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CLINICAL CARDIO RESPIRATORY DISEASES - REPEATED QUESTIONS ANALYSIS

Note: Both papers cover the same subject but under different sub-codes (6261 = old regulation, 6286 = new regulation from 2017-18 onwards). Questions have been grouped by topic across both.

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PART 1: REPEATED 5-MARK QUESTIONS (Write Notes) - WITH FREQUENCY COUNT

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PART 2: REPEATED 2-MARK QUESTIONS - WITH FREQUENCY COUNT

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PART 3: ANSWERS TO ALL REPEATED 5-MARK QUESTIONS

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1. COUGH REFLEX (5 marks) ⭐ Asked 7 times

1. Deep inspiration - 2.5 litres of air taken in
2. Closure of glottis - epiglottis closes
3. Muscle contraction - abdominal and intercostal muscles contract forcefully against closed glottis; intrapleural pressure rises to +100 mmHg
4. Sudden opening of glottis - explosive release of air
5. Air rushes out at 960 km/hour (nearly speed of sound)

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2. ATRIAL SEPTAL DEFECT (ASD) (5 marks) ⭐ Asked 6 times

• Ostium secundum (most common, 70%) - in fossa ovalis region
• Ostium primum (25%) - near AV valves
• Sinus venosus - near superior vena cava

• Usually asymptomatic in childhood
• Dyspnea on exertion, fatigue
• Recurrent respiratory infections
• Wide and fixed splitting of S2 (hallmark sign)
• Pulmonary systolic ejection murmur

• Medical: Treat heart failure, prophylaxis for infective endocarditis
• Surgical (if Qp:Qs >1.5): Open heart surgery with patch closure or suture closure on cardiopulmonary bypass
• Catheter-based: Amplatzer septal occluder device (for secundum ASD)

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3. CARDIAC ARREST (5 marks) ⭐ Asked 5 times

• Hypoxia, Hypovolemia, Hypothermia, Hypo/hyperkalemia
• Tension pneumothorax, Tamponade, Toxins, Thrombosis (PE/MI)

1. Ventricular Fibrillation (VF) - most common shockable rhythm
2. Pulseless Ventricular Tachycardia (VT) - shockable
3. Pulseless Electrical Activity (PEA) - non-shockable
4. Asystole - non-shockable

• Call for help, check unresponsiveness
• Start chest compressions: 100-120/min, depth 5-6 cm, ratio 30:2
• Defibrillation for VF/pulseless VT: 360 J monophasic, 150-200 J biphasic
• Epinephrine (adrenaline) 1 mg IV every 3-5 minutes
• Amiodarone 300 mg IV for refractory VF
• Treat reversible causes

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4. PLEURAL EFFUSION (5 marks) ⭐ Asked 5 times

• Transudates (protein <3g/dL): Heart failure, cirrhosis, nephrotic syndrome, hypoalbuminemia
• Exudates (protein >3g/dL): Pneumonia (parapneumonic), TB, malignancy, pulmonary embolism

1. Pleural fluid protein / serum protein > 0.5
2. Pleural fluid LDH / serum LDH > 0.6
3. Pleural fluid LDH > 2/3 upper limit of normal serum LDH

• Dyspnea, pleuritic chest pain, dry cough
• Decreased chest expansion on affected side
• Stony dull note on percussion
• Absent breath sounds on auscultation
• Trachea pushed away from effusion (if large)

• Treat underlying cause
• Therapeutic thoracocentesis if causing dyspnea
• Intercostal drain (ICD) for large effusions
• Chemical pleurodesis for recurrent malignant effusion
• Decortication for chronic empyema/fibrothorax

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5. LUNG COMPLIANCE (5 marks) ⭐ Asked 5 times

1. Static compliance - measured during no airflow
2. Dynamic compliance - measured during breathing

• Surfactant (increases compliance by reducing surface tension)
• Lung volume (C-shaped compliance curve)
• Fibrosis (decreases compliance - stiff lungs)
• Emphysema (increases compliance - floppy lungs)
• Age (decreases with age)
• Posture (lower in supine)

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6. EMPYEMA THORACIS (5 marks) ⭐ Asked 4-5 times

• Pneumonia (most common cause - parapneumonic empyema)
• Post-thoracic surgery
• Lung abscess rupture
• TB
• Chest trauma
• Subphrenic abscess

1. Exudative stage - free flowing fluid, thin pus
2. Fibrinopurulent stage - loculations, fibrin deposition
3. Organizing stage - thick peel, lung trapped

• Fever, rigors, toxemia
• Chest pain, dyspnea
• Decreased chest expansion
• Dull percussion
• Reduced/absent breath sounds
• Pleural rub (early stage)

• Stage 1: Antibiotics + needle aspiration
• Stage 2: ICD tube drainage + antibiotics; fibrinolytics (streptokinase) for loculations
• Stage 3: Decortication (surgical removal of fibrous peel)

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7. FRACTURE RIB (5 marks) ⭐ Asked 4 times

• Trauma (road accident, fall, sports injury)
• Pathological: osteoporosis, metastasis, Paget's disease

• Localized chest pain - worse on breathing, coughing
• Point tenderness over fracture site
• Splinting (shallow breathing to avoid pain)
• "Springing" test positive

• Flail chest (multiple adjacent rib fractures)
• Pneumothorax, Haemothorax
• Pulmonary contusion
• Injury to liver (right lower ribs), spleen (left lower ribs)
• Pneumonia (due to splinting)

• Adequate analgesia (NSAIDs, opioids, intercostal nerve block)
• Deep breathing exercises
• Chest physiotherapy
• Intercostal block for pain
• Hospitalization if multiple ribs, elderly, underlying lung disease
• Surgical stabilization for flail chest

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8. PNEUMOTHORAX (5 marks) ⭐ Asked 4 times

1. Spontaneous - Primary (young tall males, no lung disease) / Secondary (underlying COPD, asthma, TB)
2. Traumatic - penetrating chest injury, iatrogenic (post-CVP line)
3. Tension pneumothorax - emergency, one-way valve mechanism, mediastinal shift

• Sudden onset chest pain (pleuritic)
• Dyspnea
• Tachycardia
• Decreased chest expansion
• Hyperresonant percussion
• Absent breath sounds
• Trachea shifted away from affected side (tension)

