Level of students: Undergraduates
Level of Cognition: C 1
Theme: Myocardial infarction
Sub-Theme: Management
Stem:
A 48-year-old male presents to the emergency department with sudden onset chest pain radiating to his left arm and jaw for the last 2 hours. He appears diaphoretic and anxious. He is hypertensive and diabetic. On examination, his blood pressure is 160/90 mmHg, heart rate is 100 bpm, and oxygen saturation is 95% on room air with normal rest clinical examination. His ECG done in ER showed ST-segment elevation in leads II, III, and aVF.
Lead In statement:
What is the most appropriate initial management step in this patient?
Options:
A) Give aspirin and refer for primary coronary PCI.
B) Administer morphine and give oxygen
C) Start Fibrinolytic therapy immediately
D) Perform an exercise stress test
E) Obtain a chest X-ray and do cardiac enzymes
Key: (A) Give aspirin and refer for primary PCI
Importance: Essential
Difficulty Level: Easy
Reference: Griffin BP, Menon V. Manual of cardiovascular medicine2019; Wolters Kluwer. USA. Chapter No, 1 page No.2
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MCQ 1
Level of Students: FCPS Cardiology
Level of Cognition: C2
Theme: Cardiac arrhythmia
Sub Theme: Investigations
Stem:
A 60-year-old male presented to OPD with history of palpitations and recurrent falls. He is non-diabetic and non-hypertensive. He has no exertional shortness of breath or chest pain. His vitals are normal with normal clinical examination. His ECG and echo are within normal limits. His stress thallium scan is also within normal limits.
Lead in Statement:
What is the most appropriate next step?
Options List:
A) Head up tilt table test
B) 48 hours Holter monitoring
C) Loop recorder for two months
D) Electrophysiological study
E) Signal average ECG
Key: D)
Importance: Essential
Difficulty Level: Hard
Reference: Libby,Bommow,Mann,Tomaselli, Bhatt. Braunwald’s .Heart Diseases: A Text Book of Cardiovascular Medicine 12Th Edition, Page No 1391.
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MCQ 2
Level of students: FCPS Cardiology
Level of Cognition: C 2
Theme: Acute Myocardial infarction (AMI)
Sub-Theme: Complications of AMI
Stem:
A 38-year-old male presents to the emergency department with sudden onset 2 hours duration chest pain radiating to his left arm and jaw. He appears diaphoretic and anxious. He is hypertensive and current heavy smoker. On examination, his blood pressure is 110/90 mmHg, heart rate is 98 bpm, and oxygen saturation is 94% on room air with basal lung crepitations. His ECG done in ER showed ST-segment elevation in leads I, aVL and from V1-V4.
Lead in Statement:
Which of the following complications is this patient at highest risk for?
Options:
A) Ventricular fibrillation
B) Cardiogenic shock
C) Atrial fibrillation
D) Pericarditis
E) Ventricular tachycardia
Key: B) Cardiogenic shock
Importance: Essential
Difficulty Level: Moderate
Reference: Griffin BP, Menon V. Manual of cardiovascular medicine2019; Wolters Kluwer. USA. Chapter No, 1 page No.2
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MCQ 1
Level of Students: FCPS Cardiology
Level of Cognition: C3
Theme: Valvular Heart Disease
Sub Theme: Management
Stem:
A 34-year-old female of 26 weeks pregnancy is refereed to your clinic for antenatal work up. She is complaining of shortness of breath on walking. She is having normal vitals and her precordial examinations revealed a grade 2/6 systolic murmur at apical area. Her ECG is normal with normal routine labs.. Her Echocardiography revealed rheumatic mitral valve with moderate mitral regurgitation and normal left ventricular ejection fraction.
Lead in Statement:
What you will recommendation to her?
Options List:
A) ACE inhibitors + Diuretics
B) Nitrates+ Hydralazine + Diuretics
C) Referral for mitral valve replacement
D) Endocarditis prophylaxis at time of delivery
E) No therapy but just routine follow up
Key: (E
Importance: Essential
Difficulty Level: Moderate
Reference: Libby ,Bommow, Mann , Tomaselli, Bhatt. Braunwald’s . Heart Diseases: A Text Book of Cardiovascular Medicine 12Th Edition, Page No 1463
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MCQ 2
Level of students: Undergraduates
Level of Cognition: C 3
Theme: Myocardial infarction
Sub-Theme: Secondary prevention
Stem:
A 68-year-old male presents to the emergency department with sudden onset chest pain radiating to his left arm and jaw for the last 2 hours. He appears diaphoretic and anxious. He is hypertensive and diabetic. His ECG done in ER showed ST-segment elevation in leads I, aVL and V1-V4. He underwent successful angioplasty with drug eluting stent to his left anterior descending coronary artery and was discharged home on 4th admission day.
Lead in Statement:
Which intervention would be most effective in this patient regarding secondary prevention?
Options:
A) Starting a low dose statin regimen
B) Initiating regular exercise training
C) Prescribing a daily low-dose aspirin
D) Counseling on smoking cessation
E) Recommending a low-sodium diet
Key: D) Counseling on smoking cessation
Importance: Essential
Difficulty Level: Moderate
Reference: Griffin BP, Menon V. Manual of cardiovascular medicine2019; Wolters Kluwer. USA. Chapter No, 1 page No.2
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Level of students: FCPS Cardiology
Theme: Arrhythmia (Atrial Fibrillation)
Sub-Theme: Pathophysiology, Clinical presentation, Management
A 78-year-old man presents to the emergency department with palpitations, shortness of breath, and fatigue. He has a history of hypertension and type 2 diabetes mellitus. On examination, he is afebrile with normal breathing; he has irregularly irregular pulse with rate of 130 bpm with a blood pressure of 150 / 90mmHg. His ECG confirms the diagnosis of atrial fibrillation. Discuss the pathophysiology, clinical presentation, and management options for atrial fibrillation in this patient, keeping in mind his comorbidities.
Marking Scheme:
a) Explain the underlying mechanisms of atrial fibrillation ( 3 marks )
b) Describe the typical symptoms and signs, and explain the specific presentation in the given patient (3 marks )
c) Discuss both acute and long-term management strategies, considering the patient's comorbidities ( 4 marks )
Reference: Libby, Bonnow. Mann, Tomaselli, Bhatt. Braunwald’s Heart disease: A Text Book of Cardiovascular medicine 12TH edition
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Level of Students: FCPS Cardiology
Theme: Acute ST Elevation Myocardial Infarction (STEMI)
Sub-Themes: Diagnosis , investigations, Management
Clinical Scenario:
A 58-year-old male presents to the emergency department with severe chest pain radiating to his left arm and jaw for the past 30 minutes. He appears diaphoretic and anxious. His blood pressure is 150/90 mmHg, heart rate is 110 bpm, respiratory rate is 22 breaths/min, and oxygen saturation is 95% on room air. On auscultation of precordium there is a short systolic murmur. An ECG reveals ST-segment elevation in leads II, III, and aVF and right sided chest leads.
a. What is the most likely diagnosis?
b. Name three differential diagnoses.
c. What are three relevant investigations?
d. What is the best treatment?
Scheme of Marks Distribution:
a. Acute Inferior ST elevation MI + RV infarct ( 2 marks)
b. Pulmonary embolism, aortic dissection, pericarditis ( 3 marks, one each)
c. ECG, cardiac biomarkers, echo ( 3 marks, one each)
d. Urgent coronary angiography and percutaneous coronary intervention ( 2 marks)
Reference:
Griffin BP, Menon V. Manual of Cardiovascular Medicine 2019; Walters Kluwer. USA. Chapter 01 page 2