Special Patho-CVS Class test RMC 2011

DEPARTMENT OF PATHOLOGY

RAWALPINDI MEDICAL COLLEGE RAWALPINDI 4^th year 2nd term test (23/5/2011)

SEQ`s Paper    Time allowed:   50 minutes                                                      Total Marks: 50

  INSTRUCTIONS: 1.As usual.  Any questions?  Ask quietly.

  2.Attempt all questions. Mark the appropriate square on the response sheet 3. Be precise and answer in one word preferably what has been asked.

Be sure you hand in your answer and response sheets with your names and roll numbers.  Failure to return both will result in a grade of zero.  There are 10 SEQ`s and 25 MCQ`s. questions  in total.

Q. No 1: A young 38 year old man presents in the emergency with history of paroxysmal recurrent sub sternal             chest discomfort.

a. Enlist the types of Angina.                                                                                                 1.5

b. What is the mechanism underlying unstable angina?                                             3.

Q. N0 2: A young patient from Rawalpindi lands

in the emergency with   chest pain, the patient    

could not be managed properly due to deteriorating  health care delivery system, and died..         

a. Enumerate the specific biomarkers used for the diagnosis of myocardial infarction?   4

b. Which is the most useful and why?                                                                                1

Q. No 3.  12 year old boy develops migratory arthritis after an episode of Phryrangitis weeks earlier.  He is having fever with tachycardia.

b. What is the most probable diagnosis?                           1

b. Write the Jones diagnostic criteria for this condition.   4

Q. No 4: Tabulate the differences between acute and subacute infective endocarditis.   5

Q. No 5:a. Enumerate the complications of myocardial infarction.                           2.5

              b. Enlist the causes of Left sided heart failure.                                            2.5

Q. No 6.  A fifty year old diagnosed patient of HIV develops red purple lesions on the skin of his feet. On investigation the lesions are found to be vascular tumor .

               a. What is the diagnosis?                                                                             1.5

               b. Name four different type of this tumor                                                   2

               3. Name the three different morphological appearances of the disease.  1.5

Q. No 7.  A thirty year old women gas had coldness and numbness in her arms and decreased vision in her Eye for the past five months. On examination radial pulses are not palpable. Femoral pulses are strong with decreased sensation and cyanosis in her arms with no warmth or swelling.

a. Name the probable diagnosis?                                                                                0.5

b. List three morphological changes seen in this condition.                           1.5

c. Enlist three major groups of vasculitis and give two examples of each      3

Q, No 8.  . A woman brings her 2 yr child with a soft bluish swelling on her face, which was present at birth. She also told that it is expanding for last 2 year. Diagnosis of capillary hemangioma was made.

a. Give gross and microscopic picture of this condition?                                           2

b. Give classification of vascular tumors?                                                                  3

Q.  No. 9 A 58-year-old male Principal of a Medical College  reports having repeated and progressively prolonged and severe episodes of pericardial chest pain over the last 6 months. The episodes have become more frequent over the past 2 months and occur on minimal physical exertion. Angiography shows 50% stenosis of left anterior descending artery (LAD).

a. Given that this degree of stenosis in itself does not precipitate an acute myocardial event, what changes in the atherosclerotic plaque must have precipitated these attacks in this patient?

2. What do you understand by ‘vulnerable plaques’?                                        (4+1)

Q. No 10 A 58-year old bureaucrat is diagnosed with acute myocardial infarction after he collapsed on his office desk. He is a known hypertensive and smokes 10 to 12 cigarettes per day and drinks socially. Serum cholesterol level is elevated and he confesses being fond of desserts and Gulab jamans. His BMI and waist circumference are increased for his height. His father died of myocardial infarction, and his mother has stable angina.

a. Enumerate the identified the major risk factors for atherosclerosis in this patient and categorize them as constitutive (non modifiable) and potentially controllable. 

b. Also list the minor risk factors for atherosclerosis in this patient.                          (3+2)

The first person finishing gets bonus 5 marks if claimed. Also write your challenges on it.  You are also allowed to follow the standard procedure (see us for a challenge form) -- but why wait? If u have time jot down.

 This exam is not intended to be especially difficult.  Be prepared for somewhat more challenging exams in the future           GOOD LUCK!

Paper setters: Prof. Abbas Hayat  Dr. Atifa Dr. Homera Niazi Dr. Aiman.Aijaz  Dr. Fareeha Dr.Saad Amjad  Dr. Azer Majeed Dr. Fahim Dr.M.  Fateen  Rashed       

DEPARTMENT OF PATHOLOGY

RAWALPINDI MEDICAL COLLEGE RAWALPINDI 2^nd term test 3^rd Prof. 2011

MCQ`s  Paper   Time allowed:   25 minutes                   Total Marks: 2 x25= 50

  INSTRUCTIONS:

 1. As usual.  Any questions?  Ask quietly.

 2.Attempt all questions. Mark the appropriate square on the response sheet 

1.      Pressure overload is not associated with:

a.                  Ventricular hypertrophy

b.                  Concentric hypertrophy

c.                   Hypertension

d.                  Aortic stenosis

e.                  Aortic regurgitation

2.      Which of the following is not a feature of Fallot’s tetrology?

a.                  Aortic stenosis

b.                  Pulmonary stenosis

c.                   Ventricular septal defect

d.                  Overriding of aorta

e.                  Right ventricular hypertrophy      

3.      An I/V drug abuser complains of high grade fever with shortness of breath and tachycardia. His blood CP shows leucocytosis and raised ESR.. What is the likely diagnosis?

a.                  Acute thrombophlebitis

b.                  Acute infective endocarditis

c.                   Acute urinary tract infection

d.                  Acute chest infection

e.                  Pyrexia of unknown origin

4.      What is the likely causative organism for the above answer..

a.                  Streptococcus Viridans

b.                  B hemolytic streptococcus

c.                   Staphylococcus aureus

d.                  CMV

e.                  Salmonella

5.      The earliest biochemical change developing after myocardial ischemia is:

a.                  ATP depletion to 10% of normal

b.                  Cessation of aerobic metabolism with onset of ATP depletion

c.                   ATP depletion to 50% normal

d.                  Loss of contractility

e.                  Irreversible cell injury

6.      Irreversible cell injury develops in ischemic heart disease after:

a.                  10 – 15 min

b.                  20 – 30 min

c.                   One hour

d.                  12 hours

e.                  One day

7.      Granulation tissue begins to appear at the site of myocardial infarction on:

a.                  1^st day

b.                  3^rd day

c.                   5^th day

d.                  7^th day

e.                  2 weeks

8.      Myocardial infarction becomes grossly visible after:

a.                  2 hours of ischemia

b.                  12 hours of ischemia

c.                   24 hours of ischemia

d.                  48 hours of ischemia

e.                  3 days of ischemia

9.      A young boy is diagnosed to be suffering from acute Rheumatic fever. His heart will show all the following morphological changes except one, which?

a.                  Pancarditis

b.                  Aschoff bodies

c.                   Vegetations on mitral valve

d.                  Ring abscesses in myocardium

e.                  Mitral stenosis

10. A patient underwent cardiac valve replacement 6 months back. Now he develops PUO and is suspected to be suffering from infective endocarditis. Which organism is the most likely cause for his infection.

a.                  Staph Aureus

b.                  Streptococcus viridans

c.                   Hemolytic streptococcus

d.                  HACEK group of viruses

e.                  Staph epidermidis

11. Hypertrophy of heart seen in CCF is associated with:

a.                  Increased protein synthesis

b.                  Myocyte proliferation

c.                   Induction of fetal gene program

d.                  Abnormal proteins

e.                  Inadequate vasculature

12. Pulmonary congestion seen in left sided heart failure is not associated with:

a.                  Pulmonary edema

b.                  Widening of alveolar septa

c.                   Heart failure cells

d.                  Accumulation of edema fluid in alveoli

e.                  Shrunken collapsed lungs

13. The commonest tumor of the heart in children are:

a.                  Fibroma

b.                  Lipoma

c.                   Myxoma

d.                  Rhabdomyoma

e.                  Rhabdomyosarcoma

14. In Kawasaki's disease, you will probably NOT see

              A enlarged lymph nodes containing granulomas 

              B.   erythema of the palms

               C.   fever

                               D.   reddening of the oral mucosa

               E.   reddening of the surfaces of the eyes

15. What's the major risk factor for Buerger's thromboangiitis obliterans?        

              A.   alcohol abuse

              B.   cocaine use

              C.   old age

              D.   sexual promiscuity / multiple partners

              E.   smoking 

16. Most "unstable angina" is probably due to

               A.   a thrombus forming and lysing 

               B.   extreme hypercholesterolemia and rapid atherogenesis

               C.   multiple emboli to the coronaries

               D.   serial hemorrhages within a plaque

               E.   various rhythm disturbances developing and disappearing

17.  Listen carefully to your ankylosing spondylitis patients because they are much more likely than other folks to develop:

A.   aortic insufficiency 

B.   aortic stenosis

C.   carotid bruits

D.   mitral insufficiency

E.   pulmonic stenosis

18. Primary site of involvement in AS is:

a.                  Intima

b.                  Media

c.                   Adventitia

d.                  Endothelium

e.                  ECM

19. Various factors influencing plaque change include all but:

a.                  Cholesterol content of plaque

b.                  Collagen metabolism

c.                   Emotional stress

d.                  Hypertension

e.                  Total triglyceride levels in blood

20. One of the following statements is not true, which one?

a.                  Myocardial infarction leading to severe pump failure is associated with 70% mortality.

b.            Cardiac rupture leads to formation of true aneurysms.

c.                   Acute plaque change triggers Unstable Angina

d.                  Thromboembolism is an important complication of Myocardial infarction

e.                  Maximum granulation tissue formation occurs around 10 – 14 days after infarction.