• Small (<2cm): Observation, O2, rest
• Moderate to large: Intercostal drain (ICD) - 2nd intercostal space, mid-clavicular line
• Tension pneumothorax: Immediate needle decompression at 2nd ICS, MCL followed by ICD

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9. CORONARY CIRCULATION (5 marks) ⭐ Asked 4 times

• Arises from right sinus of Valsalva
• Supplies: Right ventricle, Right atrium, SA node (60%), AV node (85%), posterior wall of left ventricle
• Right dominant circulation in 70% of people
• Right marginal artery is a branch

• Arises from left sinus of Valsalva
• Divides into:
  • Left Anterior Descending (LAD): Supplies anterior wall of LV, anterior 2/3 of interventricular septum, apex - "Artery of sudden death"
  • Left Circumflex (LCx): Supplies lateral wall of LV, SA node (40%)

• Coronary sinus (drains into right atrium)
• Thebesian veins (directly into heart chambers)

• LAD occlusion → Anterior MI (most common)
• RCA occlusion → Inferior MI
• LCx occlusion → Lateral MI

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10. PNEUMOCONIOSIS (5 marks) ⭐ Asked 4 times

• Progressive dyspnea
• Chronic cough
• Chest tightness
• Clubbing (late)
• Complications: Pulmonary fibrosis, TB (silicosis + TB = silicotuberculosis), cor pulmonale, mesothelioma (asbestosis)

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11. TETRALOGY OF FALLOT (5 marks) ⭐ Asked 4 times

1. Pulmonary stenosis (infundibular/valvular) - most important, determines severity
2. Right ventricular hypertrophy
3. Overiding aorta (dextroposition)
4. Ventricular Septal Defect (large)

• Cyanosis from infancy (worsens with crying/feeding)
• Clubbing (fingers and toes)
• Squatting position (increases systemic resistance, reduces shunt)
• "Tet spells" (hypercyanotic spells) - acute episodes of cyanosis
• Right ventricular heave
• Single S2, systolic ejection murmur
• "Boot-shaped heart" on X-ray (Coeur en sabot)
• Polycythemia (compensatory)

• Acute cyanotic spell: Knee-chest position, O2, morphine, propranolol, IV fluids
• Surgical: Total correction (VSD patch + RVOT relief) - preferred; Palliative (Blalock-Taussig shunt) if correction not possible

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12. LUNG ABSCESS (5 marks) ⭐ Asked 4 times

• Aspiration (most common) - alcoholism, stroke, dental procedures, unconscious patient
• Pneumonia (Staphylococcus, Klebsiella, anaerobes)
• Bronchial obstruction (carcinoma)
• Hematogenous spread (septic emboli)
• Amebic abscess (right lower lobe)

• Fever, rigors, night sweats
• Productive cough - large amounts of foul-smelling, purulent sputum (500-600 ml/day)
• Hemoptysis
• Clubbing (chronic)
• Decreased breath sounds, dull percussion over abscess

• CXR: Thick-walled cavity with air-fluid level
• CT scan (gold standard)
• Sputum culture

• Prolonged antibiotics: Metronidazole + Clindamycin (anaerobes), Amoxicillin-clavulanate
• Postural drainage
• Bronchoscopy (remove obstruction)
• Surgical resection if refractory (lobectomy)

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13. CPR / CARDIOPULMONARY RESUSCITATION (5 marks) ⭐ Asked 4 times

• Rate: 100-120 compressions/min
• Depth: 5-6 cm (2-2.4 inches)
• Allow full chest recoil
• Minimize interruptions (<10 sec)
• Position: Heel of hand on lower half of sternum

• Head tilt-chin lift (no trauma)
• Jaw thrust (if cervical spine injury suspected)

• 2 rescue breaths after every 30 compressions (30:2 ratio)
• Each breath over 1 second
• Avoid excessive ventilation

• As soon as AED available
• Shock VF/pulseless VT: 360J monophasic, 150-200J biphasic
• Resume CPR immediately after shock

• Epinephrine 1mg IV every 3-5 min (all rhythms)
• Amiodarone 300mg IV for refractory VF
• Sodium bicarbonate for hyperkalemia
• Atropine no longer recommended for asystole/PEA

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14. ARTERIAL BLOOD GAS (ABG) ANALYSIS (5 marks) ⭐ Asked 4 times

1. Check pH: <7.35 = acidosis, >7.45 = alkalosis
2. Check PaCO₂: >45 = respiratory acidosis cause, <35 = respiratory alkalosis cause
3. Check HCO₃: <22 = metabolic acidosis, >26 = metabolic alkalosis
4. Determine if compensated/uncompensated

• Respiratory Acidosis: ↓pH, ↑PaCO₂ (COPD, hypoventilation)
• Respiratory Alkalosis: ↑pH, ↓PaCO₂ (hyperventilation, anxiety)
• Metabolic Acidosis: ↓pH, ↓HCO₃ (DKA, renal failure, lactic acidosis)
• Metabolic Alkalosis: ↑pH, ↑HCO₃ (vomiting, diuretics)

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15. MYOCARDITIS (5 marks) ⭐ Asked 4 times

• Viral (most common): Coxsackie B virus (most common), Echo virus, HIV, Influenza
• Bacterial: Diphtheria (Corynebacterium), Lyme disease
• Protozoal: Chagas disease (Trypanosoma cruzi)
• Autoimmune: Rheumatic fever, SLE
• Drugs: Doxorubicin, cyclophosphamide

• Young person with chest pain, fever, dyspnea
• Tachycardia disproportionate to fever
• Palpitations, fatigue
• Heart failure signs
• Pericardial rub (if pericarditis also present)

• ECG: ST changes, arrhythmias
• Cardiac enzymes: Troponin elevated
• Echocardiogram: Dilated, poorly functioning ventricle
• Cardiac MRI (gold standard for diagnosis)
• Endomyocardial biopsy (Dallas criteria for confirmation)

• Bed rest, restrict physical activity
• Treat underlying cause (antivirals, antibiotics)
• Heart failure management: ACE inhibitors, beta-blockers, diuretics
• Immunosuppression (steroids) in autoimmune causes
• IVIG in pediatric cases
• LVAD/transplant if refractory

