Question 8.
Cardiac tamponade:
a) is caused by a left-to-right shunt due to rupture of the intraventricular septum
b) is a haemodynamically significant accumulation of fluid in the pericardial sac
c) may be caused by blood or by serous fluid accumulation.
d) initially compromises diastolic filling of the left ventricle more than that of the right
e) is a high cardiac output state in which there is profound peripheral vasodilation
(2.5 marks)2006
Question 7.
Cardiac tamponade:
a) is a high cardiac output state caused by profound peripheral vasodilation
b) is a haemodynamically significant accumulation of fluid in the pericardial sac
c) is caused by a left-to-right shunt due to rupture of the intraventricular septum
d) initially compromises diastolic filling of the right ventricle more than that of the left
e) may be caused by either blood or serous fluid accumulation.
(2.5 marks)

Initial Patient Presentation
Mr Tom Lewis, a 66 year old previously healthy man has noted that, during the last month or so, he
has developed chest tightness and unusual shortness of breath after walking briskly or going up
slopes; if he stops to rest, he quickly feels better. He has consulted his GP, because of concern about
this problem.
Question 10.
List and justify:
a) The key history questions you suggest the GP should ask this patient.
(10 marks)
b) The key examination findings you suggest the GP should elicit.
(5 marks)
c) The preliminary investigations that you suggest the GP might arrange at this initial
(5 marks)

Question 13.
List the various patterns of cardiac-related pain experienced by patients. Give the underlying basis
for cardiac pain distribution patterns.
(5 marks)

Mr Lewis was referred for exercise ECG test.
Exercise ECG Test: ST segment depression on exercise in anterior leads at high workload.
Question 14.
What do the ST segment changes seen on exercise ECG suggest?
(2 marks)
Question 15.
What treatment and medication(s), if any, would you advise at this time to address Mr Lewis’s
problem at this time? Please give your rationale.
(10 marks)
Initial Patient Treatment
Mr Lewis was given the drug treatment regimen you advised.
Further Development
6 months later, Mr Lewis presents to the FMC Emergency Dept. after developing prolonged chest
tightness and shortness of breath while eating breakfast at about 7 am this morning. He took three
glyceryl trinitrate tablets (600 mcg) 10 minutes apart with no relief of his pain; he then called an
ambulance. There are no other symptoms.
He is anxious, sweaty, and complains of continued chest discomfort. His blood pressure is 90/60,
heart rate 110/min, respirations 16/min, temp 37°C.
Investigation Results
Electrocardiogram: (8:55 am) Abnormal ECG: ST segment elevation in
leads V3, V4, V5. Machine Diagnosis: Acute MI.
Troponin T (taken at 0900am) Negative
Chest X-ray: (9:30 am) Normal
Question 16.
Comment on the clinical significance of the negative Troponin T test result in this instance
(3 marks)
Question 17.
What pathological process(es) is/are taking place within Mr Lewis’s coronary vasculature to explain
this acute event?
(10 marks)
Question 18.
List 5 possible acute complications which may ensue from Mr Lewis’s myocardial infarction.
(5 marks)
Question 19.
What changes would be seen within the myocardium at autopsy, macroscopically and
microscopically, if Mr Lewis were to die:
a) at 11.00 on the day of the myocardial infarction?
b) 2 days post myocardial infarction?
c) 3 months post myocardial infarction?
(10 marks)
Mr Lewis was taken urgently to the Cardiac Cath Lab, where percutaneous coronary angiography
showed thrombotic occlusion of the LAD.
The acute blockage was treated by balloon angioplasty with coronary stent placement, restoring
flow at the previously occluded site. He sustained a limited anterior myocardial infarct with only
mild left ventricular impairment, shown on a subsequent echocardiogram.
Mr Lewis was discharged 5 days later. On discharge, he was prescribed aspirin, clopidogrel,
metoprolol, ramipril and atorvastatin. He returned to work after 1 month’s recuperation at home.
Suggestion: Check that you know (i) what each of these drugs does and
(ii) WHY Mr Lewis was prescribed each drug!

In July 2005, Mrs Jones calls her son at 4:00 am, in distress. She has woken from her sleep with
severe chest pain, which has now been constant for the last 15 minutes.
Her son dials 000 for an ambulance, but when the ambulance arrives at her home, Mrs Jones is
unconscious, not breathing, and pulseless.
Cardiopulmonary resuscitation is commenced by the ambulance paramedics.
Question 18
What cardiac rhythms may be seen on a cardiac monitor during a cardiac arrest?
(4 marks)

The cause of Mrs Jones chest pain may have been thrombotic occlusion of a coronary artery,
resulting in a major myocardial infarction. If this event was to prove fatal, it could cause her death
either immediately, or at a later time. If her relatives agreed, Mrs Jones’ heart could have been
examined at a subsequent post mortem examination.
Question 19
Outline the sequence of gross and microscopic appearances seen in the affected myocardium after a
myocardial infarct, where death occurs at 0, 24, 48, 72, hrs, 1-2 weeks, and 2 months post infarct.
(12 marks)
The cardiopulmonary resuscitation commenced urgently by the ambulance team (supplemental O2
by mask, defibrillation, and basic life support) was ultimately successful; she was transferred
urgently to hospital.
On admission, an ECG revealed an acute anterior MI; Mrs Jones was treated in the Cardiac Cath
Lab, where thrombotic occlusion of her LAD was revealed. The blockage was successfully treated
with a drug eluting stent, per-cutaneously.
Mrs Jones recovered well from the operation without complications, and was discharged 10 days
later (on several drugs) to convalesce at her son’s home, after short stays in ICU, Coronary Care,
and the Cardiac Ward.