be continued for at least 10
days or until the acute inflammation subsides.
 Anti-inflammatory medications: Anti-inflammatory medications such as aspirin and corticosteroids may
be prescribed to reduce inflammation and relieve pain. Aspirin can also prevent blood clots from forming
on the heart valves, which can cause further damage.
 Bed rest: Patients with carditis may require bed rest until the acute inflammation subsides. Bed rest can
help reduce the workload on the heart and prevent further damage.
 Monitoring: Patients with carditis should be closely monitored for any signs of heart failure, such as
shortness of breath or edema. They should also undergo regular echocardiography to assess the extent of
valve damage and to monitor for any changes in heart function.
 Surgery: In severe cases of rheumatic carditis, surgery may be necessary to repair or replace damaged
heart valves. This is usually done in cases where the valve damage is causing significant impairment of
heart function or if there is a high risk of heart failure.
Long-term prophylactic antibiotics to prevent recurrence of ARF and reduce the risk of developing rheumatic
heart disease.
5. A 5 years old boy presents with fever & swelling of knee and ankle joint for 3 weeks. Write down 3
important D/D. Discuss the treatment of acute rheumatic fever with carditis. (DU-09Ju)

Three important differential diagnoses of a 5-year-old boy presenting with fever and joint swelling for 3 weeks
include:
 Septic arthritis: This is an acute bacterial infection of a joint that causes similar symptoms to rheumatic
fever but is usually monoarticular and associated with more severe pain, redness, and tenderness of the
affected joint. Septic arthritis requires urgent drainage and antibiotics.
 Juvenile idiopathic arthritis: This is a group of chronic autoimmune disorders that can present with fever,
joint swelling, and stiffness. The diagnosis is based on clinical features, laboratory tests, and imaging
studies. The treatment may include nonsteroidal anti-inflammatory drugs, disease-modifying antirheumatic
drugs, and biologic agents.
 Reactive arthritis: This is an inflammatory joint disease that can occur after an infection, especially with
certain bacteria such as Chlamydia, Salmonella, or Shigella. Reactive arthritis usually affects the lower
limb joints, such as knees, ankles, and feet, and may be associated with skin rash, eye inflammation, or
urethritis. The treatment may include antibiotics, nonsteroidal anti-inflammatory drugs, and corticosteroids.
Assuming the diagnosis of acute rheumatic fever with carditis, the treatment usually involves a combination of
antibiotics and anti-inflammatory drugs. The antibiotics aim to eradicate the streptococcal infection and prevent
further rheumatic fever recurrences, while the anti-inflammatory drugs aim to reduce the inflammation and
symptoms of carditis. The specific regimen may vary depending on the severity of carditis, the presence of other
complications, and the patient's age and weight. In general, the following principles apply:
 Antibiotics: A 10-day course of oral or intramuscular penicillin is the first-line antibiotic for acute
rheumatic fever, as it is effective against most strains of streptococci and has low toxicity. Alternative
antibiotics may be used for patients who are allergic to penicillin or have recurrent rheumatic fever despite
adequate penicillin therapy. Long-term prophylaxis with penicillin is recommended to prevent recurrences,
usually until the age of 21 years or for 10 years after the last episode of rheumatic fever, whichever is
longer.
 Anti-inflammatory drugs: High-dose aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) such as
ibuprofen or naproxen are usually given for the first 2-3 weeks of acute rheumatic fever to control fever,
pain, and inflammation. Corticosteroids such as prednisone or methylprednisolone may be used in severe
cases of carditis or when other therapies are not effective or contraindicated. The duration and dose of anti-
inflammatory drugs should be tailored to the patient's response and adverse effects, such as gastric irritation
or bleeding.