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16. COARCTATION OF AORTA (5 marks) ⭐ Asked 4 times

• Preductal (infantile) - proximal to PDA, severe, presents in infancy
• Postductal (adult) - distal to PDA, mild, detected later

• Upper body hypertension - headache, epistaxis
• Lower limb hypoperfusion - claudication, cold legs, weak pulses
• Radio-femoral delay (hallmark) - pulses in arms before legs
• BP difference: Upper limb > lower limb (>20 mmHg)
• Hypertension in young
• Rib notching on CXR (from collateral circulation via intercostal arteries)
• Systolic murmur in back (between scapulae)
• "Figure of 3 sign" on CXR

• Balloon angioplasty ± stenting (catheter-based)
• Surgical: End-to-end anastomosis, subclavian flap repair, patch aortoplasty

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PART 4: ANSWERS TO ALL REPEATED 2-MARK QUESTIONS

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1. Draw a Normal ECG and Label Parts ⭐ Asked 7 times

• P wave: Atrial depolarization; duration < 0.12s; amplitude <2.5mm
• PR interval: 0.12-0.20s (AV conduction time)
• QRS complex: Ventricular depolarization; duration 0.06-0.10s; amplitude 5-25mm
  • Q wave: Septal depolarization
  • R wave: Main ventricular depolarization
  • S wave: Terminal depolarization
• ST segment: Isoelectric; early ventricular repolarization
• T wave: Ventricular repolarization; normally upright in most leads
• QT interval: 0.35-0.45s (total ventricular activity)
• U wave: After T wave; due to Purkinje fiber repolarization

• Heart rate: 60-100 bpm
• PR interval: 0.12-0.20s
• QRS duration: 0.06-0.10s
• QT interval: 0.35-0.45s

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2. Cyanosis ⭐ Asked 6 times

1. Central Cyanosis: Visible on tongue and mucous membranes; due to cardiac or pulmonary cause (cyanotic CHD, severe pneumonia, ARDS); tongue is blue
2. Peripheral Cyanosis: Tips of fingers, toes, earlobes; due to reduced peripheral circulation (heart failure, shock, cold exposure); tongue is normal
3. Differential Cyanosis: Lower limbs blue, upper limbs pink - seen in PDA with pulmonary hypertension

• Cyanotic CHD (TOF, TGA, Eisenmenger's)
• Severe respiratory disease
• Methemoglobinemia

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3. Clubbing ⭐ Asked 5 times

• Grade 1: Fluctuation of nail bed (softening)
• Grade 2: Loss of nail bed angle (>180°)
• Grade 3: Drum-stick appearance, parrot-beak shape
• Grade 4: Hypertrophic pulmonary osteoarthropathy (HPOA)

• Carcinoma of bronchus (most common)
• Lung suppurative diseases (abscess, empyema, bronchiectasis)
• Ulcerative colitis, Crohn's
• Bronchiectasis
• Bacterial endocarditis
• Inflammatory bowel disease
• Nail: Cyanotic congenital heart disease
• Gut: Cirrhosis

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4. Dead Space ⭐ Asked 5 times

1. Anatomical Dead Space: Volume of conducting airways (nose, pharynx, trachea, bronchi up to terminal bronchioles) where no gas exchange occurs. Normal = 150 ml (approximately 1 ml/pound body weight)
2. Alveolar Dead Space: Alveoli that are ventilated but not perfused (V/Q = infinity). Normally = 0 in healthy persons; increased in PE, shock
3. Physiological Dead Space = Anatomical + Alveolar Dead Space

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5. Weaning from Ventilatory Support ⭐ Asked 4 times

• Spontaneous breathing trial tolerated
• Oxygenation: PaO₂/FiO₂ > 200 on PEEP ≤5 cmH₂O
• Airway reflexes intact (able to cough)
• Patient awake, hemodynamically stable

1. SBT (Spontaneous Breathing Trial) - most effective; T-piece or CPAP for 30-120 min
2. Synchronized Intermittent Mandatory Ventilation (SIMV) - gradually reduce mandatory breaths
3. Pressure Support Ventilation (PSV) - gradually reduce pressure support

• RR > 35/min
• SpO₂ < 90%
• Accessory muscle use
• Tachycardia, hypertension
• Anxiety, agitation

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6. Patent Ductus Arteriosus (PDA) ⭐ Asked 4 times

• Continuous "machinery murmur" (Gibson murmur) - best heard at left infraclavicular area
• Bounding pulse, wide pulse pressure
• Collapsing pulse
• Cyanosis only if Eisenmenger's develops
• Heart failure in large PDA

• Premature neonate: Indomethacin or Ibuprofen (COX inhibitors - close PDA medically)
• Term infant/older: Surgical ligation or catheter-based coil/device occlusion
• Keep PDA open: Prostaglandin E1 (in duct-dependent lesions like pulmonary atresia)

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7. Cardiac Output ⭐ Asked 4 times

• Cardiac Output = 5 L/min (at rest)
• Stroke Volume = 70 ml/beat
• Heart Rate = 70 beats/min

• Preload (EDV - Frank-Starling law): ↑ preload → ↑ SV → ↑ CO
• Afterload (peripheral resistance): ↑ afterload → ↓ SV → ↓ CO
• Contractility (inotropy): ↑ contractility → ↑ SV → ↑ CO
• Heart Rate: ↑ HR → ↑ CO (up to a point)

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8. Status Asthmaticus ⭐ Asked 4 times

• RR > 30/min
• HR > 120/min
• PEFR < 50% predicted
• SpO₂ < 92%
• PaCO₂ normal or raised (fatigue)
• Unable to speak in full sentences
• Silent chest (most dangerous - no airflow)
• Pulsus paradoxus > 15 mmHg

• High flow oxygen (aim SpO₂ 94-98%)
• Nebulized salbutamol 2.5-5mg every 20 min (continuous)
• IV Hydrocortisone 100-200 mg or oral prednisolone
• Ipratropium bromide nebulized
• IV Magnesium sulphate 1.2-2g over 20 min
• Aminophylline IV (second-line)
• IV fluids for hydration
• Intubation + mechanical ventilation (if no improvement, rising PaCO₂)

