Explanation

Correct Answer D. Diabetes mellitus

The worst risk factor for Coronary Artery Disease (CAD) is diabetes mellitus. Patients with diabetes have the highest rates of CAD when followed over a long period of time such as 10 years. The most clearly agreed upon risk factors for coronary artery disease include diabetes, tobacco smoking, hypertension, hyperlipidemia, family history and age. Physical inactivity, excessive alcohol intake and emotional stress etc. are among the minor risk factors.

Choice A. Incorrect Answer. Age above 45 in men and above 55 in women is a potential risk factor for coronary artery disease.

Choice B. Incorrect Answer. Family history is of no value if CAD develops in elderly relatives or if the affected relatives include grandparents, cousins, aunts or uncles. Only CAD in first degree relatives and premature CAD in a family member conveys a risk of CAD for the patient.

Choice C. Incorrect Answer. Hypertension (defined as a blood pressure above 140/90) is more common than diabetes with about 20% of the total population suffering from it. So, hypertension could be the most common risk factor in CAD patients but it is not the worst factor leading to development of CAD.                                      

Choice E. Incorrect Answer. Emotional stress is a less reliable but a probable risk factor for CAD.

Educational Objective:

Diabetes mellitus is the worst risk factor for developing Coronary Artery Disease (CAD).

Explanation

Correct Answer E. Congestive cardiac failure

Dyspnea due to pulmonary cause has a history of asthma, tuberculosis, COPD and other respiratory disorders while in case of dyspnea of cardiac origin there is history of angina, MI, hypertension and other cardiac disorders. Symptoms of left heart failure include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue, nocturia and chronic non-productive cough. Examination may show bulging of precordium due to cardiomegaly, displaced apex beat of heaving character and gallop rhythm. All such features correspond to congestive cardiac failure in this patient.

 Choice A. Incorrect Answer. Chest pain or discomfort is the chief complaint of Myocardial ischemia. Associated symptoms may include nausea, vomiting, weakness, dizziness, palpitations, profuse sweating, syncope or other atypical presentations. Usually there is no cardiomegaly in acute MI.

 Choice B. Incorrect Answer. Interstitial lung diseases are a potential cause of shortness of breath but dyspnea resulting from pulmonary causes has a previous medical history of respiratory problems.

 Choice C. Incorrect Answer. Constrictive pericarditis is due to progressive thickening, fibrosis and calcification of pericardium which leads to enclosure of heart in a solid shell and thus heart does not fill properly. As a result signs of systemic venous congestion and impaired ventricular filling appear. There is usually no cardiomegaly as well as no gallop rhythm in constrictive pericarditis.                                     

Choice D. Incorrect Answer. Bronchial carcinoma is again a pulmonary cause of dyspnea which in this case is of no practical value due to insignificant past medical history.

Educational Objective:

CCF manifests as dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue, nocturia and chronic non-productive cough. Examination may show bulging of precordium due to cardiomegaly, displaced apex beat of heaving character and gallop rhythm.

Explanation

Correct Answer E. Revascularization

The women is suffering from Tako-Tsubo cardiomyopathy which is an acute myocardial damage most often occurring in post-menopausal women (as she is 58 years old), immediately following an overwhelming, emotionally stressful event. This leads to ballooning and left ventricular dyskinesis. As with ischemic disease, it is managed with beta blockers and ACE inhibitors. Cardiac revascularization is of no value since the coronary arteries usually remain normal.

Choice A. Incorrect Answer. Control of cardiac pain is typically accomplished with the combination of nitrates, morphine, oxygen and beta blockers.

Choice B. Incorrect Answer. ACE inhibitors form an important element of management. They prevent or at least reduce the left ventricular dilatation and cardiac failure following myocardial infarction.

Choice C. Incorrect Answer. Beta blockers are also important in the effective management of Tako-Tsubo cardiomyopathy and in other types of MI. Acute beta blockade reduces the risk of cardiac rupture, decreases ischemic chest pain and infarct size. It also reduces the incidence of ventricular arrhythmias.

Choice D. Incorrect Answer. Aspirin causes 30% reduction in short term mortality on its own and enhances the effect of thrombolytic therapy.

Educational Objective:

Revascularization is of no value in Tako-Tsubo cardiomyopathy since the coronary arteries usually remain normal in this form of MI.

Explanation

Correct Answer B. Immediate surgical exploration

The child is having a testicular torsion. It is a surgical emergency. The surgical repair needs to be performed within 6 hours to prevent any reduction in the viability of the testicular tissue. Both cremestraic reflex and phrens sign are negative in this patient along with the swollen and erethamatous testicular tissue aids in clinical diagnosis. Presence of left testicle at a higher position when compared to the right testicle is a normal sign.

Choice A. Incorrect Answer. Ultrasound investigations will lead to loss of valuable time and leads to further damage of testicular tissue. This is a clear case of testicular torsion which can be diagnosed clinically.

Choice C. Incorrect Answer. Radio nucleotide studies can be helpful in equivocal cases of torsion but this is a clear case of testicular torsion .

Choice D. Incorrect answer. Testicular torsion is an surgical emergency and the pain is not going to subside unless the torsion is relieved

Choice E. Incorrect answer. Antibiotics are helpful in epidydimitis. Both cremastric reflex and a phrens sign are positive in epididymitis. It usually present in post pubertal age group . The pain is usually gradual and evolves over 24 hours

Educational Objectives

Testicular torsion is a surgical emergency and is diagnosed clinically. Pain is relieved only after distortion. Successful detorsion with in 6hrs can retain almost 100percent viability of the testicular tissue.

Reference: Uptodate

Explanation

Correct Answer (D): As per JNC recommendations combination therapy should be started when the BP was more than 20/ 10 above the goal .He should be initiated with a combination drug. It has been suggested that ACE inhibitors have a cardio protective effect independent of blood pressure lowering in patients at high risk for a cardiovascular event. Thaizide diuretics will increase the hyperglycemia, so they are never the choice of treatment in this patient. 

Choice A. Incorrect Answer. Thiazide diuretics may cause hyperglycemia. Hence they are avoided in a patient with diabetes. Moreover his current BP suggests the need of a combination therapy rather than monotherapy

Choice B. Incorrect Answer: Chlorthalidone is more potent than hydrochlorothiazide and is long acting at the same dose . It has more hypertensive affect than hydrochlorothiazide and more importantly reduces mortality. However in this patient a combination therapy is needed. The amount of blood pressure reduction is the major determinant of reduction in cardiovascular risk in both younger and older patients with hypertension and the choice of antihypertensive drug.

Choice C. Incorrect answer Even though ACE inhibitor are an ideal choice, thiazide diuretics will cause hyperglycemia and are better avoided in this patient .

Choice E. Incorrect answer. ACE inhibitor is better in a patient with who is both diabetic and hypertensive and thiazide needs to be avoided in this patient

Educational Objective: Administering a combination therapy is the treatment of choice if the goal of reduction is greater than 20/10 mm Hg above the normal. Amount of blood pressure reduction is the major determinant of the cardiovascular risk in both young and elderly and not the choice of hypertensive.

Reference : Uptodate