 Supportive care: Patients with acute rheumatic fever and carditis may require hospitalization for close
monitoring of vital signs, fluid balance, and electrolyte status. They may also need bed rest, oxygen therapy,
or diuretics to manage heart failure or pulmonary edema. Regular follow-up with a cardiologist or
rheumatologist is necessary to monitor the progression of carditis and adjust the treatment accordingly.
6. A 15 year old boy presented with oligoarthritis involving large joints for 2 week. He had
fever about 3 weeks back and suffered from sore throat. (DU- 13Ja)
a) What is your provisional diagnosis? Mention the other important physical findings that
you will look for in this case.
b) Name important investigation that can be done to establish the diagnosis.
a) The provisional diagnosis in this case would be acute rheumatic fever. Other important physical findings that
should be looked for include:
Evidence of carditis such as tachycardia, a new murmur or changes in existing murmurs, pericardial rub or signs of
heart failure
Skin manifestations such as erythema marginatum, subcutaneous nodules, or a non-pruritic rash
Sydenham's chorea, which is a disorder of involuntary movements and affects about 10% of patients with
rheumatic fever
b) The important investigations that can be done to establish the diagnosis of acute rheumatic fever include:
 Throat culture to detect the presence of group A streptococcus, the bacteria responsible for strep throat,
which is a precursor to acute rheumatic fever
 Blood tests to look for elevated levels of inflammatory markers such as C-reactive protein (CRP) and
erythrocyte sedimentation rate (ESR)
 Electrocardiogram (ECG) to look for evidence of abnormal heart rhythms or other cardiac abnormalities
 Echocardiography to assess the structure and function of the heart, particularly if carditis is suspected
 Joint aspiration to rule out other causes of joint pain and swelling
** 7. A 13 years old girl presents with migrating polyarthritis for 2 weeks. Her Pulse is
120 beats/min asucultations reveal soft 1st heart sound with pansystolic murmur at
apex. (DU-11Ju)

a. What is your most likely diagnosis?
b. What others clinical manifestations you will look for in favour of your diagnosis?
c. How will you treat her?
a. The most likely diagnosis is acute rheumatic fever.
b. Other clinical manifestations that may support the diagnosis of acute rheumatic fever include a history of recent
streptococcal infection, fever, migratory polyarthritis, and the presence of cardiac murmurs or signs of carditis.
c) treatment--
 Antibiotics are used to treat the underlying streptococcal infection that caused acute rheumatic fever.
 Anti-inflammatory medications such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) are
given to reduce inflammation and prevent damage to the heart valves.
 Bed rest is recommended for patients with carditis to minimize the workload on the heart.
 Corticosteroids may be prescribed in addition to anti-inflammatory medications to further reduce
inflammation and prevent long-term damage to the heart.
 Immunoglobulin therapy may be considered for patients with severe carditis or when other treatments are
ineffective.
 Surgery may be necessary in some cases to repair or replace damaged heart valves.
 Prophylactic antibiotics are given to prevent further episodes of acute rheumatic fever and to prevent
recurrence of streptococcal infections.
* 8. A 15 years old boy presents with polyarthritis. (DU-11Ja)
a. What diagnostic criteria would you look for to establish the diagnosis of rheumatic fever?
b. Give an outline of management of rheumatic fever.
a. To establish the diagnosis of rheumatic fever, the diagnostic criteria that need to be looked for are the modified
Jones criteria. These criteria consist of major and minor criteria. The major criteria include:
 Carditis (inflammation of the heart)
 Polyarthritis (inflammation of multiple joints)
 Chorea (involuntary movements)
 Erythema marginatum (rash)
 Subcutaneous nodules
The minor criteria include:
 Fever
 Arthralgia (joint pain)
 Elevated acute-phase reactants (e.g. erythrocyte sedimentation rate, C-reactive protein)
 Prolonged PR interval on ECG

The diagnosis of rheumatic fever requires the presence of either two major criteria or one major and two
minor criteria, in addition to evidence of a preceding group A streptococcal infection.
b. The management of rheumatic fever includes the following:
 Antibiotic therapy to eradicate the streptococcal infection and prevent further episodes of rheumatic fever.
 Symptomatic treatment of joint pain and inflammation with nonsteroidal anti-inflammatory drugs
(NSAIDs) or corticosteroids.
 Treatment of heart failure, if present, with diuretics, angiotensin-converting enzyme inhibitors, and beta-
blockers.
 Prophylaxis against future episodes of rheumatic fever with long-term antibiotic therapy, usually with
benzathine penicillin G injections every 3-4 weeks.
 Close monitoring for the development of rheumatic heart disease, which may require surgical intervention
in severe cases.
9. How will you differertiate rheumatoid arthritis from rheumatic fever? (DU-08Ja)
Rheumatoid arthritis (RA) and rheumatic fever (RF) are two distinct diseases that can present with similar
symptoms, making their differentiation crucial. Here are some key differences between the two conditions:
 Age of onset: Rheumatic fever typically affects children aged 5-15 years, while RA usually presents in
adults over 40 years old.
 Joint involvement: In rheumatic fever, the joints involved are usually large joints (knees, ankles, elbows),
and the arthritis is migratory, meaning it moves from one joint to another. In contrast, RA involves the
small joints of the hands and feet and is usually symmetrical.
 Extra-articular manifestations: Rheumatic fever can cause carditis (inflammation of the heart), which
can result in heart failure, while RA does not typically involve the heart.
 Laboratory findings: RF is diagnosed based on the modified Jones criteria, which include laboratory tests
for evidence of recent group A streptococcal infection (such as elevated anti-streptolysin O titer or positive
throat culture). In RA, there are specific antibodies present, including rheumatoid factor and anti-cyclic
citrullinated peptide antibodies.