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9. Pulsus Alternans ⭐ Asked 3-4 times

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10. Defibrillator ⭐ Asked 3 times

1. External defibrillator: Paddles placed on chest wall
2. Internal/Implantable (ICD): Implanted in chest
3. AED (Automated External Defibrillator): Portable, voice-guided, for public use

• Monophasic: 360 J
• Biphasic: 150-200 J (first shock), 200 J if not successful

• Paddle positions: Right subclavicular + left axillary (anterior-lateral)
• Ensure no one touching patient
• Synchronize for cardioversion (NOT for VF/pulseless VT)

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11. Complications of Tracheostomy ⭐ Asked 3 times

• Hemorrhage
• Surgical emphysema
• Pneumothorax
• Aspiration

• Tube displacement
• Tube obstruction (secretions)
• Wound infection
• Difficulty swallowing

• Tracheal stenosis (most serious late complication)
• Tracheomalacia
• Tracheo-oesophageal fistula
• Tracheo-innominate artery fistula (life-threatening)
• Persistent tracheocutaneous fistula
• Subglottic stenosis
• Dysphonia, difficulty swallowing

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12. Surfactant ⭐ Asked 3-4 times

1. Reduces surface tension within alveoli (prevents alveolar collapse)
2. Maintains alveolar stability (prevents small alveoli from emptying into large ones)
3. Prevents pulmonary edema
4. Antimicrobial defense (opsonization)

• Respiratory Distress Syndrome (IRDS/NRDS) in premature neonates (< 32 weeks) - deficient surfactant
• ARDS in adults - surfactant dysfunction
• Treatment: Exogenous surfactant (beractant, poractant alfa) - intratracheal instillation in IRDS
• Antenatal corticosteroids (betamethasone) given to mother to promote fetal lung maturity

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13. Vital Capacity ⭐ Asked 2-3 times

• IRV (Inspiratory Reserve Volume) = 3000 ml
• TV (Tidal Volume) = 500 ml
• ERV (Expiratory Reserve Volume) = 1100 ml

• Decreased in: Restrictive lung diseases (fibrosis, scoliosis), neuromuscular diseases
• Used to assess respiratory muscle strength
• VC < 15 ml/kg → Indication for mechanical ventilation

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14. Four Common Cell Types of Lung Cancer ⭐ Asked 2-3 times

1. Squamous Cell Carcinoma (30%) - central location, cavitation, associated with smoking
2. Adenocarcinoma (35%, most common) - peripheral location, associated with non-smokers/smokers; most common in women
3. Small Cell Carcinoma (15%) - most aggressive, central, paraneoplastic syndromes (SIADH, Cushing's), chemotherapy primary treatment
4. Large Cell Carcinoma (10%) - peripheral, poorly differentiated, worse prognosis

• SCLC (Small Cell Lung Cancer) - chemotherapy based
• NSCLC (Non-Small Cell Lung Cancer) - squamous + adeno + large cell; surgery preferred

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15. Bradycardia ⭐ Asked 2-3 times

• Physiological: Athletes, sleep, vagal stimulation
• Pathological: Complete heart block, sick sinus syndrome, inferior MI (vagal), hypothyroidism, Stokes-Adams attacks
• Drugs: Beta-blockers, digoxin, verapamil, diltiazem, amiodarone

• Dizziness, syncope (Stokes-Adams attack)
• Fatigue, exercise intolerance
• If severe: Hypotension, pulmonary edema

• Asymptomatic: No treatment needed
• Symptomatic: Atropine 0.5 mg IV (up to 3 mg)
• Refractory: Transcutaneous pacing → Transvenous pacing → Permanent pacemaker

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16. Causes for Pneumothorax ⭐ Asked 3 times

1. Primary spontaneous: Young tall thin males, no underlying disease, rupture of apical blebs
2. Secondary spontaneous: COPD, asthma, pulmonary fibrosis, TB, lung abscess, cystic fibrosis
3. Traumatic: Penetrating chest injury, rib fracture
4. Iatrogenic: Central venous catheter insertion, thoracentesis, mechanical ventilation, lung biopsy
5. Catamenial: Occurring during menstruation (endometriosis in pleura)

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17. Indications for Closed Heart Surgery ⭐ Asked 2-3 times

1. Mitral stenosis - Closed mitral valvotomy/commissurotomy
2. Patent Ductus Arteriosus (PDA) - ligation
3. Coarctation of aorta - resection and anastomosis
4. Pulmonary artery banding
5. Pericardectomy (constrictive pericarditis)
6. Vascular ring - surgical correction
7. Blalock-Taussig shunt (palliative for TOF)
8. Systemic-pulmonary shunt procedures

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18. Posterolateral Thoracotomy ⭐ Asked 2-3 times

• Pneumonectomy, lobectomy, segmentectomy
• Esophagectomy
• Thoracic aortic surgery
• Decortication, empyema drainage

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19. Pigeon Chest (Pectus Carinatum) ⭐ Asked 2 times

1. Chondrogladiolar - lower sternal protrusion (most common)
2. Chondromanubrial - upper sternal protrusion

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20. Drugs Used for Heart Failure ⭐ Asked 2-3 times

1. ACE inhibitors (enalapril, ramipril) - first-line
2. Beta-blockers (carvedilol, bisoprolol, metoprolol) - reduce mortality significantly
3. MRA/Aldosterone antagonists (spironolactone, eplerenone)
4. ARNI (Sacubitril/Valsartan - Entresto) - superior to ACE inhibitors
5. SGLT2 inhibitors (dapagliflozin, empagliflozin) - newest, reduce hospitalizations

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21. Indications for Tracheal Intubation ⭐ Asked 2 times

1. Respiratory failure (PaO₂ < 50mmHg on O₂, PaCO₂ > 50mmHg)
2. Airway protection (unconscious patient, GCS < 8)
3. During general anaesthesia
4. Cardiac arrest (CPR)
5. Severe asthma unresponsive to treatment
6. Severe head injury
7. Massive haemoptysis
8. Complete upper airway obstruction
9. Epiglottitis
10. Before major thoracic/abdominal surgery

