Diagnosis of cardiovascular disorders MCQs

The cardiac axis represents the overall direction of electrical activity as it spreads through the cardiac conduction system The normal cardiac axis is directed downward and slightly to the left. It falls within the range of -30° to +90°. Left Axis Deviation (LAD): When the QRS axis is less than -30°. Right Axis Deviation (RAD): When the QRS axis is greater than +90°. Extreme Axis Deviation: Occurs when the QRS axis lies between -90° and 180° ("Northwest Axis") Reference: Harrison's Principles of Internal Medicine 21 st edition Page 1870

This patient was immobilized for prolonged period, which can lead to rhabdomyolysis and renal failure, as evidenced by the high Creatine kinase levels. In addition, he has hyperkalemia and severe metabolic acidosis. Also, he has boggy swelling and tenderness of his muscles, suggestive of compartment syndrome or bilateral DVT. So he is having multiple issues that requires rapid correction. Hence hemodialysis is the best treatment Forced alkaline diuresis may renal failure is established with life-threatening hyperkalemia and acidosis, it is inappropriate. Reference: Harrison's Principles of Internal Medicine, 21st edition, chp:310, pg: 2307.

Cocaine is a psychostimulant . The other agents belonging to this group are, Methamphetamine, MDMA and Cathinone. There are certain therapeutically used psychostimulants too. These include Methylphenidate and Dextroamphetamine, used in the treatment of ADHD. Phenylpropanolamine was a psychostimulant used previously for weight reduction and is now withdrawn due to the risk of intracerebral bleed. The table depicts the symptoms of overuse of all the psychostimulants. Their cardiovascular effects produce tachycardia and not bradycardia. Withdrawal produces hypersomnia, depressed mood and increased appetite.

Answer- A. Cardiovascular anomalies Diaphragmatic Hernia is defined as a communication between abdominal & thoracic cavities with or without abdominal contents in thorax. Females are affected more than males. More common on left side and is posterolateral. Associated anomalies may be seen 30% of cases CNS lesions, esophageal atresia, omphalocele and CVS lesions. Most cases are sporadic. Cardiac anomalis is MC anomalis.

The patient has ventricular tachycardia and is hemodynamically unstable indicated by loss of consciousness. Immediate treatment consists of cardioversion followed by a suitable anti-arrhythmic such as lidocaine IV or amiodarone and correction of any electrolyte imbalance. Myocardial infarction (MI) is the likely cause of ventricular tachycardia, hence treatment for MI would be indicated if required. Programmed stimulation may only be carried out when the patient is stable. Reference: Harrison's Principles of Internal Medicine 21 st edition Page no: 2252

Tricsupid regurgitation - Around 90% is secondary to left sided valvular heart disease and pulmonary hypertension - Syndromes associated with primary TR include Marfan syndrome, Carcinoid syndrome and with Ebstein anomaly - Clinical examination shows elevated JVP with prominent c-v waves (Lancisi sign) and pulsatile hepatomegaly - Pansystolic murmur is typically heard in the left lower sternal border that increases during inspiration (Carvallo sign) Pansystolic murmur at apex is typically caused by mitral regurgitation. PSM at left lower sternal border can be caused by TR and VSD. Reference : Harrison's Principles of Internal Medicine 21 st edition Page 2003

Pheochromocytomas are catecholamine secreting tumours arising from the adrenal gland. Pheochromocytoma may occur in patients with von Recklinghausen's disease (NF-1) and von Hippel-Lindau syndrome. Skin neurofibromas and multiple cafe au-lait spots occur in peripheral (NF1) neurofibromatosis, while haemangioblastomas are commonly seen in those with the von Hippel-Lindau syndrome. Carney's triad includes Pheochromocytoma /paraganglioma, pulmonary chondroma and Gastrointestinal stromal tumour (GIST) Ataxia telangiectasia is not associated with pheochromocytomas. Reference : Harrison's Principles of Internal Medicine 21 st edition Page 2976

The history here suggests a lower limb deep vein thrombosis with peripheral embolus through a patent foramen ovale, leading to a left sided cerebrovascular event. This is termed the paradoxical embolus - so-called because a thromboembolus arising from the venous circulation can end up in the systemic circulation. Transoesophageal echocardiography is the investigation of choice to investigate for a patent foramen ovale, although transthoracic echocardiography with contrast may be an alternative. Reference: Harrison’s Principles of Internal Principles, 20 th edition, ch:273 pg:1913