 Response to treatment: Treatment for rheumatic fever involves antibiotics to eradicate the streptococcal
infection, as well as anti-inflammatory medications to control inflammation and prevent complications. In
contrast, RA is treated with disease-modifying antirheumatic drugs (DMARDs) and immunosuppressants.
In summary, while both RA and RF can present with joint symptoms, the age of onset, joints involved, extra-
articular manifestations, laboratory findings, and response to treatment can help differentiate between the two
conditions.
Mitral valve disease
1. How will you investigate a case of mitral valvular heart disease? (DU-08Ja)
Investigation of a case of mitral valve disease may include the following:
 Medical history: Taking a detailed history is essential to identify any risk factors for valvular heart disease,
such as a history of rheumatic fever or infective endocarditis.
 Physical examination: A thorough physical examination can identify any abnormal heart sounds
(murmurs) or rhythm disturbances.
 ECG (electrocardiogram): An ECG can detect any abnormal heart rhythms and evidence of left
ventricular hypertrophy.
 Chest X-ray: A chest X-ray can show evidence of an enlarged heart, pulmonary edema or other signs of
congestive heart failure.
 Echocardiography: This is the most important test for diagnosing mitral valve disease. It uses ultrasound
waves to create images of the heart and its valves to assess the valve anatomy, function, and severity of
regurgitation or stenosis.
 Cardiac catheterization: This invasive procedure involves inserting a catheter into the heart to measure
pressures in the heart chambers and to assess the degree of valvular stenosis or regurgitation.
 MRI or CT scan: These tests can provide more detailed images of the heart and its structures and help
assess valve morphology, function, and complications such as thrombus or abscess formation.

The choice of investigation may depend on the individual patient's presentation and the suspected underlying
etiology of the valve disease.
2. How will you treat a case of mitral stenosis clinically? (DU-16Ja,11Ju)
The treatment of mitral stenosis depends on the severity of the disease and the symptoms of the patient. The
following are some of the clinical treatment options:
 Medications: Medications such as diuretics, beta-blockers, and calcium channel blockers may be
prescribed to manage symptoms like shortness of breath and palpitations.
 Anticoagulation: Patients with mitral stenosis are at increased risk for developing blood clots, which can
lead to stroke or other complications. Therefore, anticoagulant medications like warfarin may be prescribed
to reduce the risk of blood clots.
 Balloon valvuloplasty: This is a minimally invasive procedure that involves inflating a balloon in the
mitral valve to widen the opening and improve blood flow. This procedure is typically recommended for
patients with moderate to severe mitral stenosis who are symptomatic and have favorable valve anatomy.
 Surgical repair or replacement: For patients with severe mitral stenosis or those who are not candidates
for balloon valvuloplasty, surgical repair or replacement of the mitral valve may be necessary. The choice
of procedure depends on the patient's overall health, the severity of the valve disease, and the extent of
damage to the valve.
 Antibiotic prophylaxis: Patients with mitral stenosis are at increased risk of developing infective
endocarditis, which is an infection of the heart valve. Therefore, patients may require antibiotic prophylaxis
before dental or other invasive procedures to reduce the risk of infection.
The treatment of mitral stenosis should be tailored to the individual patient based on their symptoms, disease
severity, and overall health.
*** 3. A 40 year old woman presents with palpitation and exertional breathlessness for two months.
Examination of precordium reveals soft second heart sound and an early diastolic murmur at the
aortic area. (DU-22M)
a. What other sign you would look for during her clinical examination?
b. Mention investigation to arrive at a diagnosis along with expected findings.