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22. Residual Volume ⭐ Asked 2-3 times

• Keeps alveoli open, prevents lung collapse
• Increases in: Emphysema, COPD (air trapping)
• Decreases in: Pulmonary fibrosis

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23. Stroke Volume ⭐ Asked 2 times

• ↑ Preload (Frank-Starling law)
• ↑ Contractility (catecholamines, digoxin)
• ↓ Afterload

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24. Cobb's Angle ⭐ Asked 2-3 times

1. Identify the most tilted vertebra at top of curve (upper end vertebra)
2. Identify most tilted vertebra at bottom (lower end vertebra)
3. Draw perpendicular lines from end plates of these vertebrae
4. Angle between these lines = Cobb's angle

• < 10° = Normal variation
• 10-25° = Mild scoliosis
• 25-40° = Moderate scoliosis

• 40-50° = Severe scoliosis (surgery considered)

• 50° = Surgery recommended (affects cardiorespiratory function)

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SUMMARY: TOP MOST REPEATED QUESTIONS (MUST PREPARE)

5-Mark (Short Notes) - Highest Frequency:

2-Mark (Short Answers) - Highest Frequency:

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5-MARK ANSWERS: QUESTIONS 16 TO 30

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17. CONDUCTIVE SYSTEM OF HEART (5 marks) ⭐ Asked 3-4 times

• Location: Junction of superior vena cava and right atrium
• Intrinsic rate: 60-100 beats/min
• Generates impulse spontaneously (automaticity)
• Blood supply: RCA (60%), LCx (40%)

• Three tracts connect SA node to AV node:
  • Anterior (Bachmann's bundle - also to left atrium)
  • Middle (Wenckebach tract)
  • Posterior (Thorel tract)

• Location: Koch's triangle (base of interatrial septum, above coronary sinus)
• Intrinsic rate: 40-60 beats/min
• Delays impulse by 0.1 sec (allows atrial contraction before ventricular)
• Blood supply: RCA (85%), LCx (15%)

• Passes through the fibrous AV ring
• Divides into Right and Left bundle branches

• Runs along right side of interventricular septum

• Divides into: Left Anterior Fascicle + Left Posterior Fascicle

• Fastest conduction: 4 m/sec
• Spread impulse to all ventricular muscle cells
• Intrinsic rate: 20-40 beats/min

• AV block → Bradycardia, syncope → Pacemaker required
• Bundle branch block → Widened QRS on ECG
• SA node failure → Junctional/ventricular escape rhythm

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18. HOSPITAL ACQUIRED PNEUMONIA (HAP) (5 marks) ⭐ Asked 3-4 times

• Early HAP (<5 days): Similar to community organisms - Streptococcus pneumoniae, H. influenzae, MSSA
• Late HAP (>5 days) / VAP: Multi-drug resistant (MDR) organisms:
  • Pseudomonas aeruginosa (most common)
  • MRSA (Methicillin-resistant Staphylococcus aureus)
  • Klebsiella pneumoniae
  • Acinetobacter baumannii
  • Enterobacter species

• Mechanical ventilation (highest risk)
• Prolonged hospitalization / ICU stay
• Supine position
• Aspiration, impaired gag reflex
• Immunosuppression
• Prior antibiotics
• H2 blockers / PPI (reduce stomach acidity)

• New fever > 38.3°C
• Purulent sputum (new or increased)
• New/worsening chest X-ray infiltrates
• Rising WBC count
• Worsening oxygenation

• CXR / CT chest (new infiltrate)
• Sputum culture, BAL (Bronchoalveolar lavage) for VAP
• Blood cultures
• Clinical Pulmonary Infection Score (CPIS)

• Early HAP: Beta-lactam (piperacillin-tazobactam) or 3rd/4th generation cephalosporin
• Late HAP / VAP: Antipseudomonal beta-lactam + anti-MRSA agent (vancomycin/linezolid)
• Guided by culture sensitivity results (de-escalation)

• Head of bed elevation 30-45°
• Daily sedation vacation and SBT
• Oral chlorhexidine antiseptic
• Subglottic suctioning
• Hand hygiene

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19. CARDIAC TAMPONADE (5 marks) ⭐ Asked 3 times

• Malignancy (most common cause worldwide - lung, breast cancer)
• Pericarditis (viral, bacterial, TB)
• Post-cardiac surgery / trauma (hemopericardium)
• Aortic dissection
• Myocardial infarction (Dressler's syndrome)
• Renal failure (uremic pericarditis)
• Iatrogenic (cardiac catheterization)

1. Hypotension (↓ CO)
2. Raised JVP / Distended neck veins (impaired venous return)
3. Muffled/distant heart sounds (fluid around heart)

• Pulsus paradoxus > 10 mmHg (hallmark) - exaggerated drop in BP during inspiration
• Tachycardia
• Dyspnea, orthopnea
• Kussmaul's sign (JVP rises on inspiration) - more in constrictive pericarditis
• "Electrical alternans" on ECG (alternating QRS amplitude - pathognomonic)

• ECG: Low voltage QRS, sinus tachycardia, electrical alternans
• CXR: Enlarged globular "water-bottle" shaped cardiac silhouette
• Echocardiography (gold standard): Pericardial effusion + diastolic collapse of RV/RA

• Emergency pericardiocentesis (needle aspiration) - subxiphoid approach under echo guidance
• IV fluids (temporizing measure)
• Surgical pericardial window (for recurrent effusion)
• Pericardiectomy (for constrictive pericarditis)
• Avoid diuretics and vasodilators (worsen filling)

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20. HYPERTENSION (5 marks) ⭐ Asked 3 times

• Primary/Essential (95%) - no identifiable cause; multifactorial (genetic + lifestyle)
• Secondary (5%) - identifiable cause: Renal artery stenosis, pheochromocytoma, Conn's syndrome, coarctation of aorta, Cushing's syndrome

• Age, male sex, family history
• Obesity, sedentary lifestyle
• High salt diet, smoking, alcohol
• Diabetes, dyslipidemia
• Stress

• Usually asymptomatic (silent killer)
• Headache (occipital, early morning)
• Dizziness, visual disturbances
• Epistaxis, palpitations
• Hypertensive retinopathy (AV nipping, papilloedema)
• LV hypertrophy signs