21. Dilated Cardiomyopathy is associated with:

a.                  Conduction defect

b.            Systolic dysfunction

c.                   Diastolic dysfunction

d.                  Vavular dysfunction

e.                  Myocardial ischaemia

22. All statements about Rheumatic Heart disease are true except:

a.                  Carditis is immune mediated

b.                  Aschoff Bodies are pathognomonic of RHD

c.                   Bread and Butter Pericarditis is a feature of RHD

d.                  Aortic valve is most commonly affected in RHD

e.                  Fibrosis in valvular leaflets leads to “Fishmouth” stenosis

23.    An increased incidence of atherosclerosis has been correlated with all of the following except

a.                  HTN

b.                  Diabetes mellitus

c.                   Increased serum high density lipoprotein

d.                  Increased serum low density lipoprotein

e.                  Use of oral contraceptives

24. A child with fever, arthralgias, GIT and renal involvement and hemorrhagic urticaria like lesions of the skin – most likely diagnosis is:

a.                  Takayasu arteritis

b.                  Polyarteritis nodosa

c.                   Temporal arteritis

d.                  Henoch-Schonlein purpura

e.                  Wegener granulomatosis

25. A.  58 -year-old  Principal  of a medical college known hypertensive with a sedentary lifestyle experiences severe choking substernal chest pain that lasts for about 10 minutes. What degree of stenosis in his coronary arteries would have caused his symptoms?

a.            90%

b.                  50%

c.                   10%

d.                  20%

e.                  <1%

KEY FOR SEQs:

Q. No 1:          Stable Angina / Typical Unstable Angina / Crescendo Prinzmetal Angina / Variant

                        At rest Prolonged duration Disruption of stable atheroma à thrombosis Embolization, vasospasm

Q. No 2:          CPK , CK MB AST LDH Troponins I & T II , CRP Homocysteine levels BNP

Troponin I & T is the best because it is the most sensitive and specific marker of myocardial damage. Their levels begin to rise after 2-4 hours and peak at 48 hours. Their levels remain elevated for 7-10 days

Q. No 3:          a. rheumatic fever  b.Major criteria: Migratory polyarthritis   Carditis Subcutaneous nodules

Erythema marginatum Sydenham chorea

                        Minor criteria: Fever   Pain right upper quadrant abdomen  Raised ESR Raised CRP Elevated ASO titers EKG changes Presence of 2 major or 1 major + 2 minor criteria is diagnostic of RF

Q. No 4:                     

ACUTE IE	SUBACUTE IE
Develop on healthy valves	Develop on diseased valves / prosthesis
Caused by highly virulent organisms	By organisms of low virulence
Acute & severe	Insidious
50% mortality	Recovery common
Destructive necrotizing	Less destructive

Q. No 5:          Complication of MI:

1.      Contractile dysfunction à crdiogenic shock 2. Arrhythmias 3. MC rupture 4 cardiac rupture syndrome 5  Pericarditis 6. Right ventricular infarction  7. Extension 8. Mural thrombosis 9. Ventricular aneurysm 10 Papillary muscle dysfunction 11. Progressive late heart failure

Left sided heart failure:

Causes:IHDn  HTN Aortic, mitral valvular disease Non ischemic MC disease (myocarditis, cardiomyopathy) Pericarditis  Thyroid disease Pregnancy  Septic shock

Q. No 6:          a. kaposis sarcoma

                        b. chronic  c.  lymphadenopathci d  transplant associated  kaposis sarcom e.  AIDS-associated Kaposi sarcoma

                  c.patch,plaque and nodule

Reference ROBINS page 535,chapter 12

Q. No 7:          a. takayasu arteritis

                        b.irregular thickening of aortic or branch vessel wall with intimal wrinkling

                            adventitial mononuclear infiltration with perivascular cuffing

                            granulomatous changes with patchy necrosis and giant cells

             c.large vessel vasculitis(giant cell arteritis,takayasu arteritis)

                       medium sized vasculitis(PAN,kawasaki)

                     small vessel vasculitis(wegeners granulomatosis,churg strauss)

       Reference ROBBINS page 519,page 517-chapter 12

Q no 8                       

 Pathologic Basis of Disease 6^th edition, Chapter 12, page 531,532

a.       Gross----few mm to several cm, bright red to blue, slightly elevated intact covering epithelium. Microscopic-----lobulated, unencapusalted aggregates of closely packed thin walled capillaries, blood filled, lined by flattened endothelium, scant CT.

b.      Benign Neoplasm----Hemangioma, Lymphangioma, glomus tumor, vascular ectasias, reactive vascular proliferations. Intermediate Grade Neoplasm----Kaposi sacrcoma, Hemangioendothelioma. Malignant neoplasm----Angiosarcoma, Hemangiopericytoma    

Q.NO.9

  a..haemorrhage into artheroma,rupture,fissuring,erosion,ulceration

b. which has a thin fibrous cap and is vulnerable to these changes.

Q.N.10 KEY Q 10 Robbins and Cotran Pathologic Basis of Disease 7^th Ed. 520, Table 11-2

Major Risk factors:

Non-modifiable: Increasing age, Male gender, Family history

Potentially controllable: Hyperlipidemia, Hypertension, cigarette smoking

Minor risk factors:

Obesity, Physical inactivity, High carbohydrate intake, alcohol

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