a. In addition to the soft second heart sound and early diastolic murmur at the aortic area, I would also look
for:
 Presence of a thrill (a vibratory sensation felt on palpation over the aortic area)
 Signs of left ventricular hypertrophy (e.g. heaving apex beat, displaced and sustained apical impulse)
 Signs of heart failure (e.g. raised jugular venous pressure, pulmonary crackles, peripheral edema)
 Corrigan's sign: Visible and palpable carotid pulsation
 De Musset's sign: Head nodding in time with the heartbeat
 Quincke's sign: Pulsations of the nail bed
 Hill's sign: Significant difference between brachial and femoral arterial blood pressures
b. To arrive at a diagnosis, the following investigations may be performed:
 Electrocardiogram (ECG): may show left ventricular hypertrophy and/or atrial fibrillation
 Echocardiogram: this is the most useful diagnostic tool and can confirm the presence of aortic
regurgitation, as well as assess the severity and underlying cause. Echocardiography may show dilatation of
the ascending aorta, bicuspid aortic valve, or infective endocarditis as underlying causes.
 Chest X-ray: may show cardiomegaly, pulmonary congestion, or signs of aortic dilatation if present.
 Blood tests: may be performed to identify underlying causes or complications, such as elevated
inflammatory markers in infective endocarditis, or elevated B-type natriuretic peptide (BNP) in heart
failure.
The expected findings depend on the underlying cause and severity of the aortic regurgitation. In general,
echocardiography will show a retrograde flow of blood from the aorta back into the left ventricle during diastole,
and may also show dilatation of the left ventricle and/or aortic root. If the underlying cause is a bicuspid aortic valve,
echocardiography may show fusion of two of the aortic valve cusps. If the patient has infective endocarditis, blood
cultures may be positive for the infecting organism.
4. A 30 year old woman presents with palpitation and exertional breathlessness for six
months. Examination of precordium reveals loud first heart sound and a mid-diastolic
murmur at the apex. (DU-20Nov)
a. Mention investigations to support your diagnosis with expected findings.
b. Write down complications she might develop.
a. The following investigations may be helpful to support the diagnosis of the patient:
Electrocardiogram (ECG) to evaluate the heart rhythm and electrical activity
Echocardiogram to assess the heart structure and function, and to visualize the mitral valve

Chest X-ray to evaluate the size and shape of the heart, and to detect any fluid accumulation in the lungs
Expected findings may include:
 ECG may show irregular heart rhythm, atrial fibrillation, or other abnormalities
 Echocardiogram may show thickening or enlargement of the heart, mitral valve prolapse, or mitral
regurgitation
 Chest X-ray may show enlarged heart or fluid in the lungs.
b. The patient might develop the following complications:
 Pulmonary edema
 Heart failure
 Infective endocarditis
 Embolism (blood clots that can travel to other parts of the body)
 Arrhythmias (abnormal heart rhythms).
Early detection and management of these complications are crucial to prevent further complications and improve the
patient's outcome.
3. A 40 year old woman presents with palpitation and exertional breathlessness for two months.
Examination of precordium reveals soft second heart sound and an early diastolic murmur at the aortic
area. (DU-22M)
a. What other sign you would look for during her clinical examination?
In addition to the soft second heart sound and early diastolic murmur at the aortic area, there are a few other signs
that might be looked for during the clinical examination of a patient with suspected aortic regurgitation. Some of
these signs include:
Corrigan's sign: Visible and palpable carotid pulsation
De Musset's sign: Head nodding in time with the heartbeat
Quincke's sign: Pulsations of the nail bed
Hill's sign: Significant difference between brachial and femoral arterial blood pressures
These signs may suggest the presence of aortic regurgitation and can help in making a diagnosis.

5. A 26 years old lady presented to you with gradually developing dyspnoea with irregularly
irregular pulse and loud first heart soud with low pitched apical mid-diastolic murmur.
How will you manage her? (DU-06Ja)
The clinical presentation described in the scenario suggests the possibility of atrial fibrillation with mitral stenosis.
The management of the patient involves:
 Confirmation of diagnosis: This can be done by performing an echocardiogram to confirm the presence of
mitral stenosis and assess the severity of the disease. A 12-lead electrocardiogram (ECG) should also be
done to confirm the presence of atrial fibrillation.
 Control of symptoms: The patient's symptoms of dyspnea can be managed with diuretics to reduce fluid
overload and oxygen therapy as needed. Anti-arrhythmic medications such as beta-blockers, calcium
channel blockers, or digoxin can be used to control the heart rate in atrial fibrillation.
 Anticoagulation therapy: Patients with atrial fibrillation and mitral stenosis are at a higher risk of
developing blood clots, which can cause stroke or other complications. Therefore, anticoagulation therapy
should be initiated with medications such as warfarin or direct oral anticoagulants (DOACs).
 Interventional therapy: In severe cases of mitral stenosis, surgical intervention may be necessary to repair
or replace the damaged valve. In less severe cases, balloon valvuloplasty may be an option.
 Long-term management: The patient should be monitored regularly for symptoms and complications,
with follow-up echocardiograms to assess the progression of the disease and the effectiveness of treatment.
Lifestyle modifications, including salt and fluid restriction and smoking cessation, can also be helpful in
managing symptoms and slowing the progression of the disease.