• Heart: LVH, IHD, heart failure
• Brain: Stroke, TIA, hypertensive encephalopathy
• Kidneys: Chronic kidney disease, nephrosclerosis
• Eyes: Hypertensive retinopathy, blindness
• Blood vessels: Aortic dissection, peripheral vascular disease

• Weight reduction (DASH diet)
• Salt restriction (< 2.4 g Na/day)
• Regular aerobic exercise
• Quit smoking and alcohol
• Stress management

• 1st line agents (A-B-C-D):
  • A - ACE inhibitors / ARBs (enalapril, losartan) - especially in diabetics, CKD
  • B - Beta-blockers (atenolol, metoprolol) - especially in IHD, post-MI
  • C - Calcium Channel Blockers (amlodipine) - elderly, isolated systolic HT
  • D - Diuretics (thiazide - hydrochlorothiazide) - first-line in uncomplicated HT
• Hypertensive emergency: IV labetalol, IV nitroprusside, IV nicardipine; reduce BP by max 25% in first hour

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21. POSTURAL DRAINAGE (5 marks) ⭐ Asked 2 times

• Bronchiectasis
• Cystic fibrosis
• Lung abscess
• COPD with excessive secretions
• Post-operative pulmonary care
• Pneumonia with retained secretions

• Recent spinal surgery / unstable spine
• Hemoptysis (active)
• Severe hypertension or hypotension
• Raised intracranial pressure
• Undrained tension pneumothorax
• Pulmonary embolism

• Percussion and vibration (manual chest physiotherapy)
• Active cycle of breathing technique
• Huffing / assisted coughing

• Not performed after meals (wait 1.5-2 hours)
• Monitor oxygen saturation and heart rate
• Stop if patient experiences chest pain, worsening dyspnea

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22. NORMAL ECG (5 marks) ⭐ Asked 2 times

• Small square = 1mm = 0.04 sec (horizontal), 0.1 mV (vertical)
• Large square = 5mm = 0.2 sec
• Paper speed: 25 mm/sec

• Represents atrial depolarization
• Duration: < 0.12 sec (3 small squares)
• Amplitude: < 2.5 mm
• Morphology: Upright in leads I, II, aVF; inverted in aVR

• From start of P wave to start of QRS
• Normal: 0.12 - 0.20 sec (3-5 small squares)
• Prolonged = heart block; shortened = WPW, junctional rhythm

• Represents ventricular depolarization
• Duration: 0.06 - 0.10 sec (< 3 small squares)
• Widened (> 0.12 sec) = bundle branch block, ventricular rhythm

• From end of QRS (J point) to start of T wave
• Normally isoelectric (flat)
• Elevation > 1mm = STEMI / pericarditis
• Depression > 0.5mm = NSTEMI / ischemia

• Ventricular repolarization
• Normally upright in I, II, V3-V6; inverted in aVR
• Tall peaked T = hyperkalemia, early MI
• Inverted T = ischemia, LVH

• Total ventricular activity
• Normal: 0.35 - 0.45 sec (corrected for HR - QTc)
• Prolonged QTc > 0.44 sec = risk of Torsades de Pointes (VF)

• Small deflection after T wave
• Prominent U wave = hypokalemia, bradycardia

• Rate = 300 / number of large squares between R-R interval

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23. PULMONARY FUNCTION TEST (PFT) (5 marks) ⭐ Asked 2 times

• FVC (Forced Vital Capacity): Total air exhaled forcefully; Normal = 4.8 L (male), 3.7 L (female)
• FEV₁ (Forced Expiratory Volume in 1 sec): Air exhaled in first second; Normal = 3.8 L
• FEV₁/FVC ratio: Most important parameter; Normal = >70% (0.7)
• PEFR (Peak Expiratory Flow Rate): Maximum flow rate; Normal = 500-600 L/min

• Measures TLC, RV, FRC (cannot be measured by spirometry)

• Mild: ≥70%
• Moderate: 50-69%
• Severe: 30-49%
• Very severe: < 30%

• Assess severity of lung disease
• Pre-operative respiratory assessment
• Monitor disease progression
• Assess response to bronchodilators (reversibility test)
• Fitness for surgery

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24. MITRAL STENOSIS (5 marks) ⭐ Asked 2 times

• Mild: > 1.5 cm²
• Moderate: 1.0-1.5 cm²
• Severe: < 1.0 cm²

• Rheumatic heart disease (most common cause - 99%)
• Congenital
• Calcific mitral stenosis (elderly)
• Lutembacher's syndrome (MS + ASD)

• Symptoms: Dyspnea on exertion (most common), orthopnea, PND, hemoptysis (Barlow's syndrome), palpitations (AF), fatigue
• Signs:
  • Mitral facies (malar flush) - pinkish-purple discoloration of cheeks
  • Tapping apex beat (palpable S1)
  • Loud S1 (snapping)
  • Opening snap (OS) after S2
  • Mid-diastolic rumbling murmur with presystolic accentuation (Graham Steell murmur if pulmonary regurgitation)
  • Parasternal heave (RVH)

• Atrial fibrillation (most common complication)
• Systemic embolism / stroke
• Pulmonary edema
• Infective endocarditis
• Right heart failure

• ECG: P mitrale (bifid P), AF, RVH
• CXR: LA enlargement (double shadow right border, splaying of carina), pulmonary plethora, Kerley B lines
• Echocardiography (gold standard): Valve area, gradient, "hockey stick" deformity of anterior mitral leaflet
• Wilkins score (for balloon valvotomy suitability)

• Medical: Diuretics, digoxin (if AF), anticoagulation (AF), beta-blockers (rate control), prophylaxis for IE and RF
• Interventional:
  • PTMC (Percutaneous Transvenous Mitral Commissurotomy/Balloon valvotomy) - preferred if anatomy suitable; Wilkins score ≤8
  • Closed Mitral Valvotomy - without CPB; historical procedure
  • Open Mitral Valvotomy - with CPB; direct vision repair
  • Mitral Valve Replacement (MVR) - mechanical or bioprosthetic; for severe disease with unsuitable anatomy

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25. CARDIOMYOPATHY (5 marks) ⭐ Asked 2 times

• Ventricular dilation + systolic dysfunction (reduced EF)
• Causes: Idiopathic, viral (Coxsackie B), alcohol, chemotherapy (doxorubicin), pregnancy (peripartum), genetic
• Features: Heart failure, cardiomegaly, AF, emboli
• ECG: LBB, AF; Echo: Dilated, poorly contracting LV
• Treatment: Heart failure drugs (ACE-I, BB, diuretics, ARNI), ICD, transplant

• Asymmetric septal hypertrophy + diastolic dysfunction; most common cause of sudden cardiac death in young athletes
• Autosomal dominant - sarcomere protein mutations (beta-myosin heavy chain)
• Features: Dyspnea, angina, syncope, sudden death; HOCM (with outflow obstruction)
• Signs: Jerky pulse, double apex, systolic ejection murmur increases with Valsalva
• Treatment: Beta-blockers, verapamil; avoid inotropes; ICD for high-risk; septal myectomy or alcohol ablation for HOCM

• Impaired ventricular filling (diastolic dysfunction) with normal systolic function
• Causes: Amyloidosis, sarcoidosis, hemochromatosis, endomyocardial fibrosis, radiation
• Features: Predominantly right heart failure, JVD, peripheral edema
• Difficult to treat; treat underlying cause

• RV myocardium replaced by fibrofatty tissue
• Causes ventricular tachycardia and sudden death in young people

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26. LOBECTOMY (5 marks) ⭐ Asked 2-3 times

• Right lung: Upper, Middle, Lower lobectomy (or bilobectomy = 2 lobes)
• Left lung: Upper, Lower lobectomy

• Carcinoma of lung (most common, NSCLC - standard treatment)
• Bronchiectasis (localized, refractory to medical therapy)
• Pulmonary tuberculosis (destroyed lobe, cavitary)
• Lung abscess (refractory)
• Benign tumors
• Congenital lung malformations (sequestration, cyst)
• Aspergilloma

• FEV₁ < 40% predicted (inadequate respiratory reserve)
• Diffuse bilateral disease
• Distant metastasis (in cancer)
• Poor cardiac function (severe cardiac disease)

• PFT (FEV₁, FVC, DLCO)
• ABG analysis
• CPET (cardiopulmonary exercise testing)
• Predicted post-operative FEV₁ calculation

• Posterolateral thoracotomy (open) or VATS (Video-Assisted Thoracoscopic Surgery - minimally invasive)
• Division of lobar bronchus + lobar vessels
• ICD placement post-operatively

• Hemorrhage
• Air leak / Bronchopleural fistula
• Pneumonia, empyema
• Cardiac arrhythmias (AF most common post-thoracic surgery)
• Respiratory failure
• Post-pneumonectomy syndrome

• Deep breathing exercises + IPPB
• Incentive spirometry
• Early mobilization
• Chest physiotherapy (postural drainage, percussion)
• Shoulder mobilization
• Breathing retraining

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27. MASSIVE HAEMOPTYSIS (5 marks) ⭐ Asked 2 times

• Most common: Bronchiectasis, tuberculosis (most common cause in developing countries)
• Lung carcinoma
• Lung abscess / aspergilloma (Rasmussen's aneurysm in TB cavity)
• Pulmonary embolism / infarction
• Arteriovenous malformation
• Mitral stenosis
• Trauma

• Amount of blood, rate of bleeding
• Associated features: Fever (infection), weight loss (TB/cancer), dyspnea
• Airway obstruction risk is the main danger - NOT blood loss

• CXR (opacification, cavity, mass)
• CT angiography of chest (localize bleeding source)
• Flexible/Rigid bronchoscopy (identify source, therapeutic intervention)
• Sputum culture, AFB smear, cytology

1. Maintain airway - position patient bleeding side down (lateral decubitus with bleeding lung dependent) - protects good lung
2. High flow oxygen
3. IV access, blood transfusion if needed
4. Sedation (suppress cough reflex)
5. Rigid bronchoscopy + endobronchial tamponade / cold saline lavage

• Bronchial artery embolization (BAE) - treatment of choice for massive haemoptysis; interventional radiology
• Surgery (lobectomy/pneumonectomy) - if embolization fails or localized disease
• Treat underlying cause (antituberculous drugs, antifungals for aspergilloma)

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28. MEDIAN STERNOTOMY (5 marks) ⭐ Asked 2-3 times

1. Coronary Artery Bypass Grafting (CABG)
2. Valve replacement/repair (aortic, mitral)
3. Correction of congenital heart defects (ASD, VSD, TOF)
4. Pericardectomy
5. Aortic root surgery
6. Thymectomy
7. Pericardiectomy
8. Double lung transplantation

• Both sides of heart accessible simultaneously
• Less pain than thoracotomy
• Better access to anterior mediastinum

• Sternal dehiscence - separation of sternum (especially in diabetics, obese, osteoporotic patients)
• Mediastinitis / Deep sternal wound infection (most serious - 1-2%; mortality 25%)
• Hemorrhage
• Phrenic nerve injury (left nerve at risk)
• Wound infection
• Prolonged pain, sternal instability

• Deep breathing exercises (diaphragmatic)
• Incentive spirometry
• Sternal precautions for 6-8 weeks: No pushing/pulling > 5 kg, no bilateral arm elevation above head
• Sternal support with pillow when coughing
• Early ambulation
• Shoulder and trunk mobilization (avoiding sternal stress)

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29. ASPERGILLOSIS (5 marks) ⭐ Asked 2-3 times

• Hypersensitivity response to Aspergillus
• Seen in asthma and cystic fibrosis patients
• Features: Worsening asthma, recurrent wheeze, brown mucus plugs, eosinophilia, fleeting CXR infiltrates
• Diagnosis: Raised IgE (total + Aspergillus-specific), skin prick test positive, central bronchiectasis on CT
• Treatment: Oral corticosteroids + itraconazole

• Aspergillus colonizes pre-existing lung cavity (TB, bronchiectasis, sarcoidosis)
• Forms a fungal ball (mycetoma)
• Features: Asymptomatic OR massive haemoptysis (most dangerous complication - Rasmussen's aneurysm)
• CXR/CT: Oval opacity in cavity with crescent-shaped air space above it ("air crescent sign" / Monod sign)
• Treatment: Antifungals (itraconazole, voriconazole); surgical resection for massive haemoptysis; BAE for bleeding