6. A 40 years old lady presented to you with mitral stenosis with atrial fibrillation. How will you
manage such lady (DU-06S)
The management of a patient with mitral stenosis and atrial fibrillation would involve several aspects, including
medical management, control of symptoms, and prevention of complications. Some of the key management steps
are:
 Anticoagulation therapy: Patients with mitral stenosis and atrial fibrillation are at an increased risk of
thromboembolism. Therefore, anticoagulation therapy with medications such as warfarin or direct oral
anticoagulants (DOACs) is necessary to prevent stroke and other thromboembolic events.
 Rate control: Atrial fibrillation can cause a rapid heart rate, which can worsen symptoms in patients with
mitral stenosis. Therefore, controlling the heart rate with medications such as beta-blockers, calcium
channel blockers, or digoxin may be necessary to improve symptoms and reduce the risk of complications.
 Rhythm control: In some cases, attempts may be made to restore normal sinus rhythm with medications
such as amiodarone or cardioversion. However, this may not be feasible or effective in all patients.
 Diuretics: Mitral stenosis can cause fluid buildup in the lungs and other parts of the body, leading to
symptoms such as dyspnea and edema. Diuretics such as furosemide may be prescribed to relieve these
symptoms.
 Balloon valvuloplasty or surgery: In some cases, mitral stenosis may be severe enough to warrant
invasive treatment such as balloon valvuloplasty or surgery to repair or replace the mitral valve.

 Antibiotic prophylaxis: Patients with mitral stenosis are at increased risk of infective endocarditis, and
therefore, antibiotic prophylaxis is recommended before certain dental or medical procedures.
Overall, the management of mitral stenosis with atrial fibrillation requires a multidisciplinary approach involving a
cardiologist, electrophysiologist, and cardiac surgeon as necessary. The treatment plan should be tailored to the
individual patient's needs and preferences, taking into account factors such as the severity of symptoms, the presence
of comorbidities, and the potential risks and benefits of various treatment options.
Infective Endocarditis & Pericardial Effusion
1. Write important C/F of infective endocrditis. Give investigation of this disease. (DU-09Ju)
Infective endocarditis (IE) is an infection of the endocardial surface of the heart, including the heart valves, chordae
tendineae, and mural endocardium. The following are important clinical features of IE:
 Fever
 New or changing heart murmur
 Signs of systemic embolization, such as petechiae, splinter hemorrhages, or Janeway lesions
 Osler nodes (painful nodules on the pads of fingers and toes)
 Roth spots (retinal hemorrhages with a white center)
 Clubbing of fingers
Investigations that can be done to establish the diagnosis of IE include:
 Blood cultures: Two or three sets of blood cultures should be taken before starting antibiotics.
 Echocardiography: Transthoracic echocardiography (TTE) is usually done first. Transesophageal
echocardiography (TEE) is more sensitive and specific but is more invasive.
 Complete blood count (CBC): Anemia and leukocytosis may be present.
 Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): These are markers of
inflammation that may be elevated in IE.
Other investigations may be done to look for complications of IE, such as chest X-ray or computed tomography (CT)
scan to evaluate for pulmonary embolism or septic emboli, or brain imaging to evaluate for stroke or abscess
formation. Treatment of IE typically involves a prolonged course of antibiotics, often given intravenously, and in
severe cases, surgical intervention may be necessary
2. Give the management & complications of infective endocarditis. (DU-04M)