• Occurs in severely immunocompromised (neutropenic, transplant, HIV, high-dose steroids)
• Aggressive angioinvasion → tissue necrosis, infarction
• Features: High fever, pleuritic chest pain, haemoptysis, rapidly progressive
• CT chest: "Halo sign" (ground-glass opacity around nodule) - early sign; "Air crescent sign" - late sign
• Diagnosis: CT + Serum galactomannan (Aspergillus antigen), bronchoalveolar lavage culture
• Treatment: Voriconazole (drug of choice); alternatives: Isavuconazole, Amphotericin B, Caspofungin

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30. VENTRICULAR SEPTAL DEFECT (VSD) (5 marks) ⭐ Asked 2 times

1. Perimembranous / Membranous (most common, 70%) - in membranous septum near AV node
2. Muscular (5-10%) - within muscular septum; may be multiple ("Swiss cheese")
3. Inlet/AV canal type - below AV valves
4. Outlet/Supracristal - below pulmonary valve; risk of aortic regurgitation

• Asymptomatic
• Loud harsh pansystolic murmur at left lower sternal border (LSE)
• May close spontaneously by age 5 (muscular VSDs)

• Heart failure in infancy (tachypnea, feeding difficulty, failure to thrive, sweating)
• Recurrent chest infections
• Loud pansystolic murmur + thrill
• Parasternal heave, displaced apex

• Cyanosis, clubbing
• Pulmonary hypertension signs
• Soft murmur (equalizing pressures)
• Inoperable

• ECG: LVH (small VSD), biventricular hypertrophy (large VSD), RVH (Eisenmenger's)
• CXR: Cardiomegaly, pulmonary plethora
• Echo (Doppler - diagnostic): Defect location, size, shunt direction, gradient

• Small VSD: Observe (spontaneous closure possible); prophylaxis for IE
• Large VSD with heart failure: Diuretics, digoxin, ACE inhibitors; elective surgical closure 3-6 months age
• Surgical: Patch closure on cardiopulmonary bypass (open heart surgery)
• Catheter-based device closure: Amplatzer occluder (for suitable muscular VSDs)
• Eisenmenger's: Inoperable; bosentan (pulmonary vasodilator), heart-lung transplant

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QUICK REFERENCE SUMMARY (Q16-30)

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16. COARCTATION OF AORTA (5 marks) ⭐ Asked 4 times

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Definition

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Incidence

• 5-8% of all congenital heart defects
• More common in males (2:1 male to female ratio)
• Strong association with Turner's syndrome (45 XO) - found in 30% of Turner's females

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Types

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Associated Anomalies

• Bicuspid aortic valve (most common association - 50-85%)
• Turner's syndrome
• Berry aneurysms of circle of Willis
• VSD, PDA
• Mitral valve abnormalities

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Pathophysiology

Narrowing of aorta
        ↓
Obstruction to blood flow
        ↓
↑ Blood pressure PROXIMAL (upper body hypertension)
        ↓
↓ Blood pressure DISTAL (lower body hypoperfusion)
        ↓
Development of COLLATERAL CIRCULATION
(via internal mammary, intercostal, subscapular arteries)
        ↓
Collaterals dilate and erode inferior rib margins
→ RIB NOTCHING on X-ray

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Clinical Features

Symptoms:

• Headache, dizziness, epistaxis - from upper body hypertension
• Claudication (leg pain on exercise), cold legs, numbness - from lower body ischemia
• Hypertension in a young patient
• Easy fatigability

Signs:

• Hypertension in upper limbs with normal or low BP in lower limbs (difference > 20 mmHg - hallmark)
• Radio-femoral delay - radial pulse felt before femoral pulse (pathognomonic)
• Weak or absent femoral pulses
• Bounding arm pulses
• Visible/palpable pulsating collateral vessels around scapula
• Systolic murmur heard best over back / between scapulae
• Continuous murmur (if collaterals are well-developed)
• Signs of LV hypertrophy (heaving apex)

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Investigations

• Left ventricular hypertrophy (LVH) - tall R waves in V5-V6

• "Figure of 3 sign" - most characteristic finding:
  • Upper bulge = dilated aortic knuckle proximal to coarctation
  • Indentation = site of coarctation
  • Lower bulge = post-stenotic dilatation
• "Reversed Figure of 3 (E sign)" - on barium swallow
• Rib notching - bilateral, involves 3rd to 8th ribs (due to dilated intercostal collateral arteries eroding inferior rib margins)
• Cardiomegaly (LVH)

• Identifies site and severity of coarctation
• Detects associated defects (bicuspid AV, VSD)
• Doppler gradient across coarctation

• Gold standard for anatomy and surgical planning
• Best shows extent, length, and collaterals

• Measures pressure gradient across coarctation
• Gradient > 20 mmHg = significant

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Complications

• Hypertension (persists even after repair - major cause of morbidity)
• Heart failure (LV pressure overload)
• Aortic dissection / rupture
• Stroke (hypertension, Berry aneurysm rupture)
• Infective endocarditis / endarteritis
• Premature coronary artery disease
• Renal failure (hypertension-induced)

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Management

Medical (temporary / pre-operative):

• In neonates with critical coarctation: Prostaglandin E1 infusion (to maintain PDA patency and allow blood flow to lower body)
• Anti-heart failure medications if in failure
• Antihypertensives (beta-blockers) pre-operatively

Interventional (Preferred):

• Treatment of choice for older children, adolescents, adults
• Native coarctation or re-coarctation after surgery
• Balloon dilates the stenosis; stent placed to maintain patency
• Less invasive, shorter recovery

Surgical (for neonates and infants):

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Physiotherapy Role (Post-operative)

• Breathing exercises and chest physiotherapy post-thoracotomy
• Early ambulation
• Monitor BP in all four limbs post repair
• Shoulder mobilization (thoracotomy approach)
• Exercise rehabilitation - gradually introduce exercise under supervision
• Long-term: BP monitoring, exercise guidelines, activity restrictions

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Summary Box