Management of infective endocarditis involves a multidisciplinary approach and includes antimicrobial therapy,
surgical intervention, and supportive care. The specific treatment regimen depends on the causative organism, the
site and severity of infection, and the presence of complications.
 Antimicrobial therapy: Antibiotics are the mainstay of treatment for infective endocarditis. The choice of
antibiotic regimen depends on the causative organism and its antibiotic susceptibility pattern. Empiric
therapy should be started immediately, and the regimen should be modified once the results of blood
cultures are available. Antibiotic therapy is usually given for 4-6 weeks, and the patient's clinical response
is monitored closely.
 Surgical intervention: Surgery may be necessary in patients with complications such as valve dysfunction,
heart failure, or persistent infection despite adequate antimicrobial therapy. Surgical options include valve
repair or replacement, removal of infected tissue, and drainage of abscesses or pericardial effusion.
 Supportive care: Patients with infective endocarditis require close monitoring for complications such as
embolic events, heart failure, and arrhythmias. They may also require symptomatic treatment such as
antipyretics, analgesics, and diuretics.
Complications of infective endocarditis include:
 Valve dysfunction: Valve dysfunction can result in heart failure, arrhythmias, and embolic events.
 Embolic events: Emboli can occur in various organs, causing infarction and tissue damage.
 Perivalvular abscess: Abscess formation can lead to valvular and myocardial destruction.
 Systemic complications: Systemic complications such as septicemia, renal failure, and respiratory failure
can occur in severe cases.
 Neurological complications: Neurological complications such as stroke and transient ischemic attacks can
occur due to emboli or septicemia.
 Fungal endocarditis: Fungal endocarditis is a rare but serious complication that can occur in
immunocompromised patients.
 Prosthetic valve endocarditis: Prosthetic valve endocarditis is a serious complication that requires prompt
surgical intervention.
3. How would you differentiate chest pain of acute MI from acute pericarditis? (DU-05M)

Chest pain is a common presenting symptom for both acute myocardial infarction (MI) and acute pericarditis.
However, there are some differences in their clinical presentations that can help differentiate between the two
conditions.
Acute MI typically presents with severe, crushing, and persistent chest pain that is often described as a pressure or
tightness in the chest. The pain may radiate to the left arm, neck, jaw, back, or epigastric region. It is usually
associated with sweating, shortness of breath, nausea, vomiting, and palpitations. The pain is not relieved by rest or
nitroglycerin and may last for several hours or longer.
Acute pericarditis, on the other hand, presents with a sharp, stabbing, or pleuritic chest pain that is usually located
retrosternally or left precordial region. The pain may radiate to the left shoulder and arm. The pain is worsened by
deep breathing, coughing, swallowing, or lying flat and is relieved by sitting up or leaning forward. The patient may
also have a fever, malaise, and a pericardial friction rub on examination.
In terms of investigations, electrocardiogram (ECG) is a useful tool to differentiate between acute MI and acute
pericarditis. In acute MI, ECG typically shows ST-segment elevation or depression, T-wave inversion, or Q waves
in the affected leads. In acute pericarditis, ECG may show diffuse ST-segment elevation, PR-segment depression,
and PR-segment elevation in aVR lead. Echocardiography may be useful to confirm the diagnosis of acute
pericarditis and to assess for the presence of pericardial effusion.
In summary, while both acute MI and acute pericarditis can present with chest pain, their clinical presentations and
ECG findings can help differentiate between the two conditions.
3. How would you differentiate chest pain of acute MI from acute pericarditis? (DU-05M)
Distinguishing chest pain between acute MI and acute pericarditis can be done by the following:
Chest Pain in Acute MI:
 Typically, chest pain in MI is severe, crushing or squeezing in nature.
 Pain usually starts in the center of the chest and may radiate to the left arm, neck, jaw, or back.
 Pain in MI often lasts for more than 20 minutes and does not get relieved by rest or nitroglycerin.
 The patient may also experience shortness of breath, sweating, nausea, and vomiting.
Chest Pain in Acute Pericarditis:

 The chest pain in acute pericarditis is usually sharp, pleuritic, and positional.
 The pain worsens with deep breathing, coughing, and lying down, and improves with sitting up or leaning
forward.
 The pain in pericarditis is not usually relieved by nitroglycerin.
 The patient may also experience fever, malaise, and myalgias.
In summary, the key differences between chest pain in acute MI and acute pericarditis are the nature and duration of
pain, associated symptoms, and response to nitroglycerin. It is important to differentiate between the two as they
require different management approaches.

MBBS QUESTION ANSWER 4 PDF.pdf

Recommended

Recommended

More Related Content

Similar to MBBS QUESTION ANSWER 4 PDF.pdf

Similar to MBBS QUESTION ANSWER 4 PDF.pdf (20)

More from PROFESSOR DR. MD. TOUFIQUR RAHMAN

More from PROFESSOR DR. MD. TOUFIQUR RAHMAN (20)

Recently uploaded

Recently uploaded (20)

MBBS QUESTION ANSWER 4 PDF.pdf